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A triage system for dogs and cats: Is it significantly better than common sense? Author: M.E.Gunning Studentnr. 0245976 June 2008 – October 2009 Supervisors: J.H. Robben, PhD, Diplomate European College of Veterinary Internal Medicine – Companion Animals Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, The Netherlands. L.J. Ruys, Resident Emergency and Critical Care Spoedkliniek voor Dieren Amsterdam, The Netherlands. Small Animal Clinics, Faculty of Veterinary Medicine, University of Bern, Switzerland. -A triage system for dogs and cats: Is it significantly better than common sense?- Contents Contents __________________________________________________________________ 2 Abstract ___________________________________________________________________ 3 Introduction _______________________________________________________________ 5 Materials and Methods _______________________________________________________ 7 Results ___________________________________________________________________ 11 Discussion ________________________________________________________________ 20 Acknowledgements _________________________________________________________ 24 References ________________________________________________________________ 25 Addendum 1: The Manchester Triage System (MTS) _____________________________ 26 Addendum 2: Flow charts of the VTS __________________________________________ 28 Addendum 3: Assignment of patients __________________________________________ 40 2 -A triage system for dogs and cats: Is it significantly better than common sense?- Abstract Introduction - Triage refers to the process of prioritizing patients based on the urgency of their medical condition so as to treat patients in an appropriate order when resources are insufficient for all to be treated simultaneously. With an increase in both patient numbers and waiting time periods in veterinary emergency clinics, it becomes more and more important to sort all patients appropriately in order to be able to give all of them the medical treatment they need in a timely manner. There is still no such thing as a widely accepted and standardized veterinary triage system. Most veterinary nurses tend to sort patients intuitively or based on prior experience, or apply a self-construed, non-validated triage system. The veterinary emergency clinic “Spoedkliniek voor Dieren in Amsterdam” currently uses a highly subjective triage based on intuition, experience and common sense of the veterinary nurses. The aim of the present study was to determine whether this subjective triage is adequate in comparison to a newly designed Veterinary Triage System (VTS) based on the human Manchester Triage System (MTS). Additional aims were to determine if nurses, when triaging their patients, link higher urgency to priority over less urgent patients and if decisions differ for trauma and non-trauma patients. Materials & Methods - This study recorded the actual waiting time period (i.e. the time period the patient had to wait before it was seen by a veterinarian), history and data from a physical examination for 500 patients (193 dogs and 307 cats) visiting a companion animal emergency clinic, the “Spoedkliniek voor Dieren Amsterdam” (SDA). In addition, at arrival of the patient, the veterinary nurse was asked to state the desired waiting time period for each patient, i.e. the time period in minutes the nurse considered acceptable for each patient to wait before being seen by a veterinarian. In retrospect all 500 history and physical examination data were evaluated and subsequently the patients were labelled with an urgency category based on the VTS. Furthermore, 109 patients presented with a history of trauma were considered separately. Results - This study demonstrates that significant correlation exists between actual and desired waiting time periods and urgency categories determined in retrospect, declining with lower urgency. Despite this correlation, over 50% of cases is over- or underestimated by nurses, compared to the VTS. Nurses tend to overtriage more than undertriage patients. Overtriage is also reflected by the 0.52 predictive value of the estimation of high urgency by 3 -A triage system for dogs and cats: Is it significantly better than common sense?- nurses. Trends are similar for trauma patients, with the exception of a much higher percentage of prioritisation of urgent patients. Discussion - Although it is difficult to tell how much overtriage is still acceptable, Long et al. described the “next-to-ideal” criteria as having 15-20% overtriage and no undertriage3. Both overtriage (37.8%) and undertriage (21.2%) in this study fail to meet these criteria, which could be caused by the lack of objective measures to determine the need for immediate veterinary care. Recognition of urgency did not lead to the prioritisation of urgent patients per se. Improving communication between nurses and veterinarians will probably lead to more efficiency on this level. Possibly, nurses prioritize trauma patients more because of their presentation or worried owners. Conclusions - This study demonstrates that nurses’ triage decisions of both trauma and non-trauma patients based on experience, intuition and common sense differ significantly from urgency classifications stated retrospectively using the VTS. However, further studies on the reliability and validity of the VTS are needed. The underestimation of immediate and very urgent patients and the overestimation of less urgent patients makes triage without guidelines inefficient. The development of a veterinary triage system, increasing reliability of urgency estimations and thereby safety of patient care in small animal emergency departments, should be considered. 