Question
Asked 23rd Oct, 2013

Instead of the traditional nurse led triage unit, what is your opinion of a team triage unit within the emergency department?

I am a student completing a thesis on the improvement of a specific emergency department in Toronto, Canada. I am seeking professional opinions about a team triage unit; 1 physician, 2 nurses, 1 assistant nurse, and 1 registrar.
Do you think that this can increase efficiency within the emergency department? Decrease waiting times by immediately discharging non-emergency cases? Decrease the amount of patients who leave without being seen? Your thoughts and opinions on this subject would be greatly appreciated.

Most recent answer

2nd Oct, 2020
Azharuddin kappil Kappil
Hamad Medical Corporation
I believe it is better to keep a clinical nurse specialist who is well trained in triage. He can be triaged and put needed orders for the patients with out waiting for a physician to assess and put the orders.

Popular answers (1)

13th Nov, 2013
Rosalinda S Hulse
University of Massachusetts Boston
A bigger team as you suggested is not cost effective and may delay rather expedite being seen and discharged. Remember, this is triage. A quick assessment and disposition is what should happen. Assign patients where they need to go in the quickest way possible.
8 Recommendations

All Answers (54)

24th Oct, 2013
Steve Glow
Montana State University
This is obviously only applicable to a large facility with a volume that would justify this staffing level. In the US if this level of staffing was affordable, a more common model would be to have the nurse and registrar in triage. The non-emergency cases are then seen in a "fast track" or "urgent care" setting staffed by the MD and additional nurses. By diverting the cases than can be evaluated, treated and discharged rapidly, the main ED can focus on more complex (and time consuming) cases. Overall, the result is that the non-emergency cases (and perhaps the others as well) have a shorter length of stay, overall ED throughput is increased, and there will be a reduction in LWBS cases. Reimbursement issues that influence this model may not be present in your system. Here is a reference from Canada: J Emerg Med. 1997 May-Jun;15(3):397-9.
Does reduced length of stay decrease the number of emergency department patients who leave without seeing a physician?
Fernandes CM, Price A, Christenson JM.
1 Recommendation
24th Oct, 2013
Paul Traicus
Universidade NOVA de Lisboa
Prof. Glow, thank you kindly for your response.
I would like to add a little bit of information in order for you to get a better understanding of the current situation which I am facing. Hopefully you will have time to respond once again.
The hospital where I am thinking of suggesting this implementation is one that sees an inflow of roughly 60 000 patients per year. At the moment there are three experienced nurses who operate this triage system. One severe weakness to this emergency room is that it is extremely small for number of patients it receives and is lacking resources (front line professionals as well as physical space). During moments where there is a high influx of patients, which happens often, the emergency room resembles a war zone. Patients sitting/laying on the floor, on chairs, standing, etc. Having an 'official fast track unit' is physically and financially not feasible.
For 8 hours in a day, each and every day, there are 2 emergency room physicians working. At peak moments, there would be no more than 13 nurses.
Now my thought behind the team triage unit would be as follows:
- Team triage operates only during peak hours
- These peak hours would be when there are two physician on
- One physician would be re-allocated to the team triage unit
- Substitute a registrar and a nurse assistant for one registered nurse
- Therefore, refrain from additional expenses, and operate with the same level of staff
This setup can then allow for:
- The majority of the patients (33%) who are considered non-emergency (who come in for a sore throat, stitches, sprained ankle, etc.) cases, can be rapidly treated by team triage and discharged immediately
- Allow for the physician to administer and begin treatment immediately upon triage assessment
- Ensure all necessary test are ordered and available upon reassessment
- Patients can immediately be re-allocated to consultation services if necessary (e.g. urology, cardiology, etc.)
Due to previous literature, which was created based on the implementation of a team triage unit, I believe this could possibly;
- Decrease the overcrowding issue
- Increase the patient access to physician
- Decrease overall waiting times
- Decrease patients who leave without being seen
- Decrease prolonged patient suffering
- Increase patient satisfaction
I apologize for the lack of the quantitative 'picture' and I am not saying that these would be dramatic increases/decrease but I am proposing that it would be a benefit to each of these point. I am also not saying that this is a 'solution' would solve all problems that this hospital faces. This project is on what can be done on a organizational level and not on the many things that need to be done on a national level and/or provincial level in order to improve our health system.
