How Long Can My Patient Wait?

• One of the known vulnerable areas susceptible to staffing shortages and lack of experience is the emergency department triage nurse. 
• Nursing shortages and triage wait times are a deadly combination. The goal of a triage nurse is to categorize patients based on the immediacy for medical treatment. If there is not enough staff to patient ratio, that means someone is waiting longer than needed. 
• ESI, or emergency severity index is a triage tool used to mitigate a patient’s risk. This article analyzes tools like ESI and others, on their efficacy towards ED triage wait times.

The shortage of qualified nurses has reached dangerous levels and affects every part of healthcare. The pandemic, meshed with fluctuations in the underlying nursing labor market, will make high-risk areas of healthcare more vulnerable as a lack of experienced nurses grows. 

One of the known vulnerable areas susceptible to staffing shortages and lack of experience is the emergency department triage nurse.  

Adverse staffing can affect more than key emergency department (ED) through-put metrics, such as patient satisfaction. The ED is the primary throughput for a significant percentage of patients requiring hospitalization.  

In the emergency room, the triage nurse is a frontline tool in risk mitigation. Within minutes, experienced nurses categorize un-triaged patients who might need a potential life-saving intervention. Prompt triage decisions spotlight waiting room patients needing emergency care. 

Hospitals are required via the Centers for Medicare and Medicaid Services (CMS) to report time-based metrics that evaluate emergency department (ED) performance. Metrics can include time to triage from arrival, time to discharge or admission, and time to emergency department interventions.  

Time is the variable of concern. Time drives patient complaints. How long am I going to have to wait? And time can help the triage nurse rank and stratify the waiting room. Time is an essential variable within the new triage nurse’s algorithm.

ESI Model: A Triage Tool

The multi-pronged model of ESI can be cumbersome for the new triage nurse. Beyond level 1 and 2 triage categories, the triage nurse has two questions for the remaining triage categories. How soon do we see the patient? What resources does the patient require?

Resources include labs, CT, other intravenous or intramuscular medications. Resources have more to do with time spent in the emergency department than time to treatment. The driving question is how long can this patient wait?  

There is growing debate on the accuracy of ESI. When compared to traditional nurse triage, machine learning accuracy of assigned acuity for ESI was 27% more accurate than the average nurse. In large part, the predictive differences in machine learnings ability are based on excluding racial biases, internal biases, and external variables. 

Without excluding the established benefits of the ESI model or specific hospital-based triage training, nurses can enhance their triage efficiency by considering the value of time. How long can the eighty-year-old abdominal pain patient with mild hypotension wait? If we assign a triage category level 2, then care should be expedient. With a level 3 ESI, this patient could wait hours in a busy academic medical center waiting room. But should they?

According to time-based triage models, this patient receives care within 30 minutes. Does this happen in the U.S.? What the triage nurse needs to avoid is significant delays for a patient with a high-risk presentation within the overcrowded waiting room. Time matters.

Triage Dilemma

Emergency departments are complex areas of healthcare, and the waiting room is fraught with potential liabilities. Proper and functioning triage systems are essential, and the decisions made in triage dictate the population and safety of the waiting room.  

Coined by French, the word triage means to pick, choose, or sort. In simple terms: sick, not sick. See me now, see me later. No wait for the dying. There are a handful of ways to label triage with catch phrases. But identifying physiological harms with speed and accuracy is the primary mission of the emergency department.  

Any combination of physical and psychological distress, which manifests secondary to stressful circumstances, where a sudden, often unexpected, life-threatening condition leads a patient to triage, is a tenuous circumstance.

The goal should be to triage waiting room patients within 10 to 15 minutes. Overcrowding and staffing shortages have compromised this metric.  

It is unacceptable to place a level 2 in the waiting room, yet it happens everywhere and every day throughout the U.S. The bottom line, improper triage, can place sick patients in the waiting room and at risk for harm.

Effectiveness of the ESI Model

Among the three major five-tiered triage systems used throughout the world (Manchester Triage System (MTS), Emergency Severity Index (ESI) and Australasian Triage System (ATS), the data shows these established triage systems have reasonable validity. Prior to the five-tier triage, the earlier 3-level triage systems lacked precision. 

In the United States, the ubiquitous ESI model does not delineate time to examination for a patient triaged level 3-5. Within ESI, triage level 1 patients declare themselves as acute with a life-threatening condition, and without needing triage.  

In addition, a triage level 1 patient requires no vital signs in triage. This parallels triage level 2 patients. Both level 1 and level 2 triage patients present with serious conditions and getting vital signs on these acuity levels will only delay treatment. Placing the patient into a treatment room is a priority.  

According to the ESI handbook, ESI level 2 is determined unsafe and unable to stay in the waiting room for any length of time. Yet, this occurs. The ESI model states level 2 patients are a “high-priority, high-risk patient” though the model categorizes a needle stick in a healthcare worker and signs of a stroke that do not meet level-1 criteria, as high-risk. For stroke, time is paramount. Time is not an essential variable for a needlestick in acute parameters. Though a troubling event.  

ESI vs Other Models

How can a new triage nurse benefit from understanding how comparable triage systems function? Unlike ESI, other triage models focus on time not resources. For example:

CTAs

The Canadian Triage and Acuity Scale (CTAS) uses time in the following manner.  

• Triage level 1: resuscitation – time to physician immediate 
• Triage level 2: emergent – time to physician ≤ 15 min 
• Triage level 3: urgent – time to physician ≤ 30 min 
• Triage level 4: less urgent – time to physician ≤ 1 hour 
• Triage level 5: non-urgent Time to physician ≤ 2 hour 

ATS

The Australasian Triage System (ATS) defines categories through physiological predictors such as airway, breathing, circulation, and overall disability to determine the maximum ideal waiting time for treatment. This is time to treatment, not time to a physician.  

• Triage level 1: immediate 
• Triage level 2: 10 minutes 
• Triage level 3: 30 minutes 
• Triage level 4: 60 minutes 
• Triage level 5: 120 minutes   

Only the ATS and CTAS models use the duration of time from waiting room to patient examination as a component of acuity. The ESI model does not specify time as a metric, which identified in the earlier paragraphs for triage level 1and level 2, are self-declaring categories.  

Yet within ED metrics, time is an essential measurement including: 

• Door-to-doctor time 
• Door-to-room time (An average ED will be about 25 minutes) 
• Door-to-PCI (Cath lab) within 90 minutes 
• Door-to-disposition 

Countless factors influence treatment and wait times, including patient ratios and number of patients to beds. Time to doctor and time to treatment are different. The patient population of your local hospital may vary from a larger academic medical center with complex patients. Using time as a metric for the unexperienced nurse may be helpful. 

To mitigate risk and ease overcrowding, new triage models have a high-level provider screening patients with the triage nurse the patient’s arrival. The provider, often an attending physician, will order initial labs and imaging if warranted. Again, this is not treatment. It first-look ordering by a physician. 

The Bottom Line

For the new triage nurse, advocating for your patient based on time may be useful. Comparisons of ESI and other triage models within a broken U.S. healthcare system are difficult. In the U.S., over-run emergency departments equate to catastrophic wait times.

Understand that using resources as triage categorizing tool are helpful, but time is the variable that determines life and death outcomes. Think of your patients and ask, ‘how long can they wait?’

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