Ethical dilemmas in Emergency Medicine 4: The ethics of triage

Triage (1) It’s been a while since we published our last ‘Ethical Dilemmas’ post at St. Emlyn’s. Hopefully you’ve already seen the other posts in this series but, if not, you should check out part 1, part 2 and part 3. This time let’s take a look at triage – something we do every day in the ED, probably without giving it a second thought.

When we talk about triage, we could mean several things.  We might mean the triage of patients arriving in the ED to assign clinical priority (because not everyone can be seen instantly); we might mean the triage of patients in a major incident or battlefield scenario; or we could mean the triage of patients to an appropriate level of care within the hospital. (E.g. Critical care or a general ward)

All of these types of triage suggest that our resources aren’t adequate to meet demands at any particular moment in time.  This means that ‘triage’ is similar to ‘rationing’.  Perhaps the key difference is that ‘triage’ implies the shortage is only temporary – and that we’ll sort it out given a bit of time – whereas rationing suggests that we just don’t have the resources – full stop. In this post we’re just going to talk about the triage of patients arriving in the ED, to decide how urgently they need to be seen.

How does triage work?

We need triage because we just can’t make sure that every patient is seen by a doctor as soon as they arrive in the ED.  We don’t have the resources for that and there’s a waiting time.  If every patient waited in time order regardless of how urgent their problem was, the critically ill patients could die or come to permanent harm while they’re waiting to be seen.  Triage is there so that the patients with the most urgent problems are seen quickest.

There are several ways to triage.  Nurses could just use their judgement – without any set structure or system.  You can imagine that this might be quite variable though.  There are some systems to help us avoid that.

The Manchester Triage System (MTS) is one example, which is used around the world.  It was developed by Kevin Mackway-Jones, who brought the likes of me and Simon through the ranks. The MTS uses over 50 algorithms based on patients’ presenting complaints.  There are 5 ‘priorities’: red, amber, yellow, green and blue.  Just like the structured ‘ABCDE’  approach to any critically ill patient, the MTS starts by asking the questions that will identify the most critically ill patients.  The questions are called ‘discriminators’ and we have discriminators to identify patients for each of the 5 priorities.

Ultimately, the MTS decides how long each patient might reasonably be expected to wait to see a doctor in the ED, as follows…

MTS

You can find some great slides about the MTS from Kevin Mackway-Jones himself at this link.

Why is it important to think about the ‘ethics’ of triage?

It might seem quite a straightforward issue.  Sicker patients get seen quicker.  That’s obvious – otherwise people might die while we see to other patients with minor injury and illness.  Our patients tend to understand that too.  But, when you take a deeper look, there are lots of potential ethical issues that we need to think about. Is a breathing problem, for example, always more urgent than a circulation problem?

Using some hypothetical scenarios, let’s look at some of the ethical dilemmas that triage might present us with.  The aim of this post isn’t to provide answers.  It’s to generate questions.  As with all of the posts in this series, it’s the discussion it generates that matters most – so please feel free to comment.

Scenario 1: a simple question of relative urgency

There are 6 patients waiting to be seen in the Amber (Majors) area of the ED and all of them have been given a ‘Yellow’ triage priority, meaning that they ought to be seen within 60 minutes of arrival.  The first 3 patients have been waiting for over 2 hours.

A new patient arrives and is given an ‘Amber’ triage priority.  She ought to be seen within 10 minutes of arrival and, with the resources you have, you know that you won’t achieve that unless she is seen next – before any of the ‘Yellow’ category patients.

Image by nemo on pixabay

Image by nemo on pixabay

Where does the ‘Amber’ patient go in the queue?  And who decides?  How should they make their decision?   Is it a simple judgement call about who is the sickest?  Does the time a patient has waited outweigh the clinical priority at some point?  Would it matter if the ‘Yellow’ priority patients had waited for 10 hours instead of 2 hours?  If so, would it still matter if the new patient had a priority of ‘Red’ (see immediately) rather than ‘Amber’?

