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SNOII VIdD~IENOD C1NV 'SIN_qNOdI410O 'SId_.qONOO

I

TRIAGESECTION I "

'I

TRIAGEMD

AMBULANCE ENTRANCE EMERGENCY DEPARTMENT

MEDICAL

ACUTE MINOR ILLNESS CLINIC

OTHER PATIENT CARE AREAS

AMOSIST I I AMOSISTMD

Ob-Gyn Gen. Surgery Pediatrics Urology Dermatology Gastroenterology Podiatry Immunization Physical Exams

I SURGICAL

Refill

Fig. 1. Dispositions possible from the Triage Section. is a 600-bed, g e n e r a l t e a c h i n g hospital, which provides care for the active d u t y m i l i t a r y personnel at F o r t S a m Houston, Texas, as well as for eligible m i l i t a r y d e p e n d e n t s and ret i r e d m i l i t a r y personnel in the San Antonio, Texas, area. The Emergency Services Section, under the D e p a r t m e n t of M e d i c i n e , o p e r a t e s 24 h o u r s a day_ T h e m e d i c a l s t a f f c o n s i s t s of f o u r p e r m a n e n t l y assigned physicians, house staff physic i a n s on a r o t a t i n g b a s i s , a n d 15 physician-extenders. C o n s u l t a t i o n in all medical a n d surgical subspecialties is available. The Triage Section is located n e a r the e n t r a n c e of the E m e r g e n c y Services Section in a large w a i t i n g roomreception a r e a t h a t also contains the outpatient records room and the central reception desk. A n incoming a m b u l a t o r y p a t i e n t receives his outp a t i e n t records at the records room and is directed to t h e Triage S t a t i o n w h e r e he is i n t e r v i e w e d , u s u a l l y w i t h i n 5 to 10 minutes. The T r i a g e Section is staffed by p e r s o n n e l c a l l e d ~screeners_" T h e y are u s u a l l y basic medical corpsmen, t h o u g h this is not a r e q u i r e m e n t for the position. The t r a i n i n g of screene r s c o n s i s t s of a p p r o x i m a t e l y 25

Page 870 Volume 5 Number 11

classroom hours, d u r i n g which t h e y are t a u g h t basic medical v o c a b u l a r y and concepts a n d mechanics of t r i a g e by a l g o r i t h m . T h e r e a f t e r , t h e y rec e i v e a p p r o x i m a t e l y 120 h o u r s of on-the-job t r a i n i n g in the T r i a g e Sect i o n , d u r i n g w h i c h t h e i r w o r k is closely supervised. W h e n a screener is capable of performing t r i a g e efficiently and accurately, he is certified by the senior screener and the chief of t h e E m e r g e n c y S e r v i c e s Section. There is c o n t i n u i n g a u d i t of certified s c r e e n e r s . T h e s e n i o r s c r e e n e r rev i e w s a p p r o x i m a t e l y 10% of completed t r i a g e notes for accuracy_ Errors are recorded a n d personnel are counseled w h e n necessary. Patient Care Areas

On t h e b a s i s of t h e a n s w e r s to questions from t h e t r i a g e algorithms, several dispositions are possible from the Triage Section (Figure 1)_ There are three a r e a s of p a t i e n t care w i t h i n the E m e r g e n c y Services Section: 1) a medical e m e r g e n c y room where pot e n t i a l l y serious medical complaints such as chest p a i n and d y s p n e a are t r e a t e d , 2) a s u r g i c a l e m e r g e n c y room where t r a u m a cases are evalua t e d and t r e a t e d , a n d 3) a n Acute Minor Illness Clinic (AMIC) w h e r e less serious cases, such as upper res-

piratory infections, are evaluated and treated: The AMIC is f u r t h e r divided into the t h r e e areas: 1) v i t a l signs station (AMIC t r e a t m e n t room) where vital signs of i n c o m i n g p a t i e n t s are taken and daily blood p r e s s u r e r e a d i n g s are t a k e n for p a t i e n t s under evaluation for hypertension; 2) an a r e a staffed by p h y s i c i a n - e x t e n d e r s k n o w n as AMOSISTS (Automated Military O u t p a t i e n t S y s t e m Specialists) who also use a l g o r i t h m s in the evaluation of p a t i e n t s a n d have r e a d y access to a c o n s u l t i n g p h y s i c i a n , a n d 3) an a r e a s t a f f e d by. a p h y s i c i a n , the A M O S I S T MD, who t r e a t s patients w i t h more c o m p l i c a t e d i l l n e s s e s or u n u s u a l complaints. C e r t a i n p a t i e n t s m a y be sent by t r i a g e to a r e a s outside the Emergency S e r v i c e s S e c t i o n in accordance with c r i t e r i a m u t u a l l y agreed upon by the E m e r g e n c y Services Section and the a r e a to which the p a t i e n t is sent (Table 1). If the t r i a g e a l g o r i t h m directs imm e d i a t e r e f e r r a l to an a r e a which is closed, the screener "overrules" the a l g o r i t h m logic a n d . r e f e r s t h e pat i e n t to one of the open a r e a s in the E m e r g e n c y Services Section. If a p a t i e n t has confusing or un"