4 -A triage system for dogs and cats: Is it significantly better than common sense?- Introduction The concept of triage was first developed on the battlefields to sort the treatment of injured soldiers in order to make sure that those who were able to fight again after treatment were taken care of first. However, the concept has become more widely known because of its use in waiting rooms of emergency services with a somewhat different goal. Triage in this situation refers to the process of prioritizing patients based on the urgency of their medical condition so as to treat patients in an appropriate order when resources are insufficient for all to be treated simultaneously. The word “triage” is derived from the French word “trier” which means “to sort”. In human hospitals triage has become a vital part of the emergency service and is gaining more and more significance caused by the growing workload at these departments. The growing number of self-referring patients has made it necessary to distinguish the urgent patients from people suffering from only minor injury or illness. A well known and widely used triage system in human medicine is the Manchester Triage System (MTS). This system is not based on diagnoses, but on the patients’ presenting complaints, the main signs and symptoms that bring the patient to the treatment centre. The MTS works with colour codes that are linked to the degree of emergency for the potential condition(s) underlying the complaints (see Addendum 1 for more information). The MTS has shown to be a sensitive tool for detecting those who need emergency care1. However, it did fail to detect some patients who deteriorated after arrival. This emphasizes the fact that triage systems have to be used as dynamic systems. As in human medicine, the workload at veterinary emergency clinics is gradually increasing2. With an increase in both patient numbers and waiting time periods in veterinary emergency clinics, it becomes more and more important to sort all patients appropriately in order to be able to give all of them the medical treatment they need in a timely manner. Many veterinary clinics have some sort of triage system instated based on intuition, experience, common sense. At present there is not a widely accepted and validated triage system for use in companion animals. The veterinary emergency clinic “Spoedkliniek voor Dieren in Amsterdam” (SDA) currently uses highly subjective triage based on intuition, experience and common sense of the veterinary nurses. The aim of the present study was to determine whether this subjective and experience based triage is adequate in comparison to a newly designed Veterinary Triage 5 -A triage system for dogs and cats: Is it significantly better than common sense?- System (VTS) based on the MTS. Additional aims were to determine if nurses, when triaging their patients, link higher urgency to priority over less urgent patients and if decisions differ for trauma and non-trauma patients. 6 -A triage system for dogs and cats: Is it significantly better than common sense?- Materials and Methods Patients During a two-month period, all dogs and cats that were presented to the Spoedkliniek voor Dieren Amsterdam (SDA) were enrolled in the study with the prerequisite that at least one of two researchers (LR, MG) was present in the clinic. All patients were subdivided into “presentation groups” (PGs) based on their major reason for presentation. These PGs were selected by the researchers prior to the start of the study based on the 12 most common clinical presentations of cats and dogs visiting the SDA in the past. Twelve PGs were distinguished: 1. Trauma 7. Abscesses & local inflammations 2. Gastrointestinal problems 8. Urinary problems 3. Abnormal behaviour & seizures 9. Abnormal posture & gait 4. Respiratory problems 10. Collapse & anorexia 5. Suspicion intake poison/foreign body 11. Pregnancy & genital problems 6. Progression of known problem 12. Haemorrhage. Data collection Instruction of personnel Prior to the start of the study, the personnel of the SDA were informed about their tasks in the study through a short presentation and a written correspondence. This was done for several reasons. Since this study was carried out in a busy clinic with many nurses and veterinarians in the two busiest months of the year, preparing all personnel for their tasks could increase adherence to study methods and data collection. Also, patient emergency care was not to suffer under the study, so preparing personnel for their tasks could reduce the time needed to fulfil them. Nurses and veterinarians were only told about their tasks, not about hypotheses or goals of the study. Although this could have caused a bias effect, the researchers thought these measures were necessary in the interest of the patients. Waiting time periods On presentation of the patient, the receiving nurse stated a “desired waiting time period” (DWTP) (i.e. the time period in minutes the nurse considered acceptable for the patient to wait prior to be seen by a veterinarian) based on their impression of the emergency of the 7 -A triage system for dogs and cats: Is it significantly better than common sense?