>From: John Chambers <[log in to unmask]>

>If doctors do the Triage is the Triage area not then really part of the
>Emergency Department where a doctor/patient encounter is taking place?  -
>and with all the duty of care and accountability which this implies?
>Here in NZ there was a brief spell in our hospital, driven by a long since
>sacked Health Board in the early 90s,  of doctors "triaging and redirecting
>inapproriate patients" to the local GP out of hours clinic after a brief
>chat in the waiting room without undressing them , examining them, logging
>them as attendances etc etc
>An Aortic aneurysm patient, one with an AMI and a "stable cystic fibrosis
>patient" with pneumonia (three most serious ones I can recall) were all 
>sent
>straight back to the ED with angry letters from the GP. The practice was
>stopped and I was left with the firm impression that doctors were actually
>very poor at performing triage - especially if they adopt a "she'll be
>right" attitude  rather than a more cautious pessimism which is the key to
>safe Emergency Medicine care.
>Have now had nurse triage in operation for years and no such episodes have
>occured.
>I sympathise with those who face a workload of hundreds of patients/day but
>would suggest that a face to face encounter with a doctor needs to 
>resourced
>as a consultation not as Triage "encounter" or you grossly underestimate
>your resource requirements and expose both the doctors and patients to
>additional risk.
>LEAVE TRIAGE TO THE EXPERTS - THE NURSING STAFF!!
>	JohnC

... So what you are saying is that once a medical degree is conferred upon 
one, one is no longer capable of this "nursing skill" of triage? Or are 
doctors merely incapable of acting responsibly instead of overconfident 
know-it-alls.

Nurses are NOT automatically experts at Triage or anything else, no more 
than doctors are. They merely follow logical rules and guidelines, use their 
eyes and brains and come to a decision about how to allocate scanty 
resources. Surely, at least some doctors are capable of this...

There are surely quite a few paramedics who can teach us all a few things 
about triage where it really counts... There are some BASICs people on this 
list who can probably triage despite being doctors...

I am often asked by colleagues (nurses, doctors) why I don't just go over to 
triage and "get rid" of some people when we're too busy. I have had a few 
sessions at Triage where I am confident I kept the numbers lower than others 
would have (but others would do better than I did). I did not send any any 
cyctic fibrosis patients with pneumonias home to have an aneurysm. In fact I 
refuse to send anyone home at all! I don't know of such a triage category as 
"home". Perhaps because I have worked overseas, in money-for-service 
systems, that I consider it a patients right to have a doctor see them in 
due course (or a nurse practitioner) and I do not consider a triage 
assessment to be sufficient to comply with this right.

I do, however, use Triage to:
1. Provide analgesia, attempting to go for specific agents, which sometimes 
expedite diagnosis as well (I won't get into detail here).
2. Expedite investigations, such as X-rays for those who will need them and 
can thus do something useful while waiting.
3. Provide advice!!! Face to face, not by phone, so I can see in their eyes 
whether they understand, disagree, have something else to say which 
sometimes needs prompting (like "I am running out of my GTN because my 
angina is worse").

Often, with advice, patients decide they no longer wish to wait and might 
decide to leave or arrange a GP appointment. I had someone come in with his 
son saying, I need to book him in because he needs paracetamol for his cold. 
While writing up his booking-in slip, I explained it was not a prescription 
medicine, told him where the pharmacy was and where he could wait to be seen 
after he fetched the stuff and gave his son some. He said "what do I need to 
see the doctor for, then?"

A simple case, just to illustrate. If someone comes in to be seen because 
they say the have flu, I book them in and tell them what we will advise 
should we find they indeed have flu after their 
so-many-hours-wait-in-departemnt. I give them as much analgesia stat as I 
can make an excuse for + liquids + even a lozenge (I used to keep a box in 
pocket just for that) + advice sheet and THEN let them wait, which they 
often don't. Now, one of them could also have an aneurysm... But they can 
stay and be seen - no-one gets sent home!

So (at last, you may say), triage IS part of the department, where PART of 
the doctor/nurse/patient encounter takes place. Nothing wrong with that. I 
have not mentioned here any methods I invented. We all exercise these 
somewhere sometime. Triage is not easy, even face to face.

The best triage, however, has nothing directly to do with doctors, nurses or 
patients. It has to do with the government "triaging" the NHS to a category 
well lower than say the "dome" and other political objectives when it comes 
to money. The biggest improvemnt in hospital triage would come when enough 
money was invested to ensure people waited less time no matter what category 
and we had enough GPs and A&E resources to cancel out at least some of the 
need to look for ways of relieving their stresses.

Jeez... Aren't we all having an exciting week on the list this week?
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