Ensuring that the sickest patients receive treatment at the correct time is one of the key remits of an ED. Triage is used to identify these patients. In this study, all EDs reported to triage their patients, and approximately three of four used a triage scale. Many used self-composed scales. Only 17 emergency departments used internationally recognised five-level triage scales.
More than half of the self-composed scales had only three or four levels. These have been shown to discriminate less well between patients and to have a poorer reliability than five-level scales (4, 5). The self-composed scales specified varying times before medical attention should take place, and in some cases no time interval was provided. During the inspections undertaken by the Norwegian Board of Health Supervision in 2007, nurses and doctors had differing views on levels of urgency and the time when the patient should receive medical attention (14). We believe that this may result in delayed medical assessment or unnecessary use of resources. The use of a recognised triage scale with time-specific levels of urgency and a shared nomenclature could prevent this from happening.
Nor did some of the self-composed scales provide any decision-making support. This may lead to differing assessments of the level of urgency, depending on the person who undertakes the assessment. An erroneous decision may lead to undertriage, which at worst may delay treatment and harm the patient (17). Decision-making support of various kinds, such as in the recognised five-level scales (Table 1), may help triage personnel make more consistent decisions (18). Better discrimination between patients, better reliability, shared nomenclature and built-in decision-making support speak in favour of using recognised five-level scales instead of self-composed ones in Norway as elsewhere. It is essential, however, that these scales be tested also in our country.
We found that triage was organised differently in the various EDs. Goal evaluation is a critical aspect? of this organisation. 31 EDs had defined goals, but only 21 of these reported that these goals were being evaluated. Only nine EDs possessed electronic statistics tools for undertaking such evaluations. Existing ICT systems in Norwegian hospitals include few good applications for use in EDs (19), and such applications are essential for evaluation of goals.
Only half of the EDs had guidelines identifying the personnel that should perform triage. The health authorities in some other countries have issued guidelines stating who should perform this task (4, 5). Norwegian health authorities have not issued any guidelines other than stating that triage should be undertaken in a systematic manner (13, 14). This study shows that in Norway, triage is primarily undertaken by nurses. This is in line with international experience (3, 7) – (10, 20) – (23).
Moreover, we found that only half of the EDs reported to impose requirements for triage training. It has been shown that factual knowledge rather than experience has the best effect on triage decision-making (24), and triage training should comprise factual knowledge, for example about the triage scale being used and assessment skills (25). We believe that all triage nurses ought to undertake such training.
Designated physical premises for triage, such as a triage area or a triage room, were uncommon. Several EDs sometimes used the corridor, which could prolong the triage process, affect the decision and at worst result in undertriage (26, 27). In addition, this may violate the right to confidentiality. When new EDs are being planned, inclusion of designated triage premises should be considered.
There was a tendency towards a correlation between the EDs’ reported patient volume and their use of a triage scale and their organisation of triage. One may ask whether triage is necessary in EDs with small patient volumes. However, even these EDs have peak times, and we therefore believe that it is important for them to use recognised triage scales and organise their triage. A precondition for triage to function at peak times is that the personnel is accustomed to practising it. In their recommendation to undertake triage in a systematic manner, the health authorities do not distinguish between small and large patient volumes (13, 14). EDs with small patient volumes tend to have fewer doctors, and in Norway these are often tied up with tasks outside the department. Use of triage may help identify serious conditions that the patients are developing while in the ED, and ensure timely alert of adequate medical competence.
Göransson and collaborators discussed whether poor organisation of triage could be partly caused by the fact that doctors rarely have any obligations to the ED apart from being on duty on behalf of the parent department (3). In some countries there is a major interest on the part of the doctors, and the recognised scales have been developed in collaboration between emergency doctors and nurses or their organisations (7) – (10).