A comparison of emergency triage scales in triaging poisoned patients.

BACKGROUND: Triage of toxicology patients presents a challenge due to their complexity, underlying psychosocial issues, and additional pharmacological considerations. Two emergency department triage systems used in Australia, the Australasian Triage Scale (ATS) and the Manchester Triage System (MTS), were compared in triaging patients presenting with poisoning and envenoming. METHODS: In this simulation-based study, 30 triage nurses from three hospitals were given 8 tabletop scenarios and asked to provide a triage category. 20 nurses from two hospitals using the ATS, and 10 nurses from a third hospital using the MTS, triaged 8 scenarios, grouped into "commonly encountered" (n=4) and "rarely encountered" (n=4). Triage systems and scenario groups were compared for median triage category and variance in scoring. Triage nurses also noted if they would seek help from toxicology services or the poisons information centre (PIC) for advice. RESULTS: Overall, MTS nurses triaged all 8 scenarios with a lower acuity triage category, though statistically significant for only 3 scenarios. ATS nurses scored higher acuity triage category in all 4 "rare" highly toxic presentations, whereas MTS nurses scored higher acuity when vital signs were abnormal. MTS showed wider variance in triage scores in both scenario groups when compared to the ATS. Triage nurses without access to local toxicology services chose to contact PIC in most cases. CONCLUSIONS: When compared to the ATS, MTS gave a lower acuity triage score for all common and rarely encountered poisoning scenario groups, which included highly toxic ingestions that appear well at triage but may progress to severe poisoning. Triage nurses should refer to information on highly toxic exposures and envenomation guidelines during their triage risk assessment.

A stream for complex, ambulant patients reduces crowding in an emergency department.

OBJECTIVE: The study aims to evaluate the effect of adding a stream for complex, ambulatory patients in an ED. METHODS: The setting was an ED in a principal referral hospital in New South Wales, Australia. In 2011, a new stream was added to the pre-existing acute care (high complexity patients) and fast track (low complexity patients) streams. Space in acute care was set aside for the purpose of assessing patients who would previously have been assigned to acute care and who were capable of sitting in a chair with limited nursing care. The stream was separately resourced with staff redeployed from acute care. Early involvement of an emergency physician was a core characteristic of the process. Two 13 week periods before and after the intervention were compared. RESULTS: Presentations increased by 8.2%. Forty-three per cent of patients were triaged to the new stream. The median ED length of stay fell from 327 (interquartile range [IQR] 192-527) min to 267 (IQR 163-412) min (P < 0.001), the average daily occupancy of the department fell from 38.1 patients to 34.9 patients (95% confidence interval [CI] for difference 1.6-4.8, P < 0.001) and the proportion of patients who did not wait to be seen fell from 12% to 5.6% (95% CI for difference 5.8-7.1, P < 0.001). CONCLUSION: The use of an appropriately resourced stream directed towards seeing a complex group of patients who do not require ongoing nursing care and who are capable of sitting in a chair improved departmental flow.