TRIAGE IN EMERGENCY ROOMS 8
Triage in emergency rooms and delivery of emergency care is acritical component. Emergency room triage identifies a patient’slevel of urgency for treatment through rapid assessment,physiological assessment and interpretation of clinical history forpurposes of determining the priority of medical urgency. The firstimperative role of triage is identifying life threatening conditionsand emergency conditions amongst patients and initiating appropriateinterventions. The second role is allocating a patient to anappropriate area or stream within the emergency department. Theintention of triage is to improve the emergency care and prioritizemedical cases in terms of clinical urgency.
Emergency care is amongst the most sensitive areas of health care.According to Moskop et al. (2008), this sensitivity is based onfactors like urgency of care provided, decongesting the room andattending to patients. The urgency of care needed in the emergencyroom calls for immediate and effective attention. A slight mistake inthe emergency room triage can lead to adverse consequences likedelayed health care, poor physician-patient communication, unprovidednecessary care altogether, compromise to confidentiality andinfluence tough decisions like who to save when not everyone can besaved. Such consequences greatly challenge ethical quality inemergency care. The use of triage in emergency rooms thus remainscrucial and is very imperative to health care. To understand theimportance of triage in emergency rooms a review of scholarlyreferences will be used to identify trends, missing information,theories and find solutions.
Triage is a term that was derived from the French word trier meaningpick/sort. The first triage systems were used to prioritize healthcare in the Napoleonic wars of late 18thcentury (Iserson &Moskop, 2007). Since then, triage systems have refined in trends andtechnology, leading to definitive care. The importance of triage inthe emergency rooms has had significant trends leading to manychanges through the years that aim to improve medical care.Internationally, five tire triage scales are used as valid andreliable methods of categorizing patients in emergency rooms andother departments (Robertson, 2006).
ATS (Australian Triage Scale)
ATS also formerly referred to as NTS (National triage scale) wasfirst used in Australia. It was used in all Australian publiclyfunded emergency departments after its implementation in 1993. Thelate 90’s saw NTS go through a refinement process to beingsubsequently renamed as ATS. ATS classifies levels of acuity intofive namely
immediately life threatening,
potentially life threatening/ severe pain/ important critical treatment,
potentially life serious or situational urgency,
less urgent (Robertson, 2006)
This category has been endorsed for emergency medicine by theAustralian college and was adopted in the Australian council onhealthcare standards performance indicators.
Canadian Triage and acuity scale (CTAS)
CTAS was officially included in the Canadian policy in 1997.Canadian association of emergency physicians and national nursesaffiliation of Canada have endorsed it. It is very similar to ATS interms of treatment times except the second category which is 15mininstead of 10min in ATS (Travers, 2002).
Manchester Triage scale
Emergency and British Association jointly developed MTS scale foraccidents. Royal college of nursing accident also contributedequally. It differs from CTAS and ATS in the algorithm- basedapproach of decision-making. MTS uses 52 separate flow charts throughwhich a decision maker is expected to select the appropriatealgorithm on the basis of presented complain. After that they shouldgather and analyze information according to how life threatening itis, pain complains, hemorrhage/bleeding, level of consciousness,temperature and signs and symptoms. This scale requires standarddocumentation that is believed to save time with simplifieddocumentation and a streamlined approach. MTS is said to bebeneficial to nurses as the decision making process occurs at welldefined parameters.
ESI (Emergency Severity Index)
ESI is a system that is based on acuity and resource consumption. Inacuity it refers to how soon a patient should be treated whileresource consumption explains the required resources. This method hasbeen found reliable on testing it through written case scenarios. Itis currently is being considered for use across the US.
The role that triage plays is very crucial for patients. Itsdecision making entails an inherently complex and dynamic process.Decisions have to be made within a time sensitive environment withlittle information for patients who do not have a medical diagnosis.Due to multifaceted roles of triage, nurses and physicians areexpected and required to possess specialized skills on injuries andailments. The invention of technology is a new trend that hassignificantly improved triage in emergency rooms. The effectivenessand accessibility of technology has made triage processes faster andthus facilitated treating emergencies and saving lives. With newtechnologies, improved healthcare in triage for emergency rooms hasbecome possible.