- case. To estimate the DWTP the nurse was free to examine the patient and ask the owner questions but no procedure guidelines were provided. The options for the DWTP to choose from were: 0, 15, 30, 60 and 120 minutes. Subsequently, the patient was sent to the waiting room and clients were asked to wait for the veterinarian to call them in. The DWTP was not entered in the digitalized patient record and was not presented to the veterinarian on call. Therefore, no consequences were coupled to the statement of the DWTP by the nurse. If the nurse thought a patient needed priority the veterinarian was warned following normal routine in the clinic. Retrospectively an “actual waiting time period” (AWTP) was calculated based on the difference between the time of arrival in the waiting room of the clinic and the time the patient was seen by the veterinarian. Physical examination The following physical parameters were recorded by the receiving veterinarian: mental status, type and frequency of breathing, presence of dyspnoea, heart rate, presence and intensity of a heart murmur, intensity of the pulse, colour and moistness of mucous membranes, capillary refill time, peripheral and rectal temperature, lung auscultation and abdominal palpation. Additionally to these data the history and additional findings from the physical examination were recorded in the digitalized patient data system. The Veterinary Triage System The Veterinary Triage System was formed by extrapolating the discriminators of the flowcharts of the MTS to the veterinary situation. Additional discriminators have been added, based on the opinion of several veterinary specialists. After careful selection of the final discriminators 12 veterinary triage flow charts were constructed based on the PGs mentioned earlier, finally forming the Veterinary Triage System (VTS) (see Addendum 2). Retrospective use of the Veterinary Triage System Based on the patient’s presenting symptoms/signs a specific flow chart of the VTS was chosen. Within this flow chart, we used specific data from history and physical examination as discriminators to determine what urgency category had to be chosen by the nurse. We assigned patients to either urgency category 1 (acute, patient should be seen by a veterinarian immediately), 2 (very urgent, patient should be seen by a veterinarian within 30 minutes), 3 (urgent, patient should be seen by a veterinarian within 60 minutes), 4 (standard, patient 8 -A triage system for dogs and cats: Is it significantly better than common sense?- should be seen by a veterinarian within 120 minutes) or 5 (not an emergency patient, treatment of medical condition can wait until tomorrow without deterioration). Determination of the category took place in a stepwise manner starting with category 1. In case none of the discriminators was present, the patient ended up by default in category 5. In this way a UC of the VTS was selected for each patient based on the data collected at their presentation in the clinic. Priority To determine if nurses linked higher urgency to priority, the researchers retrospectively classified each patient as “priority given”, “no priority given” and “no priority needed”. A patient was classified as “priority given” if the patient was prioritized by the nurse over another patient with a longer DWTP. If a patient arrived at the clinic with no other patients waiting, there was no priority to be given and the patient was classified as “no priority needed”. Statistical analysis All data were collected in a spread sheet program (MS Excel®: Microsoft, Seattle, USA) in preparation of statistical analysis. Separate statistical analysis was done for the total patient group and for patients of the PG “trauma”. AWTPs and DWTPs were compared to the UCs assigned based on the VTS using the Kruskal-Wallis and Chi square test. Using the KruskallWallis test patients were assigned to a certain rank, depending on their AWTP and DWTP. This rank denotes a score through which independent groups can be compared using a nonparametric test. Regression was investigated through analysis of variance (ANOVA). To see which of the UCs were different from each other, a Mann Whitney U test for individual groups comparison was performed on AWTPs, DWTPs and UCs with an adjusted level of significance because of multiple testing (P<0.01). The Mann Whitney U test for comparison between AWTPs and UCs was two-tailed. Statistical analysis was performed with SPSS15.0 (SPSS Inc., USA). DWTPs were compared with target waiting times of the retrospectively assigned UCs of the VTS in order to see how many patients were given a higher or lower urgency by the nurses. If a patient is given a shorter DWTP and thus a higher urgency, this patient is “overtriaged”. If a patient is given a longer DWTP and thus a lower urgency, this patient is “undertriaged”. 9 -A triage system for dogs and cats: Is it significantly better than common sense?- Sensitivity, specificity and predictive values of the estimated urgency were calculated. For this purpose, a dichotomy was created between the life-threatening or potentially lifethreatening categories of urgency (UC 1/2 and DWTP 0/15/30) and the remaining categories (UC 3/4/5 and DWTP 60/120). Data are presented as mean ± standard deviation (sd) if not stated otherwise. Results were considered as statistically significant for P values <0.05 if not stated otherwise. 10 -A triage system for dogs and cats: Is it significantly better than common sense?