Aniello Iannuzzi: Triage needs treatment

AFTER countless “emergency” calls for incorrect triage — especially those that disrupt sleep and busy office sessions — I am well aware of the inconsistencies of the emergency department.

I am therefore relieved that the Emergency Triage Education Kit (ETEK) is under review.

Triage is a French term, derived from military medicine. The concept started with three categories in the Napoleonic wars and was revived in World War I.

The Australasian Triage Scale (ATS) is a modern variation on the original theme, ranging from triage 1 for patients with life-threatening conditions who should be seen immediately in 100% of cases, to triage 5 for patients whose condition is less urgent with at least 70% of patients to be seen within a 2-hour waiting time.

I have pored over the ETEK and Australasian College of Emergency Medicine (ACEM) guideline documents aimed at good triage, and believe there are a number of problems and incorrect assumptions.

For example, ACEM suggests that a blood sugar level (BSL) of more than 16 mmol/L warrants a triage 3, meaning 75% of patients are to be seen within 30 minutes. There must be thousands of Australians in community and nursing homes with BSLs above 16 mmol/L, many of whom are not even aware of it. A BSL of 26 may be closer to the mark for a triage 3.

The ETEK is full of examples of what I consider plain nonsense, such as the recommendation that an otherwise well 47-year old who hurt his wrist playing volleyball and has a good range of movement with some pain on rotation be seen within an hour.

Or a 27-year old travelling to India in a week who presents for advice about vaccines who “should wait no longer than 2 hours”. And a man whose girlfriend is concerned about a mole on his back should be seen within 2 hours to exclude melanoma.

The ETEK is more reliable with the triage 1 and 2 categories. It also states that “environmental factors such as staffing, skill-mix and ED activity level must not influence urgency allocation”.

There are particular challenges in rural and remote areas when no doctor is on site or even in the town. Multiple casualties are another challenge — if several triage 1 or 2 patients present at once, it requires a very skilled and calm clinician to prioritise.

We also need to be mindful of the time from presentation to triage, as well as the time from triage to treatment. In too many EDs, big and small, patients spend excessive time filling in forms and registering before they’re even triaged.

ACEM conducted a literature review recently and published the following ideas:

• The ATS in its current form should only be used to describe urgency

• Separate measures are needed to describe severity, complexity, workload and staffing, and to assess quality of care

• Standard definitions are needed for terms such as urgency, severity and complexity as they are used interchangeably, contributing to confusion

These points are valid, but I would like to add some of my own:

• The National Triage Working Party include representatives of rural and remote doctors, GPs, physicians and surgeons to prevent inappropriate triaging (eg, are emergency physicians really trained to advise on travel vaccines and melanoma?)

• Triage 6 be established for cases that need to be seen on the day but are by no means an immediate threat to patient’s health

• Triage 7 be introduced for patients that should not be seen in EDs at all

• Patients in triage 5, 6 and 7 be billed privately if seen by a doctor in ED or be sent to a primary care setting

• Ambulance officers have more responsibility for triage in the field, so patients are taken to appropriate facilities, especially in rural areas.

The ETEK review is a golden opportunity to address many important issues. We have to teach the public — and ourselves — to stop confusing convenience, urgency and emergency.

The term “emergency department” is fast becoming a misnomer as EDs are increasingly used as medical convenience stores.

Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.

Posted 22 April 2013

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