3
4
5
6
7
8
after mass screening with mammography. Lancet 1985;i: 829-32. Day NE, Walter SD, Collette B. Statistical models of disease natural history: their use in the evaluation of screening programmes. In: Prorok PC, Miller AB, eds. Screening for cancer. I. General principles on evaluation of screening for cancer and screening for lung, bladder and oral cancer. Geneva: International Union Against Cancer, 1984:55-70. (Technical report No 78.) Duffy SW, Tabar L, Fagerberg G, Gad A, Grontoft 0, South MC, et al. Breast screening, prognostic factors and survivalresults from the Swedish two-county study. Br J Cancer 1991 ;64: 1133-8. Andersson I, Aspegren K; Janzon L, Landberg T, Lindholm K, Linell F. Mammographic screening and mortality from breast cancer: the Maldno mammographic screening trial. BMJ 1988;297:943-8. Miller AB, Baines CJ, To T, Wail C. The Canadian national breast screening trial. In: Miller AB, Chamberlain J, Day NE, Hakama M, Prorok PC, eds. Cancer screening. Cambridge: Cambridge-University Press, 1991:45-55. Frisell J, Eklund G, Hellstrom L; Lidbrink E, Rutqvist LE, Somell A. Randomized study of mammography screeningpreliminary report on mortality in the Stockholm trial. Breast Cancer Res Treat 1991; 18:49-56. Tabar L, Fagerberg G, Duffy SW, Day NE, Gad A, Grontoft 0. Update of the Swedish two-county program of mammographic screening for breast cancer. Radiol Clin N Am 1992;30: 187-210.
Nurse triage in accident and emergency departments
1 George S, Read S, Westlake L, Williams B, Fraser-Moodie A, Prithy P. Evaluation of nurse triage in a British accident and emergency department. BMJ 1992;304:876-8. (4 April.) 2 Blythin P. Would you like to wait over there please? Nursing Mirror 1983;157:23, 35-6. and colleagues disparage SIR,-Steve George 3 nurse Derlet RW, Nishio DA. Refusing care to patients who present toin triage because it increases waiting Medicine time an emergency deparnment. Annals of Emergency an 1990;1:262-7. accident and emergency department without, in the-accident and 4 improving Yates DW. Nurse triagesatisfaction.' emergency departpatient Triage, however, ment.intended 1987;4:153-4. JR Soc Health is not solely to decrease waiting time..but 5 Carew-McColl M, Buckles E. A workload shared. Service to Journal the quality improve of.care and rationHealth services.2-5 1990;100 (165182):27. theD,absence 6 In Rock Pledge M.ofPriorities triage how of carecan for the the walking authors wounded. justify Professional 1991;6:463-5. in accident and emergency long waitimgNursetimes
waiting times, particularly in those requiring the most urgent attention," lacks foundation: only 24 of the 70 patients in the triage group who were assigned to priority category 1 (most urgent) had actually been assessed by a triage nurse. Furthermore, the efficacy of both triage and informal assessments inevitably depends on. the skills and experience of the staff concerned. George and colleagues fail to describe the methods oftraining and audit (if any) used in the department they evaluated.. But the nurses who made formal (triage) assessments probably also made informal (no triage) assessments. As the assessments made during these periods are likely to have been similar it is not surprising that the, study failed to identify differences in patients' satisfaction. Several factors may have influenced whether patients in the triage group were actually assessed by a triage nurse. For instance, during periods of undue, workload the triage nurse may have been called to help elsewhere in the department, resulting in a tendency for triage to stop when waiting times were longest. Patients clearly in need of immediate care, such as those requiring resuscitation, may also have missed out on formal assessment. Another source of bias might have resulted from some patients leaving the accident and emergency department after being assessed by a triage nurse (before registration); they would not have'appeared in the sample of patients. The method of assigning'patients to the triage and no triage groups is unlikely to have adequately controlled for variability in workload, staffing levels, and the experience of triage nurses, and therefore a multivariate method of analysis should have been used. At King's College Hospital we are also developing and evaluating our system of triage, including. methods for initial training, regular updating and assessment of the competence of staff, and intervention and retrainingafter poor performance. This should fill an important gap. It will provide a baseline against which to compare and evaluate alternative models, of assessing patients. attending the accident and emergency department.
