Follow-through of triage protocol

Abstract

We read with great interest the article by de Coster et al. exploring caller characteristics associated with following nurse telephone advice. We would like to congratulate the authors for their study, very well designed, reporting >170 000 calls. With the tendency for increased emergency department (ED) use and overcrowding, triage has become a critical step in ED functioning. Cost-containments efforts have focused on prescreening of patients by telephone to determine who may be redirected to a routine visit or given home advice instead of seeking in the ED. We would like to go further into the debate and highlight that compliance of both patients and clinicians with triage protocol is the corner stone of triage efficiency. And we would only point out that in real life experience, the rate of compliance of triage personnel with guidelines can be low. The use of a computerized triage system, as the software used by Alberta nurses, could theoretically improve triage by improving its completeness and enhance reproducibility. But telephone triage relies on accurate triage tools to identify major cases and compliance with the triage protocols. Wacher et al. (evaluating the implementation of a set of standardized telephone triage protocols) have found that 58% of nurses felt confined by the protocols and 42% admitted intentional deviation from them, when they believed that optimal patient care mandated that they do so. Correlation among dispositions determined by triage providers was poor, despite instructions to follow protocols as closely as possible. Although it is a basic assumption that protocols operate by standardization, these results indicate that nurses did not reliably choose the same protocol in a given case and did not reach the same triage endpoint even when they followed the same protocol. As suggested by Poole et al., nurses may decide ‘under some circumstances to follow their intuition rather than the protocol’s recommendation’. Piccotti et al. assessed the percentage of consistency with the triage process drawn up at the level of paediatric ED and concluded that there is a need for further efforts to improve compliance with the protocol and pursue a higher degree of uniformity in evaluation by triage personnel. And it was found that physicians can easily break from protocols to achieve disposition of patients, especially the more experienced one. Although patients’ compliance with advices is a key point, compliance of triage personnel with triage protocols must be evaluated, as well as under triage and over triage before targeting initiatives to improve follow-through of telephone advices. Telephone triage protocols are a complex and challenging issue, and many bias linked with poor protocols compliance or under triage can make telephone triage less seducing in practice.