- Results All patients A total of 500 patients were enrolled in the study: 307 were dogs, 193 were cats. In the end, 5 patients were taken out of the study. Excluded were patients of which no UC could be determined during the review of their file and physical examination form due to lack of data. A high workload and ethical considerations (one patient of which the owner requested immediate euthanasia) were the reason that not all data could be collected in these cases. See addendum 3 for more information about the assignment of enrolled patients to the 12 PGs. Urgency categories Urgency categories are summarized in Table 1. For more detailed information on the distribution of urgency categories over the 12 PGs, see addendum 3. Table 1: Distribution of patients over urgency categories. Urgency category Total number (%) Number of trauma patients (%) 1 64 (12.8%) 4 (3.7%) 2 88 (17.6%) 22 (20.2%) 3 177 (35.4%) 42 (38.5%) 4 164 (32.8%) 40 (36.7%) 5 7 (1.4%) 1 (0.9%) Total 500 (100%) 109 (100%) Comparison of waiting time periods with urgency categories in the total patient group The average AWTP and DWTP for all 500 patients and UCs was 31.0 ± 27.9 minutes and 55.1 ± 41.1 minutes, respectively. Using the Kruskall-Wallis test, the mean ranks of all 5 UCs were compared (Table 2). There was a significant difference between AWTPs of patients in all UCs except between categories 3 and 4 and between category 5 and all other four categories. Figure 1 displays the means of AWTPs for the 5 UCs. There was a significant difference between DWTPs of patients in all UCs except between 3 and 5 and between 4 and 5. Figure 2 shows the means of DWTPs for the 5 UCs. 11 -A triage system for dogs and cats: Is it significantly better than common sense?- Table 2: Mean ranks of actual waiting time periods (AWTP) and desired waiting time periods (DWTP) in the 5 urgency categories in the total patient group. Urgency category 1 N 64 Mean rank AWTP 156.45 Mean rank DWTP 96.57 2 88 215.01 186.65 3 177 276.05 264.20 4 164 279.56 324.41 5 7 229.71 382.57 Total 500 N = number of patients in each category. Brackets denote significant differences between urgency categories. Figure 1. Actual waiting time periods (AWTP) (mean ± standard deviation (whiskers)) in the 5 urgency categories for all patients. 12 -A triage system for dogs and cats: Is it significantly better than common sense?- Figure 2: Desired waiting time periods (DWTP) (mean ± standard deviation (whiskers)) in the 5 urgency categories for all patients. An analysis of variance demonstrated that AWTP and DWTP were significantly correlated (P<0.001). Over- and undertriage in the total patient group For 205 (41.0%) of triage contacts in the total patient group, the urgency estimation by DWTP was in concordance with the retrospectively assigned UC (Table 3). For the 295 nonconcordance contacts, the urgency estimate of 231 (46.2%) triage contacts differed not more than 1 category, and for 64 (12.8%) of the contacts, the urgency estimates differed more than 2 categories. For 189 (37.8%) contacts the nurses scored higher urgency and for 106 (21.2%) contacts the nurses scored lower urgency than the urgency category assigned afterwards. In UC 1, 34 of the 64 patients were undertriaged. This means that for these 34 patients the nurses chose a desired waiting time of 15 minutes or more. Overtriage in this category was not possible. Within UC 2 12.5% of patients was overtriaged; 35.2% was undertriaged. In UC 3 40.6% was overtriaged and 23.2% was undertriaged. In the UC 4 60.4% was overtriaged; undertriage was not possible as a waiting time of 120 minutes was the highest possible choice for the nurses. 13 -A triage system for dogs and cats: Is it significantly better than common sense?- Table 3: Urgency as set by nurses through the desired waiting time period (DWTP) relative to urgency category in all patients. DWTP 0 15 30 60 120 Total Urgency category 1 2 30 11 18 26 11 20 3 25 2 6 64 88 3 9 24 39 64 41 177 4 2 7 28 62 65 164 5 0 0 0 3 4 7 Underlined number denote correct estimation, compared to the retrospectively assigned urgency categories using the VTS. Sensitivity, specificity and predictive values of DWTPs The capacity of the nurses to discriminate (potentially) life-threatening cases from less urgent cases was examined through comparison of estimations of life-threatening and non-lifethreatening urgency with life-threatening and non-life-threatening UCs. The sensitivity was 0.76 (116/152) and the specificity was 0.69 (239/348). The positive predictive value of the estimates of the nurses was 0.52 (116/225). This is higher than the 0.30 ((64+88)/500) a priori probability of a life-threatening problem. The negative predictive value of the estimates of the nurses was 0.87 (239/275), while the a priori probability of a non-life-threatening problem was 0.69 ((177+164+7)/500). Priority In the total patient group (Table 4), 5 immediate and 53 very urgent patients (13 with a DWTP of 15 minutes, 40 with a DWTP of 30 minutes) were not prioritized over patients with a longer DWTP (and thus lower estimated urgency). This is respectively 9.4% and 30.8% of the immediate and very urgent patients according to the nurses based on DWTP. Table 4: Priority given by nurses over 5 categories of desired waiting time periods in all patients Desired waiting time No priority given Priority given No priority needed 0 5 21 27 15 13 14 47 30 40 4 54 60 92 0 65 14 -A triage system for dogs and cats: Is it significantly better than common sense?