departments before assessment? In the department studied, triage simply prioriandofcolleagues' SIR,-Steve failure to George tised patients bythe severity injury. Surely prioritiidentify many generally benefits ofin accepted sation is not anofadequate response to an increase in for accident and triage emergency departments demand services. This should include training should be viewed with scepticism.' wasto study Thp nurses in accident and emergency departments based on into and no classifying patients triage or instigate management independently manage triage to patients' time ofinarrival, according and togroups the encourage primary care team dealing but a minority (48%) of the triage group were withonly minor injuries. assessed aenthusiastically a result,in Department of General Practice and Primary Care,JEREMY DALE actually by triage -nurse. Asadopted Triage has been many of the conclusions seem to all be invalid. College School of Medicine and Dentistry, accident andstudy's emergency departments over the King's For example, "triage extended London SE5 9PJ nowconclusion seems to that a duplicated country6 and the provide assessment procedure and possibly, as George and S, Read S, Wesdlake L, Williams B, Fraser-Moodie A, colleagues suggest, an increase in waiting time. If 1 George Pritty P. Evaluation of nurse triage in a British ascident and service providers wish to do more than merely emergency department. BMJ 1992;304:876-8. (4 April.) respond passively to ever increasing demand then consideration will have to be given as to the best management of those who attend accident and emergency departments, and triage could have a SI,- Steve George and colleagues' paper on nurse large role in managing and diverting patients. triage is clearly invalid as -only 48% of patients RONA A CRUICKSHANK presenting during the triage period were actually seen by a triage nurse.' This suggests that triagee Trafford Health Authority, Manchester M31 3FP was abandoned when the department became busy or short of nurses for whatever reason; thus the patients assessed by a triage nurse during this period would be seen less rapidly simply because the department was busy.- It follows that the comparison is wortMess because in effect busy times are being compared with relatively slack times; obviously patients have to wait longer when the department is busy. Furthermore, lack of a triage nurse on six half day shifts within weeks allocated to triage necessitated redesignating these shifts as no triage shifts; and triage was then run instead on the corresponding half day shifts of the following no triage weeks. It is absurd, however, to suggest. that, for example, all Tuesday afternoons are busy: a single seriously ill patient can.change the situation within seconds. I suggest that the arrival of- a patient subsequently classified as being in priority category 1 sometimes led. to a tendency to abandon triage (due to nursing shortages) for an entire shift rather than for just some patients, so that a triage shift was redesignated as a no triage shift. This would explain whiy.a higher proportion of patients allocated to priority category 1 were
1378
seen during no triage shifts (4-3%) than during triage shifts (2 8%). Specifically, a waiting time of either 16 minutes or 26-5 minutes for patients in priority category 1 can hardly be considered to be satisfactory (their table IV). This study clearly fails to compare like with like. JOHN BACHE
Leighton Hospital, Crewe, Cheshire CW1 4QJ 1 George S, Read S, Westlake L, Williams B, Fraser-Moodie A, Pritty P. Evaluation of nurse triage in a British accident and emergency department. BMJ 1992;304:876-8. (4 April.)
SIR,-Steve George and colleagues challenge the value of nurse triage in accident and emergency departments.' Triage is rapidly increasing in importance nationally, and the conclusions of this study, which suggest additional delays, have major implications for the development of accident and emergency care. We believe, however, that clinical aspects of the study flaw the conclusions. Retrospective categorisation of patients by a consultant in accident -and emergency permits subjective error unless triage categories are defined for specific clinical conditions. This, however; defeats one of the prime objects of triage, which is to categorise patients to reflect the workload in the accident and emergency department. -Triage should be' a dynamic process with patients moving between categories depending on their own clinical circumstances and those in the department. Without this information reviews based on casualty records alone will be inaccurate. Blinded retrospective categorisation by other triage nurses may have increased validity. The authors confirm, however, that patients who have early contact' with a nurse, whether through formal triage or informally, obtain the same benefits in terms of satisfaction. The apparent deficiency of triage is increased delay before treatment for those patients in the more urgent clinical categories. If retrospective observer error is discounted the conclusions reflect local implementation of triage policy and represent a valuable audit finding in need of correction. The results cannot be extrapolated nationally. JOHN HEYWORTH M PLEDGE Queen Alexandra Hospital, Cosham, Portsmouth, Hampshire P06 3LY 1 George S, Read S, Westlake L, Williams B, Fraser-Moodie A; Pritty P. Evaluation of nurse triage in a British accident and emergency department. BMJ 1992;304:876-8. (4 April.)
