Asplin, B (2001). "Undertriage, overtriage, or no triage? In search of the unnecessary emergency department visit." Annals of Emergency Medicine 38(3): 282-5.

FULL TEXT
"In view of these crucial advantages of the emergency department over scheduled clinics and private practitioners, perhaps we should stop asking why people come to an emergency department and instead ask why anyone gets his care anywhere else."1-Julius Roth, PhD
The struggle to eliminate unnecessary ED visits predates the recognition of emergency medicine as a specialty. In 1971, Julius Roth studied utilization patterns at several EDs and cited reliability of access, efficiency of diagnostic services, and availability of specialists as "crucial advantages" that encouraged nonurgent use of the ED. He also predicted that over time the conflict about nonurgent ED use would subside. Thirty years later, that conflict is thriving.
It is not surprising that policymakers and payers pay attention to ED use. This year, more than 100 million people will visit hospital EDs in the United States.2 Even though the marginal cost of nonurgent ED visits is reasonable,3 charges are higher in the ED than in other settings, which means that payers will continue to encourage patients to find alternatives.4 In addition to concerns about health care costs, attention has once again turned to the problems of ED crowding and ambulance diversion.5,6 Although nonurgent ED visits more commonly lead to waiting room crowding than ED crowding, it certainly is reasonable and appropriate to look for reliable alternatives for patients who could be served in other settings. The questions are simple. How do we identify the patients who can be safely triaged away from the ED, and who makes the decision?
In this issue of Annals, Pointer et al7 demonstrate why the answers to these questions are far from simple. They asked paramedics to triage patients into 1 of 4 categories and then compared paramedic triage decisions with the judgment of a physician panel. The physician raters knew each patient's final diagnosis, including the results of all diagnostic tests performed in the ED. One could question whether this was an unfair advantage for the panel. If the goal was only to identify the interrater reliability of the guidelines, the physician raters should have only had access to the presenting patient information. However, if the goal was to test the effectiveness of the guidelines in practice, the authors asked exactly the right policy question. Ultimately, these guidelines will be evaluated on the basis of what happens to patients because of paramedic triage decisions. If use of the guidelines leads to bad patient outcomes, it makes little difference whether a physician would have made a similar triage decision using the same information.
The authors appropriately conclude that paramedic triage is not safe using these guidelines. Ten percent of patients were undertriaged, and paramedics would have refused advanced life support transport for 22 (2% of all calls) patients who ultimately were admitted to the hospital. The study included convenience samples of both patients and paramedics. Because only those patients who were transported to the ED could be included, the study population was more severely ill than the overall out-of-hospital patient population. Also, paramedics who volunteered for the study may have been more motivated than nonparticipants. However, these facts only serve to make the findings more troubling.
The heart of the study boils down to one question: Does this patient need to go to an ED? By collapsing the 4 triage categories into 2 and using physician ratings as the criterion standard, paramedics identified patients needing ED evaluation with a sensitivity of 89.7% and a specificity of 36.5%. Although it is easy to agree that undertriaging 10% of patients is unacceptable, when would the sensitivity be high enough for us to consider paramedic triage safe? I do not have the answer to that question, but it seems clear that, if we were finally able to reach an "acceptable" sensitivity (ie, an acceptable degree of undertriage), the specificity would be so low that the potential for saving system resources would be marginal at best. The findings were remarkably consistent with those of other authors8,9; paramedics triaged a small percentage (10% to 15%) of patients to "no ED visit" or "no transport" and, of these patients, about half were misclassified. On the basis of these results, the emergency medical services (EMS) system in Albuquerque, NM, abandoned paramedic triage.10
For proponents of paramedic triage, a natural reaction to these data is to call for further research to either refine the guidelines, improve paramedic education, or both. Before embarking on this work, investigators should address 2 policy dilemmas that raise questions about the need for more research on paramedic triage. The first dilemma is that the potential for saving system resources using EMS triage is probably vastly overstated. Unless paramedic triage significantly reduces ED visits, system cost savings will be modest. The second dilemma is the broader problems associated with access barriers and triage of nonurgent patients away from the ED. When placed in context, these paramedics had the same difficulties with triage that other providers have had at every training level. We all know that unnecessary ED visits exist, but it is difficult to identify only "inappropriate" patients without triaging out of the ED a small but disturbing percentage of patients with serious conditions. Although it would be premature to call for an end to research on EMS triage, it is reasonable to ask investigators to justify how future work could overcome these problems.
