print version

ABSTRACT

I researched the availability of triage in the A/E departments of Ireland. I sent a 16 item questionnaire to the sisters‑in charge of the 36 A/E departments in the country. 35 (97.2 % ) replied.

I expected to find that triage is mainly available in the large A/E departments, who also employ consultants in A/E medicine and are mostly situated in Dublin. I also wondered if the availability of triage would be influenced by the department being in a teaching hospital.

Indeed triage is only available in 12 (34.2 %) of A/E departments in Ireland. 11 (91.6 %) of these Accidents and Emergency departments have over 20,000 patients per annum, are situated in a teaching hospital and employ a consultant in A/E medicine. 25 % of the A/E departments in Ireland are situated in Dublin. Yet 66.6 % of A/E consultants and 50 % of triage facilities are in Dublin.

Of the 22 (64.7 %) of A/E departments without triage 2 (9 %) thought it was unnecessary ‑ 1 of these departments had less than 10,000 patients per annum, while the other had between 10,000 ‑ 20,000 patients per annum. The remaining departments gave the following reasons for lack of triage facilities.

_ lack of staff and space 12 (52.1 % )

_ lack of staff only 3 (13.0 % )

_ lack of space only 6 (26.0 % )

I realise that most departments, 15 (65.1 %) would need an increase in staffing levels, but as triage is such an important area with huge benefits for patients and staff, that management should be strongly urging the Department of Health to approve staff for this area.

I find it worrying that only 12 (34.2 %) of A/E departments in Ireland have triage and only 2 (8.6%) of the A/E departments without triage are looking into establishing triage. It is difficult enough to treat patients with the "usual" complaints on an "ordinary" day and not have an ill patient waiting inappropriately in the waiting room, but in the event of a major incident I shudder to imagine the scene in the A/E department without triage. The staff will be forced to triage patients probably for the first time in their careers. To be efficient at triage you need not only knowledge and A/E experience but also prior triage experience. An A/E department during a major incident is not the place to get this experience.

Of the 12 (35.2 %) A/E departments who do provide triage only 5 (41.6 %) departments have 24 hour cover. The evening and night shifts seem to be the areas lacking triage. This is often the busiest time with the least staff, when triage would be of most value.

2 (16.6 %) A/E departments require no prior A/E experience to work in triage. This is extremely serious, as I would consider this a basic requirement. Indeed 2 ‑ 3 years experience has been recommended by a group in the U. K. (1) and 6 months is required by the emergency Nurse Associations in the USA (2). Personally I feel that 2 Years experience is a "must".

Educational requirements varied. Only 2 (16.6 %) departments required an A/E Course, again something I feel is essential. 5 (41.6 %) had informal training for triage. Without the foundation of education how can a triage nurse make an informed decision?

The tests initiated by the triage nurses varied hugely with triage nurses in 2 (16.6 % ) departments unable to initiate any tests. Only in 1 (8.3 %) department could the triage nurse initiate all the tests listed. Except for X ray examinations, these tests were fairly ordinary and I fail to see why they cannot be initiated by experienced triage nurse.

In todays health care environment, where "quality of care" and "quality assurance" are the buzz words, why is triage not a requirement for A/E departments. Triage has been shown to improve the standard of patient care and after all isn't patient care our basic role. (1

INTRODUCTION

Triage is the French word that means to sort. It was first used to categorise patients on the battlefields during World War 1. The purpose then was to treat the "most salvageable" patients and return them to the battlefield. In addition to military situations, it has been used in major incidents and A/E departments. It was first introduced in the USA in the late 1950's or early 1960's (2), in the U.K. (1) and Ireland in the 1980's.

I chose to research triage facilities available in Ireland for a number of reasons. Prior to commencing the A/E Nursing Course in St. James's Hospital I had no experience of formal triage. I wanted to know more about

Most of the above queries I had were answered by the available literature. I was able to get plenty of information on triage in the UK, USA and Australia, but I found no literature referring to triage in Ireland.

