How simply LOOKING at patients in A&E is the best way to work out those who need the most urgent care
- Common sense is better at predicting whether or not a patient will die soon
- Countries around the world use formal systems which rank patients’ needs
- One expert says health authorities should rethink how they triage patients
Just looking at a patient in A&E could be the best way of working out how desperate they are for medical treatment, a study has claimed.
Medics using their common sense could be more effective than a structured triage algorithm based on checklists which grade patients’ symptoms.
Health workers who ‘eyeballed’ patients were better able to predict whether or not they would die, according to a study done in a Danish hospital.
Experts claimed the study ‘should make us rethink’ hospitals’ current processes for triaging people in emergency departments.
Medical workers should use their common sense to judge how urgent a patient’s need for treatment is, instead of relying on a checklist or formal algorithm, Danish researchers say
Researchers led by Copenhagen University followed nurses, medical students and phlebotomists – staff trained to take blood from patients – over three months.
They all worked at the North Zealand University Hospital on Denmark’s Zealand island, and prioritised a total of 6,290 patients using both methods.
The 64 nurses used the normal Danish Emergency Process Triage (DEPT), which is similar to systems in Sweden and Canada but not widely used around the world.
DEPT involves measuring a patient’s vital signs and noting what is wrong with them – the more urgent of the two sets the triage level.
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A nurse has the power to bump patients up or down one level of urgency.
However, the 10 phlebotomists and 10 medical students made their decisions by just looking at each patient to judge how sick they seemed.
And those using their own common sense could more accurately predict whether someone would die within the next two or 30 days.
The study is named ‘A simple clinical assessment is superior to systematic triage in prediction of mortality in the emergency department’.
The staff judging patients just by looking at them were not even highly trained or experienced in emergency medicine and still performed better.
Writing about formal scoring systems, which are used around the world, experts warned that many patients get lost in the middle.
Dr Ellen Weber, editor of the Emergency Medicine Journal in which the research was published, wrote an editorial alongside the study.
HOW DOES TRIAGE WORK IN THE NHS?
The most common triage systems in NHS hospitals are the Manchester triage scale and the Emergency Severity Index (ESI).
The ESI algorithm is a flowchart taking staff through different scenarios and assigning patients a number depending on how urgently they need to be seen.
If someone needs immediate help to save their life they are automatically given grade one, for example.
Whereas if they do not, they’re not in a high risk situation, they don’t have vital signs in the ‘danger zone’ and multiple tests will be needed, they’re given the lowest priority of five.
The Manchester triage scale has a similar ranking of one to five and attaches a time frame in which a patient should be seen by a doctor – the most urgent, one, should be seen immediately, whereas category five has a time target of two hours.
The Manchester triage system is one of the most commonly used in Europe.
And it combines the severity of someone’s condition with their complaint to work out what the best course of treatment is.
She argued that complicating triage may not be worth the effort.
Dr Weber said: ‘In short, we have adopted complex systems that take up the time of highly qualified nurses, potentially delay care, to create what is probably, at best, a “meh” result.
‘We need to ask ourselves in these days of rising medical costs and rising patient numbers if we can afford to continue doing it the way we have always done it if we can do it just as well or better a simpler way.’
The NHS does not use DEPT but has formal triage systems which are based on a member of staff judging how serious someone’s condition is, categorising them and assigning them a time target for when they should be seen.
The most commonly used systems in the NHS are the Manchester triage system and the Emergency Severity Index.
Both focus on grouping patients into one of five categories ranging from red or one – which means they need urgent treatment – to blue or five – those with only minor problems who can wait.
Dr Adrian Boyle, quality chair for the Royal College of Emergency Medicine said: ‘This was a limited observational study using a triage system that is not widely used. As such much more research is required.
‘Structured triage systems are important, however checklists should not trump common sense – where a patient is quite obviously sick they should and would be admitted without delay.’
Dr Weber said: ‘While these scores may be able to distinguish the very sick from those with minor illness, they have more trouble distinguishing patients with worrisome complaints who may deteriorate or need admission from those who need a bit of fluid and can be discharged.
‘Like a saggy bed, too many patients fall to the centre. In a five-level system, the majority of patients will be assigned a middle score’.
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