Will paramedic triage save money? On the basis of what we know to date, the answer is probably no. Only 180 (10%) of the patients were triaged to "no ED visit"; unfortunately, the physician panel thought that 99 of these patients needed to be seen in the ED. An additional 196 patients were triaged to "no transport" by paramedics (category 2). We do not know how many of these patients, if any, would have been transported by basic life support providers, by other transportation, or not at all. Although a total reduction in transports of this magnitude (376 patients [32%]) would be significant, there are 2 important caveats. First, each of these calls requires an EMS response and paramedic triage evaluation, so the response volume for the system would not be reduced. Furthermore, if basic life support providers transported patients in category 2, the response of a second ambulance would erode resource savings for the system. Second, because of the degree of undertriage, the number of patients triaged to "no transport" would undoubtedly go down with further refinements of the triage guidelines. By the time an acceptable level of paramedic undertriage is achieved, the number of patients in the "no transport" category likely would be so low that potential system savings would be marginal. In today's medical-legal environment, one adverse patient outcome after a refusal to transport could wipe away all of the system savings generated by paramedic triage.
Another way to look at the resource issues involved is to examine fixed and marginal costs. Fixed costs are those that are unrelated to patient volume and are difficult to eliminate on a short-term basis. Conversely, marginal cost is the added expense of caring for one additional patient. EDs have high fixed costs and relatively low marginal costs.3 In many respects, EMS systems have similar properties. Modest reductions in EMS patient transports (ie, <10%) are unlikely to reduce fixed system costs. Given the research to date, it is optimistic to expect paramedic triage to reduce patient transports by even 10%, and, by definition, it cannot reduce initial EMS responses. Unfortunately, many of the system resources for EMS calls are expended by the time patients are triaged to no transport or alternative transport. Furthermore, the concept of nonemergency triage centers potentially ignores the fixed versus marginal cost argument for EDs. If these centers fail to use existing resources for patient care, they could duplicate fixed ED costs and lead to higher system expenditures.
To evaluate patient safety, Pointer et al7 appropriately focused on the subset of patients who were undertriaged. However, to evaluate the potential to save system resources, it is important to look also at the rate of overtriage. Using the physician panel as the criterion standard, 734 (62%) of 1,180 patients were overtriaged, including 141 patients who physicians thought did not need an ED visit, but paramedics did. If the overall goal of EMS triage is to reduce system costs, this overtriage rate is particularly concerning.
The second dilemma that should be addressed before designing future research is the elusiveness of the truly "unnecessary" ED visit. In retrospect, each of us can identify patients who could have been seen in other settings. Prospectively, almost everyone's experience has been mixed at best. Derlet and Nishio11 prospectively triaged more than 4,000 patients out of the ED during a 6-month period and reported no adverse patient outcomes. Unfortunately, these promising findings could not be duplicated in other settings.12,13 In a multicenter survey of all ambulatory ED patients during a 24-hour period, more than 3,000 patients were classified as nonurgent by nursing triage. Of these "nonurgent" patients, 166 (5.5%) were admitted to the hospital.
Preauthorization requirements are another mechanism for triaging patients away from the ED. Several investigators have shown how preauthorization requirements place patients at risk for adverse outcomes.14-16 Most important, diverting patients from the ED often does not affect future care-seeking patterns. Gadomski et al17 studied a cohort of pediatric patients who were denied care in the ED because of nonurgent complaints. Although there were no adverse outcomes, subsequent ED utilization rates were unchanged.17 Shah-Canning et al18 described the persistence of ED care-seeking patterns for inner-city families without a regular provider during a 3-decade period.
Even after the ED visit, it is difficult to find agreement about the appropriateness of ED use. Gill et al19-21 found persistent disagreement about the urgency of ED visits between nurses and nurses, emergency physicians and nurses, and nurses and patients. Other investigators have documented disagreement between emergency physicians and patients22 and between emergency physicians and internists.23 Furthermore, in a series of focus groups discussing ED case vignettes, laypeople had diverse and strongly held opinions about the appropriateness of ED use.24 No matter who one asks, it is hard to find agreement about the urgency and appropriateness of ED visits.
The conflict about nonurgent use of the ED highlights broader questions about the ED's role in the health care system.25 Access barriers such as lack of health insurance, transportation problems, poor education, exposure to violence, and lack of a regular source of care are all associated with use of the ED.26-29 Although it is easy to criticize vulnerable populations for coming to the ED with nonurgent complaints, they often have limited alternatives. In the Medicaid Access Study, less than half of 953 practice sites offered an appointment or authorization for a walk-in visit, and only 8% of clinics offered after-hour care within 2 days without a cash copayment.30 Considering these data, it is not surprising that the ED is an essential safety net in today's fragmented health care system.31
The access barriers that are associated with nonurgent ED use almost certainly contribute to requests for ambulance transportation and raise several questions for future research. Before refusing transport to out-of-hospital patients, it would be helpful to understand the access barriers that are associated with requests for EMS response. How are inappropriate ambulance requests related to disparities in health care access? Which access barriers contribute to inappropriate 911 calls, and what system interventions will alleviate these barriers? How does the availability of transportation alternatives affect nonurgent ambulance requests in high-risk neighborhoods? Do patients contact EMS to avoid long delays in overcrowded EDs?
