The Decline and Fall of Triage in the ER

The national trend toward overcrowding in emergency rooms is having an interesting effect on a process that was conceived to handle a large number of injured patients: triage. One might expect that as more and more patients flow into the ER, the process of triage would become even more central to the smooth flow and efficient management of an emergency department. In fact, the opposite is the case, and for one simple reason: the new patients flooding the ERs generally aren’t having an emergency. 

Triage, or the quick sorting of patients according to how severe their injury, is really designed to assist doctors during a mass casualty event, whether a war or a natural disaster. In such terrible circumstances, where some patients will benefit from emergency intervention far more than others, triage is an essential tool to make the best use of limited medical resources, such as a doctor’s time or an available hospital bed.

However, emergency rooms are rarely the site of a mass casualty event. And while emergency rooms are increasingly busy, they are being crowded more from people who do not have access to primary care and by patients with non-critical issues than by the victims of war or natural disaster. In this environment, triage is the wrong strategy.

The changing demands of emergency medicine have led our group to implement a number improvements to the smooth flow of the ER, but one that stands out is our increasing effort to bypass the triage process and bring patients straight back to an open bed so they can be given a more comprehensive evaluation more quickly.

The “straight-back” process, as we creatively call it, has reduced crowding and improved the flow of patients through our emergency departments, so much so that it can make the ER look far less crowded, when in fact we are just moving patients through faster.

More than improving efficiency, though, the straight-back process is notable for the deeply-ingrained triage process that it replaces. Many emergency departments are quite attached to triage, and getting a team to move away from it can be hard. We generally test the straight-back process during short stretches when we know the department will be quiet – non-peak times when staff know there are beds available. From there we build up to larger stretches, ultimately aiming for a straight-back process 24-hours a day.

The change is a crucial part of dealing with the trend toward increased volume in emergency rooms. It is also a key step away from providing care as if we are dealing with a life-threatening emergency in all cases, at all times. The reality is that emergency rooms have become the primary care stop of first resort for a large percentage of U.S. healthcare patients. Getting them seen quickly, so we can diagnose, treat, and perhaps discharge them, is a key part of addressing overcrowding in the ER.