This article is Part II of a 2-part series on triage. Click here for Part I – “The trouble with triage”.
Triage is a band-aid solution for long wait times for specialist care, ensuring that scarce resources are allocated where they are most needed. But perversely, triage is one of the reasons that specialist wait times are getting longer in the first place.
The use of triage must be curtailed, and in parallel we must solve the problem of increasing wait times. A practical, seven-step approach can help us achieve this:
1. Triage only when appropriate
Occasionally triage is necessary, when two criteria are present:
ii) Demand temporarily exceeds capacity.
In these situations, difficult decisions are required. Triage is used to focus efforts where they will provide the greatest benefit. For instance, in emergency departments, patients are triaged to ensure that someone with urgent care needs, such as a trauma victim, is seen without delay. Even in the emergency department, however, recent evidence suggests that waiting increases mortality and many hospitals are trying to reduce or eliminate triage.
2. Manage urgent and non-urgent care differently
If triage is required, then only two triage categories should be defined; urgent and non-urgent. Patient demand and specialist capacity should be managed separately for these two groups of patients. For urgent patients, enough capacity should be reserved to manage the high end of the variation in daily demand. If it’s not required, unused capacity can then be released for non-urgent patients shortly before it is scheduled. For non-urgent patients, the average capacity should match the average demand. If demand temporarily exceeds capacity, non-urgent patients can safely be delayed to a future date.
3. Triage in primary care only
In Canada all patients presenting for medical care are assessed by primary care providers, who are qualified diagnostic experts, before they are referred to specialist care. Triage does not necessarily need to be repeated by specialists. Primary care providers can be assisted with their triage decisions if specialists provide them with referral advice, for instance a list of indications, contraindications and “red-flags”.
4. Simplify triage
Triage is never perfect no matter how much time you put into it. Instead of striving for perfection, triage should be simplified so that it is “good enough”: rapid yet reasonably accurate. The emergency care system exists to manage unexpected, urgent patient care. It has and will continue to serve as a safety net for those patients who need it.
5. Balance patient demand and specialist capacity to stabilize wait lists
Wait times increase when demand exceeds capacity. Incentives for appropriate access to specialty care (or disincentives for inappropriate access) can reduce patient demand. There are options, such as better patient education about the risks and benefits of treatment, financial incentives/disincentives for patients, and positioning primary care providers as gatekeepers to secondary care.
To increase specialist capacity, we either have to improve productivity or add additional resources. One option is to reduce the amount of time spent with stable patients, and potentially to discharge some stable patients back to primary care. Process improvement tools and techniques can be used to increase both productivity and quality.
6. Work through the wait lists
Once average patient demand and specialist capacity are balanced, a temporary increase in capacity is required to work through the backlog of currently waiting patients. After this is achieved, capacity can be decreased to meet the average demand.
7. Stop triaging
If there are no wait lists, then there is no need to triage. Patients for whom it is appropriate should start treatment immediately, without being triaged.
- Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. Guttmann A, Schull M, Vermeulen M, et al. BMJ. 2011. http://www.bmj.com/content/342/bmj.d2983
- Applying Lean: Implementation of a Rapid Triage and
Treatment System. Murrel K, Offerman S, Kauffman M. Western Journal of Emergency Medicine. 2011. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3099605/pdf/wjem12_2p0184.pdf
- Improving Access to Specialty Care. Murray M. The Joint Commission Journal on Quality and Patient Safety. 2007. http://www.internetgroup.ca/clientnet_new/docs/02-Murray.pdf