An International Search for a Better Way

Around the English-speaking world, five-level triage systems have gained popularity in the past decade as emergency physicians and nurses have sought a more rational system for establishing the order in which patients in the emergency department should be seen. Acceptance of the four existing systems varies. In Australia, the government mandates use of the National Trauma Scale. The Manchester triage system is widely disseminated in the United Kingdom although there is no rule requiring its use. In Canada, a five-level system is actually mandated in a couple of provinces, and several others are being considered. In the United States, the Emergency Severity Index has received considerable notice, and its use among hospitals is growing. However, the index has yet to receive the imprimatur of a national emergency medicine body, and is being accepted only on a hospital-by-hospital basis. Australia The Australian triage scale was developed in the mid-1970s by the staff at the Box Hill Hospital in Melbourne. The five-tiered, time-based scale used different colored stickers on medical records to indicate the priority of a particular patient. Later, the scheme was modified, and named the Ipswich Triage Scale. In the 1990s, it was further modified so that it could be more easily adapted to computer use. In 1993, the Australiasian College of Emergency Physicians adopted the National Triage Scale, as it was then called. As it now exists, the National Triage Scale or the Australasian Triage Scale has five categories of patients: immediately life-threatening, imminently life-threatening, potentially life-threatening, potentially serious, and less urgent. All patients who come to the emergency department for care are triaged by a specially trained nurse, and placed in a particular category. All of those in the immediately life-threatening category should be seen immediately. At least 80 percent of patients in the next category of imminently life-threatening should be seen within in 10 minutes. Seventy-five percent of the third category of patients (potentially life-threatening) should be seen within 30 minutes. Of those in the fourth category, 70 percent need to be seen within an hour, and 70 percent of those in the less urgent category should be seen within two hours. The Australasian College of Emergency Physicians noted in a statement on its web site: “It is neither clinically nor ethically acceptable to routinely expect any patient or group of patients to wait longer than two hours for medical attention. Prolonged waiting times for undifferentiated patients presenting for emergency care is viewed as a failure of both access and quality.” Canada Canada soon followed Australia's lead, developing what became the Canadian Triage and Acuity Scale for Emergency Departments. As listed on the Canadian Association of Emergency Physicians' web site, the goals of the system are: ▪ To identify rapidly patients with urgent, life-threatening conditions. ▪ To determine the most appropriate treatment area for patients presenting to the ED. ▪ To decrease congestion in emergency treatment areas. ▪ To provide ongoing assessment of patients. ▪ To provide information to patients and families regarding services expected, care, and waiting times. To contribute information that helps to define departmental acuity, visit www.caep.ca/002.policies/002-docs/ctased16.doc. The levels of triage under the Canadian system called CTAS as listed on the web page of the Ottawa Central Ambulance Communication Center include: ▪ Level 1-Resuscitation: This type of emergency patient is suffering from either severe respiratory distress and or unconsciousness resulting from a major trauma. Typically the patient is unresponsive with either unstable or absent vital signs. The patient is deemed to be suffering from conditions that are a threat to life and/or limb requiring immediate aggressive intervention. ▪ Level 2-Emergent: Conditions that fall into this category pose a potential threat to life and/or limb and require rapid medical intervention. This emergency patient could be suffering from symptoms such as but not limited to an agitated mental state, chest pain, abdominal pain, symptoms associated with diabetes, some head pain or trauma, or high fever (especially in children) marked with other ailments such as vomiting and/or diarrhea. ▪ Level 3-Urgent: Conditions could progress to a serious problem requiring emergency intervention. These patients may be suffering from serious discomfort and/or an interruption in their daily living routine. Examples of symptoms may include but are not limited to head pain, chest pain, mild to moderate asthma, mild to moderate bleeding, and any symptoms associated with dialysis. ▪ Level 4-Less Urgent: Conditions that are related to patient age, distress, or potential for deterioration. Symptoms could involve but are not limited to chest pain, head pain, back pain, abdominal pain, and depression. ▪ Level 5-Nonurgent: Conditions that may be acute but nonurgent as well as conditions that are part of a chronic problem with or without evidence of deterioration. Intervention can be delayed and/or referred to other areas of the health care system. Symptoms can be but are not limited to minor trauma, emotional distress, sore throat, and abdominal pain. United Kingdom The Manchester Triage System is now widely used throughout the United Kingdom. Like those in Australia and Canada, it is a five-level tiered system that stratifies patients by how quickly they need to be seen (www.emergency-nurse.com/resource/tleaflet.html). The groups in order include: ▪ Patients who need immediate attention. This includes those who are serious injured or ill and in danger of losing their lives if they are not treated immediately. Examples of patients of this type would be those who hearts had stopped or who had suffered many injuries. These patients are seen immediately. ▪ Patients whose need for treatment is extremely urgent and whose conditions might deteriorate without the prompt delivery of treatment. People who had suffered heart attacks or injuries that caused severe bleeding would be in this group as would individuals with severely broken limbs. These patients will be seen as soon as possible, preferably within 10 minutes of coming to the emergency department. They will not be seen ahead of patients in the first group. ▪ Patients who have severe injuries or illnesses that are not immediately life- or limb-threatening and need to be treated quickly. Patients with moderate asthma or broken legs or thighs would be among those classified in this group. Group 3 patients will be seen as soon as possible, within an hour but not until all patients in groups 1 and 2 have been seen. ▪ Patients who need the care of physicians and nurses but whose conditions would not get worse if they have to wait for treatment are in the fourth group. Those with sprains or strains, simple cuts, and ankle or arm fractures would be in this classification. If possible, these patients will be seen within three hours but only after group 3 patients have been seen. ▪ Patients who come to the emergency department when they could easily be treated in the office of their general practitioners are in the fifth groups. Among these are those with long-term problems such as coughs and colds or those wanting second opinions. These patients will not be seen until all other patients have been seen. United States The Emergency Severity Index began with the master's in business administration project of David Eitel, MD, MBA, and the enthusiasm of the late Richard Wuerz, MD, who died before his project was completed. The ESI, as they called it, was based both on the severity of the patients' problems and the number of resources that would be consumed. Again, patient conditions are stratified into five levels. Those in level 1 are patients whose hearts had stopped, trauma patients who had to be intubated, or patients suffering from a severe overdose of pharmaceuticals; in other words, those whose cases are immediately life-threatening. Level 2 patients are those with chest pain probably caused by ischemia, those with multiple injuries who can respond to commands, a child with fever and lethargy, and psychiatric patients who are disruptive. Those in level 3 might be patients with abdominal pain or gynecological disorders as well as elderly patients with hip fractures. Level 4 patients are those with closed trauma to an extremity, simple lacerations, cystitis, or a typical migraine. Level 5 patients are those with symptoms of a cold, minor burns, or patients who had come in for a recheck of their symptoms.

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