Tuesday, April 10, 2012

The Role of the Provider in Triage

The proposed addition of a physician’s assistant or nurse practitioner at triage adds a new wrinkle in the fabric of patient processing. The political and administrative motivation to do so is usually an external demand to achieve “door to provider” times of less than 30 minutes. If claimed by a hospital, usually in the form of “see the doctor within 15 min or less,” it is a powerful advertising tool.

The clinical benefits of adding a high-level provider at triage include immediate reliable assessment, pre-ordering of tests, and direct, speedy, discharge of minor problems.  The upside to these is the potential to create often needed space in the ED and/or waiting room. The downside is that these results provide no guarantee that average patient LOS will be any shorter than if triage were performed by a qualified nurse or other non-physician staff.


Q: What kind of provider is necessary out in triage? 

A:  At minimum, triage requires a highly skilled physician’s assistant or nurse practitioner, with extensive experience, who understands the clinical needs and operational characteristics of the particular ED in question. Since an associated goal is to also improve the patient experience and ultimately his/her satisfaction, the personality characteristics of the triage provider are essential. Optimal personalities do not “grow on trees,” yet even if uncommon, one would look for those who exhibit a “gentle touch,” a welcoming, understanding manner, and an ability to skillfully handle the stresses of triage.

Q: Can a physician do this job?

A: Yes, but it is expensive and some, perhaps most, physicians are better suited to encounter (conscious) patients after other staff has done the initial meet, greet, & initiate functions.

Q: How much of a work-up is needed from triage?

A: As usual it depends on the presentation and context.  If space is an issue, the proper ordering of tests can lead to prompt disposition (admit or discharge) shortly after the treating provider arrives to see the patient (1 stop-shop). This works in even complex patients, if an excellent triage provider orders the appropriate tests and initiates key treatments. Whether one test or multiple tests are needed, the treating provider can often make a final disposition (“close the deal”) if results are back and response to treatment can be assessed at the first physician encounter.

Q: What about flow?

A: A good working relationship between the triage provider, and the charge nurse can significantly benefit patient flow through an ED.  Communication between triage and the unit are key to quickly identifying patients at high risk and making appropriate and efficient bed assignments.  While the standard use of 5-level triage has some value, it is not subtle enough to make distinctions between those in the middle, who are often gray-zoned until results come back. That is, not all 3’s are equal; after the dust settles and tests are back, many middle tier patients can be sent to Fast Track or discharged without even being placed in a bed.

Q: What’s the bottom line?

A: The triage provider needs to be an exceptional, dynamic, individual, one with extensive clinical experience, who can not only multi-task but is also able to function as an ED Flow expert.

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