At some point, all of us working in the ED have to weigh the time a particular patient has waited to be seen against the clinical priority of those still waiting to be seen.  Clinical priority can’t be the only consideration, otherwise the patients with less urgent problems might never be seen! Time has to factor.  How we make that judgement is something that we might never have thought about so much.  And yet it’s important – because it happens every day – and it involves peoples’ wellbeing, and peoples’ lives.

Scenario 2: does suffering factor?

Two patients arrive in the ED after taking overdoses with low lethality. Both have normal observations and are clinically stable. The first patient to arrive is pretty quiet, seems calm and gives an appropriate history. He’s given a triage priority of ‘Green’. The second patient, who arrives 30 minutes later, is extremely tearful and distressed. The triage nurses recognises ‘Marked distress’ and assigns a ‘Yellow’ triage priority. This means that the second patient (who arrived 30 minutes after the first one) is seen first.

Image by OpenClips at Pixabay

Image by OpenClips at Pixabay

This scenario introduces a new consideration: triage isn’t just about balancing pure clinical urgency against time. We might not just be interested in the chances that a patient might die or get complications of their disease while they’re waiting. Maybe we’re also interested in making sure that the patients who are suffering the most get seen quickest.

It might seem like quite obivous. But there are lots of things to think about. Suffering is very subjective. How do we measure it? (You might want to check out a blog post I wrote on one of my recent papers) Should we make our own judgement about how much the patient seems to be suffering? (Maybe – but this is notoriously unreliable) Or should we ask patients? If we do ask patients, how do we stop them abusing the system? They could basically tell us that they have a lot of pain or are very distressed and they’ll get a higher priority with a shorter waiting time.  Those who exaggerate their pain scores would be seen quicker.  Is it right to let that happen?

A triage system that takes no account of a patient’s suffering seems heartless and inhuman.  A system that prioritises the treatment of patients in pain or distress over other, more comfortable patients seems to be just.   But taking account of and quantifying suffering is extremely difficult.

It leaves us with a big question about how we weight suffering against physical illness.  Do time critical physical injuries or illnesses always take priority over patients in significant distress?  Or is there a balance? Ultimately, if you take account of suffering in your triage, the approach seems humane but you risk over-triaging those patients who exaggerate symptoms and under-triaging the stoics.  How do we deal with that?

Scenario 3: how many ‘minors’ equal a ‘major’?

Imagine you’re the consultant in charge of a large ED.  You have the Amber (Majors) section and the Green (Minors) section, each of which is separately staffed.  You have 5 doctors on duty at the start of a shift.  There’s a 1 hour wait in the Amber area (with 5 patients waiting to be seen, all of them ‘Amber’ priority) and a 3.5 hour wait in Green (with 25 patients waiting to be seen, who are mainly ‘Green’ priority).  How do you allocate your resources?

Image by OpenClips on Pixabay

Image by OpenClips on Pixabay

Should all 5 doctors see the sickest patients while those with minor injury and illness wait?  What if new ‘amber’ priority patients keep coming in?  Should all the doctors keep seeing them ahead of the patients in the ‘Green’ (Minors) area?  If you work in the UK (or Australia, in the near future) you’ll be conscious of the 4 hour target, which means that all patients should be seen and either admitted or discharged within 4 hours of arrival.  How should that influence your decision?

If your focus is on the target, would you put most of your doctors in the ‘Green’ (Minors) area?  That’s the only way of giving the hospital a chance of hitting the target.  But should that even be a consideration?

This scenario is actually the sort of thing that, as a consultant (or attending) in charge of a large ED, you have to deal with every day.  We probably don’t give these things a second thought.  But they’re real issues.  I’m sure that every one of us would say that we put patient care ahead of targets.  But how much do we value clinical urgency over the time a patient has waited?  How much should we?  These are important things to think about.

Scenario 4: The ethics of ‘fast tracking’

There’s a 3 hour wait in the Green (Minors) area.  Most patients in the queue seem to have complaints that would only take a few minutes to sort out – infected insect bites, sprained ankles, neck sprains, etc.  They’re not particularly urgent but you know that you could take most of them out of the queue if an experienced doctor saw them all quickly.  The rest of the patients have problems that are probably more urgent – abdominal pain, chest pain, headache, collapse – but they’ll take longer to sort out.  

