Secondary 'over-triage' attacked but causes make change difficult

Evidence-based practices can help address the challenge

The term "over-triage" certainly sounds ominous and wasteful, but as researchers at the University of California, San Diego (UCSD) School of Medicine note in their recent paper in The Journal of Trauma, Injury, Infection, and Critical Care,1 it is anything but simple.

The authors note that, not unlike the challenge of call panels, over-triage involves several dynamics outside the immediate control of ED managers, such as a shortage of available specialists and the potential threat of lawsuits. They add, however, that some strategies, such as practicing evidence-based medicine, can help reduce the incidence of over-triage.

They also differentiate between "primary over-triage," which refers to the transport of patients from the field to hospitals, and "secondary over-triage," which refers to the transport of patients between hospitals — thus involving the decision-making of hospital-based providers. The average cost of a patient who faces secondary over-triage is $5,917, they say.

If patients are discharged within 24 hours, it is unlikely they needed to be transferred in the first place, says David Chang, PhD, MPH, MBA, director of the UCSD Center for Surgical Systems and Public Health and one of the paper's authors.

"We're not saying these patients should not be evaluated," Chang explains. "We are saying that if they could be discharged so quickly, they probably could have just been given a follow-up examination shortly thereafter."

Kevin Corrigan, DO, medical director of the ED at Lexington (NC) Memorial Hospital, says, "My initial reaction to the paper was that a lot of times we transfer people out because we do not have the capability to care for them in case they 'go south.' We try to put them in a facility that could take care of them in case of an adverse outcome rather than coordinating an emergency transfer in the middle of the night, where the transfer time could be beyond the 'golden hour.'"

So, for example, if a pregnant patient who had recently received dialysis was the victim of blunt abdominal trauma, she would be transferred, notes Corrigan.

"It's possible that she would be discharged from that facility within 24 hours if she did not need dialysis, but the fear is for whatever reason that she would need emergent dialysis or need emergent surgery, and we do not have the facilities to do that," he explains.

Such situations often arise with rural facilities, note ED managers, who add that fear of lawsuits is a significant factor in this cautious approach. Hayley Osen, research analyst in the Department of Surgery at the UCSD Center for Surgical Systems and Public Health and lead author of the paper, says, "I would agree with that. I also want to highlight that we are not blaming the physicians or trauma teams. It's really a systems level issue."

Specialty coverage is an over-triage issue at Samaritan Hospital in Troy, NY, according to John Janikas, MD, director of emergency medicine. "In my hospital we have no neurosurgeons, orthopedists, or even plastic surgeons. If we receive a pediatric trauma victim, I do not have anyone I can talk to," he says. A child with a small head bleed might be discharged within 24 hours from a trauma center, but Janikas says he doesn't have specialists in the facility with whom he feels comfortable discussing such a situation.

Use evidence-based medicine

Despite these challenges, the researchers say secondary over-triage can be reduced through the use of evidence-based medicine.

Chang says, "We need to have more decisions based on the literature."

Osen suggests, "Review comparative effectiveness in the research, and create a culture of evidence-based medicine where providers can be more confident in their decision-making."

Their position received qualified support from ED managers including Janikas. "That's a great way to practice," he says. "The problem is that while you can use research to come up with best practice guidelines, there's a disconnect between what is considered a best practice because one journal said so and the time it takes to filter through and become standard of care." (Janikas offers several other strategies for reducing over-triage, below.)

Tim Hall, MD, FACEP, medical director of the ED at Carolinas Medical Center — University in Charlotte, NC, says, "Without specifics that's hard to comment on. You can take situation 'X' and say you have 'Z' risk of adverse outcome, but what constitutes an acceptable risk is hard to know."

Corrigan says, "It comes to the point you get down to the art of medicine; having protocols for every situation is pretty impractical." For example, he notes, from a potential jury standpoint, children who are trauma victims are a high-risk population. "The risk tolerance is pretty close to zero there," he notes.

Reference

  1. Osen H, Bass RR, Abdullah F, et al. Rapid discharge after transfer: risk factors, incidence, and implications for trauma systems. J Trauma Injury Inf Cric Care 2010; 69:602-606.

Over-triage can be curbed

While secondary over-triage presents a significant challenge, John Janikas, MD, director of emergency medicine at Samaritan Hospital in Troy, NY, says there are several ways to reduce such incidents.

For example, your local EMS can serve a significant triage function, he says. "We have a very strong regional EMS organization here, and they have lots of protocols," says Janikas. "For example, they know that if there are multiple traumas, they are to triage ahead of time and go straight to regional trauma centers." Such situations occur often in his area, he says.

Janikas says that he has a couple of physicians on his staff who work well with EMS and had previously worked with several agencies, and that ED managers should identify such physicians. "The biggest thing is to get involved," he says. "Get an ED director or someone on their staff that has an interest in EMS to really get involved with re-education and outreach, and to help develop protocols and educate paramedics so everyone is on the same page." By taking this action, everyone will know ahead of time what will be done in certain situations, he says.

"Developing your team is a part of any good leader's role, and finding those people on your team who are interested in EMS is critical," he emphasizes. "At my site, we have one doctor with decades of EMS experience, and he manages the program and our meetings." The more invested the ED can become with education, outreach, and protocol development, the better your triage process is going to be over time, says Janikas.

Sources

For more information on over-triage, contact:

  • David Chang, PhD, MPH, MBA, Director, University of California San Diego Center for Surgical Systems and Public Health, San Diego. E-mail: dchang1@ucsb.edu.
  • Kevin Corrigan, DO, ED Medical Director, Lexington (NC) Memorial Hospital. Phone: (336) 248-5161.
  • Tim Hall, MD, FACEP, ED Medical Director, Carolinas Medical Center — University, Charlotte, NC. Phone: (704) 512-6962.
  • John Janikas, MD, Director of Emergency Medicine, Samaritan Hospital, Troy, NY. Phone: (518) 271-3450.
  • Hayley Osen, Research Analyst, Department of Surgery, University of California San Diego Center for Surgical Systems and Public Health. Phone: (626) 533-5279. E-mail: HBO@ucsd.edu.

Management Tip

Know what your ED can handle

When making the medical decision concerning whether a patient should be transferred, you have to know what your facility can do and what it can't handle, says Kevin Corrigan, DO, medical director of the ED at Lexington (NC) Memorial Hospital.

"As soon as you know you have a patient your facility can't handle, the sooner you transfer the better," Corrigan says. "They should not be at your facility any longer than necessary."

So, for example, if you have a 400-pound man with appendicitis and your tables cannot accommodate him, he should be transferred as soon as possible. "As soon you realize that, there's no reason to do any more testing," Corrigan says. "Rapid transport is the best option."