November 1976 ~ P

Table 1 EXAMPLES OF TRIAGE OUTSIDE EMERGENCY SERVICES SECTION Type Referral

Area

Indication

ObstetricsGynecology

1. Obstetric patient with any problem 2. Request for routine pap test 3. Vaginal bleeding a. Heavy, pregnant, or < 10 days b. Post menopausal, none of above

Stat Routine

Dermatology

Warts

Routine

Urology

Hematuria, without trauma, dysuria

Stat

Physical Exam Service

Requests routine physical; no current problem

Routine

Pediatric Emergency Clinic

12 years old or younger, no trauma or acute distress

Stat

Stat Routine

SORE THROAT 2 Associated with headache? 1. Yes 2. N o - - - [

II

Patient can touch chin to chest? 1. Yes 2. No

• AMOSIST

a n d 7:00 am. Screeners work eight h o u r s h i f t s . F r o m one to t h r e e screeners are o r d i n a r i l y assigned to each shift.

Examples of triage algorithms a r e shown (Figures 2 and 3). The answer to e a c h q u e s t i o n l e a d s e i t h e r to a n o t h e r q u e s t i o n , to a n o t h e r algorithm, or to a disposition. Other c o m p l a i n t s t h a t m a y be associated with the chief complaint are listed for the i n f o r m a t i o n of the screener. A second complaint, if n o t listed, is r u n t h r o u g h t h e a l g o r i t h m appropriate for t h a t complaint. Approximately 70 triage algorithms are in use at the present time. The e n t i r e triage encounter will often take only one to two m i n u t e s , and will almost always be less t h a n five minutes. The screener m a y order basic laboratory studies as directed by the algorithm, for example, a u r i n a l y s i s when the chief complaint is dysuria. A copy of the completed triage note ( F i g u r e 4) serves as the p a t i e n t ' s "ticket" to the next phase of his medical encounter_

METHOD OF SURVEY Medical Emergency Room

AMOSIST

Associated Complaints: Sinus problems Allergy/hayfever Runny/stuffy nose Fever Headache Muscle aches VS: T P

Triage dispositions for the calendar y e a r 1975 were s t u d i e d retrospectively. The d a t a was collected from m o n t h l y reports submitted by t h e T r i a g e S e c t i o n , log books i n which patients treated in the Emerg e n c y S e r v i c e s S e c t i o n are registered, a n d 24-hour n u r s i n g reports for the year 1975. Other information was o b t a i n e d by i n t e r v i e w i n g screeners and by a survey of recent triage notes.

D-23 RESULTS Fig. 2. Sore throat algorithm. usual c o m p l a i n t s or circumstances, the screener consults with one of the physicians i n the E m e r g e n c y Services Section who acts as a ~'triage MD" and assigns the p a t i e n t to the a p p r o p r i a t e t r e a t m e n t a r e a . The screener records the r e c o m m e n d e d disposition i n the appropriate space 0a the triage note and refers the patieat to t h a t area. The m e d i c a l a n d s u r g i c a l emergency rooms have a direct a m b u l a n c e access a r e a . N o n - a m b u l a t o r y pa-

~P

November 1976

tients a r r i v i n g by a m b u l a n c e are always e v a l u a t e d i n i t i a l l y in one of these two areas_ Even though they do n o t u n d e r g o a f o r m a l t r i a g e encounter, triage notes are completed on these patients for a d m i n i s t r a t i v e purposes. The triage section has been operational 24 hours a day since A u g u s t 1, 1975. P r i o r to t h a t , it was operational from 7:00 am to 11:00 pm only and there was no formal triage of pat i e n t s a r r i v i n g b e t w e e n 11:00 pm

D u r i n g the year, a total of 84,442 patients presented to the Emergency Services Section (Table 2). Of these, 78,822 were processed by the Triage S e c t i o n . T h e 5,620 p a t i e n t s n o t t r i a g e d a r r i v e d b e t w e e n 11:00 p m and 7:00 am the first seven months of the y e a r before t r i a g e was ext e n d e d to i n c l u d e these h o u r s . A n average of 207 patients per day were triaged the first seven months. With the addition of n i g h t triage in August, the average rose to 228 per day. The average for the day and e v e n i n g shifts r e m a i n e d c o n s t a n t throughout the year, b u t the average n u m b e r of