Attached is the current 'patients flow' at the hospital and the 'proposed patient flow' at the hospital. All based off of lean management principles; decrease waste, increase efficiency, and promote flow through the system
Now Prof. Glow, and anyone else who would care to have there input, do you, based on your professional opinion, and on the information (I do understand it's quite limited) that I just presented to you, believe that this type of setup is feasible? Do you think is would be 'decreasing waste', 'increasing efficiency' and 'promoting flow through the system'?
Thank you kindly and I look forward to your responses.
24th Oct, 2013
Paul Traicus
Universidade NOVA de Lisboa
Current Patient Flow Chart
24th Oct, 2013
Steve Glow
Montana State University
It sounds like your space limitations may be more of a factor than staffing. I would suggest combining your flow sheets in a way that shows both space and providers. Have you considered a less expensive nurse practitioner or physician's assistant rather than a MD as the addition to the triage team? If your peak staffing is 2 MDs for a unit that sees 60K patients, I do not see pulling one of them to the triage team as a viable option. You will probably decrease the LWBS, and shorten the time for the non-emergency patients without decreasing your total time in department for all patients. The reason is it would increase the time in department for the emergency patients. I caution against any plan that decreases the number of providers and increases time to care for those who need care the most.
28th Oct, 2013
Mark Hauswald
University of New Mexico
Physician triage may shorten LOS for "sick" patients if the physicians can combine their work ups. The usual triage system is redundant and everything done in triage is repeated later. Having tests done in triage can work but if done by (nursing) protocol often leads to over testing. SG points out correctly that if a physician in triage serves only to dispo minor problems the situation is the same as having a fast track or urgent care and will have little impact on critical patients. You might check my Academic EM manuscript on the topic
1 Recommendation
29th Oct, 2013
Heather M Mcclelland
Independent Researcher
A number of early intervention, both nurse- and doctor-led systems, have been tested and implemented widely in the UK. This is based primarily on the re-organisation of emergency care because of the 4 hour standard (95% patients admitted or discharged within 4 hours). There is a range of evidence published about 'rapid assessment teams', 'interventional assessment' 'consultant-led assessment etc. which identify better journey times through the ED, improved time to decision, shorter intervention times and good patient experience. The re-organisation has prompted a real shift in workflow throughout emergency care, including separation of the minor injury stream (often including minor illness), so that the bulk of minors going through triage are removed or seen separately. This streaming process can successfully be achieved at the point of registration. That leaves the major, or more complex patients who need further investigation, and greater capacity (and often space). Some areas have delivered rapid assessment in a specific number of cubicles (for 60,000 patients, 2-4 should be ample), with nursing and healthcare assistant staff doing an assessment and initiation of investigations/treatments. Someone senior in nursing is vital for this process, with advanced assessment skills so we get the right decisions at the right time. Other areas have added a consultant for a specific number of hours (availability/numbers) who bring the expertise to the decision-making, and will discharge patients where possible at this point. Obviously, in all cases there are patients who clearly need admission where a bed can be requested at assessment, others who can be discharged, freeing up some space, and those who need further assessment by ED. Of course, much of the capacity issue will not be addressed by this alone, and you need to ensure you have some out-flow to in-patient areas (still our biggest challenge). By measuring your time to decision, rather than total journey time, you will be able to isolate where the problem lies. You want to make sure you are measuring the things you can have an impact on within the ED, not those that are affected by other systems.
You have clearly thought this through thoroughly but the success for implementation will come from the data you retrieve from testing your options (use QI methods) and proving that it is better for the patient (decision-making, experience and efficiency), better for cost (investigation efficiency, reduction in admission from senior decision-making), and better for staff (over-crowding, violence rates).
Hope that's vaguely useful.
2 Recommendations
29th Oct, 2013
Geraldine A Lee
King's College London
I agree with all the above comments and what you are considering is streaming. The use of a physician and an advanced ED nurse at triage is definitely advantageous but can only work if there are no further delays within the department (e.g. waiting for radiology, hospital beds etc). If you become too efficient at treating in ED, you may become the victim of your own success and all those treated will return routinely for treatment (seen with good NPs in ED where patients just automatically go to them instead of primary care).
Good luck
1 Recommendation
29th Oct, 2013
Hadi Morshedi
Qazvin University of Medical Sciences
The use of a physician and an advanced ED nurse at triage is definitely advantageous. I agree with comments Dr Mark Hauswald. The use of a physician and an advanced ED nurse at triage is definitely advantageous but can only work if there are no further delays within the department.