Payers will continue to push EMS systems to control costs. Although it may be possible to refine triage guidelines and to enhance paramedic education, the potential system savings from paramedic triage are modest. As Pointer et al7 have demonstrated, patient safety is the most important criterion for evaluating EMS system changes. Experience to date suggests that triaging patients away from the ED after they have requested emergency care leads to adverse patient outcomes and fails to save significant system resources. Although less research has been done in the out-of-hospital setting, EMS triage could be equally disappointing. It would be unfortunate if a series of barriers to ambulance transport were constructed to test this assumption.
We have a lot of work to do to improve access to care, to increase the availability of reliable alternatives to ED use, and to improve the efficiency of care in both EMS systems and hospital EDs. The access barriers experienced by EMS and ED patients reflect broad problems with the organization and financing of care in the US health care system. We certainly need more research to identify the EMS system characteristics that will ensure access to appropriate emergency care and ambulance transportation, especially for vulnerable populations. However, much of the work of reducing inappropriate ambulance transport should occur before the 911 call is made.
REFERENCES
1. Roth JA. Utilization of the hospital emergency department. J Health Soc Behav. 1971;12:312-320.
2. McCraig LF. National Hospital Ambulatory Medical Care Survey: 1998 Emergency Department Summary. Hyattsville, MD: National Center for Health Statistics; 2000.
3. Williams RM. The costs of visits to emergency departments. N Engl J Med. 1996;334:642-646.
4. Baker LC, Baker LS. Excess cost of emergency department visits for nonurgent care. Health Aff (Millwood). 1994;13:162-171.
5. Derlet RW, Richards JR, Kravitz RL. Frequent overcrowding in US emergency departments. Acad Emerg Med. 2001;8:151-155.
6. Kellermann AL. Déjà vu. Ann Emerg Med. 2000;35:83-85.
7. Pointer JE, Levitt MA, Young JC, et al. Can paramedics using guidelines accurately triage patients? Ann Emerg Med. 2001;38:268-277.
8. Schmidt T, Atcheson R, Federiuk C, et al. Evaluation of protocols allowing emergency medical technicians to determine need for treatment and transport. Acad Emerg Med. 2000;7:663-669.
9. Hauswald M, Brillman J, Raynovich W, et al. Training paramedics to determine who does not need ambulance transport: validation of an educational program and protocol [abstract]. Acad Emerg Med. 1999;6:474.
10. Albuquerque halts EMS triage program. EMS Insider. 1999;8.
11. Derlet RW, Nishio DA. Refusing care to patients who present to an emergency department. Ann Emerg Med. 1990;19:262-267.
12. Lowe RA, Bindman AB, Ulrich SK, et al. Refusing care to emergency department patients: evaluation of published triage guidelines. Ann Emerg Med. 1994;23:286-293.
13. Birnbaum A, Gallagher EJ, Utkewicz M, et al. Failure to validate a predictive model for refusal of care to emergency department patients. Acad Emerg Med. 1994;1:213-217.
14. Derlet RW, Hamilton B. The impact of health maintenance organization care authorization policy on an emergency department before California's new managed care law. Acad Emerg Med. 1996;3:338-344.
15. Bitterman RA. Managed care authorization for emergency department services: a medical risk for patients, a legal risk for doctors and hospitals. N C Med J. 1997;58:260-263.
16. Zautcke JL, Fraker LD, Hart RG, et al. Denial of emergency department authorization of potentially high-risk patients by managed care. J Emerg Med. 1997;15:605-609.
17. Gadomski AM, Perkis V, Horton L, et al. Diverting managed care Medicaid patients from pediatric emergency department use. Pediatrics. 1995;95:170-178.
18. Shah-Canning D, Alpert JJ, Bauchner H. Care-seeking patterns of inner-city families using an emergency room: a three-decade comparison. Med Care. 1996;34:1171-1179.
19. Gill JM, Riley AW. Nonurgent use of hospital emergency departments: urgency from the patient's perspective. J Family Pract. 1996;42:491-496.
20. Gill JM, Reese CL, Diamond JJ. Disagreement among health care professionals about the urgent care needs of emergency department patients. Ann Emerg Med. 1996;28:474-479.
21. Gill JM. Nonurgent use of the emergency department: appropriate or not? Ann Emerg Med. 1994;24:953-957.
22. Gifford MJ, Franaszek JB, Gibson G. Emergency physicians' and patients' assessments: urgency of need for medical care. Ann Emerg Med. 1980;9:502-507.
23. O'Brien GM, Shapiro MJ, Faggan MJ, et al. Do internists and emergency physicians agree on the appropriateness of emergency department visits? J Gen Intern Med. 1997;12:188-191.
24. Asplin BR, Goold SD, Leung T, et al. Layperson perceptions of the appropriateness of emergency department utilization [abstract]. Acad Emerg Med. 2000;7:555-556.
25. Steinbrook R. The role of the emergency department. N Engl J Med. 1996;334:657-658.
26. Rask KJ, Williams MV, Parker RM, et al. Obstacles predicting lack of a regular provider and delays in seeking care for patients at an urban public hospital. JAMA. 1994;271:1931-1933.
27. Jones DS, McNagny SE, Williams MV, et al. Lack of a regular source of care among children using a public hospital emergency department. Pediatr Emerg Care. 1999;15:13-16.
28. Baker DW, Stevens CD, Brook RH. Regular source of ambulatory care and medical care utilization by patients presenting to a public hospital emergency department. JAMA. 1994;271:1909-1912.
29. Pane GA, Farner MC, Salness KA. Health care access problems of medically indigent emergency department walk-in patients. Ann Emerg Med. 1991;20:730-733.
30. The Medicaid Access Study Group. Access of Medicaid recipients to outpatient care. N Engl J Med. 1994;330:1426-1430.
31. Fields WW, ed. Defending America's Safety Net. Dallas, TX: American College of Emergency Physicians; 1999.

