2018/01/27 18:17 1/4 Australasian Triage Scale (ATS)

Australasian Triage Scale (ATS)

see also:

administrative issues
vital signs, clinical deterioration, MET calls, acute illness scoring systems (eg. NEWS)
ACEM policy - Australasian Triage Scale Nov 2000 (pdf)
“Where Emergency Department resources are chronically restricted, or during periods of
transient patient overload, staff should be deployed so that performance is maintained in
the more urgent categories.”
“Prolonged waiting times for undifferentiated patients presenting for emergency care is
viewed as a failure of both access and quality.”
ACEM Triage Guidelines Implementation (pdf)
ACEM paper - ATS 4 and 5 are DIFFERENT to GP type patients (pdf)
"non urgent" patients in the ED

The Australasian Triage Scale

ATS Category Treatment acuity KPI target

(max. waiting time) (% seen within max. wait)
1 0 min 100%
2 10 min 80%
3 30 min 75%
4 60 min 70%
5 120 min 70%

patients dead on arrival are usually given an ATS category of 6.

Category 3 Risk Amelioration Project

Introduction

The Australasian Triage Scale (ATS) was agreed upon in the late 1980's and arose out of sorting
systems to categorize patients arriving at the hospital's emergency department in order of urgency.
Dr Ed Brentnall OAM was a key figure. As Director of Box Hill ED the system he implemented closely
resembled the one we now use.

Historically, triage can be traced to battlefield decision-making and the efforts to save the most lives.
Overwhelming numbers of injured fallen led to a need to prioritize who would be treated and in what
order.

Triage is not an indicator of whether a person should have attended the ED. And triage should not be
a tool for turning people away from the ED.

Triage Category 3 is classified as “Urgent” which translates to a waiting time recommendation of

“Less than 30 minutes”.

The normal day at Sunshine ED sees about 85 of the 240 or so people arriving to Triage being
allocated a category of 3.

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Staffing is distributed in rostered shifts in such a way as to best meet the needs of these arriving
patients.

Situation

More than two-thirds of Triage Category 3 patients are not given access to a cubicle or are not able to
have a focused history taken by a doctor within the recommended maximum wait time of 30 minutes.

This is a diverse group of patients, some of whom have high-risk, high-lethality medical conditions.

A Triage Category 3 patient in the waiting room beyond 30 minutes starts to accumulate unmanaged
risk.

Previously a RAZ system was implemented to try to address this issue.

RAZ has enjoyed limited success chiefly due to a lack of consistent staffing for that “care-model”, but
also due to its day and evening shift implementation without night shift support.

Risk-reduction strategies which are workable during the night shift hours of 10.30pm to 7.30am are
the main aim of this initiative. If the night shift staff find the processes detailed here useful, then
scaling the methods up to cover the day and evenings shifts is reasonable.

Background

The demography of Western Melbourne has determined the rising overall attendances to Sunshine
ED. The Hospital frequently suffers from crowding (bed occupancy well over 100% capacity) which
leads to access block (admitted patients boarding in the ED for more than 8 hours after presentation).

The hospital is also situated in a region of low health-literacy and low socio-economic means.

For these two reasons people may present late in the course of their illness and may be less inclined
to advocate for themselves and their family. A large number of at-risk patients are not fluent in
English.

Assessment

Triage Category 3 patients are quite likely to discharge-prior-to-being-seen which poses an

unacceptable risk to themselves. Last month the DNW (Did Not Wait) percentage was above six for
Triage Category 3.

Those who do wait, may suffer a deterioration in their condition while in the waiting room, which could
have consequences in terms of the safety and effectiveness of their management.

Triage Category 3 patients (who by definition have urgent clinical issues) would be reassured if their
local hospital attended to them in a timely fashion, and this could lead to a drop in complaints.

Request

At the commencement of each shift medical staff are advised to hand over all Triage Category 3
patients who are yet to be seen by a doctor.

The on-coming doctor in charge is advised to update tracking-screen notes at this time to reflect
urgency of review.

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Re-triage remains the best option for mitigating risk. This can be communicated to the nurse in
charge and the triage and flow nurses.

The ED Status application (copyright Dr G. Ayton) can be used to get a glimpse of unseen Category 3
patients, their triage notes, and the wait time. Modifications can be made to this program after
feedback is obtained from staff.

The following steps could be used to help manage excess Triage Category 3 waits. This is a joint task
for our doctors in charge, nurses in charge, and flow nurses.

Identify Risk Factors:

1. Patients who are not fluent in English

2. Elderly patients (age >74)
3. Patients with abnormal vital signs or pain persisting after analgesia
4. Those with a history of ESRF or CRF
5. Any patient whose triage assessment leads to concern or diagnostic doubt

Order and Review Imaging:

In line with recent strategies to help the efficiency of Fast-track it is possible to organise high-yield
imaging studies from the waiting room - for instance CXR, CT-Brain and CT-KUB.

The hospital is working towards an ED-driven request system for non-constrast CT for specific
indications which will not require approval from an off-site radiology registrar.

Make use of the sonosite ultrasound early in the assessment of Category 3 patients who are in a
cubicle to evaluate their problem and assist in disposition.

Provision of more timely imaging for certain patient groups may lead to a reduction in adverse
outcomes.

Advocate for the patient:

Early communication with the access manager (“after hours” or “bed manager”) to escalate
appropriately the need for waiting room patients to gain entry to ED cubicles. Wards may be able to
assist by taking another patient on a four-hour plan.

Prioritise at-risk Category 3 patients for access to cubicles. Although bringing waiting room patients
directly into EOU may be an option, the potential for cognitive errors, inefficient bed use, and queue
errors make this strategy less likely to be a viable solution.

Explain the wait:

Provide explanation to patients and to colleagues regarding realistic time-frames for assessment and
management.

Managing each patient's (and their family's) expectations is part of our role in providing rapid care in
a busy Emergency Department.

References

Ayton, G., “EDStatus.exe” desktop application, Desiderata Software.

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Dunn, R., Brookes, J., Rogers, I., et al, Emergency Medicine Manual.

Burke, J.A., Greenslade, J., Two hour evaluation and referral model for shorter turnaround times in the
emergency department, EMA, Vol 29, Issue 3, 2017.

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