- 120 59 0 59 In situations where patients with an DWTP of 0, 15 or 30 minutes did not receive priority over patients with a longer DWTP, this was not because another urgent patient got priority over them. Trauma patient group The trauma patient group included 72 dogs and 37 cats. Most common causes for presentation of patients in the trauma group were bite wounds, falls from heights and car accidents. Comparison of waiting time periods with urgency categories In the trauma group the average AWTP and DWTP was 28.3 ± 27.3 minutes and 54.0 ± 42.0 minutes, respectively. DWTPs and AWTPs of the trauma patients were compared to the UCs retrospectively assigned based on the VTS. Using the Kruskall-Wallis test, the mean ranks of all 5 UCs were compared (see Table 5). There was a significant difference between AWTPs of patients in all UCs except between all UCs and UC 5, between 2 and 4 and between 3 and 4. Figure 3 shows the means of AWTPs in the 5 UCs. There was a significant difference between DWTPs of patients in all UCs except between 3 and 4 and between 5 and all other UCs. Figure 4 shows the means of the DWTPs in the 5 UCs. An analysis of variance demonstrated that AWTP and DWTP were not significantly correlated in the trauma patients group (P=0.230). Table 5: Mean ranks of actual waiting time periods (AWTP) and desired waiting time periods (DWTP) with urgency categories in the trauma patient group . Urgency category 1 N 4 Mean rank AWTP 7.38 Mean rank DWTP 7.00 2 22 38.61 29.23 3 42 66.32 57.63 4 40 57.70 70.89 5 1 22.50 68.00 109 Total N = number of patients in each category. 15 -A triage system for dogs and cats: Is it significantly better than common sense?- Brackets denote significant differences between urgency categories Figure 3: Actual waiting time periods (AWTP) (mean ± standard deviation (whiskers)) in the 5 urgency categories in the trauma patient group Figure 4: Mean of desired waiting times (DWTP) (mean ± standard deviation (whiskers)) in the 5 urgency categories in the trauma patient group 16 -A triage system for dogs and cats: Is it significantly better than common sense?- 17 -A triage system for dogs and cats: Is it significantly better than common sense?- Over- and undertriage For 39.4% of all trauma patient triage contacts, the urgency estimation by DWTP was in concordance with the UC assigned afterwards (see Table 6). For the 66 non-concordance contacts, the DWTP of 49.5% triage contacts differed not more than 1 UC, 11.0% differed more than 2 UCs from the UC assigned afterwards. For 48.6% of contacts the nurses scored higher urgency and for 11.9% lower urgency than the UC assigned afterwards. Table 6: Urgency as set by nurses through the desired waiting time period (DWTP) relative to urgency category in the trauma patient group. Desired Waiting Time 0 15 30 60 120 Total Urgency category 1 2 4 7 0 7 0 5 0 2 0 1 4 22 3 1 8 11 12 10 42 4 1 2 6 16 15 40 5 0 0 0 1 0 1 Underlined number denote correct estimation, compared to the retrospectively assigned urgency categories using the VTS. Sensitivity, specificity and predictive values of DWTPs The capacity of the nurses to discriminate (potentially) life-threatening cases from less urgent cases in the trauma patient group was examined. The sensitivity was 0.88 (23/26) and the specificity was 0.65 (54/83). The positive predictive value of the estimates of the nurses was 0.44 (23/52). This is higher than the 0.24 ((4+22)/109) a priori probability of a lifethreatening problem. The negative predictive value of the estimates of the nurses was 0.95 (54/57), while the a priori probability of a non-life-threatening problem was 0.76 ((42+40+1)/109). Priority In the trauma patient group (see Table 7), all immediate patients were prioritized in case other patients were ahead of them in the waiting room. Of the patients with an DWTP of 15 and 30 minutes, 20.5% of the very urgent patients were not prioritized over less urgent patients by the nurses based on DWTP. 18 -A triage system for dogs and cats: Is it significantly better than common sense?- Table 7: Priority given by nurses over 5 categories of desired waiting times in trauma patients Desired waiting time No priority given Priority given No priority needed 0 0 5 8 15 2 3 12 30 6 1 15 60 21 0 8 120 14 0 14 In situations where patients with an DWTP of 0, 15 or 30 minutes did not receive priority over patients with a longer DWTP, this was not because another urgent patient got priority over them. 19 -A triage system for dogs and cats: Is it significantly better than common sense?- Discussion This study demonstrates that significant correlation exists between AWTPs, DWTPs and UCs, declining in the lower UCs. Despite this correlation, over 50% of cases is over- or undetriaged by nurses, in comparison to a triage based on the VTS. Nurses tend to overtriage more than undertriage patients, but still the degree of undertriage of urgent patients is unsatisfactory. Overtriage is also reflected by the extremely low predictive value of the estimation of high urgency by nurses. Although it is difficult to tell how much overtriage is still acceptable, Long et al. described the “next-to-ideal” criteria as having 15-20% overtriage and no undertriage3. The triage by the nurses fails to meet these criteria, which could be caused by the lack of objective measures to determine the need for immediate veterinary care. Recognition of urgency did not lead to the prioritisation of urgent patients per se. Improving communication between nurses and veterinarians will probably lead to more efficiency on this level. Trends are similar for trauma patients, with the exception of a much higher percentage of prioritisation of urgent patients. Possibly, nurses prioritize these patients more because of their presentation and/or worried owners. In this study, urgency estimations of nurses were compared to UCs assigned to patients in retrospect, based on the VTS. The VTS is based on an accepted human system; the MTS. The MTS is a triage system