SIR,-The difficulties in attempting to assess objectively the value of a nursing procedure such as triage should not be underestimated. I do not think that Steve George and colleagues have succeeded, and I question the validity of their results.' Triage means "sorting" and in my department is sixnply the assessment of the degree of.urgency of every incoming patient's condition. It should be a dynamic process, altered if the patient's condition changes. In this context the difference between formal triage and informal prioritisation is not clear from the. paper, and in both groups waiting times closely mirrored the prioritisation, suggesting to me. that some degree of triage was in fact being carried out throughout. A valid study would need to compare triage with. no. sorting at all, patients being seen as far as possible in order of ,arrival, as is still the case in a few departments. The two groups are acknowledged to- be different, and in the tri4ge group under half of the patients actually u.nderwent the procedure supposedly iunder study. My department achieves triage for99% of patients: triagecannot be bypassed because it is the receiving nurse's responsibility
BMJ VOLUME 304 4 23 MAY 1992
and as much a part ofthat nurse's initial assessment as deciding what observations to carry out or whether to lay the patient down. I am also concerned about the wide discrepancies between the triage assessment of priority and that of the consultants. Either the consultants benefited from hindsight or there had been depressingly little prior communication in the department. Clear guidelines on assessing urgency were drawn up in my department by consultation between medical and nursing staff. New staff are properly trained in their use, and the accuracy is regularly monitored, consistently reaching over 90%. The use of median waiting times is questionable; centile times convey a clearer picture. A median waiting time of 26 minutes for patients in priority category 1, however, is alarming. We define this group as patients who cannot safely wait more than 15 minutes for medical attention, and 97% of them receive attention within this time. Triage should not be expected to cut waiting times. It does not after all reduce the amount of work to be done, it simply redistributes waiting times away from the more seriously ill towards those who will not suffer unduly from delays. A reduction in waiting times requires some patients to be treated or discharged by the assessing nurse -that is, it requires a nurse practitioner to be introduced. This is an entirely separate concept, and one of the references quoted by George and colleagues refers to a nurse practitioner system and not to triage.2 Prioritisation is clearly vital in the effective running of our seriously overloaded accident and emergency departments, and I am concerned that the often hesitant progress towards improving such prioritisation will be threatened by this well intentioned but, in my view, seriously flawed study. J E PORTER
Southend Hospital, Westcliff on Sea, Essex SSO ORY 1 George S, Read S, Westlake L, Williams B, Fraser-Moodie A, Pritty P. Evaluation of nurse triage in a British accident and emergency department. BMJ 1992;304:876-8. (4 April.) 2 Maller J, Woolwich C. Triage in accident and emergency departments. JAdv Nurs 1990;15:1443-51.
SIR, -Steve George and colleagues have raised several important issues about using triage nurses in accident and emergency departments, particularly the possibility that triage might increase waiting times for all patients.' It is difficult, however, to determine from their paper the precise cause of the additional delays experienced by patients when triage was in use. Only 48% of patients were actually assessed by a triage nurse during the triage periods, yet the median waiting times for all patients in the triage group were longer than those for the patients in the no triage group. Were the delays caused by the time taken for triage itself or by subsequent queuing problems as patients proceeded through the accident and emergency department? Perhaps one way of clarifying this would be to analyse further the extended waiting times during the periods when triage was being done. The waiting times of the 48% who were assessed by a triage nurse could be compared with the waiting times of the 52% of attenders during the same periods who were not. This might indicate whether the triage itself or subsequent queuing caused the delays. - The authors also analysed waiting times according to a retrospective judgment of urgency, made by a consultant in accident and emergency, rather than the prospective assessment of urgency made by the triage nurse. Given that the prospective assessment is intended to be a major determinant of waiting times (indeed, it is the whole purpose of triage), why did the authors not conduct such a prospective analysis? The authors conclude that some torm of priori-
BMJ
VOLUME
304
23 MAy 1992
tisation will benefit patients in most urgent need of care, but they question whether this needs to be formalised and called nurse triage. What system do they therefore recommend? Are they not simply calling for a more efficient form of nurse triage rather than none at all? DAVID ST GEORGE
Royal Free Hospital, London NW3 2QG 1 George S, Read S, Westlake L, Williams B, Fraser-Moodie A, Pritty P. Evaluation of nurse triage in a British accident and emergency department. BMJ 1992;304:876-8. (4 April.)