All UK A/E departments now operate some form of triage (3) as this is a requirement of the Patients Charter 1992 (4). In the USA some states have passed legislation stating that emergency departments must have triage (5.2). Most Australian A/E departments operate a triage system. The National Triage Scale for Australian Emergency Departments (1993) states that "all patients presenting to an emergency department for assessment and treatment will be assessed to determine the urgency of their clinical condition" . (6)

I contacted An Bord Altranais and the Department of Health neither of which had any. recommendations that triage be provided in A/E Departments. It is not even necessary to have triage in order to provide an A/E Nursing Course.

I also looked at triage with regard to the Major Incident Plan. Each health board area has a major incident plan which is based on the patients being triaged at the scene. I contacted a representative of either the ambulance service or health board in each region and none of the Major Incident Planners have recommended that triage should be available in the A/E departments. A copy of the on‑site triage system is provided for each hospital but it is up to the hospital to draw up its own Major Incident Plan . This plan need not necessarily contain any triage plans but common sense dictates that it would. If triage is included in the plan it may be carried out by either doctors or nurses who are not sufficiently familiar with the system or indeed it may be their first encounter with triage. While written triage protocols are necessary, practice is a huge part of becoming proficient and confident in triaging patients. A major incident is not the time to start learning.

After researching triage I cannot understand why no recommendations have been made to have triage available in all A/E departments. It is not essential to have a fully equipped room, just a semi‑private area to interview patients and record basic observations. A minimum increase on basic staffing levels of 2.8 whole time equivalents has been recommended for triage. I will discuss the benefits of triage at a later point. I think it is only common sense that the benefits far outweigh the costs.

The introduction of the first emergency nurse practitioner (ENP) to Ireland, in 1996, in St. James's Hospital, further enhances the triage system. The ENP examines the patients charts post triage and selects appropriate non‑urgent patients to treat. If the patient is not triaged it is not possible for an ENP to work (7), indeed it has been suggested that the role of ENP and triage nurse maybe combined, but during busy periods the ENP/triage nurse has to revert to triaging duties only (8).

Hypothesis

It is my opinion that triage is sadly lacking in the majority of A/E departments in Ireland. The receptionist is still fulfilling this role. There is therefore a high probability of seriously ill patients, who do not object, receiving delayed treatment which creates unnecessary problems.

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)

(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)

_ 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 greater

Skill 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.

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)

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.

Benefits of Triage

The benefits of triage are widespread and agreed upon in the literature reviewed.

The most important and obvious benefit is the early assessment of the patient thus reducing any harmful delays. (11,10,4).

Used in conjunction with the ENP it reduces waiting times for non‑urgent patients. (3)

Requests may be made for old notes, X rays, results (9,10,11) creating a more efficient service and reducing waiting time as all information is available together. Inappropriate attenders may be redirected, e.g. to GP, chiropodist, thus reducing waiting times for other patients (1).

Early assessment of the patient allows a rapport to be established between the patient and the nurse, reassuring the patient that he will be seen and not feel forgotten (10,9,7).

The triage nurse has the opportunity of seeing the interaction between family and patient. Having already met the family the triage nurse is then in a better position to communicate the patient's condition to them, while they are separated in the A/E department. (7)

Infection control may be initiated at the earliest possible time, thus eliminating the problem of an infectious patient sitting in the waiting room for hours (10,11,4). First aid is given thus making the patient more comfortable (10,9,11,7).

The triage nurse has the opportunity to offer appropriate advice to the patient and to promote and distribute health education literature (1,10, 9,11, 7, 6, 4).

Reassessment of the patients in the waiting room creates a safe environment as a patient's priority needs may change at any time. (10,11,7).

There is improved public relations and increased patient satisfaction as they are assessed and appropriate treatment given soon after arrival. They do not feel forgotten, as they have regular contact with a nurse. (10,9,11,4).

As a result of this there is a reduction in verbal and written complaints. (1,15).

In case triage seems too good to be true the problems encountered are in the next section.

