How Good Are Your Urgency Protocols in Triage?
How Good Are Your Urgency Protocols in Triage?
Interview with Donna Kinser, MD, Division of Emergency Medicine, University of California, Davis Medical Center, Sacramento, CA
Editor’s note: In today’s health care environment, determining the urgency of a presenting complaint in the ED and then finding the best and most cost-effective site of treatment is one of the foremost challenges for ED personnel. Triaging patients away from the department to lower-acuity treatment centers may please MCOs, but it may carry significant clinical and legal risks. Yet, non-urgent patients clogging ED waiting rooms often results in unnecessary delays in patient care. In 1995, Kinser participated in a five-year study of non-urgent patients presenting in the emergency department at University of California-Davis, to determine whether a set criteria can be used successfully to safely triage patients out of the ED. The study was led by Robert W. Derlet, MD, chief of U.C. Davis’s Division of Emergency Medicine.1
MCED: Why has gauging urgency under managed care been so important lately?
DK: Part of the reason is that urgency hasn’t been looked at in that context until recently. Today people are looking more closely at how and where patients choose to be seen for their medical problems. But there’s considerable disagreement over gauging what is urgent. Partly, the argument concerning who needs to be seen in the emergency department (ED) is a sociological one. If several people observe the same incident, each observer is likely to have a different impression of what has occurred.
The Gill study pointed out that there’s quite a lot of variation, maybe more variation than we anticipated, when a patient’s clinical situation is reviewed and gauged in terms of urgency.2 Therefore, we’re going to be coming up with indefinite definitions of emergency throughout our experiences.
MCED: Is that the reason the subject has been so highly debated?
DK: Even if we knew exactly what the problem was and how things were going to turn out, we’d have different opinions of how that problem should be addressed. The issue gets complicated by the fact that the ED has traditionally been viewed as a "no-questions-asked" setting for care. Society assumes that care will be rendered to anybody at any time.
Beyond that, there is the matter of priorities. For us as clinicians, the importance of determining urgency is foremost a patient-care issue. Gauging urgency in triage is essential to redirecting patients as is necessary to the most clinically appropriate setting for care, whether that is the ED, the physician’s office, or a clinic setting.
In an era of managed care, assessing degree of urgency has financial implications as well. But not providing care for all patients who present to an ED is a significant departure from past medical practice. And it is treacherous because if a patient is misclassified, the patient may suffer complications by inappropriately being deprived of emergency care. The institution also may face penalties under COBRA (Consolidated Omnibus Budget Reconciliation Act) patient-dumping legislation.
MCED: On the surface, health plans favor the same priority, don’t they?
DK: There’s been a fair amount of discussion regarding how important urgency is to health plans in light of the view held by most that they are overpaying for patients who aren’t emergency cases.
In fact, it is very costly to treat patients with minor problems but not just in the way managed care organizations (MCOs) assert. Some surveys suggest that between 15- 50% of all ED visits are considered non-emergencies.3 Prospective reviewers have felt the figure is closer to 15% to 20% But the implications on cost go far beyond reimbursement dollars.
As we all know, the demand for services by non-urgent cases has resulted in overcrowding, long waits, and delays in treating seriously-ill patients. It can also severely compromise quality assurance and efficiency. There is a direct relationship between gauging urgency and proper reimbursement. But as a physician, I see the cost factors as much broader and more serious in scope.
MCED: Well, what would you suggest can be done? Is there a reliable basis for setting urgency criteria?
DK: The research team led by Robert W. Derlet, MD at UC Davis performed a five-year study of non-emergency patients. The goal was to determine whether non-urgent cases could be prospectively identified by triage nurses and safely triaged out of the ED without treatment.
What came out of the study was a safe methodology to screen out patients having minor problems only. For a case to be defined as a non-emergency, four criteria were developed. (For explanations of the following criteria, see the Table on page 101.) The criteria are as follows:
• vital signs within a specific range
• presence of one of 50 potentially non-emergent chief complaints
• absence of key indicators based on screening exams
• absence of chest or abdominal pain, any severe pain, and inability to walk
MCED: Is there a scientific basis for this approach?
DK: We looked at the patient charts of all cases that presented to the triage area between July 1, 1988 and June 30, 1993. Patients were divided according to chief complaint: those who could not be sent to a clinic, those who needed ED resources, and those who needed minimal intervention. Excluded were all high-risk cases: pediatric, chest and abdominal pain, psychiatric cases, and patients unable to walk.
During the study period, 176,074 adults presented to the ambulatory triage area. Of these, 31,065, or 18% were categorized as non-emergent and triaged out of the ED. Not considered were children and ambulance cases.
We then performed follow-up investigation to determine outcomes for these patients through telephone interviews and surveys of referral clinics.
MCED: What’s your assessment of this methodology?
DK: Our triage categorization approach isn’t perfect. There were weaknesses inherent in both the design of the study and the difficulty of performing outcomes research. The problem of obtaining outcomes data on all patients who use the ED in urban areas is a universal one.
But, if you look at the criteria we used to triage out patients, they seem to be much more conservative and better studied than the criteria that are being applied by MCOs. In effect, our criteria were generally more stringent those of MCOs for gauging urgency. We’ve taken a small step and shown that it’s safe. The question then becomes what degree of error are we willing to accept? From individual practitioner’s standpoint, we don’t want to make any.
MCED: But how do you get health plans to go along with this classification system?
DK: Negotiate with the payer. We have tried to forge relationships with MCOs that have worked. We’ve said:
"Look, we have a set of criteria for identifying non-urgent cases. We would like you to accept our criteria. The fact that we do have a program for identifying our patients puts us in a credible position for saying that we’ve made a legitimate effort for identifying what is minor or urgent. Some EDs may see things differently. Some may be willing to treat absolutely everything out of a sense of obligation. Those policies obviously makes it harder for MCO’s to accept and pay for certain services.
We also need to educate society, which continues to believe that an ED is good place for any patient. There needs to be a new mindset that hospitals should be used primarily for urgent or emergency situations. Developing urgency criteria helps send a message that in fact, the ED should be used primarily for urgent or emergency situations, and that the clinic is a more appropriate setting for treating minor problems.
References
1. Derlet RW, Kinser D, et al. Prospective identification and triage of nonemergency patients out of an emergency department: a 5-year study. Ann of Emerg Med 1995;25:215-223.
2. Gill J, Reese CL, et al. Disagreement among health care professionals about urgent care needs of emergency department patients. Ann Emerg Med 1996;28:474-478.
3. Health Care Advisory Board. Redefining the emergency department: five strategies for reducing unnecessary visits. Washington, DC. The Advisory Board 1993.
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