AUTHORS' REPLY,-Jeremy Dale and John Bache note that only 48% of patients attending during a triage period saw a triage nurse and conclude that outcome measurements for our triage group cannot be used to deduce the effects of triage itself and that our study is invalid. They misunderstand the principle of intention to treat trials. We made the decisions to redesignate shifts at the beginning of each day, not at a moment's notice, and we ensured that triage ran during each session designated. The periods in which nurse triage ran and did not run were entirely comparable and were not dictated by workload. In real life triage nurses may leave their stations to undertake clinical duties elsewhere, but this applied equally to both arms of our study. Ours is a valid study of the effectiveness of nurse triage in real life, whereas Dale and Bache propose a study of the efficacy of nurse triage under ideal circumstances. John Heyworth and M Pledge suggest that urgency should be assessed retrospectively by nurses rather than doctors. This is irrelevant. So long as both groups are judged by the same assessors the assessors may be nurses, doctors, or, indeed, others. All have equal validity. J E Porter questions the nature of the difference between formal triage and informal prioritisation in our study. Formal triage is a documented assessment governed by strict protocols, whereas the informal assessment is undocumented, intuitive, and dynamic and fits well with Porter's description of what happens in her department. Triage ran for five years preceding our study. All triage nurses attend six lectures, are tested on theory, and undertake supervised practice before starting triage. Their collective skills and experience are considerable. Dale and Porter are correct, therefore, when they state that informal assessment was performed by nurses familiar with triage. But the question "Does prioritisation of patients by degree of urgency produce benefits compared with their being seen in strict order of arrival?" is artificial. It is nonsense to suggest that any accident and emergency department in the United Kingdom functions entirely in this fashion. At its simplest level, the urgent attention awarded a patient arriving by emergency ambulance is prioritisation, and the relevant question is "Does formal nurse triage produce benefits when compared with an existing scheme of informal prioritisation?" This was our question. David St George requests an analysis of waiting times by prospective urgency. This would be ethically unacceptable as it would entail every patient being assessed for triage and then the
decision being ignored in half the cases. To answer his question regarding the cause of delays, however, we reanalysed waiting times, deducting the time taken for patients to see the triage nurse before booking in at reception. The results are essentially unchanged, showing that queuing problems after triage cause delays, rather than the triage process itself (table). Our and other studies show that nurses consistendly give patients a higher priority than do clinicians.'5- We must consider whether this benefits patients and, if not, how best it can be modified. Our conclusion is to make triage more efficient rather than abandon it. Prioritisation by degree of urgency obviously benefits patients whose condition is most urgent, and this principle should be instilled in all who work in accident and emergency departments. It is the method by which that prioritisation is to be accomplished that is for debate. STEVE GEORGE SUSAN READ
LINDA WESTLAKE BRIAN WILLIAMS
Medical Care Research Unit, Department of Public Health Medicine, University of Sheffield Medical School, Sheffield S10 2RX ALISTAIR FRASER-MOODIE Derbyshire Royal Infirmary, Derby DEl 2QY
PAUL PRITTY
1 Russo RM, Gururaj VJ, Bunye AS, Kim YH, Ner S. Triage abilities of nurse practitioner vs pediatrician. Am J Dis Child
1975;129:673-5. 2 Zwicke DL, Bobzein WF, Wagner EG. Triage nurse decisions: a prospective study. Journal of Emergency Nursing 1982;8:132-8. 3 Albin S, Wassertheil-Smoller S, Jacobsen S, Bell B. Evaluation of emergency room triage performed by nurses. Am J Public Health 1975;65: 1063-8. 4 Mills J, Webster AL, Wofsy CB, Harding P, D'Acuti D. Effectiveness of nurse triae in ED of an urban county hospital. Journal of the American College of Emergency Physicians
1976;5:877-82. 5 Rivara FP, Wall HP, Worley P, James KD. Pediatric nurse triage; its efficacy, safety and implications for care. Am J Dis Child 1986;140:205-20.
In search of the unknown primary SIR,-Christopher Bradley and Peter Selby succinctly identify the dilemmas that challenge all clinicians who must decide how best to manage patients presenting with metastases from an unknown primary.' An exhaustive search for the primary is clearly clinically unjustifiable once malignancies that can be therapeutically influenced have been excluded. While such possibilities are being investigated, however, the time required for imaging and to obtain specialised histopathological results and measurements of serum markers should not be allowed to delay adequate palliation in symptomatic patients. Many patients labelled as having an unknown primary present with pain from bone metastases. Palliative radiotherapy given in one day or over one week will relieve pain promptly in over 80% of patients without either delaying any essential investigation or compromising the ability to give adequate cytotoxic chemotherapy subsequently. Patients with disseminated malignancy from an unknown primary are stressed by uncertainty
Median waiting time by study group and retrospective priority category. Figures givenfor triage group are exclusive (and inclusive) of time taken to see triage nurse Median waiting time (minutes) Retrospective priority category 1 (Most urgent) 2 3 4 (Least urgent)
Triage group (n=25 15)
No triage group (n=2522)
26 (26-5) 44 (46)
16 37-5 55 62
56(58) 62-5 (66)
95% Confidence interval Difference for difference* (triage minus no triage) 10 65 1 0-5
1-5 to 13 1 to 11 Oto2 -4 to 4
*Calculated using method described by J P Nicholl, meeting of International Society of Clinical Biostatistics, Maastricht, September 1989.
