Optimizing triage and hospitalization in adult general medical emergency patients: the triage project

Abstract

BackgroundPatients presenting to the emergency department (ED) currently face inacceptable delays in initial treatment, and long, costly hospital stays due to suboptimal initial triage and site-of-care decisions. Accurate ED triage should focus not only on initial treatment priority, but also on prediction of medical risk and nursing needs to improve site-of-care decisions and to simplify early discharge management. Different triage scores have been proposed, such as the Manchester triage system (MTS). Yet, these scores focus only on treatment priority, have suboptimal performance and lack validation in the Swiss health care system. Because the MTS will be introduced into clinical routine at the Kantonsspital Aarau, we propose a large prospective cohort study to optimize initial patient triage. Specifically, the aim of this trial is to derive a three-part triage algorithm to better predict (a) treatment priority; (b) medical risk and thus need for in-hospital treatment; (c) post-acute care needs of patients at the most proximal time point of ED admission.Methods/designProspective, observational, multicenter, multi-national cohort study. We will include all consecutive medical patients seeking ED care into this observational registry. There will be no exclusions except for non-adult and non-medical patients. Vital signs will be recorded and left over blood samples will be stored for later batch analysis of blood markers. Upon ED admission, the post-acute care discharge score (PACD) will be recorded. Attending ED physicians will adjudicate triage priority based on all available results at the time of ED discharge to the medical ward. Patients will be reassessed daily during the hospital course for medical stability and readiness for discharge from the nurses and if involved social workers perspective. To assess outcomes, data from electronic medical records will be used and all patients will be contacted 30 days after hospital admission to assess vital and functional status, re-hospitalization, satisfaction with care and quality of life measures.We aim to include between 5000 and 7000 patients over one year of recruitment to derive the three-part triage algorithm. The respective main endpoints were defined as (a) initial triage priority (high vs. low priority) adjudicated by the attending ED physician at ED discharge, (b) adverse 30 day outcome (death or intensive care unit admission) within 30 days following ED admission to assess patients risk and thus need for in-hospital treatment and (c) post acute care needs after hospital discharge, defined as transfer of patients to a post-acute care institution, for early recognition and planning of post-acute care needs. Other outcomes are time to first physician contact, time to initiation of adequate medical therapy, time to social worker involvement, length of hospital stay, reasons for discharge delays, patient’s satisfaction with care, overall hospital costs and patients care needs after returning home.DiscussionUsing a reliable initial triage system for estimating i...

The accuracy of nurse performance of the triage process in a tertiary hospital emergency department in Gauteng Province, South Africa

“…[1] Triage systems should ideally allow for patient care to be given within an acceptable time, thus decreasing overcrowding, increasing patient satisfaction, allowing urgent patients to receive appropriate care, and preventing non-urgent patients from receiving unnecessary treatment. [2] In 2004, the South African Triage Scale (SATS) was developed to be used as a nurse-led, in-hospital triage tool. It has since been adopted by numerous EDs.…”

Nurses' Opinion on Risk Classification in Emergency Services

“…3,15 A tomada de decisão dos enfermeiros na CR, mesmo utilizando protocolos validados em sinais e sintomas que objetivam o tratamento clínico, constitui-se em resultado do conhecimento que os enfermeiros possuem a respeito do e necessidades para os pacientes que buscam atendimento na rede de atenção às urgências. 5,14 Para o desenvolvimento da CR, os participantes concordaram que os enfermeiros utilizam a escuta qualificada das queixas e das condições de saúde do paciente para a identificação do problema que motivou a busca pelo serviço de urgência. Pesquisa demonstrou que a partir da escuta dirigida, o enfermeiro identifica o risco e a vulnerabilidade e acolhe a avaliação do próprio paciente, para tomar uma decisão na CR.…”

“…Estudos desenvolvidos em serviços de urgência demonstram que os enfermeiros enfrentam um excesso de demanda para propiciar atendimento aos pacientes que buscam esses serviços. 5,9,24 O inadequado quantitativo de enfermeiros na CR e de outros profissionais no serviço de emergência diante da excessiva demanda e dos conflitos decorrentes da priorização de atendimento têm sido considerados como fatores geradores de desgaste e sobrecarga emocional para esses profissionais. 21,22 A falta de profissionais de todas as categorias para enfrentar a complexidade do serviço de emergência, somada à superlotação que ocorre nesses serviços, também vai impactar a demora dos atendimentos.…”

“…21 A demora na reavaliação do paciente já classificado, que aguarda por atendimento médico está relacionada à superlotação do serviço e consequente aumento na demanda de trabalho. 4,5 Dessa forma, o enfermeiro terá de amparar sua conduta na CR, em protocolos institucionais,para que não haja nenhum dano ao seu exercício profissional. citações periódicas para a atualização dos enfermeiros da CR, o que contraria o preconizado pelos protocolos da CR.…”

“…1 Também há a possibilidade da CR se transformar em um obstáculo no fluxo do paciente no serviço, resultando em um aumento do tempo de espera por atendimento. 5 A tensão gerada no ambiente da sala de espera reflete-se no trabalho dos enfermeiros, pois é para eles que chegam essas demandas. 6 Além disso, existem fatores que envolvem a organização da rede de atenção às urgên-cias para os encaminhamentos necessários, os quais também interferem na CR.…”