Australasian College for Emergency Medicine (1998). Policy Document - Triage. http://www.acem.org.au/: 1-3.

The Australasian Triage Scale (ATS) is designed for use in hospital-based emergency services throughout Australia and New Zealand. It is a scale for rating clinical urgency. Although primarily a clinical tool for ensuring that patients are seen in a timely manner, commensurate with their clinical urgency, the ATS is also a useful casemix measure. The scale directly relates triage code with a range of outcome measures (inpatient length of stay, ICU admission, mortality rate) and resource consumption (staff time, cost). It provides an opportunity for analysis of a number of performance parameters in the Emergency Department (casemix, operational efficiency, utilisation review, outcome effectiveness and cost).

Bhimani, M, Li, G, et al. (2001). "The impact of physician rapid assessment program at triage on ED overcrowding." Academic Emergency Medicine 8(5): 578.

Background: Emergency department (ED) overcrowding is again reaching crisis proportions nationwide, with attendant risk to patient care and outcomes.
Objective: To test the hypothesis that a physician-driven Rapid Assessment Program (RAP) will decrease the walkout rate and patient length of stay (LOS) in a cost-effective manner in a large university ED.
Methods: RAP, consisting of an attending board-certified EM physician performing brief medical screenings on all patients at triage, and ordering any necessary laboratory tests or radiographic evaluations, was initiated during the busiest 12 hours each weekday during a consecutive 4-month period in the fall of 2000. RAP was not extended to the weekends. Walkout rates and lengths of stay, adjusted for patient volume, were compared to the same time period in 1999 and to the month prior to and after the induction of the program. Cost-effectiveness of the program was calculated and annualized.
Results: Despite a 12% increase in patient volume (17,266 vs 19,311) during the study period compared to the same period the year before, the overall walkout rate decreased 33% (9.6% vs 6.4%) (p < 0.01). The walkout rates the month prior to and the month after the program stopped were 30% and 29% higher, respectively (p < 0.01). Length of stay for discharged patients decreased from 351 min to 310 min (11%), compared to the 4 months prior to the program (p <0.01). Conservatively estimated annualized revenue recovery for the program based on current reimbursement patterns is $398,000 ($57,000 professional fees, $341,000 facilities fees) and does not include laboratory, radiology, ancillary services, consultations, and admission-related revenue. Annualized direct cost of the program is $338,000.
Conclusions: Although RAP was in place for only 30% of the available weekly hours, it appears to be cost-effective in decreasing the walkout rate and length of stay.

Bindman, A (1995). "Triage in accident and emergency departments: We need to consider what kind of errors we can afford." British Medical Journal 311(7002): 404.