1379
4
5
6
7
8
after mass screening with mammography. Lancet 1985;i: 829-32. Day NE, Walter SD, Collette B. Statistical models of disease natural history: their use in the evaluation of screening programmes. In: Prorok PC, Miller AB, eds. Screening for cancer. I. General principles on evaluation of screening for cancer and screening for lung, bladder and oral cancer. Geneva: International Union Against Cancer, 1984:55-70. (Technical report No 78.) Duffy SW, Tabar L, Fagerberg G, Gad A, Grontoft 0, South MC, et al. Breast screening, prognostic factors and survivalresults from the Swedish two-county study. Br J Cancer 1991 ;64: 1133-8. Andersson I, Aspegren K; Janzon L, Landberg T, Lindholm K, Linell F. Mammographic screening and mortality from breast cancer: the Maldno mammographic screening trial. BMJ 1988;297:943-8. Miller AB, Baines CJ, To T, Wail C. The Canadian national breast screening trial. In: Miller AB, Chamberlain J, Day NE, Hakama M, Prorok PC, eds. Cancer screening. Cambridge: Cambridge-University Press, 1991:45-55. Frisell J, Eklund G, Hellstrom L; Lidbrink E, Rutqvist LE, Somell A. Randomized study of mammography screeningpreliminary report on mortality in the Stockholm trial. Breast Cancer Res Treat 1991; 18:49-56. Tabar L, Fagerberg G, Duffy SW, Day NE, Gad A, Grontoft 0. Update of the Swedish two-county program of mammographic screening for breast cancer. Radiol Clin N Am 1992;30: 187-210.
Nurse triage in accident and emergency departments
1 George S, Read S, Westlake L, Williams B, Fraser-Moodie A, Prithy P. Evaluation of nurse triage in a British accident and emergency department. BMJ 1992;304:876-8. (4 April.) 2 Blythin P. Would you like to wait over there please? Nursing Mirror 1983;157:23, 35-6. and colleagues disparage SIR,-Steve George 3 nurse Derlet RW, Nishio DA. Refusing care to patients who present toin triage because it increases waiting Medicine time an emergency deparnment. Annals of Emergency an 1990;1:262-7. accident and emergency department without, in the-accident and 4 improving Yates DW. Nurse triagesatisfaction.' emergency departpatient Triage, however, ment.intended 1987;4:153-4. JR Soc Health is not solely to decrease waiting time..but 5 Carew-McColl M, Buckles E. A workload shared. Service to Journal the quality improve of.care and rationHealth services.2-5 1990;100 (165182):27. theD,absence 6 In Rock Pledge M.ofPriorities triage how of carecan for the the walking authors wounded. justify Professional 1991;6:463-5. in accident and emergency long waitimgNursetimes
waiting times, particularly in those requiring the most urgent attention," lacks foundation: only 24 of the 70 patients in the triage group who were assigned to priority category 1 (most urgent) had actually been assessed by a triage nurse. Furthermore, the efficacy of both triage and informal assessments inevitably depends on. the skills and experience of the staff concerned. George and colleagues fail to describe the methods oftraining and audit (if any) used in the department they evaluated.. But the nurses who made formal (triage) assessments probably also made informal (no triage) assessments. As the assessments made during these periods are likely to have been similar it is not surprising that the, study failed to identify differences in patients' satisfaction. Several factors may have influenced whether patients in the triage group were actually assessed by a triage nurse. For instance, during periods of undue, workload the triage nurse may have been called to help elsewhere in the department, resulting in a tendency for triage to stop when waiting times were longest. Patients clearly in need of immediate care, such as those requiring resuscitation, may also have missed out on formal assessment. Another source of bias might have resulted from some patients leaving the accident and emergency department after being assessed by a triage nurse (before registration); they would not have'appeared in the sample of patients. The method of assigning'patients to the triage and no triage groups is unlikely to have adequately controlled for variability in workload, staffing levels, and the experience of triage nurses, and therefore a multivariate method of analysis should have been used. At King's College Hospital we are also developing and evaluating our system of triage, including. methods for initial training, regular updating and assessment of the competence of staff, and intervention and retrainingafter poor performance. This should fill an important gap. It will provide a baseline against which to compare and evaluate alternative models, of assessing patients. attending the accident and emergency department.