Problems encountered in triage

_ One study (16), which is referred to in a number of articles (12,4), failed to "show

benefits claimed for formal nurse triage" and concluded that "nurse triage may impose additional delay for patient treatment, particularly among patients needing the most urgent attention". These findings were criticised as only one A/E department was used and generalisations were made regarding all A/E departments. The authors replied by saying a more efficient triage system was needed rather than abandoning it.

_ It is an extremely stressful job, with the triage nurse being on the frontline for increased

_ There may be an increase in waiting times for patients with non‑urgent conditions, but

this can be reduced by adhering to the time recommendations for each category where possible. (6,4) The use of an ENP will also tackle this problem. (8)

There is a huge amount of literature available relating to triage. I limited my review to the literature which is summarised on the following pages. I chose to research triage, as I have already stated, because I wanted to know the reasons for introducing triage, its benefits, problems and practical aspects such as written policies, number of categories, physical facilities required, documentation, staffing level required. Information gathered suggests to me that the introduction of triage, with its inherent benefits, is a matter of common sense.

I developed a 16 item questionnaire. Ideas came from a literature search that included the Journal of Emergency Nursing (5) and Professional Nurse (1). Six A/E nurses and a market researcher reviewed the questionnaire and made suggestions. A copy of the questionnaire is included in the appendix.

In December 1996 the questionnaire was sent to 36 A/E departments in Ireland. Included were all A/E departments in general and paediatric hospitals, as listed in "Public Hospitals ‑ a list of public, voluntary, regional, district and psychiatric hospitals in the Republic of Ireland" published by the Department of Health. Completion and return of the questionnaire was voluntary. Questionnaires were returned in preaddressed stamped envelopes. Questionnaires were posted to the sister‑in‑charge of the A/E department, with a return date given of January 1997. I phoned 10 A/E departments to remind them to return the questionnaire and posted second copies of the questionnaire to 5 of these departments.

Problems Encountered

I encountered some problems with the returned questionnaires. Question number 5 presented the first problem. 3 questionnaires were ticked opposite "a visiting A/E consultant", a note had been written after these stating that it was a surgical consultant from the hospital covering the A/E department, I then interpreted these as "no A/E consultant", as these consultants were not specific consultants in A/E medicine.

After Question 5, "Does the A/E department operate a triage system?", I stated "if no, proceed to Question 6 to complete questionnaire" and "if yes, proceed to Question 7 and complete questionnaire to end". Three questionnaires that were ticked no triage, had also been answered for Question 16 ‑ "What skills are performed by the triage nurse?". As these questionnaires had already stated that triage was not available I did not interpret Question 16 in these questionnaires. From experience I realise that nurses in many A/E departments without triage can initiate many of these procedures, but I was researching from the viewpoint of triage availability and skills performed by the triage nurse. Maybe I should have questioned all A/E departments re skills performed regardless of the availability of triage.

In two of the questionnaires that had ticked no triage questions 14 and 15 were also answered. These related to experience required to work in triage. I did not interpret these answers. I can only guess that they thought the question related to experience necessary to work in the A/E department.

If I was repeating this questionnaire I would exclude Question 13. This question did not seem to be easily understood by those completing the questionnaire and therefore difficult to interpret the result. Also it was not essential to the questionnaire.

Only 12 (34.2 % ) of A/E departments in Ireland operate a triage system. No recommendations have been made by An Bord Altranais, the Department of Health or the Major Incident Planners, that triage be introduced into all A/E department. This is in stark contrast to the UK, where the Patient Charter (1992) obliges all A/E departments to operate some form of triage (3,4). In the USA some states have passed legislation requiring A/E departments to have triage 5). In a 1991 survey 95.6 % of emergency departments had triage in operation (5). When all the benefits of triage, both to patients and staff, are considered I believe that it is a basic necessity.

