Australian Emergency Departments all use the Australasian Triage Scale (ATS) to triage every patient presenting through its doors.
Triage can be defined as:

A process of assessment of a patient on arrival to the ED to determine the priority for medical care based on the clinical urgency of the patient’s presenting condition. Triage enables allocation of limited resources to obtain the maximum clinical utility for all patients presenting to the emergency department.’
The triage nurse applies an ATS category in response to the question: “This patient should wait for medical assessment and treatment no longer than….
Australasian College for Emergency Medicine. Policy Document: The Australasian Triage Scale

In Australia, the ATS is essentially a tool to sort patients according to clinical urgency, and studies have confirmed it to be reliable in doing so. At least for Category 1 and 2 presentations with some studies suggesting a bit of a drop in reliability for 3, 4 & 51.

Overall, our triage nurses do a pretty good job assigning an accurate score in an environment of high stress and workload. A study by Considine et al. found 61% of triage decisions were “expected triage” with 18% “over-triage” (that is, given a more urgent score) and 21% “under-triage decisions”2

To further improve triage quality and consistency, a national teaching resource has been developed known as the ETEK or Emergency Triage Education Kit. This kit is used in many emergency departments to train up new triage nurses as well as consolidating the knowledge and skills of existing ones.

It might be a good system but is it the RIGHT system?

So. We have a well crafted, effective and specialised tool at our disposal.
My question is this: is it the right tool to best manage the situation before us….right now?

Before you read any further, no, I don’t have an answer for this question. I certainly do not have any alternate solutions.
My thoughts on it all change when I listen to various expert peoples opinions. But after so many years of banging my head against the queue, I am both a little jaded and skeptical when it comes to the ATS.

I would love to hear your own views.

Our emergency departments have never been under greater stressors. Access block, overcrowding, pressure to meet National Emergency Access Targets, increasingly complex presentations from an ageing community.
Its bloody tough in here.

In 2009, the National Partnership Agreement on Hospital and Health Workforce Reform committed all the States and Territories in Australia to a performance benchmark that 80% of ED presentations will be seen within clinically recommended triage times.

A report card recently released by the Australian Medical Association has found that in 2011–12 only 66% of emergency department patients classified as urgent were seen within the recommenced 30 minutes.

Now this is for category 3 patients which is bad enough.
I believe the real canary in the coal mine would be seen if we had accurate and un-fudge-itated data on the national performance of our  category 2 patients during times of peak workloads.
These are time critical emergencies that should be seen within 10 minutes of presentation, some data that I have seen on these times (which to my knowledge is not in the public domain, & therefore I will not print here) is pretty grim.

And, again anecdotally, I have even heard of delays in category 1 (emergent) patients accessing definitive care, simply because there are no available beds to treat them in the unit.

The AMA report sumarised:

Health reform, as defined and constructed by governments, has failed to deliver direct improvements in the capacity of public hospitals to meet the clinical demands and performance targets placed on them.

(You can read the entire report as a pdf here: Public hospital report card 2013: an AMA analysis of Australia’s public hospital system).

When the triage system becomes a meaningless question.

Talking to my colleagues in my own and other hospitals, the feeling is that the waiting times in our emergency departments have now become so long that essentially the 5 tier ATS breaks down into a bit of a farce when the pressure is on.

The triage system in itself is still working fine. But within the context of its efficacy within our current environment of access block and overcrowding, it is simply does not achieve anything other than capturing data to be used later.

The essential question at the core of our triage system becomes meaningless: “This patient should wait for medical assessment and treatment no longer than….”
30 minutes?
Well no. How about 4 hours. Or 5. Or 7.

Basically there is little point sorting according to urgency if there is not an appropriate and timely response to that urgency.

Category 3 patients are waiting so long and build into such large group that they require sub-triaging within this category (we all do it no?). The waiting times may be so long that patients triage categories will change (sometimes several times) before they are seen.

Although officially locked into using the ATS, many emergency departments are now experimenting with other systems such as: ATS 1, 2 and then all other presentations seen in time of arrival3. Or systems based on complexity rather than urgency of the presenting complaint. Or some sort of mixed model.

There are plenty of other initiatives and workarounds that are being implemented at a local level to try to improve patient flow during peek workloads. Hey, way back in 2007 I even suggested my own tweak to the ATS to meet workload demand, a Dynamic Triage System.
Oh……I thought it was cool anyway.

Triage or Bricolage?

Today, triage nurses must triage to a queue, then care for it, and be accountable for it.

Bricolage is a term used to refer to the construction or creation of a work from a diverse range of things that happen to be available, or a work created by such a process.
The term is borrowed from the French word bricolage, from the verb bricoler, the core meaning in French being, “fiddle, tinker” and, by extension, “to make creative and resourceful use of whatever materials are at hand (regardless of their original purpose)”

Perhaps this is a better definition of what our triage nurses are doing.
What say you?

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Reference: http://www.acem.org.au/media/media_releases/2012_-ACEM_Triage_Literature_Review.pdf

  1. Gerdtz MF, Collins M, Chu M, Grant A, Tchernomoroff R, Pollard C, Harris J, Wassertheil J: Optimizing triage consistency in Australian emergency departments: The Emergency Triage Education Kit. Emergency Medicine Australasia 2008, 20(3):250–259 []
  2. Considine J, LeVasseur SA, Villanueva E: The Australasian Triage Scale: Examining emergency department nurses’ performance using computer and paper scenarios. Annals of Emergency Medicine 2004, 44(5):516–523. []
  3. I would be interested in anyone’s thoughts on the medico-legal implications of this for the triage nurses when, for example they triage someone as a ATS 3 and then place them in the queue behind 7 other category 4’s and 5’s, (unless they are covered by local policy). []

One Response to “Is it Triage? Or is it Bricolage?”

  1. It’s been a few years now since I sat on a triage desk but my feeling is that the ATS is a great tool, and that triage works. I’ve seen hospitals (not in Aus) where triage isn’t used…. it’s scarey!

    That the bare majority people are seen within the recommended times is a sad reflection on the state of australian health care, but doesn’t neccessarily mean that triage is broken. It is highighting that the whole system is broken and not coping with increased numbers and increased complexity of presentations.

    ED’s are coming up with lots of novel ways to tackle the waiting times (assigning a doctor and nurse to work through the simple cat 4&5′s who would otherwise wait until a quiet moment at 4am to have the fish hook removed from their thumb etc), but ultimately nothing will effect the system like dealing with bed block. How you do that without busting the aussie budget is a little above my pay grade!

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