departments before assessment? In the department studied, triage simply prioriandofcolleagues' SIR,-Steve failure to George tised patients bythe severity injury. Surely prioritiidentify many generally benefits ofin accepted sation is not anofadequate response to an increase in for accident and triage emergency departments demand services. This should include training should be viewed with scepticism.' wasto study Thp nurses in accident and emergency departments based on into and no classifying patients triage or instigate management independently manage triage to patients' time ofinarrival, according and togroups the encourage primary care team dealing but a minority (48%) of the triage group were withonly minor injuries. assessed aenthusiastically a result,in Department of General Practice and Primary Care,JEREMY DALE actually by triage -nurse. Asadopted Triage has been many of the conclusions seem to all be invalid. College School of Medicine and Dentistry, accident andstudy's emergency departments over the King's For example, "triage extended London SE5 9PJ nowconclusion seems to that a duplicated country6 and the provide assessment procedure and possibly, as George and S, Read S, Wesdlake L, Williams B, Fraser-Moodie A, colleagues suggest, an increase in waiting time. If 1 George Pritty P. Evaluation of nurse triage in a British ascident and service providers wish to do more than merely emergency department. BMJ 1992;304:876-8. (4 April.) respond passively to ever increasing demand then consideration will have to be given as to the best management of those who attend accident and emergency departments, and triage could have a SI,- Steve George and colleagues' paper on nurse large role in managing and diverting patients. triage is clearly invalid as -only 48% of patients RONA A CRUICKSHANK presenting during the triage period were actually seen by a triage nurse.' This suggests that triagee Trafford Health Authority, Manchester M31 3FP was abandoned when the department became busy or short of nurses for whatever reason; thus the patients assessed by a triage nurse during this period would be seen less rapidly simply because the department was busy.- It follows that the comparison is wortMess because in effect busy times are being compared with relatively slack times; obviously patients have to wait longer when the department is busy. Furthermore, lack of a triage nurse on six half day shifts within weeks allocated to triage necessitated redesignating these shifts as no triage shifts; and triage was then run instead on the corresponding half day shifts of the following no triage weeks. It is absurd, however, to suggest. that, for example, all Tuesday afternoons are busy: a single seriously ill patient can.change the situation within seconds. I suggest that the arrival of- a patient subsequently classified as being in priority category 1 sometimes led. to a tendency to abandon triage (due to nursing shortages) for an entire shift rather than for just some patients, so that a triage shift was redesignated as a no triage shift. This would explain whiy.a higher proportion of patients allocated to priority category 1 were
1378
seen during no triage shifts (4-3%) than during triage shifts (2 8%). Specifically, a waiting time of either 16 minutes or 26-5 minutes for patients in priority category 1 can hardly be considered to be satisfactory (their table IV). This study clearly fails to compare like with like. JOHN BACHE
Leighton Hospital, Crewe, Cheshire CW1 4QJ 1 George S, Read S, Westlake L, Williams B, Fraser-Moodie A, Pritty P. Evaluation of nurse triage in a British accident and emergency department. BMJ 1992;304:876-8. (4 April.)
SIR,-Steve George and colleagues challenge the value of nurse triage in accident and emergency departments.' Triage is rapidly increasing in importance nationally, and the conclusions of this study, which suggest additional delays, have major implications for the development of accident and emergency care. We believe, however, that clinical aspects of the study flaw the conclusions. Retrospective categorisation of patients by a consultant in accident -and emergency permits subjective error unless triage categories are defined for specific clinical conditions. This, however; defeats one of the prime objects of triage, which is to categorise patients to reflect the workload in the accident and emergency department. -Triage should be' a dynamic process with patients moving between categories depending on their own clinical circumstances and those in the department. Without this information reviews based on casualty records alone will be inaccurate. Blinded retrospective categorisation by other triage nurses may have increased validity. The authors confirm, however, that patients who have early contact' with a nurse, whether through formal triage or informally, obtain the same benefits in terms of satisfaction. The apparent deficiency of triage is increased delay before treatment for those patients in the more urgent clinical categories. If retrospective observer error is discounted the conclusions reflect local implementation of triage policy and represent a valuable audit finding in need of correction. The results cannot be extrapolated nationally. JOHN HEYWORTH M PLEDGE Queen Alexandra Hospital, Cosham, Portsmouth, Hampshire P06 3LY 1 George S, Read S, Westlake L, Williams B, Fraser-Moodie A; Pritty P. Evaluation of nurse triage in a British accident and emergency department. BMJ 1992;304:876-8. (4 April.)
