Transcript Triage - HIROC.com

Triage – It’s a Risky Business
Randy M. Zettle
Joy McCarron
MD, CCFP (EM), LLB, FCFP
RN, BScN
Borden Ladner Gervais
Toronto
Master Trainer Triage, OHA
Sr. Leader ER Clinical Program
Cancer Care Ontario - ATC
April 27, 2015
Why continue to Triage in Ontario
ER’s?
• Best Practice Nationally
• Accreditation Standard
• Ministry funding source Implications
2015 Risk Ranking (by claim costs)
What’s the Cost?
Rank
Category
1
Maternal/Neonate - Failure to interpret/respond to abnormal fetal status
2
Medical/Surgical - Failure to appreciate status changes/deteriorating patients
3
Maternal/Neonate - Failure to monitor fetal status
4
Maternal/Neonate - Mismanagement of induction/augmentation medications
5
Infection Control - Healthcare acquired infections
6 Inadequate triage assessment /
re-assessment
7
Diagnostic - Misinterpretation of laboratory/diagnostic imaging
8
Falls - Patients
10
Diagnostic - Failure to perform and/or communicate critical test results
11
Maternal/Neonate - Failure to communicate fetal status
12
Falls - Visitors
Education and Knowledge Retention
• Ministry funded OHA Train-the-Trainer
Program Roll-out
• Nurses receive an initial 8-hour standardized
training session
• focused on Critical Look, Chief complaint,
Subjective and Objective data, vital signs,
important modifiers, leading to a CTAS Code,
Reassessment priorities
So every triage nurse is up to date?
• Experts believe there are variations in practice
• CTAS codes applied not consistent with CTAS
Guideline
• Inconsistent in-hospital training
• Failure to update to current standards which have
evolved
• Local rules applied to Triage
• Documentation not consistently complete
The Importance of the
Initial CTAS Level
It determines the timeline
of subsequent care
Canadian Emergency Department
Triage & Acuity Scale (CTAS)
CTAS 1 (resuscitation) – immediate & continuous
CTAS 2 (emergent) – within 15 minutes
CTAS 3 (urgent) – within 30 minutes
CTAS 4 (less/semi-urgent) – within 1 hour
CTAS 5 (non-urgent) – within 2 hours
It establishes the timeline
to physician assessment
It establishes the timeline for
Triage Reassessments
Question 1
Does the triage nurse need to obtain and
interpret a complete set of vital signs at triage?
A) Yes
B) No
C) Only for CTAS 1, 2 and 3's
Vital Signs at Triage
A waste of time?
Just a little cut on my head…
Question 2
It is not necessary to perform and document Triage
Reassessments when:
1. the Triage Nurse has told the patients to advise
him/her if their condition changes
2. the patient has a very minor condition (CTAS 4 or 5)
3. there is reduced coverage at the Triage Desk
because of breaks/meals
4. the patient is seen and assessed by the MD/NP
within the recommended CTAS time interval
Triage Reassessments
(the Safety of Waiting)
Is it sufficient for the Triage
Nurse to tell patients to return to
the Triage Desk if their
symptoms or condition
changes?
The Bottom Line -
Do them and document them
at an appropriate frequency
Why?
Because the initial Triage is:
- a static assessment of a dynamic disease
process
- a ‘snapshot’ of the patient’s illness in time
The Importance of Documentation
Cannot be Over-emphasized:
Contemporaneous, appropriate and sufficiently
detailed documentation/records are extremely
important in proving the:
- care that was provided
- steps that were taken on behalf of the patient
- communication with other healthcare providers
Re-prioritization of patients
Triage is a process, not just a
number on a scale.
Processes need to be managed!
CTAS Education Program
Question
What percentage of initial triage scores are
incorrect or not consistent with the CTAS
Guideline based on triage documentation?
A) 0 - 10 %
B) 10 - 20 %
C) 30 - 40 %
Are your triage nurses getting it right?
Auditor General Audit 2010
“…one-half of files that were re-assessed… the CTAS levels
originally assigned by triage nurses were incorrect. Of these, the
majority were under-triaged.”
Independent Expert Retrospective Audit of 5000+ charts
“30% of charts were under-triaged. Themes of under-triage
included not aligning score with vital signs (especially Pediatric),
ignoring stated pain score, missed signs and symptoms of
potential cardiac presentation and potential sepsis.”
Questions ?