The usual triage system is redundant and everything done in triage is repeated later
1 Recommendation
30th Oct, 2013
Elsabeth Jensen
York University
The mix of skills is key for meeting the needs of patients. An assistant nurse is unlikely to have the skills to assess people who are coming in off the street. This is not the point where one should even consider deskilling services, even if on paper it appears to cost less. In the long run deskilling is very expensive and does harm. You do need both Registered Nurse and Physician expertise to assess properly which is essential for effective triage.
From your comments the problems are larger than can be addressed by the makeup of the team. It may be useful to take a step back to analyze the volume and flow issues as there are solutions to those that will also solve your problems. Developing a nearby urgent care and or primary care clinic can take a lot of pressure off an emergency room.
1 Recommendation
30th Oct, 2013
Mathias Wargon
Hospital Saint-Camille
I agree with all the previous comments. I think a triage team unit is expensive and it's difficult for a physician not to examine and prescribe durong the triage making it much longer and redundant. A good combination for me is a triage nurse and a fast track physician advising the triage nurse when needed. The difficulties with advising physician, flow managers etc.. ; they are giving advises not consultations.
2 Recommendations
1st Nov, 2013
Rolf Egberink
Hogeschool Zuyd
I also agree with all the above comments. What you are planning to do seems to me like a second treatment area at the front of your ED. In my opinion treatment should not be mixed with the actual triage process. Next to the risk of having no ED nurse or physician available for the next incoming patient, especially at peak moments, you could also experience a longer LOS in the ED for those who need major care. Possibly your ED could benefit from a re-organisation that includes proper and swift triage directly after registration, separating the minor from the major care patients to dedicated staff (NP/PA for minors?). Good luck and keep us posted!
1 Recommendation
1st Nov, 2013
Mark Hauswald
University of New Mexico
Triage is only needed when there is a delay to definitive care due to lack of treatment space. If you have an open bed the incoming patient can go there and "triaging" them simply wastes resources - why get the initial history and vitals twice? This is even true if the institution has separated low and high acuity treatment areas provided that they are not too far apart - it is much better to have an acute MI seen immediately in the"wrong" place than seen later in the "right" place. If you never have an open bed you do need to triage all the time - but this means that some patients will never be seen (if you doubt this you need to take a course in cueing maths). By open we mean one that can be used now and doesn't need to be reserved but we routinely see minor patients in our critical care unit - if we need it for a high acuity patient they can walk out and sit in a chair. Putting a definitive provider in the triage area is actually not triage at all, it is providing definitive care in the triage space. Depending on your situation this may make sense or it may not.
2 Recommendations
1st Nov, 2013
Jef Adriaenssens
Leiden University Medical Centre
Several triage systems are available to improve the througput (speed of passage) in emergency room. In Europe, the Manchester Triage System (or a variant) is used very often. Although several studies show that a triage nurse is very effective and efficient in grouping and guiding victims and patients, a triage team might me more appropriate. One of the main advantages is the skill and competence mix. Every team member has his own specific view on the urgency of the medical complaints. A physician will focus more on the medical context, while a nurse might have a broader holistic view (e.g. a stressed mother visiting the emergency care with a crying child wiith a possible arm fracture).
However, there are also some practical issues: (1) a triage team of 4 persons is only available in big emergency units. For example, I'm working in an ER-unit with a througput of 22.000 patients a year and we have only 4 nurses + 2 physicians in the morning shift, the same in the everning shift and during the night 3 nurses and 1 physician. This team has to manage triage, emergency care, ambulance care and the rapid response team. A triage team is not possible for our service... We have only one triage nurse per shift and although work pace is very high, this approach is rather effective. (2) is such a big team cost effective for the hospital? and (3) the speed of treatment not only depends of triage but is also influenced by delays in radiology, laboratory, ... (bottle neck) or the delay in transport towards the ward. The work flow of the complete system might be more important than the triage system.
You might also consider the introduction of a fast track/slow track system in the hospital. A lot of people who attend the emergency care in Belgium do not need a real 'emergency approach' but should be guided to their house MD or to a house MD service (slow track) as part of the ER-department. And such an approach might be very effective to speed up the care for 'real' emergency patients.