Information on recent technologies and machineries for use in theemergency departments was limited. Not many scholars have researchedon the latest triage technologies and its importance to the emergencyrooms. The impact of triage technology on emergency rooms has notbeen carried out extensively apart from the obvious benefits of fastcomputer aided processes. There is a need to further research onlatest innovations of technology of triage to learn about thebenefits it has on improving delivery of health care to emergencydepartments.
To understand the importance of triage on emergency rooms, severaltheories have been used. Ethical theories explain triage as a classicexample of distributive justice seen in addressing the benefits andburdens distributed within a population (Hartman, 2003).Traditionally, ethical theory explains greatest good for greatestnumbers and equal respect for all. The fundamental of triage is notall emergency patients requiring forms of healthcare like intensiveor emergency care can access it immediately. Triage systems are madeto help allocate decisions with this regard. These decisions gettougher when there is a life threatening condition and scarceresources for potentially saving lives. Considering ethical issues inthe emergency room is tricky. Studies revealed that dealing withemergency rooms presents an ethical dilemma for nurses and physicianswho have to make complex decisions sometimes regarding saving lives(Anderson et al. 2007). More research on proactive use of ethics intriage for emergency room is needed.
Another theory that can explain the importance of triage inemergency rooms is the principle based approach whereby respect forautonomy criterion is used. In this theory, decision making inhealthcare emergency room requires that competent persons have aright to make decisions and choices regarding their health care.Respect for patient autonomy means that nurses or caregivers takeaction based on the patient’s right to make choices. However,during emergencies, patients require utmost care and they do not evenknow what they want argues Ekwall et al (2008). Given the situation,a nurse/physician has a right to decide what medical care favors thepatient. While considering emergency room triage, autonomy becomesdifficult especially when dealing with urgent matters. It thus isimportant to find out who has the right to decide about the emergencyand how to deal with it.
Solutions identified based on ethical and principle based theoriesrevealed interesting findings. Ethical issues are a great challengein the emergency rooms and significantly impact on the patient’scare. Patients who feel that health providers for instance areevading their privacy are less likely to cooperate with them. To dealwith ethical dilemmas, health care providers should ensure thatpatients feel safe and secure. According to Van (1999), triageofficers should aim at winning the trust of patients and letting themknow that they are in caring hands. Trust can be achieved throughsigning consent forms and assuring the patients of confidentiality inthe information they provide.
With regard to principle based theory, it was revealed thatrespecting the autonomy of the patient is very critical(Widdershoven, 1999). It can beachieved through effective emergency communication. Autonomy can beexercised through health care providers being able to communicatewith patients politely and well. It is important to note thathowever, the emergency department faces unique challenges inprovider-patient communication due to lack of privacy, frequency,noise, interruption and lack of past medical relationship. Accordingto Widdershoven (1999), good communication requires listening,talking and interpersonal understanding. It is usually necessary forgiving patients information on proposed interventions and finding outwhether they want the intervention. Triage officers thus should makesure that they inform patients about their triage level and estimatedwaiting time in the emergency rooms.
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Hartman RG.(2003). “Tripartitetriage concerns: issues for law and ethics.”Crit Care Med, 31(suppl):S358-S361.
Iserson KV& Moskop JC. (2007). “Triagein medicine, Part I: Concept, history and types.”
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Moskop JC, Sklar DP, Geiderman JM, Schears RM, Bookman KJ(2009).” Emergency department crowding, part 1- concept, causes, and moralconsequences.” AnnEmerg Med, 53(5):605-11
Robertson I. (2006). “Evolutionof triage systems.” EmergMed J 2006, 23(2):154-5.
Travers DA, Waller AE, Bowling JM, Flowers D, TintinalliJ.(2002).” Five-leveltriage system more effective than three-level in tertiary emergencydepartment.”JEmerg Nursing, 28(5):395-400
Van S. (1999). “Actingfrom the virtue of caring in nursing,” NursingEthics 1999, 6:192-193.
Widdershoven G.(1999). “Care,cure, and interpersonal understanding.”Journalof Advanced Nursing 1999, 29:1163-1169.