LITERATURE REVIEW

Reasons for triage The reasons triage is necessary are very much linked to the advantages of triage. While reading the literature on triage I found that it was for the following reasons that triage was introduced into A/E.

• The continuing increasing number of patients attending A/E departments every year (9,2,7)
• Leading to increased waiting times (9)
• Which in turn leads to increased patient hostility and bad public relations. (6)
• An increasing number of patients are presenting with non‑urgent problems as hospitals are seen increasingly as community resources where treatment for any medical condition can be obtained. (2)
  
• The public's expectations have increased, they now expect a fast‑food type service (2,10)
• It is becoming more difficult to be seen by a general practitioner especially without an appointment or after clinic hours. GP's often refer patients directly to A/E department without seeing them. (2) They may refer for routine treatment which the G.P doesn't provide, e.g. it may not be cost effective. All this leads, in a vicious circle to increased patient numbers.
  
  If triage is not in operation, with increased numbers and increased waiting times, the waiting room becomes an unknown area, where seriously ill patients are at risk of having to wait too long (7,11,9,10). Triage relieves the receptionist from the responsibility of prioritising patient care, a task for which they are not prepared. (12)

The Taking of Responsibility

• It is a common point in the literature that triage should be carried out by a senior, _ experienced nurse. (5,1,11,7,3,6). Indeed some see it "as an area that requires greaterSkill than does the general treatment area" (5). The recommended amount of A/E experience necessary varies, but it has been suggested that at least 2 years, preferably 3 years, should be required. (1)
• The educational qualification necessary to work in triage has not been agreed upon in the literature. A 3'h day in‑service training program has been devised in Tameside General Hospital. (10) It has been recommended in the U.K. that a national triage training programme be available in the future (4). In a survey in the USA 51 % of hospitals indicated that some formal in‑service training and orientation was operating, but only 3 % required that the triage nurse be a certified emergency nurse (5). The Emergency Nurses Association (1992) in the USA recommended at least 6 month A/E experience and formal education with a preceptorship before functioning independently as a triage nurse. (2)
• Education and experience are essential to ensure appropriate patient care and also from a medicolegal viewpoint, as the triage nurse is accountable for all her decisions. (4,13)

Physical Facilities

Physical facilities available vary from department to department. It has been agreed that the type of facilities chosen by a particular department should be in accordance with the needs of that department. (10) The positioning of the triage nurse depends on whether she is to assess the "walking wounded" only or also ambulance referrals. If these entrances are separate it is important that she can be clearly seen from both entrances.

The following are preferable

• a private room to assess patients.
• handwashing facilities.
• internal and external telephones
• emergency call or escape facilities
• equipment for patient examination and administration of first aid (1)
  
• Other facilities are optional for triage e.g. radio control with the ambulances. (11)
  
  In a survey of 185 A/E departments in the USA (S) it was found that only 15 % had a private triage area
  
• 15 % had a private triage area
  
• 48 % had a semi‑private triage area and
  
• 36 % had a public triage area.

Performing Triage: Establishing Ground Rules

Protocols

All literature reviewed supported the development of triage protocols (7,11,1) to provide guidelines for successful screening of patients. The protocols aim to standardise patient care. They should be used in conjunction with the nurse's experience and intuition, and not as a barrier to it. (7) Failure to follow hospital protocols may result in poor patient care and a costly harrowing lawsuit (13). A survey in the UK in 1991 showed that 60.3 % of A/E departments had no written protocols. (1)

Categories

The number of categories used varies from department to department (11,3). Anything from nothing formal, e.g. now or later, to 12 separate categories (1). The National Triage Scale for Australian Emergency Departments (1993) recommend using 5 categories. These range from category 1, requiring immediate resuscitation, to category 5, who will receive treatment within 2 hour if resources allow it. (6) A UK triage scale, which is very similar to the Australian scale, is being piloted at present. The UK scale sets a 4 hour target time for category 5 patients and colour codes may be used in conjunction with the numbers of the categories (3,4).

The use of a standard triage scale in a country allows easy comparison between departments (3). It also enables management to calculate the number of nursing hours needed in the A/E department by using the PCS or Patient Classification System. (4) The formula used is (number of patients in Category 1) x (the average amount of time necessary to care for patients in category 1), and so on in each category.

Extra Staff

A minimum increase of staffing levels of 2.8 whole time equivalents has been recommended for triage departments (1). As I have explained above any additional staff needed for the department can be calculated using the PCS which is dependant on triage categorisation. (14)

Documentation

Accurate and concise documentation is vital both for continuity of patient care and legal reasons, i.e. if it's not recorded it wasn't done (7,13). A separate triage form or the A/E chart may be used. (1)

Emergency Nurse Practitioner (ENP)

The ENP has been used to enhance triage by quickly and efficiently treating patients in the non‑urgent categories (7). Thus reducing the waiting time for these patients (3). The role of the ENP and triage nurse may be combined, but during busy periods the ENP/triage nurse has to revert to triaging duties only (8), thus losing the beneficial effects of the ENP.

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