You wonder whether you should have an experienced doctor ‘fast track’ the patients who could be sorted out quickly to rapidly reduce the overcrowding in the ED.  BUT… this will mean that some patients with minor complaints are seen faster than patients with potentially more serious problems.

Image by Nemo on Pixabay

Image by Nemo on Pixabay

Again, this is a question about justice.  If you see the patients with minor complaints first you’ll remove them from the queue, reduce overcrowding in the busy ED and, by creating two separate queues, you’re making the queue shorter for the patients with more serious problems – although that queue will now move slower.  Is that fair?

Overall, the waiting time is likely to go down if you do ‘fast track’ patients.  Does that mean it’s right?  What about the impact on the individual with the more serious complaint? These are all things we ought to be mentally prepared to deal with – and, again, we have to make these decisions every day.

Scenario 5: is it right to prioritise certain patient groups?

Once upon a time the Manchester Triage System was the be all and end all.  We honoured each patient’s triage category equally.  But things have changed.  In the era of ‘trauma systems’, a Major Trauma Centre has targets to ensure that patients with possible ‘major trauma’ are seen by a consultant (attending) within 5 minutes of arrival.  Many of these patients will be seriously injured and it’s obvious that they need immediate attention.

But what about the so-called ‘silver trauma’?  These are patients who turn out to have a high injury severity score but it may not be apparent at the time they arrive in the ED.  Elderly patients are particularly likely to present with ‘silver trauma’.  They may arrive with confusion.  We find a urinary tract infection, we treat it.  Two days later, the confusion doesn’t settle and someone orders a CT brain scan, which shows a subdural haemorrhage.

Archery_target

Because of the targets, major trauma centres make great efforts to ensure that those patients are seen by consultants (attendings) within 5 minutes of arrival.  But is that right?  Do they need to be seen by a consultant – immediately – and in preference to other patients who may have airway obstructions or severe hypoxia?

These are also decisions we make every day.  When we make them, we need to ask ourselves whether we really are focused on patient care or whether hitting targets has taken preference. And, if it is the latter, is there a good (just) reason for doing so?

In summary

Triage is something we need to do in the ED because not everyone can be seen immediately. It might seem quite obvious that sicker patients get seen quicker, and that we use a system (like the Manchester Triage System) to decide how quickly. But there are still lots of difficult decisions to make.

In this post we’ve asked four key questions about the ethics of triage:

(1) How do you balance the time patients have waited against clinical urgency?

(2) How much do you take account of a patient’s suffering when deciding on clinical urgency? And, if you do take it into account, how do you measure it?

(3) How do you allocate resources when there are lots of patients with both major and minor complaints waiting? The patients with minor complaints still need to be seen – but how do you get the balance right?

(4) How do you balance pure patient care against targets?

One day, the large hospitals in developed countries might have enough doctors to ensure that nobody has to wait to be seen. Until then, triage is a vital part of Emergency Medicine – and we all need to know how we’re going to make these tricky decisions.

Please share your thoughts using the Comments section – we’d really love to hear from you!

Until next time!

Rick

12 Comments

  1. Nicola jakeman

    Add in NEWS as well as triage and that flags up a whole extra group of patients that could/should be prioritised in addition to those flagged by triage…great blog. Thought provoking

    Reply
    1. richardbody (Post author)

      Thanks a lot, Nicola! Out of interest, do you use the NEWS to assign triage priority? We don’t – but we do have a ‘Patientrack’ system, which we use to upload every set of observations that’s recorded in the ED. Patientrack pages one of our doctors automatically if the early warning score for any patient is above a set level. So – even though we don’t use the early warning score for triage per se, it’d be highly unusual for patients with physiological abnormalities to go unnoticed, even if the triage nurse hadn’t used a Manchester Triage System discriminator to assign an urgent priority.

      Thanks again!

      Rick

      Reply
  2. Dr Mohd Idzwan bin Zakaria

    Availability of resources is always an issue in the developing countries like Malaysia. Hence, to have a 5-tier triage system is a luxury for us. We adopt the 3-tier system due to human resources issue. Having a consultant on call improves real-time decision making.

