It’s another rainy night shift, in the umpteenth overcrowded day of our medical/surgical level 2 urban emergency department. After the last patient has left the emergency department without being seen, our thoughts go back to 8 years of hard work, and we wonder how much this type of emergency care setting has changed.
When we started with triage for the very first time in our emergency department, the daily admissions were about 100, and we were paying a lot of attention to the properness of triage assignation and to the timing of re-assessment. Our triage system is a 5-tier model: red—emergency (no waiting); yellow—potential life-threatening (expected waiting time: 10 minutes); green—acute /not life-threatening (expected waiting time: 30 minutes); blue—acute/not urgent (expected waiting time: 60 minutes); and white—not acute/not urgent (expected waiting time: up to 4 hours). The cultural and qualitative growth of the nursing staff underwent the auditing of congruity between the triage notes and the correspondent level assignation. While these processes were going on, other changes happened, like moving into the “new and bigger” ED location and daily evaluating an increasing number of patients who were looking for a faster and better answer for their health care needs that were not even urgent.
In the past 2 years we reached an average of 150 patients seen daily, and nowadays it is 160 to 170. The waiting time for all the patients has increased rapidly, and the whole process (diagnostic-therapeutic and nursing care) for medical and surgical patients (including major trauma) often is quite lengthened, despite having achieved a dedicated radiological unit inside the emergency department. And if the rate of patients who leave the emergency department without being visited in the year 2006 was “only” 2%, actually this important indicator of quality of care can only further rise, although some organizational measures have been implemented.
Neither diurnal fast track nor the additional working hours of one physician on the afternoon shift to midnight seem to have reduced the perception of working pressure by the triage nurses in our emergency department. Another attempt to improve the safety of the health care environment was to shift part of the working time of the charge nurse from managing general processes of care to helping the triage nurse in his task. However, this type of expedient did not give warranties about continuity of presence in the triage area because of the multi-tasking feature of the discharge nurse role. Actually, we’re living a paradoxical situation: during the daily hours the waiting list swings constantly from about 15 to 35 patients, and while the level 1 patients have immediate access in emergency room, with level 2 patients maintaining a relatively low time of staying in the triage area before the medical assessment, the “green” tier persons are waiting many hours before being visited, and at the same time the “blue” and “white” tier patients often are visited in lower lapses of time because of the fast-track stream for minor problems. From a pure statistical point of view, these type of solutions have reduced the average of patients’ waiting times, but what about the triage ethical and philosophical features, and moreover, what about the safety of level 3 patients?
All these transformations in the emergency department’s way of managing the different categories of urgent and non-urgent patients have yielded a more or less unwitting change in the triage nurse’s attitude toward the managing of the waiting list: at this moment, in the attempt to balance the length of stay of patients in the triage area, nurses frequently fix a cut-off at “the third hour” to introduce the person in the medical visit box, independently of the level of triage designation. It’s obvious that this behavior is against the “priority” rule established in triage methodology, and the triage nurses bear a certain rate of clinical and medical-legal risk to guarantee a fair allocation of health care resources for every patient and the right to be visited by a physician in “human” and not “biblical” lapses of time.
So we can say we work with a 2-tier (and not a 5-tier) triage system: on one side those who enter the medical visit box, and on the other side, those who are waiting for it (until the third hour). We call it triage made on the setting variations and not on the patients, because often we can assist in a forced overtriage on some patients to allow the access in the medical visit box after an “unacceptable” waiting time.
Where do we go from here? In the past months, some projects were undertaken, such as the implementation of a pilot trial of nursing “see and treat,” or the suggestion to anticipate at triage some nursing activities like performing ECG, arterial blood gas, intravenous catheterization, and blood testing and administering analgesic drugs according to internal policies (someone calls it “advanced triage”). But is this the real solution to the problem? Don’t we risk forgetting to monitor the internal processes to find the system point of weakness? Perhaps it is time to use structure and performance indicators to improve the ability of the hospital and staff to reduce the ED patients’ length of stay before the transfer to admittance wards and to decrease the performance timing of internal diagnostic and therapeutic procedures. But overall, for all ED staff, perhaps the major challenge for the future is to go out of the hospital door and educate the population regarding a better utilization of our emergency service.
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