1 Recommendation
5th Nov, 2013
Nathan Allen Stokes
Medical Center of Central Georgia
I agree. A brief encounter with a provider can initiate a diagnostic and therapeutic plan more efficiently and accurately than a triage nurse or advanced nurse. I think the key in time management and ED flow is managing the opportunity for the definitive provider who is actively caring for the higher acuity patients. So, like what you're saying, would a dedicated provider in triage help? I'd say yes. Would it be financially advantageous? I'm not sure. It depends on how much you'd save by avoiding the current level of unnecessary tests in your department.
1 Recommendation
6th Nov, 2013
Susan O'Hara
The Ohio State University
All of these suggestions for operational reorganization are both excellent and plausible. The optimal way to test the theories would be through computer simulation modeling. Many papers and conferences are devoted to this very topic. If you can simulate the existing conditions and then test the savings of time in system for the patient by applying staffing scenarios, decrreaed travel time, change in capacity at triage, main ED and waiting room you would have an ideal scenario to simulate.
I am currently working on a new project and would actually like to test the ideas in this conversation string. How exciting - but do any of you have statistics on these improvements? have they worked?
1 Recommendation
11th Nov, 2013
Gustav Fischmeister
St Anna's Kinderspital
i´m impressed by the responses. We live the team triage since 2010, the triage nurse (MTS) is assisted by the leading physician in charge. As soon as the physician orders medication, examinations or short treatments he is responsible for the patient, meaning he has to be experienced, and he sometimes checks the patient in a "fast track" Depending on vital signs or obvious detoriation he can decide for a bed search on the wards and start treatment or organizes a transport to another hospital.
By deciding wich examinations should be performed these can be done during the waiting time, and the physician can finish the treatment instead of ordering the examinations. This improves the efficiency and redeuces the waiting time, in my opinion it´s a logical organisational improvement and needs not to be studied. I our hospital this system is performed during the day time. During the night duty depending on the degree of comunication skills and experience sometimes the old time consuming system is used. I wish you luck, it´s a good idea, inform me if I can help, regards.
1 Recommendation
13th Nov, 2013
Rosalinda S Hulse
University of Massachusetts Boston
This practice has already been adopted in one of the community hospitals here in Massachusetts and has definitely cut down on wait times and use of resources. A nurse and an NP is assigned to triage. Cases that would normally go to the Fast Track or Walk-In side are treated by the NP, simple cases like a question of UTI.
2 Recommendations
13th Nov, 2013
Rosalinda S Hulse
University of Massachusetts Boston
A bigger team as you suggested is not cost effective and may delay rather expedite being seen and discharged. Remember, this is triage. A quick assessment and disposition is what should happen. Assign patients where they need to go in the quickest way possible.
8 Recommendations
15th Nov, 2013
Biswadev Mitra
Alfred Hospital
I think what you are referring to is an extension of triage. As Mark pointed out, in current civilian emergency care, we have to ask the question of do we really need triage? In out tertiary referral centre receiving about 60,000 patients per year, we have replaced triage with streaming. A nurse streams patients to resus, fast-track, or the RITZ (Rapid intervention & treatment zone). At the RITZ, patients are received by a team of nurses and doctor, with the medical care overseen by an emergency physician who decides on the disposition of the patient- to home, ward, or remain in the ED for further assessment & management.
1 Recommendation
17th Nov, 2013
Elsabeth Jensen
York University
When a nurse 'streams' patients according to the results of her assessment, that is called triage. I think we need to be cautious about jargonism. It has become popular to use a variety of words to describe a thing that is unchanged, to create the illusion of change. As Shakespeare told us "A rose by any other name would smell the same."
If we spend less time in committees dreaming up new words, we would have more time to get the work done.
1 Recommendation
19th Nov, 2013
Nicole Sandoval
Providence Health and Services
I think the pitfall for most systems is not remembering that triage is and should be as fluid as possible. When beds are open in the back then care and triage should be initiated in the back. When there are no beds then initiating surge plans become key. Often surge plans include pushing admitted and discharged patients out of the ED but also important is the ability to initiate care on the front end. This can be accomplished but MD approved order sets based on complaint but if you have the ability to have an NP or MD to quickly see patients and order things not commonly found in nurse initiated orders how wonderfully time saving this measure can be. By the time the patient makes it back to a room labs have resulted as well as any radiology exams. The key here is having the resources where you need them when you need them. MDs in triage can speed up throughput and help ease the bottlenecks which frequently occur on the front end of the department.
