My name is Pete Chessum I’m a Consultant ACP in ED/Acute medicine and also a PhD student studying resilience engineering in emergency departments. In 2013 I helped with a NIHR project called the Emergency Care Handover Project (ECHO). After a decade of ACP life I’ve been asked to share what I think works (or doesn’t) within Rapid Assessment and Triage (RAT) environments. This is an opinion piece, it’s also important to note that very little evidence exists specifically on RAT areas and that which does is almost always single site service improvement work. I’m going to break down some advice into seven headings ‘Communication’, ‘Equipment’, ‘Expectations’, ‘Network’, ‘Team’, ‘Training’ and ‘Stuff’ (CENTS).
The word Triage comes from the French verb Trier which means to separate, sort, shift or select (thanks Wikipedia) and as many of us know triage has been around since battlefields during Napoleonic times, if not before. Our aim with any kind of triage is to deliver emergent care to those most in need and attempt to establish those who can wait a little longer for intervention. It then gets complicated because we break modern hospital-based triage systems down to ‘streaming’, ‘minors triage’, ‘complex triage’ and finally the basis of this blog Rapid Assessment and Triage (RAT). RAT is performed differently but, in this instance, I’m presuming we are assessing complex mobile patients and all patients conveyed by ambulance.
Demand is increasing not just in terms of footfall but also in relation to the miss match of acuity/complexity, space, resources and staff to care for patients effectively. The infamous 4hr target is going but the suggested replacements still highlight time to initial assessment and that highest risk conditions defined in testing as stroke, major trauma, heart attacks (MI – STEMI), acute physiological derangement (including sepsis), and severe asthma get identified early and treatment commenced within the hour.
We appear to be asking more of staff in RAT then just sorting the sickest out quickly, we ask teams to also affect flow via throughput. An often cited but basic premise is that flow is determined by input, throughput and output. It has been suggested that teams in ED can only affect the throughput as we can’t stop people coming and we can’t magic up hospital capacity. I’m keen that we don’t give up on influencing throughput or performance blaming outflow for extinguishing any chance of in-house improvements. There remain many things we can do within EDs to improve patient experience and reduce admission rates.
There is also an expectation for RAT to influence flow by referring patients earlier to appropriate specialties re-directing through to Same Day Emergency Care (SDEC), surgical admission, trauma or even primary care at the front door with light touch ED involvement. RAT teams should initiate diagnostics and treatment quickly (but also appropriately) with an aim of improving patient condition or catalysing a diagnosis for patients. They may have a long wait until the next clinical review. Remember it can be about what we don’t do as much as what we do. Try not to make RAT painting by numbers with everyone getting the same treatment, fluids, IV ABX, XRs etc, etc…
COMMUNICATION – Is essential. You have to communicate well and be comfortable talking to families as well as many different professionals. It may get wearisome taking handovers every five to ten minutes or so but try to engage, listen and ask questions it maybe your only chance. A tension exists in that paramedics have priorities and so do we in the hospital. Most of the time we share the same goals good transfer of care, but sometimes our priorities can compete. Resentment can build as wave after wave of patients come in without space for us to see them. Frustration grows because we feel we aren’t resourced to deal with them effectively or that some were inappropriate conveyances. I suppose my tip here is to try to get above that, focus beyond it, discuss cases in real time with paramedics then really aim to see the person in front of you. Literature will tell us that a patient’s perception of the wait is always worse when they don’t know what’s happening. The bonus of a senior team at RAT is you can explain a likely trajectory at point of entry. Make time to allay concerns for patients and families when possible, discuss your initial impressions with the caveat that tests may be awaited. Remember to help out the senior team in ED, if there are patients you are worried about let the EPIC know if you are starting to struggle with offloads inform NIC early. As the clinician in charge of RAT be in every handover you can, it helps back up juniors and allows you to add pertinent points about patients you’ve seen.
EXPECTATIONS – Be realistic. Some patients are barn door admissions (#NOF etc) so fine, but one of my greatest frustrations with RAT is you will happen across senior staff down the line who will suggest that “you should have been able to refer from RAT”. Well possibly, but often there is now a raft of results back that weren’t initially available and if a patient is in a grey zone trying to refer too early is just going to waste precious time wrangling with a specialist. Limit the amount of time in the area for all staff it creates perfect conditions for decision fatigue and error. Staff who have done time in RAT know that histories begin to merge, patients stack up in corridors even back on to ambulances and pressure mounts. It’s easy to feel responsible for it all. I think if you do it properly no one should really be able to do more than 3-4hrs in RAT as a clinician. Shifts where any staff are expected to do 10-12hrs within RAT is almost asking for error.