that in human hospitals has demonstrated to be a sensitive tool for detecting those who need emergency care1. We carefully reconstructed the MTS for companion animals based on the experience of veterinary emergency clinicians, resulting in the VTS. Although the resulting VTS has not yet been validated, the authors have chosen to use it because there is no other alternative described. However, future studies must validate the usefulness of this system. Clearly, a decision that underestimates a patient’s level of clinical urgency may impede time-critical intervention4 and thus lead to possibly dangerous delays in patient care. Causes for undertriage by nurses could be inadequate knowledge and skills in emergency patient triage assessment and the lack of guidelines for decision-making. Overtriage, affecting patient care more indirectly, leads to inefficiency in the triage process. If non-urgent patients are wrongly assessed by nurses as urgent, the emergency care for truly urgent patients may be delayed5. In the human paediatric population, overtriage also seems to be a problem using the MTS. Triage of paediatric patients is difficult as triage nurses are more dependent on nonverbal communication. This is also the case in veterinary patients and thus further evaluation 20 -A triage system for dogs and cats: Is it significantly better than common sense?- on using the (adjusted) MTS in cats and dogs is needed to prevent this kind of timeconsuming overtriage. However, in the author’s opinion, a large contribution to both overand undertriage is made by the lack of objective measures to determine the need for immediate veterinary care. Also, the presence of owners or staff of animal ambulance may influence the decisions of nurses about the urgency of a patient. Education on the recognition of urgency in companion animals could improve the quality of triage decisions by veterinary nurses. For a triage process to function well, it is not only important that nurses are able to make a good assessment of the urgency of a patient, but also that a patient that is classified as acute or very urgent will indeed get priority over a patient with less need for urgent veterinary care. Or in other words: do nurses link higher urgency to priority? This acting as a consequence of a detection made is one of the fundamental criteria that determines if a triage system will succeed or fail6. In most immediate cases, nurses do link higher urgency to priority. If a patient’s urgency allows a small waiting period like in UC 2, however, prioritisation by nurses over less urgent patients declines. Possibly, nurses tend to “forget” urgency of patients if there is no need to act on it right away. Also, it may be more difficult to justify the urgency of these patients to owners of non-prioritized patients in the waiting room and thereby pose a higher risk of discontent among them. For a triage system to work properly and safely, this prioritisation must be further improved, since the classification of a patient as urgent only makes sense if consequences are carried out to act on this urgency. Enhancing objectiveness of nurses and transparency to owners in the waiting room could ameliorate this process. Prioritisation of urgent trauma patients turned out to be much better than of other urgent emergency patients. Nurses also generally overestimated the urgency of trauma patients even more than the urgency of other patients. This difference may be due to patient presentation and high appreciation of the trauma history by nurses. These patients’ urgency is more overt to owners of less urgent patients as well, making prioritisation easier for nurses. Studies in human trauma patient triage have demonstrated that improved efficiency was reached by using physiological and anatomical criteria instead of criteria based on the mechanism of injury7. Similar effects might be seen in companion animal triage. The UCs retrospectively assigned to the emergency patients are based on the VTS, a triage system that hasn’t been tested or validated yet. Although deduced from the reliable and validated human MTS, the VTS is not a gold standard and there are no guarantees to the 21 -A triage system for dogs and cats: Is it significantly better than common sense?- correctness of urgency classifications. Also, urgency classification in retrospect has its limitations compared to triage at arrival of the patient. The 5 possible DWTPs that nurses were asked to choose from, were different from the target waiting times used in the MTS. The nurses were given one extra option, namely 30 minutes and were not given the option of “no urgency”. This was done because the evaluation of the MTS in The Netherlands revealed that the target waiting time for category 2 (orange, 10 minutes) was possibly not realistic6. Also, the real waiting time of human category 2 patients was 30.82 minutes. The target waiting time of the VTS category 2 was thus stated 30 minutes in stead of the 10 minutes originally used in the MTS. Both 15 and 30 minutes were interpreted as category 2. Category 2, as stated in the VTS, thus undoubtedly differs from category orange in the MTS. Additional studies are indicated to determine the ideal target waiting time of veterinary category 2. Not providing the nurses with the option “no urgency” creates some overestimation of urgency by the nurses. Since only 7 patients were classified as category 5 (non-urgent), the effect of this overestimation was minimal. Since the nurses in this study were asked to write down a desired waiting time they were forced to think over every