FULL EDITORIAL
Triage practices in accident and emergency departments evolved from the military procedure of giving priority for medical care to those who were expected to benefit the most. The focus of triage in many accident and emergency departments today, however, is less on discriminating among the sickest patients and more on identifying patients who may not need emergency care at all. The high cost of care in an accident and emergency department and long waiting times, which result in substantial numbers of patients leaving without being seen, have led to increased scrutiny of this clinical department. [1] In the United States the growth in the use of accident and emergency departments has been attributed largely to the increase in the number of people without a regular source of primary care. [2] In the United Kingdom the problem is not so much a lack of primary care providers but that these providers may not be technologically or organisationally equipped to evaluate and manage a number of acute problems. [3] Investigators and policymakers in both countries have concluded that a large proportion of patients who come to accident and emergency departments could be managed less expensively and more effectively in alternative ambulatory settings. [4,5]
Several investigators have proposed guidelines to identify patients who present to accident and emergency departments without a true need for emergency services. In some cases the guidelines are specific and linked to policies of refusing care to patients with less urgent needs. [6] In this week's issue Dale et al propose general guidelines for separating two classes of patients: those who need accident and emergency care and those who need primary care. [7] Triage guidelines, broad or specific, generally predict the sickest patients who attend accident and emergency departments. To date, however, no triage guidelines perfectly predict which patients truly are emergencies.
Part of the difficulty of developing accurate triage guidelines is the lack of agreement on how to judge the appropriateness of a visit to an accident and emergency department. Investigators have used expert opinion, self ratings by patients, review of activities in accident and emergency departments, and subsequent admission to judge appropriateness. All these approaches find that appreciable proportions of patients presenting to accident and emergency departments do not require emergency care. When these measures were applied to a sample of patients, however, there was little agreement about which specific patients made unnecessary visits. [8]
Even if there were a gold standard for determining the appropriateness of visits, perfectly accurate triage guidelines could probably never be developed. Short nursing interviews cannot be expected to predict the seriousness of some patients' conditions. Treatment of patients in an accident and emergency department, after all, is generally not begun until after the doctor has had an opportunity to gather additional clinical data.
Triage guidelines that are not perfectly accurate may still be valuable. It is less problematic if guidelines systematically recommend care in the accident and emergency department for some patients who could be treated in alternative settings than it is if they routinely recommend alternative care for patients who truly are emergencies. The importance of errors in triage is also directly related to how easily they can be rectified. Mistaken triage in which the patient is sent to an alternative site of ambulatory care is more problematic if the site is several kilometres away than if it is across the street.
If one of the goals of sending patients to alternative sites providing primary care is to save money then Dale et al have another important message. Among a random sample of patients presenting to an accident and emergency department, primary care physicians provided less costly non-emergency ambulatory care than did emergency physicians. [9] This finding is consistent with those of other investigators who have found that emergency physicians tend to interpret clinical signs and symptoms as being potentially more serious and therefore in need of more investigation than do other providers in the ambulatory setting. [10,11]
Although recommendations for organising acute ambulatory care services may need to be modified if studies of outcome show a difference between emergency and primary care physicians, some recommendations can be offered. Hospitals with accident and emergency departments should also have a site providing drop in ambulatory care. Ideally, the two sites should be geographically close but staffed by different types of providers. Triage guidelines that are used to send patients presenting to accident and emergency departments to the alternative sites of ambulatory care should be biased towards having patients seen in the accident and emergency department. Nurses who use triage guidelines should receive standardised training on how to interpret and apply them. They should also be taught that the guidelines can be bypassed either when the patient initially presented or after further evaluation. Finally, attempts should be made to reduce the demand for care in accident and emergency departments by enhancing access to primary care providers who are equipped to offer a broad array of diagnostic and treatment services. Future studies may determine whether this is best achieved by bringing the primary care providers to the accident and emergency department or by moving more technology than currently exists into the general practitioners' practice.
REFERENCES
1. Bindman A, Grumbach K, Keane D, Rauch L, Luce J. Consequences of queuing for care at a public hospital emergency department. JAMA 1991;266:1091-6.
2. Grumbach K, Keane D, Bindman A. Primary care and public emergency department over-crowding. Am J Public Health 1993;83:372-8.
3. Singh S. Self referral to accident and emergency department: patients' perceptions. BMJ 1988;297:1179-80.
4. Office of the Inspector General. Use of emergency rooms by Medicaid recipients. Washington, DC: Department of Health and Human Services, 1992. (OE1 06-9000180).
5. Department of Health and Social Security. Royal commission on the National Health Service. London: HMSO, 1978.
6. Derlet R, Nishio D. Refusing care to patients who present to an emergency department. Ann Emerg Med 1990;19:262-7.
7. Dale J, Green J, Reid F, Glucksman E. Primary care in the accident and emergency department: I. Prospective identification of patients. BMJ 1995;311:423-6.
8. Lowe RA, Bindman AB, Ulrich SK, Scaletta TA, Norman G, Grumbach K, et al. What is an appropriate emergency department visit? An explanation for the failure to agree. Ann Emerg Med 1993;22:951.
9. Dale J, Green J, Reid F, Glucksman E, Higgs R. Primary care in the accident and emergency department: II. Comparison of general practitioners and hospital doctors. BMJ 1995;311:427-30.
10. Foldes SS, Fischer LR, Kaminsky K. What is an emergency? The judgments of two physicians. Ann Emerg Med 1994;23:833-40.
11. Baker LC, Baker LS. Excess cost of emergency department visits for nonurgent care. ? journal 1994;13:162-71.

BRC Marketing and Social Research (2001). The Evaluation of the Healthline Service. Interim Report. New Zealand, Ministry of Health: 1-62.

This report is the first Interim Report for the Healthline evaluation. Its purpose is to describe the development/implementation of the Healthline service. In particular, the report highlights the factors which have contributed to Healthline's success and those that have detracted from this success to date.
The report relates to the process component of the evaluation and covers the five month period from the time the Healthline consortium was contracted (22 December 1999) to the launch of the Healthline service (8 May 2000). This report also comments on the first six months of operation to October 2000.

Cook, C, Muscarella, P, et al. (2001). "Reducing overtriage without compromising outcomes in trauma patients." Archives of Surgery 136(7): 752-6.

Hypothesis: Changing category 1 criteria to include primarily physiologic and anatomic indicators of injury, eliminating mechanism of injury criteria, decreases the rate of overtriage without compromising outcomes.
Methods: Retrospective review of our American College of Surgeons-verified level I trauma registry from January 1, 1996, to December 31, 1998, comparing patients before and after trauma alert criteria changes.
Results: There was a significant decrease in category 1 alerts, representing a reduction in overtriage. There was a concomitant increase in injury severity and mortality in category 1 patients. There was no significant change in injury severity or mortality for category 2 patients.
Conclusions: There was a significant reduction in overtriage of trauma patients demonstrated without an appreciable impact on patient outcome. Changing trauma response criteria to more physiologic and anatomic indicators allowed improved triage of trauma patients, which improves resource allocation.