1 Recommendation
19th Nov, 2013
Giuseppe Gullace
IRCCS Multimedica
My experience is at present in Cardiology out of the Hospital. Cardiology one-stop-service to manage patients with risk factors close the clinical pathway in same session (when it is possible), involving other competencies available in the center, or address (checking in) the patient to hospital cardovascular department for high level diagnosis or admission; re take the patient at the end with closed clinical pathway and manage him in follow up with a post dimission program. Obviuosly we operate in team (cardiologist, nurses, administrative, other specialists). This increased appropriateness of interventions and the rate of hospitalization and rehospitalization. The management is also applied in emergency situations.
1 Recommendation
21st Nov, 2013
Robert S. Green
Dalhousie University
We have a mixed model: patients who self present are triage by a paramedic. Patients who present via EHS are triaged by a dedicated nurse and our charge nurse.
RG
1 Recommendation
22nd Nov, 2013
Thomas Dreher-Hummel
Universitätsspital Basel
At the moment we are starting with Rapid Team Evaluation. Our ED has an avarege of 45000 Patients a year and till now we have had a nurse led triage system. We think that the Team Evaluation is primarly a benefit for Patients with minor injuries. You can immediately order x-rays, give pain killers and treat him in a fast track. After 30 - 60 minutes the patient can leave the hospital. For patients are more complex and ill, there will be not this benefit in saving time, we think. You can inform the patient about all is coming next, how long it will take and the patient can bring his own wishes in the treatment plan, i think this is an important benefit of team triage .
2 Recommendations
22nd Nov, 2013
Malik Abdur-Razzaq
A.T. Still University of Health Sciences
Absolutely! With respect to triage and screening of mental disorders, I would strongly encourage this approach. Please reference my dissertation: "Psychiatric triage and screening: Trends, parameters, and limitations when evaluating patients in an emergency room..." found at dissertation.com
1 Recommendation
26th Nov, 2013
Joerg Krey
Asklepios Gemeinsam für Gesundheit
Your question is very interesting and important as it shows the common problem in discussions about triage: separate process steps are mixed together in the (most understandable) wish to fasten the through-put of our ED’s. You have to review your processes step by step and solve them in the same way – else your ideas would give you a temporarily relief but no longstanding assistance!
First of all: each ED needs triage, even the smallest one’s, as we are facing in all environments the problem that demand exceeds offer. This differs by time/date and extent, but all ED’s are facing this problem.
Scope of this triage should be the urgency and endangering of (the individual situation of) this patient – not less and not more. Else we will be running at the risk of prolonging waiting times for triage (as we integrate more additional tasks in our triage process). This triage should not take more than 1-2 minutes and should cover all tiers of urgency (not only the both most urgent as ESI does). If we follow the assessment of Prof. Kevin Mackway-Jones the only chance to keep in this short time frame would be a decision based on presentation and symptoms of the patient – as any reliable (exclusion of) diagnosis will possibly take up to several hours.
Several German hospitals i know integrate standard operating procedures (written down by the medical heads of the specialties of this hospitals) at the end of the triage process (e.g. defined labs to be ordered for a patient with specific symptoms). This procedure will fasten the follow ups (and shorten waiting times) but has nothing to do with triage itself.
If your ED is a large one with hugh numbers of patients (more than app. 45000) you might define streaming processes… in which fast track (or an out-of-hour GP service) describes your idea of a triage team best. Always keep in mind: this is already treatment and no longer triage! Once again: triage should help us to minimize risks fro our patients – not less and not more!
We are facing more additional problems (which can’t be solved at triage): blocked rooms, occupied stretchers in the halls of our ED, blocked beds at the wards (and therefore waiting times for admittance). Unnecessary tests (often ordered by less experienced nurses and physicians), long waiting times for results (often even due to lack of experience…). All of these lead to overcrowding and increase in length of stay. If we want to reduce unnecessary need of recourses (and come to a more responsible handling) we have to address the problems. But this should (and could) not be done by inflating triage but by structuring the follow up’s:
1. Define standards (SOP’s) for labs, pain, x-ray (if legals allow the order by nurses), treatment, …
2. Implement streaming, this could be fast-track, out-of-hour-services,… to stream patients „away“ to a more appropriate structure
3. Implement bed management (most interesting: world wide a common problem in all ED’S!) and possibly case management
4. Define/agree response times for the specialists with their head of department/specialty
Let me conclude by quoting an article by our very esteemed British colleagues Jill Windle and Kevin Mackway-Jones: "Do not throw triage out with the bathwater" which has been published ten years ago (http://emj.bmj.com/content/20/2/119.full).
