Triage
ED patient flow begins at triage. Patient assessment must be rapid and accurate in order to help prevent a
bottleneck. Triage, performed by a nurse, traditionally includes completing a lengthy triage nursing
assessment form. In the face of ED crowding, this comprehensive triage approach is problematic. Many
EDs have sped up the process by using bedside registration and a brief triage process, but that works only
so long as beds are available. Joseph Twanmoh, MD, FACEP, of Maryland, has described “triage
bypass.” In this system, if the patient arrives with what appears to be a minor complaint, the patient is
immediately taken to a fast track area. Vital signs are not taken until the patient is in the treatment area. If
the patient is found to be sicker than originally thought, the patient is moved back to the main ED. “Being
quickly assessed in a treatment bed is better than sitting in a waiting room not receiving any care.” Once
all beds are full in both the main ED as well as fast track, a computer system is used to track patients
waiting to see doctors, and they can still be moved into a bed that opens up if the patient has not yet been
triaged. The tracking system allows the nurse to put a patient into an empty bed without waiting for triage
to be done. Every patient placed into a bed from the waiting room is one less patient that the triage nurse
must assess, thus saving the triage nurse time, making the waiting room less crowded, and allowing
patients to be evaluated, treated, and discharged sooner.
In this system, if a bed becomes empty because the nurse is transporting a patient to their hospital room,
there is a backup nurse, or the charge nurse, who quickly brings another patient back to the bed rather
than waiting for the nurse to return.
Another method to speed along the triage process is to add personnel to triage as soon as a certain number
of people are pending triage, or if patients are waiting more than thirty minutes to be triaged. If another
nurse cannot be added, add on a paramedic or a nurse practitioner to help with triage. If triage is the main
bottleneck, consider a rapid triage with additional data being collected later in the process. Also, protocols
for certain diagnoses can be implemented in triage, which may help speed along evaluation and treatment.
Thom Mayer, MD, FACEP, of Virginia, describes the “Team, Triage and Treatment,” or “T3” approach.
Dr. Mayer found that over 30 percent of ED patients never need a room at all. Their injuries are such that
they may be evaluated and treated in triage before they ever get into a room. The “team” part of T3
consists of an emergency physician, an emergency nurse, a scribe, a registrar, and a technician. The five-
member team works together to begin an ED patient’s evaluation and treatment at the point-of-contact in
triage. This program was begun with a grant, and was used from 10:00 am to 8:00 pm. It may be thought
to be too expensive for many EDs to implement on a daily basis for many hours, but a variation may help
some EDs for short periods of time to address a bottleneck situation.
The rapid medical evaluation (RME) plan has been described by several groups. In this model an
emergency physician or midlevel provider is stationed in triage to rapidly see every patient who enters,
spending about 2 minutes with each patient. The triage provider can send the patient straight to the main
ED if a critical condition exists, and that patient will be seen by another ED physician immediately. For
the less acute patients, the triage provider will write orders for studies such as CT scans, ultrasounds, and
lab work, and initiate treatment such as pain meds, IV fluids, and IV antibiotics. Those patients will go
into a “mid-care” area, which has comfortable chairs and some stretchers. In the “mid-care” area, orders
are initiated, and patients stay until results are returned or a bed becomes available. The patient then is
sent into the main ED for evaluation and usually a quick discharge or admission decision from the main
ED physicians. Minor fast-track patients are discharged from triage by the triage provider after tests are
completed and the results reviewed. The goal of the triage doctor is to discharge the majority of the low
acuity patients directly out of the triage area, thereby having an extremely fast track.
3