Dent, A, Rofe, G, et al. (1999). "Which triage category patients die in hospital after being admitted through emergency departments? A study in one teaching hospital." Emergency Medicine 11(2): 68-71.

Objectives: To quantify the number of deaths per triage category (scale 1-5, Australian National Triage Scale) occurring after admission to hospital via an emergency department and to examine the causes of death in each category.
Setting: St Vincent's Hospital, Melbourne (Victoria, Australia) is an acute adult tertiary referral hospital.
Methods: Electronic collection of all hospital admissions and their subsequent destination for the calendar year 1997, with chart and/or postmortem review to determine the cause of death.
Results: The percentage of deaths per triage group decreased with urgency. Numerically, the largest group of all admissions and admissions followed by deaths consist of patients presenting in category 4 (semi-urgent).
Conclusions: Triage categories may be a useful tool for prioritizing acute patients, but patients in low triage categories often have fatal illnesses. Performance measurements and workload assessments for emergency departments may need to involve category 4 patients to take account of this factor.

Gerdtz, M and Bucknall, T (2001). "Triage nurses' clinical decision making. An observational study of urgency assessment." Journal of Advanced Nursing 35(4): 550-61.

Background: Researchers have described both the various decision tasks performed by triage nurses using self-report methods and identified time as a factor influencing the quality of triage decisions. However, little is known about the decision tasks performed by triage nurses when making acuity assessments, or the factors influencing triage duration in the real world.
Aims: The aims of this study were to: describe the data triage nurses collect from patients in order to allocate a triage priority using the Australasian Triage Scale (ATS); describe the duration of nurses' decision making for ATS categories 2-5; and to explore the impact of patient and nurse variables on the duration of the triage nurses' decision making in the clinical setting.
Design: A structured observational study was employed to address the research aims. Observational data was collected in one adult emergency department located in metropolitan Melbourne, Australia. A total of 26 triage nurses consented and were observed performing 404 occasions of triage. Data was collected by a single observer using a 20-item instrument that recorded the performance frequencies of a range of decision tasks and a number of observable patient, nurse and environmental variables. Additionally, the nurse-patient interaction was recorded as time in minutes.
Results: It was found that there was limited use of objective physiological data collected by the nurses' in order to decide patient acuity, and large variability in the duration of triage decisions observed. In addition, analysis of variance indicated strong evidence of a true difference between triage duration and a range of nurse, patient and environmental variables.
Conclusion: These findings have implications for the development of practice standards and triage education. In particular, it is argued that practice standards should include routine measurement of physiological parameters in all but the collapsed or obviously unwell patient, where further delay may impede the delivery oftime-critical intervention. Furthermore, the inclusion of arbitrary time frames for triage assessment in practice standards are not an appropriate method of evaluating triage decision making in the real world.

Gilboy, N, Travers, D, et al. (1999). "Re-evaluating triage in the millennium: A comprehensive look at the need for standardization and quality." Journal of Emergency Nursing 25(6): 468-73.

In the United States nearly 100 million people seek care in the emergency department each year.1 Each of these patient visits requires multiple forms of assessment, beginning with triage. A registered nurse (RN) must quickly and accurately triage each patient on arrival to ensure that the right patient is in the right place at the right time and that no one is overlooked. Whatever triage system is used, it must enable triage nurses to assess patient acuity accurately, consistently, and efficiently. Because emergency departments are facing increased volume, increased acuity, and enormous pressure to control costs, determining a triage system that accurately meets these objectives is imperative. As we enter the 21st century, we should take time to reflect on the evolution of triage and identify ways that the system can continue to evolve.
As often is the case with innovations in health care delivery, triage began in the military, in the 1800s, when it was determined that sorting patients according to their medical needs would be more efficient. The word triage comes from the French word trier, meaning to sort or choose. In the battlefield, wounded soldiers were sorted into 3 groups-those who were severely injured and deemed not salvageable, those who needed immediate attention, and those whose care could be delayed. ENA's Standards of Emergency Nursing Practice2 speak to the issue of triage. Comprehensive Standard VII outlines the importance of an emergency nurse triaging all patients to prioritize patient care based on physical, psychological, and social needs. The objective of any triage system is to quickly sort patients by priority of care at the time the patient comes to the emergency department. Inherent in the ED process of rapid determination of the patient's immediate needs is the context of the current demands on the department. The formal concept of triage was first introduced in emergency departments in the late 1950s and early 1960s. Emergency departments began using the principles of triage when a significant increase in patient volume occurred. It was recognized that many patients were presenting with nonurgent conditions.3 At the same time, many physician practices were becoming office based, and more physicians were entering specialties rather than general practice. Emergency departments became the principal providers of primary medical care during off-duty hours. Application of triage principles became essential to set priorities and maintain an orderly flow of patients through the department. The need was for rapid, accurate sorting of patients, separating those requiring immediate medical care from those who could wait a while before being evaluated and treated. At that time, triage nurses were able to refer patients to clinics and other appropriate areas for treatment, such as outpatient clinics and different specialty areas of the hospital. In a study at a busy New York hospital, Albin et al 4 found that 43% of triaged patients were seen in the emergency department, 46% were referred to a screening clinic, and 8% were referred to outpatient specialty clinics.
Since the early 1980s, the federal government, through the Emergency Medical Treatment and Active Labor Act (EMTALA), has required ED triage for all hospitals participating in Medicare and Medicaid. The Joint Commission on the Accreditation of Health Care Organizations (JCAHO) requires compliance with these federal regulations. In addition, EMTALA specifically requires that screening and stabilization of patients who come to the emergency department be completed before any financial information is obtained. These regulations all had an impact on how emergency departments changed the ways they did triage. These changes have set the stage for a long overdue review and revision of triage priorities, how triage is staffed, and the purpose of triage. We will discuss 4 specific areas of triage that we believe require revision: assessment, acuity systems, triage nurse competency, and reproducibility of data among hospitals.