patient’s urgency. It is not inconceivable that actual waiting times would have differed from the actual waiting times recorded in this study when no desired waiting times were asked. This forced point of urgency estimation could both shorten and prolong total waiting times. Shorten, because focussing the nurses on urgency estimation could improve recognition of very urgent patients, thus prioritizing them over less urgent patients. Prolong, because a little bit of extra time of the nurses is asked to estimate the urgency, time that cannot be used to continue their regular tasks. The strength of this study lies in the fact that it was performed in a real-world setting that is comparable with the structure of many companion animal emergency clinics. Complete data were available from 500 consecutive patients reflecting a broad spectrum of emergencies from trifles to life-threatening conditions. This study demonstrates that nurses’ triage decisions of both trauma and non-trauma patients based on experience, intuition and common sense differ significantly from urgency classifications stated retrospectively using the VTS. However, further studies on the reliability and validity of the VTS are needed. The underestimation of immediate and very urgent patients and the overestimation of less urgent patients makes triage without guidelines inefficient. The development of a veterinary triage system, increasing reliability of urgency estimations and thereby safety of patient care in small animal emergency departments, should be considered. 22 -A triage system for dogs and cats: Is it significantly better than common sense?- 23 -A triage system for dogs and cats: Is it significantly better than common sense?- Acknowledgements This study couldn’t have taken place without the cooperation of all nurses, veterinarians and staff of the SDA. Also, both the statistical analyses and the reviewing of E. Teske were of crucial importance. 24 -A triage system for dogs and cats: Is it significantly better than common sense?- References 1. Cooke MW, Jinks S. Does the manchester triage system detect the critically ill? J of Acc and Emer Med. 1999;16:179-181. 2. Drobatz KJ, Syring R, Reineke E, Meadows C. Association of holidays, fullmoon, friday the 13th,day of week, time of day, day of week, and time of year on case distribution in an urban referral small animal emergency clinic. J Vet Em Crit Care. 2009;19:Published Online: Sep 11 2009. 3. Long WB, Bachulis BL, Hynes GD. Accuracy and relationship of mechanisms of injury, trauma scores, and injury severity scores in identifying major trauma. Am J Surg. 986;151:581-584. 4. Gerdtz MF, Bucknall TK. Triage nurses' clinical decision making. an observational study of urgency assessment. J Adv Nur. 2001;35:350-361. 5. Roukema J, Steyerberg EW, Meurs Av, Ruige M, Lei Jvd, Moll HA. Validity of the manchester triage system in paediatric emergency care. Emer Med J. 2006;23:906-910. 6. Coenen IGA, Hagemeijer A, Caluwé Rd, Voeght FJd, Jochems PJJ. Richtlijn Triage Op De Spoedeisende Hulp. ; 2005. 7. Uleberg O, Vinjevoll OP, Eriksson U, Aadahl P, Skogvoll E. Overtriage in trauma - what are the causes? Acta Anaest Scan. 2007;51:1178-1183. 8. Manchester Triage Group. Emergency Triage. second ed. Blackwell Publishing Ltd; 2006. 9. Windle J. The extent to which the environment, triage event, documentation, components of the assessment and training & development affect departmental accuracy when using the manchester triage system. Sheffield: University of Sheffield. 2001. 25 -A triage system for dogs and cats: Is it significantly better than common sense?- Addendum 1: The Manchester Triage System (MTS) The Manchester Triage System (MTS) originated in 1997 from a collaboration of experienced nurses and doctors of several emergency departments from the area in and around Manchester with the aim to obtain consensus on triage standards. They wanted a simple and unambiguous system to quickly recognise and canalize severe pathology8. The MTS is an algorithmic aid to the process of triage. It utilises a series of flow charts that lead the triage nurse to a logical choice of triage category using a five-point scale. The MTS is considered to fit the European health care system better than other 5 point systems6. The basic principles that drive the MTS are recognition of the presentation of an emergency patient and consequently choosing a logical discriminator that will lead through a flow chart. Note that the system is not about diagnoses but about clinical priority; two patients with the same diagnosis may present with different complaints and thus enter the system through a different flow chart or in a different urgency category. The MTS has shown to be a sensitive tool for detecting those who need emergency care1. Research of the MTS for human emergency departments indicates that the MTS had a high interrater reliability9. Urgency categories are linked to colour codes and target waiting times, which provides the patients with both transparency and predictability. The system works with 5 different urgency categories: red (immediate), orange (very urgent), yellow (urgent), green (standard) and blue (non-urgent). Patients that enter the emergency department are seen by a triage nurse, who chooses a suitable flow chart based on the main problem of the patient. Within this flow chart the urgency category is selected based on the most urgent clinical sign (the discriminator) present in the patient. Say a patient arrives at the emergency department with abdominal pain. The patient is briefly examined and questioned by a triage nurse. The nurse chooses the flow chart that matches the main problem of the patient (e.g. abdominal pain, see figure 5). The flow chart, consisting of a list of key symptoms (so called discriminators) is checked. A symptom is either present or not. These discriminators were carefully selected to detect possible urgent causes of a general problem (e.g. gastric bleeding in abdominal pain). Every discriminator is linked to one of the urgency categories. The first discriminator present in the patient, determines his or her urgency category. If a patient with abdominal pain presents with vomiting blood and category red discriminators ‘threatened airway’, ‘insufficient breathing’ and ‘shock’ are excluded, urgency category orange is selected. 