SIR,-The difficulties in attempting to assess objectively the value of a nursing procedure such as triage should not be underestimated. I do not think that Steve George and colleagues have succeeded, and I question the validity of their results.' Triage means "sorting" and in my department is sixnply the assessment of the degree of.urgency of every incoming patient's condition. It should be a dynamic process, altered if the patient's condition changes. In this context the difference between formal triage and informal prioritisation is not clear from the. paper, and in both groups waiting times closely mirrored the prioritisation, suggesting to me. that some degree of triage was in fact being carried out throughout. A valid study would need to compare triage with. no. sorting at all, patients being seen as far as possible in order of ,arrival, as is still the case in a few departments. The two groups are acknowledged to- be different, and in the tri4ge group under half of the patients actually u.nderwent the procedure supposedly iunder study. My department achieves triage for99% of patients: triagecannot be bypassed because it is the receiving nurse's responsibility
BMJ VOLUME 304 4 23 MAY 1992
and as much a part ofthat nurse's initial assessment as deciding what observations to carry out or whether to lay the patient down. I am also concerned about the wide discrepancies between the triage assessment of priority and that of the consultants. Either the consultants benefited from hindsight or there had been depressingly little prior communication in the department. Clear guidelines on assessing urgency were drawn up in my department by consultation between medical and nursing staff. New staff are properly trained in their use, and the accuracy is regularly monitored, consistently reaching over 90%. The use of median waiting times is questionable; centile times convey a clearer picture. A median waiting time of 26 minutes for patients in priority category 1, however, is alarming. We define this group as patients who cannot safely wait more than 15 minutes for medical attention, and 97% of them receive attention within this time. Triage should not be expected to cut waiting times. It does not after all reduce the amount of work to be done, it simply redistributes waiting times away from the more seriously ill towards those who will not suffer unduly from delays. A reduction in waiting times requires some patients to be treated or discharged by the assessing nurse -that is, it requires a nurse practitioner to be introduced. This is an entirely separate concept, and one of the references quoted by George and colleagues refers to a nurse practitioner system and not to triage.2 Prioritisation is clearly vital in the effective running of our seriously overloaded accident and emergency departments, and I am concerned that the often hesitant progress towards improving such prioritisation will be threatened by this well intentioned but, in my view, seriously flawed study. J E PORTER
Southend Hospital, Westcliff on Sea, Essex SSO ORY 1 George S, Read S, Westlake L, Williams B, Fraser-Moodie A, Pritty P. Evaluation of nurse triage in a British accident and emergency department. BMJ 1992;304:876-8. (4 April.) 2 Maller J, Woolwich C. Triage in accident and emergency departments. JAdv Nurs 1990;15:1443-51.
SIR, -Steve George and colleagues have raised several important issues about using triage nurses in accident and emergency departments, particularly the possibility that triage might increase waiting times for all patients.' It is difficult, however, to determine from their paper the precise cause of the additional delays experienced by patients when triage was in use. Only 48% of patients were actually assessed by a triage nurse during the triage periods, yet the median waiting times for all patients in the triage group were longer than those for the patients in the no triage group. Were the delays caused by the time taken for triage itself or by subsequent queuing problems as patients proceeded through the accident and emergency department? Perhaps one way of clarifying this would be to analyse further the extended waiting times during the periods when triage was being done. The waiting times of the 48% who were assessed by a triage nurse could be compared with the waiting times of the 52% of attenders during the same periods who were not. This might indicate whether the triage itself or subsequent queuing caused the delays. - The authors also analysed waiting times according to a retrospective judgment of urgency, made by a consultant in accident and emergency, rather than the prospective assessment of urgency made by the triage nurse. Given that the prospective assessment is intended to be a major determinant of waiting times (indeed, it is the whole purpose of triage), why did the authors not conduct such a prospective analysis? The authors conclude that some torm of priori-
BMJ
VOLUME
304
23 MAy 1992
tisation will benefit patients in most urgent need of care, but they question whether this needs to be formalised and called nurse triage. What system do they therefore recommend? Are they not simply calling for a more efficient form of nurse triage rather than none at all? DAVID ST GEORGE
Royal Free Hospital, London NW3 2QG 1 George S, Read S, Westlake L, Williams B, Fraser-Moodie A, Pritty P. Evaluation of nurse triage in a British accident and emergency department. BMJ 1992;304:876-8. (4 April.)