2 Recommendations
26th Nov, 2013
Steve Glow
Montana State University
Does "Triage" mean something different in each country? My concept of triage is a rapid sorting into categories (I like the concept of streams described by others). I agree that getting things like labs, x-rays, and pain management started at this stage can decrease time in department and increase customer satisfaction. This could be done be a nurse, advanced practice nurse or physician, depends on knowledge, experience and scope of practice.
1 Recommendation
28th Nov, 2013
Obinna Eleweanya
The University of Edinburgh
In our setting in Cayman Islands, their is rapid streaming into either 'urgent care' or emergency room. This is done by an experienced Emergency Nurse.
The urgent care concept was introduced to relieve the 'true' emergencies.
The true emergencies are then triaged as per international standard codes, however the triage nurse in consultation with the charge ER physician can initiate either treatment (analgesics, antihistamins etc) and investigative tests like Imaging and basic tests like bHCG, urinalysis, RBG etc
Overall there is a fairly smooth flow with occasional bottlenecks that are caused by known factors like bed back ups, seasonal 'surge' and delayed labs and admissions
The team concept may be necesary in very large settings but the efficiency may be compromised by the dictum of ' 3 is a crowd'
1 Recommendation
3rd Jan, 2014
Fiona Mcdaid
Naas General Hospital
Hi
In Ireland we refer to this type of team as a Rapid Assessment Team (RAT) more information is available in the Report of the National Emergency Medicine Programme (June 2012) available through the HSE website (www.hse.ie).
where resources allow the introduction of a RAT has been successful, other site have implemented Rapid Assessment Nurses (RAN) who commence investigations according to protocolshowever thay cannot discharge patients.
1 Recommendation
6th Jan, 2014
Enrico Giustiniano
Humanitas Research Hospital, IRCCS
It is a long time I think it may be correct. I consider that only who manages emergency can do triage correctly. Just like the emengency phone number is unique (911 in US, 118 in Italy, etc), also whithin a hospital a single number must be available and the physician the only one to manage this number, as comunicating is a worldwide issue
1 Recommendation
9th Jan, 2014
Elio Carchietti
Regional Health Service
Paul indicates three major objectives for an emergency department:
1. increase efficiency within the emergency department;
2. decrease waiting times by immediately discharging non-emergency cases;
3. decrease the amount of patients who leave without being seen.
I think that all three objectives require an appropriate organization of staff , resources and services but , even more, the planning of job.
I think it is important to discern two different forms of triage:
1. a " triage of access" based on apparent clinical signs and symptoms;
2. a medical triage.
The "triage of access" must be performed by an experienced nurses that gives to each patients a color code and coordinates the accesss of patients to physicians evaluation.
Nurses who make "the triage access" should have a protocol for the identification of non-emergency cases and, for any doubt, must be able to rely on the advice of the doctor.
The patient information on waiting times must be given at "triage access" so that he can immediately tell whether it will wait or whether it will turn to other medical structure .
1 Recommendation
10th Jan, 2014
Zandro C. Tejada,MPH,CCRN
University of Queensland Medical School
Please PM me.
1 Recommendation
12th Jan, 2014
Muhammad Faisal Khilji
University Hospitals Of Morecambe Bay NHS Foundation Trust
We are doing team triage for the last three years. It is very helpful for us in reducing the number of patients and keeping flow of patients under control. It also reduced waiting time in our department, reduced no patients left without seen, reduced number of complaints. In our team one doctor two nurses do triage. This setup is sort of triage plus fast track combination where doctor at triage resolves minor issues immediately. Our hospital (SULTAN QABOOS UNIVERSITY HOSPITAL) is a tertiary care university hospital in Muscat. We cater more than 60,000 patients per year in Emergency department.
2 Recommendations
14th Jan, 2014
Dorothy Chinwendu Chanda
University of Zambia
Firstly, there is a hierarchy of health personnel in this Emergency Unit starting with the Assistant nurse who sorts out the clients and sends them to the appropriate health personnel to see. she also carries out the non-nursing duties
S/he also does the observations before sending the patient to one of the nurses.