Grant, S, Spain, D, et al. (1999). "Rapid assessment team reduces waiting time." Emergency Medicine 11(2): 72-7.

Objective: In an effort to reduce waiting times and improve the performance of the clinical indicator waiting time relative to triage category, a rapid assessment team was implemented.
Methods: The rapid assessment team consists of the rapid assessment team doctor and triage nurse. The rapid assessment team ensured, wherever possible, that patients were medically assessed prior to expiration of the waiting time appropriate to their National Triage Scale. Waiting time performance indicators, median waiting time and length of stay during the 3 months the rapid assessment team was operative were compared with the same period 1 year before.
Results: During the 3 month period where the rapid assessment team was operative, 59.0% of patients (n = 5877) were seen within accepted time standards and the median waiting time was 32 min. This compared with 39.1% (n = 3901) and 50 min, respectively, in the same period 1 year before (P < 0.001). There was no significant difference in median length of stay (3.2 h for both, P = 0.18). Improvements in waiting times occurred in all triage categories except category 1. Due to a lack of resources and funds, the rapid assessment team was discontinued on 4 October 1997.
Conclusions: The rapid assessment team reduces doctor waiting times. Departments considering implementing a rapid assessment team should ensure it is funded as a separate resource.

Health Department of Western Australia (2001). Health Call Centre and HealthDirect Service. First Annual Report. Perth, Health Department of Western Australia: 1-13.

HealthDirect is the first telephone triage service of such a scale attempted in Australia. The public's rapid take-up of the service with over 147,000 calls in its first year of operation suggests that it has met a vital need in the community. This report provides details on the service's activity and performance during its first 12 months of operation.
HealthDirect enables people in Western Australia to call and speak to a registered nurse about immediate health issues and receive immediate advice. The nurse assessment focuses on the type of health care needed and the urgency. Where appropriate, first aid or self care advice may be provided to assist the caller until face-to-face assessment is obtained.
HealthDirect is being delivered from a new state-of-the-art health call centre established in Perth and the nurses are guided by medically endorsed protocols. The Call Centre and introduction of HealthDirect was a State and Commonwealth joint initiative.

Johnson, S, Snelling, R, et al. (2001). "Comparison of out-of-hospital diagnosis of stroke with emergency department diagnosis of stroke." Academic Emergency Medicine 8(5): 489.

Objective: New American Heart Association (AHA) guidelines recommend that out-of-hospital protocols provide for expeditious recognition and urgent transport of patients with acute stroke syndromes to stroke centers. We sought to compare the out-of-hospital providers' diagnostic impression of stroke at the scene with the emergency department admission diagnosis in our EMS system prior to implementation of a triage protocol using a validated stroke scale.
Methods: This was a retrospective observational study of an out-of-hospital ALS database from 11/98 to 12/00 from an all-volunteer ALS EMS system serving a suburban/rural county of 1.4 million people. Most ALS care is delivered by EMT-critical care providers (250 hours of training), supplemented by EMT-paramedics. The EMT impression of stroke is based on statewide training using DOT objectives. Consecutive cases were identified from the database in this 2-year period with an ED admission diagnosis of CVA/TIA and compared to the EMT impression. Consecutive patients with an out-of-hospital impression of CVA/TIA were identified and compared with their ED diagnoses. Sensitivity and positive predictive value (PPVs) of the out-of-hospital impression were calculated with 95% confidence intervals.
Results: Of 504 patients identified with an ED diagnosis of CVA/TIA, 204 had an out-of-hospital diagnosis of CVA/TIA. Other out-of-hospital diagnoses included altered mental status, weakness, diabetic emergency, dizziness, chest pain, syncope, seizure, bradycardia, overdose, respiratory distress, dehydration, and allergic reaction. Of 474 patients with an out-of-hospital diagnosis of CVA/TIA, 204 had an ED diagnosis of CVA/TIA. The sensitivity of the out-of-hospital impression of stroke was 40.5% (C.I. = 36.2, 44.9). The PPV of the out-of-hospital impression of stroke is 43% (C.I. = 38.6, 47.6).
Conclusions: Evaluation of current abilities of EMS personnel to identify stroke should be conducted prior to implementing stroke triage protocols and measuring impact of further training with valid stroke scales.

