At some EDs, triage nurses order certain tests to speed care. “Triage nurse-ordered testing seems beneficial in theory,” says Michael Gottlieb, MD, RDMS, FAAEM, FACEP, associate professor in the department of emergency medicine at Rush University Medical Center in Chicago.
By ordering tests while the patient is waiting for an emergency physician (EP) evaluation, length of stay presumably shortens. Hopefully, test results return by the time the patient sees the EP. “This would be very useful, given high ED volumes and overcrowding. However, what seems beneficial is not always borne out in practice,” Gottlieb observes.
The authors of a recent analysis examined 13 studies about nurse-ordered testing at triage.1 Ten studies were about length of stay or time to diagnosis. The authors of the other three compared tests ordered at triage with tests ordered by EPs. There were some surprising findings. “In cases where no testing was actually indicated, it can increase length of stay,” notes Gottlieb, one of the authors of the analysis.
Likewise, some patients need additional testing that was not ordered at triage. “This negates the time benefits, and also means a second blood draw,” Gottlieb explains.
For example, triage nurses may order a chest X-ray and some basic lab work for a patient with difficulty breathing. However, when the EP evaluates the patient, a D-dimer is added to evaluate for pulmonary embolism.
Another unexpected finding was the variation in time benefits found in the studies. Some showed no difference or a clinically insignificant difference in length of stay, but others revealed a significantly shorter stay. Most studies did not show any time benefit at all, but the reason is unclear. “It is worth exploring whether the studies that did find a benefit were simply aberrations, or if there were unique strategies and factors present at those institutions that allowed them to capitalize on this model to maximize ED efficiency,” Gottlieb offers.
Notably, there was only moderate inter-rater reliability between the triage nurse-ordered testing protocols and physician orders. “In these cases, it is possible that some patients may receive testing that wasn’t indicated. Therefore, it is important to review protocols and ensure sufficient training, education, and oversight,” Gottlieb says.
For some patients, longer waits for tests to be ordered results in delayed diagnosis and treatment. Sometimes, those delays contribute to poor outcomes and lawsuits. “In general, we see absence of triage testing as a higher risk than the presence of triage testing,” says John Burton, MD, chair of the Carilion Clinic’s department of emergency medicine in Roanoke, VA. In general, says Burton, “the U.S. ED experience has demonstrated very few adverse outcomes due to the use of triage test-ordering protocols.”
Overall, says Burton, triage testing makes legal action less likely because care is quicker. One concern is triage testing could result in overuse of diagnostic tests. Burton says in his experience, this has not been the case. “We do not see overtesting as a consequence of thoughtfully derived triage order protocols,” he reports.
There always are times when tests ordered by EPs end up different from what was ordered at triage. “The ‘fringe’ tests tend to be things like D-dimer, brain natriuretic peptide, sedimentation rates, and perhaps even troponins,” Burton notes.
These are tests the EP might choose to order during the evaluation, which are not usually included in a triage nurse order set. “One must also reflect on who is at triage,” Burton adds.
Some larger-volume EDs place a physician assistant or EP at triage. This reflects a shift toward adding resources to triage to alleviate crowding and rapidly identify low-acuity patients who can be discharged quickly. “All triage order sets are not alike,” Burton explains. “One has to look at the providers for whom they are intended.”
Sometimes, tests are ordered at triage, but the patient is stuck in the waiting room anyway. Test results could return before the patient is assigned to an EP. “It’s certainly possible that an abnormal test result may go unnoticed for hours as the patient waits. This is an area of exposure for EDs,” Burton cautions.
A process to ensure review by a provider in the ED is essential in the thoughtful design of triage test-ordering protocols. Typically, this would entail test result alerts to EPs, either by the lab, radiology, or a triage nurse. “Tests that are deemed abnormal must be identified through this process and presented to the physician,” Burton says. Then, the EP can determine the next step.
If an ED does not use triage orders, and a lawsuit alleges delayed care, it is questionable whether a plaintiff could successfully argue the legal standard of care required triage testing. “I have not seen this argument employed in a plaintiff case,” Burton says.
Plaintiffs would face an uphill battle arguing triage test-ordering protocols are standard of care for EDs. “No authoritative bodies that I am aware have taken the position that triage protocols are an expectation as a standard,” Burton says.
It is conceivable attorneys could argue the plaintiff received subpar care compared to other, similar patients for whom tests were ordered at triage. However, such a case appears fairly unlikely. “The specifics would all have to line up for such a case to have any traction,” Burton explains.
A time-dependent therapy would have to be delayed, for one thing. Most patients undergoing time-dependent treatments (e.g., tPA for stroke) are not sent back to the waiting room. “Patients deemed high risk — trauma or heart attacks, for example — are often moved to the front of the line in priority, thus not really being the subject of triage testing protocols,” Burton notes.
Another potential legal pitfall is that ordering incorrect tests at triage could cause the EP to go down the wrong diagnostic pathway. An example of this would be a triage nurse ordering an ultrasound for a patient with an acutely swollen, painful leg without considering rhabdomyolysis or compartment syndrome. “I have not seen this in a claim to date,” Burton reports.
Hopefully, EPs would notice the error during the patient evaluation. “However, one could envision the triage test-ordering overly influencing the physician’s thinking, resulting in a bias in their medical decision-making,” Burton offers.
That could result in a missed diagnosis or treatment delay. “As a result, the physician provider must be alert to this potential in their practice, and guard against this proclivity toward bias in each encounter,” Burton says.
The same holds true for every ED patient. Theoretically, any notes triage nurses document could mislead EPs. For this reason, triage testing, according to Burton, “does not represent any real change in a potential bias pitfall that has been present historically in emergency medicine.”
- Gottlieb M, Farcy DA, Moreno LA, et al. Triage nurse-ordered testing in the emergency department setting: A review of the literature for the clinician. J Emerg Med 2021; Jan 5;S0736-4679(20)31173-2. doi: 10.1016/j.jemermed.2020.11.004. [Online ahead of print].