The trouble with triage

This article is Part I of a 2-part series on triage. Click here for Part II – “A practical approach to eliminating triage”.

I frequently work with specialists who have long wait times for new referrals, a result of inadequate capacity to meet the demand for their services. Many try to manage high patient demand by triaging referrals, so that the most urgent patients are seen first. However, triage is a flawed solution that increases wait times and ultimately makes things worse instead of better.

TriageThe Oxford dictionary defines triage as: “the assignment of degrees of urgency to wounds or illnesses to decide the order of treatment of a large number of patients or casualties”. It originated in the 1930’s when it was used to assess wounded on the battlefield. The definition implies the use of triage in exceptional circumstances, such as military conflict. It is a method of assessing urgency for patients for whom treatment would be appropriate.

Modern triage has expanded significantly beyond these battlefield origins to encompass almost all forms of medical prioritization. As patients, we are now triaged not just in exceptional circumstances, but for nearly all of our routine healthcare needs. This has serious consequences for our health. The use of triage must be curtailed to be more in line with its original use – as an assessment tool for exceptional circumstances – and in parallel we must solve the problem of increasing wait times.

Few successful businesses use triage to meet the needs of their customers. Instead, businesses adjust their staffing to match the ebbs and flows that they experience in customer demand. For instance, well-run restaurants have more servers working during the dinner rush than in the post-lunch lull. When wait lists exist, they are almost always first come, first served to ensure fairness. How would you feel if, while waiting for a table, you were bypassed by everyone that the hostess thought looked hungrier than you? Most reasonable people would agree with triage for someone who was actually starving to death – but not in normal circumstances.

In Canada, long wait times for specialist care are the norm and triage is a band-aid solution to allocate scarce resources where they are most needed. But perversely, triage is one of the reasons that specialist wait times are getting longer in the first place.

Triage is an imperfect assessment tool which can lead to inappropriate allocation of health resources. This raises ethical questions about its use in non-urgent situations. Triage delays care for non-urgent patients until they become urgent, which is a waste of health resources and leads to worse patient outcomes. And triage itself consumes the very health resources that it is meant to preserve.

Triage is a non-value-add activity. Treatment is the purpose of our health system, it is the “value-add” activity that is worth paying for. Triage delays treatment not only for low priority patients, but also for high-priority patients because it is an extra step in the process. In a perfect world, everyone would get immediate access to the treatment that they need, without any triage at all.

Triage must be frequently repeated because it delays treatment. Triage is a single assessment at a moment in time, however health conditions change over time. Triage therefore needs to be repeated when treatment is delayed, but triage itself delays treatment. The more triage that is done, the more time health providers need to spend repeating triage.

Triage is imperfect Triage is based on a partial assessment performed in a time-limited fashion. It is not a perfect assessment tool, nor can it replace the full assessment that health professionals eventually perform. Assessments are duplicated, and fixing diagnostic errors resulting from triage consumes additional health resources.

Time spent on triage comes at the expense of time spent on treatment. The ability of health professionals to assess, diagnose and treat disease develop in parallel. In general, health professionals who can triage will also have some ability to treat patients, which is a much better use of their time.

Delaying treatment leads to less specialist capacity and worse outcomes. The majority of conditions that are referred to specialists worsen over time. Sicker patients generally have worse outcomes and consume more health resources because their treatment is more complex. Triaging delays patients until they are eventually sick enough to warrant immediate treatment. This “death spiral of waiting” is obviously not a good foundation for a high-performance health system.

The ultimate goal is a health care system with no wait times.CommonwealthFund_HealthSystemRanking Most businesses work this way (while still being profitable), and many health systems have shorter wait times (and are less expensive) than in Canada.

As long as there are wait times, triage will be needed to prioritize access to specialty care. But we need to remember that triage is a non value-add activity that contributes to long wait times. We must find practical ways to reduce wait times and eliminate triage, because specialist time is better spent treating than triaging.

The trouble with triage, is triage.

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