Nurse triage in theory and in practice.

'Nurse Triage' refers to the formal process of early assessment of patients attending an accident and emergency (A&E) department by a trained nurse, to ensure that they receive appropriate attention, in a suitable location, with the requisite degree of urgency. The benefits claimed for nurse triage include better patient outcomes, through clinical management reaching those in greatest need of it first. A recent study of nurse triage in a British A&E department failed to demonstrate the benefits claimed: patients undergoing triage were delayed, especially those in the most urgent groups. No differences were noted between the two study groups in levels of satisfaction with the A&E process. The results brought forth criticism from all quarters. In this paper the points made by the critics are considered, and an attempt to answer them is made.

Differences in priorities assigned to patients by triage nurses and by consultant physicians in accident and emergency departments.

STUDY OBJECTIVES: To investigate whether the greater urgency assigned to accident and emergency patients by triage nurses than by accident and emergency doctors was uniform across all patient groups. DESIGN: Patients attending an accident and emergency department between 8.00 am and 9.00 pm over a six week period were assessed prospectively for degree of urgency by triage nurses, and retrospectively for urgency by one of two consultant accident and emergency doctors. Patients were grouped according to their clinical mode of presentation. SETTING: An accident and emergency department of a district general hospital in the Midlands, UK, in 1990. PATIENTS: 1213 patients who presented over six weeks. MEASUREMENTS AND MAIN RESULTS: As might be expected, patients' conditions were assessed as being more urgent prospectively than retrospectively. This finding, however, was not uniform across all patient groups. Nurses' assessments of urgency tended to favour children and patients who presented with eye complaints and gave less priority to medical cases, particularly those with cardiorespiratory symptoms. CONCLUSIONS: These findings have implications for all those involved in the organisation of triage systems and in the training of nurses in accident and emergency departments. It is essential that judgements on how urgently patients need to be seen are made in a completely objective manner.

Evaluation of nurse triage in a British accident and emergency department.

OBJECTIVE: To compare formal nurse triage with an informal prioritisation process for waiting times and patient satisfaction. SETTING: Accident and emergency department of a district general hospital in the midlands in 1990. DESIGN: Patients attending between 8:00 am and 9:00 pm over six weeks were grouped for analysis according to whether triage was operating at time of presentation and by their degree of urgency as assessed retrospectively by an accident and emergency consultant. PATIENTS: 5954 patients presenting over six weeks. MAIN OUTCOME MEASURES: Time waited between first attendance in the department and obtaining medical attention, and patient satisfaction measured by questionnaire. RESULTS: Complete data on waiting time were collected on 5037 patients (85%). Only 1213 of the 2515 (48%) patients presenting during the triage period were seen by a triage nurse. Patients in the triage group waited longer than those in the no triage group in all four retrospective priority categories, though differences were significant for only the two most urgent categories (difference in median waiting time 10.5 (95% confidence interval 3.5 to 14) min for category 1 and 8.5 (3 to 12) min for category 2). Responses to the patient satisfaction questionnaire were similar in the two groups except for the question relating to anxiety relating to pain. CONCLUSIONS: This study fails to show the benefits claimed for formal nurse triage. Nurse triage may impose additional delay for patient treatment, particularly among patients needing the most urgent attention.

Sensitivity to silver in a patient treated with silver sulphadiazine (Flamazine).

This report describes a 43-year-old housewife who suffered a burn and then was suspected of having a sensitivity reaction to Flamazine cream (1 per cent silver sulphadiazine). Patch testing subsequently showed she was sensitive to silver and to cetyl alcohol, but to no other constituents of Flamazine cream. The patient herself knew she was sensitive to silver but was never asked about this possibility, or told initially that Flamazine cream contained silver.

Malignant melanoma metastases to the alimentary tract.

Seven patients are presented each with symptomatic malignant melanoma metastases to the alimentary tract. Where practicable, surgical excision of the metastases is justified because two patients have had worthwhile periods of survival.