The larger the numbers of patients per annum in the A/E department the more likely it is that the department will have triage. 6 (75 % ) of the departments with over 40,000 patients per annum operate triage, but there still remains the 2 (25 % ) departments with a similar number of patients and no triage. Over 40,000 patients per annum is a huge amount of patients, with figures like that it is very likely that patients are delayed inappropriately. The figures are equally disturbing for departments with 30,000‑40,000 patients per annum, with only 50 % of these departments operating triage.

I noted from my research that A/E consultants work only in A/E departments with more than 20,000 patients per annum. It is surprising that while 2 (28.5 % ) of departments with between 20,000 ‑ 30,000 patients per annum have an A/E consultant, there is still 1 (16.6%) department with 30,000 ‑40,000 patients per annum with no A/E consultant, I believe that an A/E consultant should be appointed urgently to this department.

Triage is provided on a 24 hour basis in only 5 (41.6 % ) of A/E departments that operate this system. To provide a continuously high standard of care for all patients triage should be extended in the other 7 (58.3 % ) of departments.

The number of triage categories used should be standardised nationally to ensure that staff moving from one hospital to another are already familiar with the system and to facilitate comparison of departments to be made easier. In the UK and Australia a 5 category triage scale has been recommended (3,4,6).

6 (54.5 %) A/E departments, with triage have no written triage policy. Written policies should be compiled to standardise and aid with patient sceening (1, 7,11). A survey in the UK in 1991 showed that 60.3% of A/E departments had no written policy on triage. (1)

Only 3 (25 % ) departments have a private area for triage. This should be remedied to enable the triage nurse to fully examine the patient and to discuss any details in confidence with the patient. Our figures of 3 (25 % ) of departments with private triage areas actually compares well with a survey in the USA in 1991 (5), in which 15 % of emergency departments had a private area for triage.

One of the most startling results is that 2 (16.6 % ) departments require no prior A/E experience to work in triage. This is in stark contrast to the recommendations by the American Emergency Nurses Association that 6 months experience and education with a preceptorship is required before working independently in triage (2). It has been recommended by a study in the UK that 2 to 3 years experience is necessary (1). I believe that at least 2 years A/E experience is necessary prior to working as a triage nurse.

I was surprised that only 2 (16. 6 % ) departments required an A/E nursing course to work

in triage. But this compares favourably with a US survey where only 3 % of emergency

departments required that the triage nurse be a certified emergency nurse (5). I would

In 2 (16. 6 % ) departments the triage nurse could not initiate any investigations. In only 1 (8.3 % ) departments could all the listed investigations be initiated by the triage nurse. I was pleased to see that in 3 (25 % ) departments X Rays could be initiated by the triage nurse and this is to increase to 4 (33.3 % ) departments this year. I feel that the lack of a private triage area in 9 (75 % ) departments limited the investigations which could be initiated by the triage nurse, this then deletes some of the possible benefits of triage. I feel the skills of the triage nurse are being under‑utilised.

_ All A/E departments should operate 24 hour triage in a private area.
_

The triage nurse should be a senior experienced A/E nurse.
_ All departments with triage should provide a formal orientation course.
_ The triage nurse should be able to initiate a wider range of investigations.
_ More research needs to be done in Ireland to provide a national triage
scale.

In conclusion I wish to thank all those who helped me during this research project, especially the 35 sisters?in?charge of the A/E departments of Ireland who took the time to complete the questionnaire.

Appendix

A survey of emergency department triage in 185 hospitals: Physical Facilities, fast

track system, patient classification systems, waiting time, and qualifications, training

16. George S., Read S., Westlake L, williams B, Fraser‑Mooche A., Piity P. (1992).

Evaluation of Nurse Triage in a British A/E department BMJ 1992; 304. (876‑878)

Print Version

A survey of triage in Accident and Emergency Departments

in 36 hospitals in Ireland: availability of triage, physical

facilities, qualifications, training and skills of triage personnel.

Author: Eilish Corcoran RGN, TNCC, ACLS, PALS is

a post‑graduate student on an Accident and Emergency

Course in St. James's Hospital.