The nurses are second in the hierarchy. The nurses will then do the health assessment using the nursing process, They will come up with a nursing diagnosis and then refer the patient to either the physician or the Registrar.
These two doctors form the third in the hierarchy.
Therefore, following the roles in this triage, efficiency will be increased, the waiting time will decrease and the number of patients leaving without being seen out of frustration due to long waiting hours will obviously diminish. Conclusively, the team triage unit within the Emergency Unit should be encouraged.
2 Recommendations
15th Jan, 2014
Joshy Abraham
Christ University, Bangalore
If there is a team of people in triage, then we cannot call them any more a triage, because they are a medical team who can provide effective treatment.
2 Recommendations
28th Jan, 2014
Sandra (Alexandra) Catherine Buttigieg
University of Malta
Paul, this is a very important question and is often hotly debatable amongst Doctors-nurses working in Accident and Emergency Department. In Malta, we have nurse triage but with close consultation with A&E consultants, indeed potentially at times loosing precious time. Interestingly, I came across the following study based in Sweden comparing three models of triage. The results were "Physician-led team triage seemed advantageous, both expressed as efficiency and quality indicators,
compared with the two other models (nurse first/emergency physician
second, and nurse first/junior physician second)"
Burström et al.: Physician-led team triage based on lean
principles may be superior for efficiency and quality? A comparison of three
emergency departments with different triage models. Scandinavian Journal of
Trauma, Resuscitation and Emergency Medicine 2012 20:57.
2 Recommendations
31st Jan, 2014
Anna Ehrenberg
Dalarna University
I have been involved in a systematic review, including team triage as an intervention in the ED to improve care processes. The findings showed that team triage, with a physician in the team, will probably result in shorter waiting time and shorter length of stay and most likely in fewer patients leaving without being
seen. See: Oredsson S, Johnsson H, Rognes J, Lind L, Göransson KE, Ehrenberg A, Asplund K, Castreen M, Farokkhnia N. (2011). A systematic review of triage-related interventions to improve patient flow in emergency departments. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 19:43. Best wishes, Anna
7 Recommendations
31st Jan, 2014
Sandra (Alexandra) Catherine Buttigieg
University of Malta
Thank you Anna...very interesting paper. I am interested in POCT at A&E, and indeed posted a question on it. Do you have any research in the area.
19th Feb, 2014
Hoo Cheung
Baker College, USA
Hoo Joon Cheung
I agree with Rosalinda Hulse . There are several types of nurses I trust to triage the patients-the ED nurses with long experience and the ICU nurses that had worked in the ED previously and the nurses that have rotated through the departments...etc. A quick assessment is all that should be justified.
19th Feb, 2014
Hoo Cheung
Baker College, USA
Hoo Joon Cheung: MD. FACM FAAPM, , FABGP; Board certified by ABEM, and three other specialties. I also agree with Joshy Abraham in her comments
26th Feb, 2014
Godofredo Jr MUNAR Manzano
Lorma Medical Center
Patients are assessed in the Emergency Department by a triage nurse and given a priority rating which will determine the urgency with which they will be seen and manage first. Assessment is very much important once a patient arrives in the ED. Additional members to do the triage will just delay the necessary management for patients who need immediate attention.
10th Apr, 2014
Andrea Vlasic
I have worked in ED's ranging from large urban teaching facilities to 8 bed rural hospitals and have worked with many sorts of triage systems. Obviously, eliminating delay in patient interventions is a key in emergent disease management, as well as patient satisfaction. I personally feel that a well rounded set of standing orders and 1-2 strong triage nurses can effectively address both of these core principals of emergency care. In my experience, patients that are assessed by multiple medical staff during the initial triage phase can be irritated with having to go through the same questions by additional team members. Some patients feel that they're being bounced from place to place/provider to provider, when all they want to do is to be comfortable. An integral part of emergency nursing & medicine is developing a sense of trust with patients: this can help alleviate anxiety, decrease stress and related physiological symptoms and improve perceived quality of care provided. Providers in triage can cause a "too many cooks in the kitchen" environment within the traditionally nursing lead triage system as well. Don't get me wrong, I love my providers!
But I also feel that moving patients from the lobby where they can receive the privacy and one on one care from emergency providers that they expect is a good thing...
