Triage - Practitioner or Design dependent? A Triage Audit at Portiuncula University Hospital.
Emergency Department (ED) overcrowding is hazardous. Triage and risk classification are vital. Portiuncula University Hospital ED serves approximately 26,500 patients annually and has both paper ED documentation and an electronic patient triage tracking system. The Irish Emergency Medicine Programme (EMP) adopted the Manchester Triage System (MTS) for adults and the Irish Children’s Triage System (ICTS) for children.
An audit of triage was undertaken to direct and evaluate future quality improvement initiatives in this area.
The EMP Triage Audit Tool was utilised, two adaptations were made to its 11 elements. These assessments were the rate of over and under triage and the rate of administration of analgesia at triage. A retrospective audit of the busiest week over the winter period 2017/2018 was audited. 529 patient charts were audited after excluding 11 review patients and 6 unavailable charts. A trained MTS trainer scored the triage priority and assessed compliance.
86% were allocated a triage category with 53% accuracy, with 16% under triaged, 5% over triaged and a further 13% having insufficient documented history detail to determine category. Compliance with documentation standards were legibility 99%, dating 99%, timing 98% and signing 86% respectively. A pain score was allocated in 66% of relevant cases and analgesia administered was 27%. Evidence of re-triage was 47% overall and improved with higher categories – Cat 2: 60%; Cat 1: 67%. The min and max waiting times from registration to triage were 0 and 156 minutes respectively with an average of 30 minutes. 34% of patients with a documented time of receiving medical care were seen within the recommended time for triage category.
The audit highlighted difficulties faced by ED staff during times of overcrowding and the impact on patient flow and the need for quality improvement in key areas – accuracy of category allocation, documentation of focused history, waiting time for triage and re-triage. Certain elements of documentation standards were very good and can be further improved with small design changes to local pathways. The focus of future triage training should include emphasis on timely, accurate, focused history taking, pertinent patient observations and documentation.