Kelly, A and Richardson, D (2001). "Training for the role of triage in Australasia." Emergency Medicine 13(2): 230-2.

Objective: To characterize the prerequisite experience and training undertaken by nurses for the role of triage in emergency departments in Australasia.
Methods: Postal survey of charge nurses/unit nurse managers of all Australasian emergency departments accredited for specialist emergency physician training by the Australasian College for Emergency Medicine.
Results: The response rate was 89%. The most common duration of prerequisite experience was 12-18 months. Most programmes use a combination of educational activities, with self-directed learning packages, lectures and mentored experience being the most common. Three hospitals reported no preparation for triage.
Conclusion: In Australasia, there is wide variability in required training and experience before triage duties are performed. Strategies to set suggested minimum standards in these areas and to make training activities more accessible are recommended.

Lattimer, V, Sassi, F, et al. (2000). "Cost analysis of nurse telephone consultation in out of hours primary care: Evidence from a randomised controlled trial." British Medical Journal 320: 1053-7.

Objective: To undertake an economic evaluation of nurse telephone consultation using decision support software in comparison with usual general practice care provided by a general practice cooperative.
Design: Cost analysis from an NHS perspective using stochastic data from a randomised controlled trial.
Setting General practice cooperative with 55 general practitioners serving 97 000 registered patients in Wiltshire, England.
Subjects: All patients contacting the service, or about whom the service was contacted during the trial year (January 1997 to January 1998).
Main outcome measures Costs and savings to the NHS during the trial year.
Results: The cost of providing nurse telephone consultation was £81 237 per annum. This, however, determined a £94 422 reduction of other costs for the NHS arising from reduced emergency admissions to hospital. Using point estimates for savings, the cost analysis, combined with the analysis of outcomes, showed a dominance situation for the intervention over general practice cooperative care alone. If a larger improvement in outcomes is assumed (upper 95% confidence limit) NHS savings increase to £123 824 per annum. Savings of only £3728 would, however, arise in a scenario where lower 95% confidence limits for outcome differences were observed. To break even, the intervention would have needed to save 138 emergency hospital admissions per year, around 90% of the effect achieved in the trial. Additional savings of £16 928 for general practice arose from reduced travel to visit patients at home and fewer surgery appointments within three days of a call.
Conclusions: Nurse telephone consultation in out of hours primary care may reduce NHS costs in the long term by reducing demand for emergency admission to hospital. General practitioners currently bear most of the cost of nurse telephone consultation and benefit least from the savings associated with it. This indicates that the service produces benefits in terms of service quality, which are beyond the reach of this cost analysis.

Niegelberg, E, Slovensky, S, et al. (2001). "Prehospital triage of severe acute coronary syndrome to cardiac centers." Academic Emergency Medicine 8(5): 488-9.

Background: New international American Heart Association (AHA) guidelines recommend out-of-hospital triage of patients with critical acute coronary syndrome (ACS) and left ventricular dysfunction (BP < 100 systolic, pulse > 100, signs of shock, and congestive heart failure) to hospitals with 24-hour emergency cardiac catheterization and rapid revascularization capability. For patients less than 75 years of age this is a class I recommendation. Estimates of patient volume are necessary to identify hospital resource requirements.
Objective: The purpose of this study was to determine the potential volume of patients with critical ACS who might be triaged directly to a tertiary cardiac center in a regional EMSS serving 1.4 million patients.
Methods: Retrospective observational study of consecutive patients treated by ALS ambulance in 1999-2000. Participants were patients over age 30 with presenting chief complaint of chest pain and meeting AHA guidelines.
Results: Of 4,694 patients with chest pain, 148 had initial BP <100 and of these 39 had initial pulse >100. Of the 39 meeting both BP and pulse criteria, the ED admitting diagnosis was cardiac in 28 of the 32 patients for whom it was known. Only four of the 39 patients had rales recorded in the field.
Conclusions: In our system serving 1.4 million, only 39 of 4,694 (0.8%) patients with chest pain in a two-year period treated by ALS ambulance met initial BP and pulse criteria for direct triage to a tertiary cardiac center. This estimate of approximately 20 patients per year is useful in determining resource requirements of receiving hospitals prior to implementing triage protocols for ACS. A limitation is lack of inclusion of patients treated by BLS ambulances in the region.

Schmidt, T, Iserson, K, et al. (1995). "Ethics of Emergency Department triage - SAEM position statement." Academic Emergency Medicine 2(11): 990-5.

Emergency department overcrowding, the growth of managed care, and the high cost of emergency care are creating pressures to triage patients away from U.S. EDs. Paradoxically, this pressure to limit patient access to EDs has increased in spite of federal laws that restrict patient triage and transfer. The latter regulations view EDs as the safety net for the U.S. health care system. The SAEM Ethics Committee evaluated the ethical implications of policies that triage patients out of the ED prior to complete evaluation and treatment. The committee used these implications to develop practical guidelines, which are reported.