Wednesday, 10 August 2016

Triage: one way of avoiding the avoidable

Just because something’s avoidable, it isn’t necessarily easy to avoid.

That’s certainly true of avoiding unnecessary hospital admissions. When we’re ill, we want to feel better, as quickly as possible. Indeed, if we’re in pain or great discomfort, we want our care to start immediately – to us at least, our condition is urgent. If we can’t see a professional in one of the relatively inexpensive settings, such as a GP practice – perhaps because we can’t get an appointment soon enough, or because our condition arose out of hours – we might be inclined to head straight for a hospital. Why, we might even call an ambulance to get us there.

When we need one, we really need one
When we don’t, we really don’t
A while later, we would be standing in our local Emergency Department and explaining how ill we are. It’s possible that the person we’re talking to is a relatively junior member of medical staff or nurse, inclined to be risk-averse: that is, they would prefer to err on the side of caution, offering more treatment than we really need rather than too little.

The next thing we know is that we’ve been admitted as an emergency inpatient to the hospital. Now, if that’s what we really needed, then that’s fine. If it wasn’t, then the system has failed us. From its own point of view, it will have behaved wastefully – as I argued last time, it may have spent twenty times as much on our case than it ought to have done.

But unlike a good meal or a good holiday, where spending more generally gives greater quality, in healthcare that’s not necessarily the case. In hospital, we’re surrounded by sick people. There’s a serious chance we might pick up a disease from some of them, and actually find ourselves becoming less well rather than better from our hospitalisation. It was clearly avoidable, and avoiding it would have been desirable for both sides.

The process that would have avoided it is called triage. From the French word for sorting, triage was first extensively used in the First World War, to identify three classes of injured soldiers: those who it would be a waste to treat as they were beyond rescue, those who could wait because they weren’t that seriously hurt, and the intermediate group on whom to focus.

Today, it’s come to mean a process by which the medical condition of a patient is assessed before a decision is taken on treatment. Triage can take place in a number of ways. For instance, a GP in effect carries out triage in deciding whether a patient needs hospital care or not. But we tend to think of triage more as the kind of service a patient might phone for advice before taking off for the hospital, or that an ambulance call handler provides when we dial an emergency number.

A conversation takes place between the caller – who may or may not be the patient – and someone able to advise on treatment options.

That sounds simple enough and provides an obvious way to avoid an unnecessary hospital visit. Unfortunately, it’s not as straightforward as it sounds. Triage is a skilled task, and there are two traps, at opposite ends of the scale, that have to be avoided.

  • Excessive caution: to ensure a patient doesn’t miss out on treatment that might be necessary, the call handler decides on a referral to an urgent service when one isn’t necessary. A paramedic I once dealt with told me that the triage service locally had simply become “another way of calling an ambulance.” Far from reducing highly expensive but unnecessary care, the triage service might well increase it.
  • Under treatment: the call handler fails to spot a condition that does need urgent care, and the patient suffers as a result. In January this year, the Guardian published the horror story of a doctor who needed urgent treatment but might have been left blind by a triager failing to spot the real problem.

The impact of good triage was shown by a study carried out by the journal Acute Medicine in 2015. It showed that when triage was carried out by senior hospital physicians, 28.5% of admissions were avoided – a huge success rate. But do we really want triage carried out by senior physicians who should be treating patients?

The elusive solution would be a way of increasing the quality of decisions by call handlers who are experts in triage as such, rather than medical specialists. That’s a matter of training, though of course it can also helped by providing better support.

Another study, in BMC Medical Informatics and Decision Making in 2014, suggests that providing a clinical decision support system can help. Since that’s my own field, it’ll be the subject of the next post in this series.

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