Change the approach to triage to alleviate ER overcrowding

“Triage” is French for “to sort.” It developed as a concept on the battlefield as a way to address injured soldiers and ensure that care was provided to those most in need. In the emergency department, triage is usually the responsibility of a trained, experienced nurse. Patients present to the emergency department, the nurse obtains a history and may perform a cursory exam and then assigns the patient a “priority” based on the level of acuity. The acuity is important because it cues the providers to see the most critical patients first.

Lower acuity patients tend to wait longer for their care, while in theory, sicker patients are seen faster. Regardless of the acuity assigned, however, no one gets turned away, and as long as you are willing to wait, you will be seen. As a result, the ED is often overcrowded, meaning long-wait times for care.

The lower-acuity patients, from sore throats to ingrown toenails, are often blamed for ED overcrowding, but this is a misnomer. In truth, it is the higher-acuity, resource-intense patients as well as admitted patients that are “boarders” waiting for a bed that contribute the most. Regardless, ED overcrowding is associated with bad outcomes, so addressing how to best provide care to all of these patients is an ethical imperative.

True emergencies are actually few and far between. Upwards of 30 percent of ED visits in the United States can be categorized as non-urgent, meaning that the care could have been provided efficiently and safely at an urgent care, a PCPs office or other setting. Emergency department utilization is expected to continue to increase, with an aging population with more complex, but often chronic medical needs. This care is often best addressed in a longitudinal fashion with dedicated and consistent providers, not in an ED setting.

There have been a number of attempts to address ED overcrowding. These are well documented in the literature and include the emergence of “fast-track” areas and virtual waiting rooms. The impact of these initiatives seems to be minimal — and for good reason.

This brings us back to the concept of triage.

What if triage wasn’t just assigning acuity but assigning a destination? What if nurses became triage navigators to help the patient navigate their way to the best destination for care? What if, based on acuity, a patient could be sent to an urgent care or to their PCP? Or maybe even a skilled nursing facility, a hospice home or a detox?

This is a very different approach to triage. Patients would get an initial screening, but their care may not be in the ED itself. This would allow for the focus of the emergency departments to provide emergency care to the sickest individuals. It would free up human resources to provide more attentive care to sicker patients. It would allow physicians, nurse practitioners, and physician assistants to spend more time with patients and their families. It would lead to overall improved wait times, door to provider times and ED throughput as well.

It would likely improve patient satisfaction and reduce medical error.

Even patients who require emergency care could be more swiftly moved to an appropriate care setting. By changing the paradigm of triage nurse to nurse navigator, the physical plant of the ED itself could change, freeing up what was once waiting room space to more patient care space as patients are shuttled to more appropriate care settings.

Staffing is another area that could use a shift in paradigm. Pairing ED providers with hospitalists could allow for a game-time decision after an initial assessment as to whether or not a patient will need an admission and where the work up will take place. ED length of stay could be minimized by early, cooperative decision making. Another potential opportunity is to staff primary care providers in the ED. Patients without a PCP can be linked to a new PCP in real-time, and care can become more longitudinal and resource-efficient. This is a great opportunity for new PCPs who are looking to establish a practice.

There are some downsides. Inappropriate triage could put some patients at risk for a misdiagnosis. There is some evidence to suggest that ED triage is highly variable, and this would need to be addressed before this scale could be launched. There are also certain patient populations that would be less amenable to this approach. The elderly, confused person living at home alone who is struggling to maintain their well-being is just one example. These can be some of the most difficult cases and would require a whole other process of involving not just the nurse navigator but also case managers, geriatricians and access to skilled nursing facilities. Even if they start in the ED, however, they can be transitioned to the appropriate care setting more seamlessly if there is a system in place to manage these issues.

ED overcrowding is associated with an array of negative outcomes. Patient safety and satisfaction is paramount in any health care setting. An ED nurse navigator may be more beneficial than the current method of triage, opening the door for a novel approach to patient entry and disposition. This change in paradigm can help to alleviate overcrowding as well as shift patients to more appropriate care settings. It will take rethinking and reconstructing how care is delivered and will require some novel utilization of resources. There will be some growing pains, but considering overcrowding, the ever-rising cost of health care and the delays to access in our current system, this change in the paradigm of access to care is an ethical imperative.