    Reply
    1. richardbody (Post author)

      Thanks for sharing! That’s a really interesting insight. I’m not really sure that the 5-tier system is a sign that we’re well resourced. We may well be but I’d have thought that an under resourced area could also use the 5-tier system. In fact, I’d have expected that the longer your queue of patients at any given time, the more tiers you might need to ensure that you get the right balance between clinical priority and waiting time.

      The Manchester Triage System is actually really easy to use. It can be paper based (you just need the book for reference) or electronic. Do you think the limiting factor is getting the books or references to use a system like that? Or is there something about using a 5-tier system in particular that wouldn’t work in your area? It’s really interesting to get such great insights from Malaysia – thanks again!

      Rick

      Reply
  3. Tom Mitchell

    Thanks Rick. Blimey, some great thoughts. Thought I’d add my tuppence worth…

    The prioritisation/triage process has to be a dynamic one as you alluded to above. Although patients are assigned numbers on arrival a change in EWS/NEWS, evolving ST elevation on that ECG or a VBG showing hyperlactataemia must change priorities. Not all ‘Ambers’ are created equal.

    On top of this there are prioritisation decisions we make as consultants which fly in the face of clinical need such as VIP/vips (http://www.stemlynsblog.org/vip-ed-st-emlyns/) and, dare I mention it, seeing the patient who is ‘demanding attention’ early to avoid all staff members being drawn into the drama.

    This ‘helping the department helps patients’ principle could be applied to prioritising easy to treat or refer patients. Departments seem to have a critical workload mass beyond which they become inefficient and effective triage becomes even more difficult. Patient flow allows focus of medical and nursing resources on those requiring it….

    Just out of curiosity, how many triage category 5 patients do you get?

    Reply
    1. Simon Carley

      Not many Cat 5. I can find the exact number but it is small to be honest.

      As a consultant/most senior decision maker then the idea of smoothing the department by bypassing other priorities is certainly familiar.

      Thanks for the comments and thoughts.

      S

      Reply
    2. richardbody

      Thanks a lot, Tom. Actually, looking at our stats (from a current project), I work out that 12% of our patients are triage Category 5, which is a fairly high number. We do have a Primary Care Emergency Centre though, and most of these patients will be sent there to be seen.

      I totally agree with you both about the patient flow argument. You can’t always work on the principle that the patient with the most urgent complaint gets seen next – or else those with the least urgent problems would literally never get seen in a large ED! We could do with some more evidence to show how this is ultimately in the best interests of all patients, though. And it definitely seems to be a utilitarian principle (as per the previous ethical dilemmas) – which might not fit so well with ‘first, do no harm’ when you think about it!

      Rick

      Reply
  4. Iain Beardsell

    Rick,

    Thought provoking as ever. Unsurprisingly, I wonder how much the four hour access target has influenced this. The need to see the single patient with life threatening pathology over large numbers of “minors” patients is relatively clear in my mind, yet now it is not just about these patients. The potential large number of “breaches” may cause the hospital to be fined financially, reducing their capability to care for patients in the future, and the psychological effect on staff of “failing” and how this may effect them cannot be underestimated.

    In the current climate I think it is almost impossible to ignore the target and it does influence decision making, perhaps to the detriment of patients. And that, I truly believe, is something that we really must do something about.

    BW,

    Iain

    Reply
  5. Helen Hale

    Hi Rick, thanks for this article. It’s helped with my assignment. Targets v patient care. I used to work with you a long time ago in MRI now I’m in a London trauma centre so all very relevant. Thanks again Helen Hale

    Reply
    1. Rick Body (Post author)

      Hi Helen,

      Great to hear from you! Thanks for the nice comments and it’s nice to be in touch again. Hope you’re enjoying London!

      Rick

      Reply
  6. Deva

    Hello, i am Deva from Indonesia. is this triage used the latest? which I know there are only red-yellow-green and black

    Reply
    1. Idzwan

      In Malaysia, we are using a 3 Tier triage system; red, yellow and green. But we further classify our green, G1-G4. It is all depends on your human resource.

      Reply

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