Volume 5 Number 11 Page 871

patients seen on the n i g h t shift during the five months t h a t triage was in effect was 21, somewhat smaller t h a n the average for the entire year (Table 2). These totals include n o n a m b u l a t o ry p a t i e n t s a r r i v i n g by a m b u l a n c e , who were triaged for a d m i n i s t r a t i v e purposes. The exact n u m b e r of patients in this category could not be d e t e r m i n e d a c c u r a t e l y from available records. However, a m b u l a n c e arrivals represent less t h a n 5c~ of the total patients seen.

Triage Disposition The disposition of patients by the Triage Section was s u m m a r i z e d (Table 3). Using the triage algorithms, a disposition was possible in 96.1~ of cases between the hours of 7:00 am and 11:00 pm, and 97.4~ after 11:00 pm. The r e m a i n i n g patients required consultation with the triage MD before a disposition could be made. This averaged only 8 patients per day for the day and e v e n i n g shifts and less t h a n one p a t i e n t for the n i g h t shift.

ABDOMINAL PAIN Is pain severe (clutching abdomen)? 1. Yes --*-Medical Emergency Room 2. No

Is t h e r e n a u s e a , diarrhea? 1. Yes 2. No

v o m i t i n g or , Nausea/Vomiting/Diarrhea Sequence. Page F-3

Is there: a. Black or bloody stools? b. A b d o m i n a l t r a u m a w i t h i n 48 hours? 1. Yes 2. No

Patient pregnant? 1. Yes 2. No

mOB, T o d a y ( R e c o r d screening note)

By far the most common reason for consultation with the triage MD was t h a t the patient's complaint was not covered by t h e t r i a g e a l g o r i t h m s . Other reasons included peculiarities in the p a t i e n t ' s c i r c u m s t a n c e s t h a t made the algorithm disposition seem i n a p p r o p r i a t e and, : r a r e l y , the screener's strong impression t h a t the p a t i e n t r e q u i r e d more i m m e d i a t e care t h a n directed by the triage algorithm.

Is the pain l o w e r a b d o m i n a l ? (i.e., pelvic) 1. Yes 2.? 3. No

P a t i e n t dispositions by the triage MD are not reflected in the figures for each area (Table 3l. The majority were s e n t to e i t h e r p h y s i c i a n s or p h y s i c i a n - e x t e n d e r s i n the AMIC, with s m a l l e r n u m b e r s going to the m e d i c a l e m e r g e n c y room a n d to areas outside the E m e r g e n c y Services Section.

Associated Complaint: Back Pain

We find t h a t patients going to the surgical e m e r g e n c y room g e n e r a l l y present no triage problem since the n a t u r e of the c o m p l a i n t is u s u a l l y a p p a r e n t d u r i n g the t r i a g e i n t e r view. Therefore, very few p a t i e n t s are referred there via the triage MD. For the 72,599 patients whose disposition was possible without the inv o l v e m e n t of t h e t r i a g e MD, t h e triage d u r i n g the day and e v e n i n g Page 872 Volume 5 Number 11

6

Medical Emergency Room

LMP

on

, Pelvic Pain Sequence, Page F-7 AMOSIST MD

-~

Duration > 2 weeks? 1. Yes 2. No

, AMOSIST MD

1

AMOSIST VS: T BP

F-5

Fig. 3. Abdominal pain algorithm.

Table 2 PATIENT AND TRIAGE TOTALS

Shift

Total

%

Av./Day

Range

Triage Totals

Day

46,625

55.2

128

43-163

46,625

Evening

28,928

34.3

79

36-137

28,928

8,889

10.5

24

84,442

100.0

231

Night

1 0 - 43 " 99-303

3,269 78,822

November 1976 J ~ P i

v

TRIAGE NOTE CHIEF C O M P L A I N T :

50t'~

-~hl,'--oo.e

X ,3 d a L / 5

DURATION:

/ SUBJECTIVE:

F__NT: Sor-c ~_ht--oa~

/. L/e...< / -d (2.5..5oc_/

-bcd /Teodo

eJge

e,4;,,o

e/ ds-d

Vital signs:

~ [~/'~ {2~BP [3~RR Clinic disposition: I~IAMOSISTMD ~"AMOSIST E~Moj medical r-'}Surgery [--]Other: Logic overrule 1 7 p t request ME) r-IMD convenience I~lAdmin [ ] Other.

3ignoture,~7,