Triage nurses are one of the most valuable roles within an Emergency Department, but they are placed in increasingly difficult situations. Departments are crowded, staff are stretched, patients are frustrated or angry about how long they have waited and it can feel never-ending.
A survey conducted by the Nursing Times in January 2021 found that 86% of the nurses asked had worked shifts ‘where they felt patient safety had been at risk due to staff shortages’ and that 94% had worked shifts that were ‘short-staffed due to colleagues being off sick or self-isolating’.
Overstretched nurses in the NHS is not a new phenomenon – around 10% of registered nurse vacancies were unfilled before the pandemic. The Health Foundation’s research also shows that over the last ten years, NHS activity has risen without a corresponding increase in the nursing workforce.
There’s no doubt that COVID-19 has put additional pressure on an area of the healthcare sector that was already at a breaking point. ‘Winter pressures’ are no longer just for winter.
Does it have to be this way, for both patients and nurses? I don’t believe it does. Could we improve both the patient experience whilst improving safety and reducing inefficiencies in this process? Definitely.
Key issues needing to be addressed
There are several issues that contribute to the challenges we’re facing now across our emergency departments. Workforce and subsequently workload, patient experience and inappropriate attendances are just three.
In terms of workforce and workload, the above statistics are obviously worrying and demonstrate the impact that COVID-19 is having on already stretched resources. Many colleagues of mine know that they need more staff but aren’t able to recruit.
From the patient perspective, the process often seems confusing and inefficient. You have to give your information several times to different people throughout your time in the department, often with little privacy, and you have little idea about when you will be seen. We’ve spoken in more detail about how digital check-in and triage technology is already improving the emergency care patient experience in another blog.
Inappropriate attendances are a continual issue for the NHS, across both primary and emergency care. One study found that inappropriate attendances may account for up to 40% of presentations at accident and emergency (A&E) departments.
A lack of clarity and understanding from people over which service they require is another factor, resulting in unnecessary pressures on A&E and GP services. This is often a feature of educational campaigns because of the impact it has on the health ecosystem. In an analysis from 2015, it was estimated that self-treatable conditions were responsible for 20% of attendances in England in 2014, or around 3.7 million attendances, at a cost of £290 million.
Collecting information upfront helps triage nurses with decision making
So how can we improve this process and make the experience better for both patients and staff in the emergency department? We need to improve the amount of information triage nurses have so that they can quickly make decisions about how to manage the patients in their waiting room.
If we collect patients’ information as soon as they walk through the door we know about them and their symptoms as quickly as is physically possible. Hospital departments that have started doing this are collecting patient information, including Emergency Care Data Set (ECDS) questions, directly from patients within 5 minutes of arrival.
This self-service check-in process allows patients to answer questions about their health and why they are at the department as it includes a mix of multiple-choice and free text questions. As it’s software, it’s also flexible and easy to update as and when guidance changes. During COVID-19, questions were added immediately to the software as guidance changed, for example with the Danish mink variant, meaning that nurses didn’t have to worry about ensuring they asked these new questions.
There’s no need for patients to queue to see a receptionist – banks of tablets now allow them to do this themselves, providing them with additional privacy. If they need any support or have questions, receptionists can be on the floor supporting patients instead of behind the desk. Patients can then sit down until a triage nurse calls out their names.
As part of this digital check-in process, the clinical questions that patients answer are being used behind the scenes to triage the patient, assigning them a priority score. This information is fed into the clinical system in an easy to read and structured way. Particularly important, it alerts clinicians to the sickest patients in their waiting room, so that they can be assessed first.
As patients book themselves in, eTriage gives them a priority score between 1 (most urgent) and 5 (least urgent). Pretty much instantly we know how much risk – how many high priority, sick patients – are sitting in our waiting room.Catherine Keegan, ED Matron, Worthing Hospital
Anyone in the department can now quickly have oversight of not only the number of patients in the waiting room but also the acuity of these patients. As a triage nurse, you can now quickly call out your highest priority patients. Using the structured information they have already provided, the triage nurse can validate this information with them, ask any additional questions and make a decision about the next steps then and there. For example, they might need some pain relief or the nurse might need to arrange some investigations for them before they move on to the rest of their journey.
I can assess if I need more triage nurses on the floor. Their job is to validate the information provided through eTriage, upgrade or downgrade scores as appropriate and provide pain relief immediately if needed. It gives us a sense that we didn’t have before about how well or how sick everyone in the waiting room is. They’ve gone from an unknown to a known quantity.Catherine Keegan, ED Matron, Worthing Hospital
All of this not only provides you with the information you need for triaging, but it streamlines the patient’s consultation massively. It gives your nurses the information they need, quickly, whilst also taking work away from your stressed-out reception team. Having this information upfront means you can quickly stream patients to the right clinician, at the right time.
This automated information gathering and triaging takes a huge amount of cognitive load off each individual nurse, helping to keep you going through long hours and high periods of stress. It can also bring in some safe-keeping and auditable records into the department, as your patients should have mentioned all the key information when they checked in.
How can this technology support triage nurses safely?
The software that I’ve mentioned already exists and it’s being used in departments across the UK already. eTriage, a digital check-in and automated triage platform specifically designed for urgent and emergency care departments, has been developed by active doctors and nurses with years of expertise in digital triage.
A robust and experienced clinical governance team, led by former Emergency Department Matron Krista Burslam-Dawe, also sits behind the product, drawing in expertise from emergency medicine specialists to help devise and test the questions asked to patients.
You don’t have to take our word for it, hear more from Catherine Keegan, Matron at Worthing Hospital and what she thinks about it here.
Montse Fletcher, Senior Sister in ED. I currently work part-time as a Senior Sister and ACP in the ED of a large London teaching hospital and have worked in various roles as a nurse within emergency care for over 20 years. I also work part-time for eConsult as a Clinical Operations Lead in conjunction with another ED Sister concentrating on the growth and development of our Urgent and Emergency Care platform, ensuring the product remains up to date and in line with NICE clinical guidance.
Want to find out more about the digital triage technology we are creating for Emergency Departments and UTCs? Book in a call with our team.