1 Recommendation
13th Apr, 2014
Sara Burns
Chamberlain College of Nursing
That would be an ideal set up if you had the resources. We have paramedics in triage that quick reg and take VS, then they bring the pt straight back to a room (if level 1 or 2) and all level 3-5 go into an intake room, where the RN and MD/DO/PA provider do the assessment and determine testing, then they go to Results Waiting room for DC, or Continuing Care for interventions, then to Results Waiting. The split flow model has decreased LWBS, Door to Provider and LOS. The lower level acuity never go back into the ED.
1 Recommendation
13th Apr, 2014
Muhammad Faisal Khilji
University Hospitals Of Morecambe Bay NHS Foundation Trust
We have started almost similar triage in our Emergency department for the last few weeks. Waiting time is probably same however patients left without being seen is decreased. Remember resources are not issue in our hospital. We need to do proper study on this change.
1 Recommendation
16th Apr, 2014
Kelly Cristina Inoue
Faculdade Ingá
Generally, the triage is performed by nurses in Brazil (but physicians can do it too)... We have had improvements in agility care of critical ill patientes, but non-emergency cases are still overloading the ED because of the failure of integration with other health services. Unfortunately, I have the impression that there is little investment in the qualification of these nurses and the fear of legal and ethical implications limit the achievement of greater efficiency.
1 Recommendation
17th Apr, 2014
Mary Shamblin
Pleasant Valley Hospital, Point Pleasant, WV United States
Hello,
I think if you would want to increase speed of the ED department, you could use the NP as the team leader, have him or her see non-acutes. We have a "Fast Track" team at my facility. 1-NP, 1-RN and the tech assist as needed. Our wait times are less and non-acute emergency visits are less wait, less treatment time. Patient much happier and patients not leaving before being seen by someone. Now, there is always those bad days when the moon is full and business is booming for the ER but for the most part, wait time to discharge time has improved and patient satisfaction has been good. Just food for thought!
1 Recommendation
1 Recommendation
8th Oct, 2014
Tibor Gero
UPMC
It is my observation, that the ED in the US has become more or less an outpatient clinic,  with a significantly larger patient population of "non-urgent", for multifactorial reasons.  Triaging, has also undergone huge changes, as the "goal" is to have everyone brought into the exam room  ASAP for administrative, rather then medical reasons. 
Thus, an overall emphasis should be placed on creating an ideal model of practice, where manpower is shifted to caring for the non-urgent, and actual physician staffing reserved for the truly ill or emergent patient....resulting in reduced waiting times, increased patient satisfaction and importantly, professional satisfaction, for all.
3 Recommendations
9th Oct, 2014
Peter Jones
University of Auckland
Our ED undertook a systematic review of models of care in ED recently. Front loading triage with a team including a physician simply puts more resources towards sorting out the minor patients quicker, so if you see a lot of minor patients and currently they have long waits for treatment then this model may be useful. We have nurse practioners/clinical nurse specialists seeing a most of the minor injury patients 12-16hr per day. These patients aleady have a short wait time and our 'did not wait' percentage runs at <3% (worse overnight when no nurse practitioner on duty). So we felt that introducing a formal front loaded model would not be likely to improve care in our ED. We currently flex resources to demand - if we get a whole bunch or minor pateintsarrive all at once (say 15 an hour for a couple of hours), we will divert a doctor/nurse team to the front door to help decompress the waiting room. When this demand eases that team will go back to usual duties. If you have a big issue with Access Block / ED Crowding due to lack of inpatient beds then diverting resources to the front door won't make any difference at all - a whole hospital solution is needed.
2 Recommendations
12th Oct, 2014
Madelaine Lawrence
RnCeus Interactive
I do not believe there is a one size fits all solutions to triaging ER patients.  I've worked in a larger inner city hospital ER with one true emergency after another entering the door almost 24/7.  A team there would have been great.  Our local ER seems to handle few life and death emergencies with a waiting barely long enough to fill out the paper work.  A nurse practitioner could easily triage the patients. 
Your project could focus on the best triage system based on the volume and type of patients seen in an ER. 
2 Recommendations
2nd Oct, 2020
Azharuddin kappil Kappil
Hamad Medical Corporation
I believe it is better to keep a clinical nurse specialist who is well trained in triage. He can be triaged and put needed orders for the patients with out waiting for a physician to assess and put the orders.

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