AUTHORS' REPLY,-Jeremy Dale and John Bache note that only 48% of patients attending during a triage period saw a triage nurse and conclude that outcome measurements for our triage group cannot be used to deduce the effects of triage itself and that our study is invalid. They misunderstand the principle of intention to treat trials. We made the decisions to redesignate shifts at the beginning of each day, not at a moment's notice, and we ensured that triage ran during each session designated. The periods in which nurse triage ran and did not run were entirely comparable and were not dictated by workload. In real life triage nurses may leave their stations to undertake clinical duties elsewhere, but this applied equally to both arms of our study. Ours is a valid study of the effectiveness of nurse triage in real life, whereas Dale and Bache propose a study of the efficacy of nurse triage under ideal circumstances. John Heyworth and M Pledge suggest that urgency should be assessed retrospectively by nurses rather than doctors. This is irrelevant. So long as both groups are judged by the same assessors the assessors may be nurses, doctors, or, indeed, others. All have equal validity. J E Porter questions the nature of the difference between formal triage and informal prioritisation in our study. Formal triage is a documented assessment governed by strict protocols, whereas the informal assessment is undocumented, intuitive, and dynamic and fits well with Porter's description of what happens in her department. Triage ran for five years preceding our study. All triage nurses attend six lectures, are tested on theory, and undertake supervised practice before starting triage. Their collective skills and experience are considerable. Dale and Porter are correct, therefore, when they state that informal assessment was performed by nurses familiar with triage. But the question "Does prioritisation of patients by degree of urgency produce benefits compared with their being seen in strict order of arrival?" is artificial. It is nonsense to suggest that any accident and emergency department in the United Kingdom functions entirely in this fashion. At its simplest level, the urgent attention awarded a patient arriving by emergency ambulance is prioritisation, and the relevant question is "Does formal nurse triage produce benefits when compared with an existing scheme of informal prioritisation?" This was our question. David St George requests an analysis of waiting times by prospective urgency. This would be ethically unacceptable as it would entail every patient being assessed for triage and then the
decision being ignored in half the cases. To answer his question regarding the cause of delays, however, we reanalysed waiting times, deducting the time taken for patients to see the triage nurse before booking in at reception. The results are essentially unchanged, showing that queuing problems after triage cause delays, rather than the triage process itself (table). Our and other studies show that nurses consistendly give patients a higher priority than do clinicians.'5- We must consider whether this benefits patients and, if not, how best it can be modified. Our conclusion is to make triage more efficient rather than abandon it. Prioritisation by degree of urgency obviously benefits patients whose condition is most urgent, and this principle should be instilled in all who work in accident and emergency departments. It is the method by which that prioritisation is to be accomplished that is for debate. STEVE GEORGE SUSAN READ
LINDA WESTLAKE BRIAN WILLIAMS
Medical Care Research Unit, Department of Public Health Medicine, University of Sheffield Medical School, Sheffield S10 2RX ALISTAIR FRASER-MOODIE Derbyshire Royal Infirmary, Derby DEl 2QY
PAUL PRITTY
1 Russo RM, Gururaj VJ, Bunye AS, Kim YH, Ner S. Triage abilities of nurse practitioner vs pediatrician. Am J Dis Child
1975;129:673-5. 2 Zwicke DL, Bobzein WF, Wagner EG. Triage nurse decisions: a prospective study. Journal of Emergency Nursing 1982;8:132-8. 3 Albin S, Wassertheil-Smoller S, Jacobsen S, Bell B. Evaluation of emergency room triage performed by nurses. Am J Public Health 1975;65: 1063-8. 4 Mills J, Webster AL, Wofsy CB, Harding P, D'Acuti D. Effectiveness of nurse triae in ED of an urban county hospital. Journal of the American College of Emergency Physicians
1976;5:877-82. 5 Rivara FP, Wall HP, Worley P, James KD. Pediatric nurse triage; its efficacy, safety and implications for care. Am J Dis Child 1986;140:205-20.
In search of the unknown primary SIR,-Christopher Bradley and Peter Selby succinctly identify the dilemmas that challenge all clinicians who must decide how best to manage patients presenting with metastases from an unknown primary.' An exhaustive search for the primary is clearly clinically unjustifiable once malignancies that can be therapeutically influenced have been excluded. While such possibilities are being investigated, however, the time required for imaging and to obtain specialised histopathological results and measurements of serum markers should not be allowed to delay adequate palliation in symptomatic patients. Many patients labelled as having an unknown primary present with pain from bone metastases. Palliative radiotherapy given in one day or over one week will relieve pain promptly in over 80% of patients without either delaying any essential investigation or compromising the ability to give adequate cytotoxic chemotherapy subsequently. Patients with disseminated malignancy from an unknown primary are stressed by uncertainty
Median waiting time by study group and retrospective priority category. Figures givenfor triage group are exclusive (and inclusive) of time taken to see triage nurse Median waiting time (minutes) Retrospective priority category 1 (Most urgent) 2 3 4 (Least urgent)
Triage group (n=25 15)
No triage group (n=2522)
26 (26-5) 44 (46)
16 37-5 55 62
56(58) 62-5 (66)
95% Confidence interval Difference for difference* (triage minus no triage) 10 65 1 0-5
1-5 to 13 1 to 11 Oto2 -4 to 4
*Calculated using method described by J P Nicholl, meeting of International Society of Clinical Biostatistics, Maastricht, September 1989.
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