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Don’t throw triage out with the bathwater
  1. J Windle1,
  2. K Mackway-Jones2
  1. 1Department of Emergency Medicine, Hope Hospital, Salford/Salford University, UK
  2. 2Department of Emergency Medicine, Manchester Royal Infirmary, UK
  1. Correspondence to:
 Jill Windle, Department of Emergency Medicine, Hope Hospital, Stott Lane, Salford M6 8HN, UK; 
 jill.windle{at}srht.nhs.uk

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The concept of See and Treat has been heralded as something new and innovative that will ease the plight of emergency departments throughout England. However, anyone who has been in emergency care over the past 20 years will recognise this process as the norm during the early 1980s. Indeed triage was introduced to clinically risk manage this system of first come first serve and to re-direct the focus of scarce nursing and medical staff away from the most minor of presentations. For those who do remember these times there must have been a strong sense of déjà vu during their See and Treat workshop.

The Department of Health workshops focused on a series of exemplar hospitals who have introduced See and Treat. It is of note that they all appear to have a number of similarities, namely:

  • streaming for major and minor patients did not exist before introducing See and Treat

  • the waiting times did not appear excessive before See and Treat

  • the case mix appears skewed to more minor cases

It would be appropriate to put this information clearly into the public domain so that others can see how close the situation in these hospitals is to their own. Once this is done it will be easier to judge how much of the apparent benefit can be attributed to streaming as compared with See and Treat.

We agree with Leaman who describes blocked beds and long trolley waits and questions the appropriateness of diverting senior clinical staff away from more complex cases in under-resourced and overstretched departments. It would be a great mistake to confuse See and Treat with a quality initiative. Let’s hold it up for what it is—a means to meet targets! To achieve the average wait of 75 minutes without solving the underlying problems of flow and resource the easiest group to “See and Treat” and get back in the street, has been singled out. A more sensible and quality driven initiative designed to improve the journey for patients requiring admission to hospital would be welcome. Rapid access to beds for those requiring admission would be a far better investment for patients, and coincidentally would free considerable resource in emergency departments. Unfortunately this is not an easy option or a quick fix; it does however have benefits across the whole of healthcare delivery.

The lack of formal evaluation of See and Treat is inevitable as departments are pushed into “piloting” the system. The superficial measurable “benefits” are plain to see and enticing. A virtually empty waiting room, reduced complaints about waiting times, and the presence of senior doctors in the department. The clinical costs will be much more difficult to measure—delays in the management of the smaller number of seriously ill and injured and less supervision of clinicians dealing with such cases. Furthermore, we should not delude ourselves about how long See and Treat will remain a continuous activity for senior doctors? Not long is the probable answer as the doctors become either ‘burnt out’ with the constant pressure to speed up the consultation or they simply lose interest in the limited challenge of managing minor cases.

Triage will remain an important risk management tool until the day resources always meet demand

No discussion around See and Treat could be complete without rubbishing triage and Leaman has not let us down! Triage has received a great deal of bad press recently and been blamed for the long waiting times experienced by patients who have been assessed and deemed able to wait for treatment due to the minor nature of their presenting complaint. I have bad news, triage and indeed The Manchester Triage System (MTS) does not, has never, and will not reduce waits. This is not the purpose of triage. Triage was the first formalised system of clinical risk management, and it is surprising that in an era of Clinical Governance and CHI reviews this simple fact has not been recognised. Triage was designed to ensure that whenever demand exceeded resources (all the time in British emergency departments at present) then the limited resource was directed to the case with the greatest clinical need. It is inevitable that this will direct resources away from less urgent cases, however if we subscribe to the idea the most seriously ill and injured should receive the greatest resources, both human and environmental, then MTS priority reveals those patients safely and appropriately. The problem is not the triage priority or the system used to reach that decision, but the basic under-resourcing. In such a situation triage is just a messenger not a problem in itself.

The Manchester Triage Group would strongly reject the comment that MTS was introduced with little evaluation. While we acknowledge consensus view is the weakest form of evidence the process involved in developing the system took in excess of a 1000 person hours and that figure should be multiplied by the 20 strong group of contributors. The system was piloted and subjected to audit in the nine Manchester hospitals the system was originally developed for. This was before the group were asked to teach the system across the UK. Additionally the words “not evidence based” are often used here without an understanding that until we agree a “gold standard” method of determining how urgent conditions are, it is not possible to prove that any system works. The MTS is an attempt to break this chicken and egg conundrum, and should provide a starting point for future changes.

The final paragraph of the paper throws up the issue of “the notorious category 5 patients”. If the author were well versed with MTS he might realise just how few patients could actually meet the criteria for this non-urgent category. MTS prioritises all patients with a recent complaint (defined as within seven days) in category four, along with any with mild pain. As these discriminators describe two of the most likely reasons to seek medical attention there are few patients left for category 5. Instead of using the blue category as it was developed (to define patients who have conditions that are stable enough to wait for assessment) it has been abused to try and restrict access for patients deemed “inappropriate” in the emergency department, and surprisingly to define those who are “primary care”.

The plea for triage to remain as a means of assessing and prioritising patients is heartening but the idea of increasing the amount of activity at triage may contribute to the long waits in the first place. Many units report waits of over 40 minutes to be triaged. This seems incomprehensible, and dangerous, as the queue has merely shifted from the waiting room to the triage room. The difference in this situation is of course the waiting room queue has been assessed and prioritised, the triage queue is an unknown entity.

Few would disagree that the reconfiguration of emergency services requires a whole systems approach, of which See and Treat is just one element. If there are important benefits to See and Treat then let us evaluate them but also examine the effect on the rest of the department. Armed with this information, departments will be in a much better position to consider the options and make the system “best fit”. It would hopefully also put a stop to the currently adopted herding instinct, where we run from one new idea to another as changing is always better than staying the same. In the mean time triage will remain an important clinical risk management tool, and will continue in this role until the utopian day when resources finally match demand.

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