In some organisations people referred already to a specialty can get a second-class service with the ED just acting as a holding area until a specialist takes over. The fact that someone is the ‘medical referral’ doesn’t mean they will get seen soon or that they don’t need to be seen now. Please, please work these people up and treat them just as you would any other ED admission.
Remember this is quick, its 5-10mins (if you’re lucky) and there is often an efficiency-thoroughness trade-off. This means RAT people miss things think of it only as a primary survey. I’d also suggest that you never copy and paste the notes of RAT clinicians.
If you are working in RAT don’t try and be a hero. Occasionally some patients can be discharged from RAT but in my opinion, you may risk getting things wrong because you’ve rushed. That’s not good for you or those in your care. RAT will never be the panacea to all problems.
NETWORKS – ED isn’t an island and now more than ever before success relies on good relationships and networks. If we take referral to SDEC as an example, the identification of cases suitable from RAT to go there can be done based around pathways and ambulatory scoring systems. However, ultimately what tends to work best is a respectful relationship between the two areas. Know staff in the SDEC team, ask them to visit at given times during the day, if unsure on a referral ask SDEC to contribute to the decisions. Do the same with all specialties surgery, trauma, cardiac, mental health, gastro, respiratory and any other specialty you can name. Build those relationships! If you see a patient in RAT that could do with a specialist immediately speak to the experts first. IF we can skip the ED step and get the patient into the right specialists’ hands first time that’s best for everyone.
TEAM – is obvious but getting the right people to the patient as early as possible is key. Literature suggests that moving senior medics further forward in the process of seeing patients is beneficial. However, there are limitations to this the first being the lack of senior medics combined with the multitude of directions they are pulled in. I’d obviously therefore replace this with senior clinicians to include qualified/senior ACPs. The requirement for experience being that assessments, documentation and decisions have to be done quickly. Nursing really is key – often when working in a RAT area the nurse in charge of the area will be in and out moving patients, doing assessments, giving treatments, taking and giving handovers. It’s a thing to behold they lead the place like it’s a department within a department. Think about your emergency care assistants, phlebotomists, porters, admin staff and how each person’s knowledge and skills can contribute to the common goal. Quite commonly HALO’s (senior paramedics charge with monitoring handover/handoff times) are found in RAT areas. Ensure they feel part of the team watching for bubbles of activity occurring in the prehospital setting headed your way. If you work a system where HALOs are taking handovers on your behalf try to make sure knowledge doesn’t degrade between multiple handovers (see ECHO project Sujan et al 2013) .
TRAINING – Provide training to all levels of staff in the RAT area. Assess what boundaries maybe stretched. Look to the obvious ECGs, cannulas, and bloods by your HCAs but also XRs, PGDs, including special circumstance ABX and catheter insertion training for nursing staff. Good units develop their own cyclical training programmes and competence portfolios for nurses working within RAT areas. I’ve seen some underpinned by Universities. Think about the opportunities to sim teach the variety of presentations that may come in GI bleeds, stroke, STEMI anything really and play out each person’s role in the team. For your clinicians think about whether specialised training on rapid decision making with adjuncts such as USS for access, AAA or IFBs may improve a patient’s journey.
STUFF – It sounds obvious but look at what you need in the area and make it accessible. Ring fencing equipment can be difficult but remember there’s a lot to be done in a short amount of time so have a gas machine, USS, ECG, observation machine, blood trolly, catheters all in the area ready to go. Think also about keeping commonly prescribed treatments nearby so you don’t have to keep leaving to get things from other areas. Think lean.
Rapid Assessment and Triage is a tough place to work but I really believe it can improve the care patients receive and the flow within departments. Within resilience engineering we talk about the ability to ‘anticipate, ‘monitor’, ‘respond’, ‘Learn’ which I think fits with what a RAT team can be doing. We can anticipate future demands on the department, we can monitor conveyance screens and offload times, we can respond by treating, investigating, re-directing where appropriate and importantly we can ‘learn’ and teach the skill that is working in RAT. Too often in healthcare we look backwards at what has gone wrong or hasn’t quite worked, whereas to keep moving forward we should be looking at what does work and replicate it by teaching the next generation.