26 -A triage system for dogs and cats: Is it significantly better than common sense?- Abdominal pain Threatened airway Insufficient breathing Shock + Red + Orange + Yellow + Green Severe pain Pain radiating to the back Vomiting blood Rectal blood loss (fresh/old) Vaginal blood loss > 20 weeks pregnant Very high fever Possibly pregnant Pain shoulder Black or dark red stools Vomiting blood in history Persistent vomiting Fever Moderate pain Recent mild pain Vomiting Recent problem - Blue Figure 5: Triage flow chart “Abdominal pain adult” as used in the human Manchester Triage System 27 -A triage system for dogs and cats: Is it significantly better than common sense?- Addendum 2: Flow charts of the VTS Flowchart 1:Trauma E.g. falls, hit by car, bites, stings, burns, eye trauma, being jammed, shot wounds UC 1 Airway compromise/ inadequate breathing Exsanguinating hemorrhage Acutely distended abdomen Shock Unresponsive Eyeball luxation Acute chemical eye injury UC 2 Increased work of breathing Uncontrollable hemorrhage Severe pain Vascular compromise Continuous abnormal vocalizations High lethality envenomation Subcutaneous gas Very high fever Fever puppy/ kitten Altered conscious level Under anesthesia Abnormal pulse (arrhythmia) Externalization of organs Penetrating eye injury Cold UC 3 Mild dyspnea Open fracture/ gross deformity Acute neurologic deficit/ deterioration Uncontrollable minor hemorrhage History of unconsciousness or head trauma Moderate lethality envenomation Moderate pain Severe itch Fever Widespread rashes or blistering Anorexia puppy/ kitten UC 4 Local inflammation Recent mild pain Recent problem Swelling Warmth 28 -A triage system for dogs and cats: Is it significantly better than common sense?- Flowchart 2: Gastro-intestinal Vomiting, diarrhea, constipation, drooling, anorexia, swallowing or retching UC 1 Airway compromise/ inadequate breathing Exsanguinating hemorrhage Acutely distended abdomen Unproductive retching Shock Unresponsive UC 2 History of poisoning History of ingestion of foreign body Floppy Continuous abnormal vocalizations Petechiae/ purpura/ ecchymosis Severe dehydration (> 8%) Severe pain Very high fever Fever puppy/ kitten Altered conscious level Abnormal pulse (arrhythmia) Cold UC 3 Vomiting blood Persistent vomiting Persistent straining Melena or hematochezia Ingestion of toxin with moderate lethality Dehydration (5 – 8%) Moderate pain Fever Anorexia puppy/ kitten UC 4 Vomiting Recent mild pain Recent problem Warmth 29 -A triage system for dogs and cats: Is it significantly better than common sense?- Flowchart 3: Abnormal behaviour, neurologic deficits and seizures UC 1 Airway compromise/ inadequate breathing Hypoglycemia Currently fitting Acutely distended abdomen Unproductive retching Shock Unresponsive UC 2 Increased work of breathing History of poisoning Signs of meningism Continuous abnormal vocalizations Floppy Altered conscious level Severe dehydration (> 8%) Risk of self harm or harm to others Abnormal pulse (arrhythmia) Petechiae/ purpura/ ecchymosis Severe pain Very high fever Fever puppy/ kitten Cold UC 3 Mild dyspnea Acute neurologic deficit/ deterioration History of unconsciousness or head trauma Ventroflexion of the head Dehydration (5 – 8%) Moderate pain Severe itch Fever Anorexia puppy/ kitten UC 4 Itch Recent mild pain Recent problem Warmth 30 -A triage system for dogs and cats: Is it significantly better than common sense?- Flowchart 4: Respiration Dyspnea, coughing, sneezing UC 1 Airway compromise/ inadequate breathing Acutely distended abdomen Unproductive retching Shock Unresponsive UC 2 Increased work of breathing Acute onset after injury Exhaustion History of poisoning Continuous abnormal vocalizations Floppy Altered conscious level Severe dehydration (> 8%) Abnormal pulse (arrhythmia) Petechiae/ purpura/ ecchymosis Severe pain Very high fever Fever puppy/ kitten UC 3 Mild dyspnea No improvement with own medications Dehydration (5 – 8%) Moderate pain Fever adult Anorexia puppy/ kitten UC 4 Chest injury Recent mild pain Recent problem Warmth adult 31 -A triage system for dogs and cats: Is it significantly better than common sense?- Flowchart 5: Intoxication and foreign body UC 1 Airway compromise/ inadequate breathing Currently fitting Exsanguinating hemorrhage Acutely distended abdomen Unproductive retching Shock Unresponsive UC 2 Increased work of breathing Uncontrollable hemorrhage History of poisoning History of intake foreign body Continuous abnormal vocalizations Floppy Altered conscious level Severe dehydration (> 8%) Abnormal pulse (arrhythmia) Petechiae/ purpura/ ecchymosis Severe pain Very high fever Fever puppy/ kitten UC 3 Mild dyspnea Acute neurologic deficit/ deterioration Dehydration (5 – 8%) Restlessness Persistent straining Black or redcurrant stool Moderate pain Fever adult Anorexia puppy/ kitten UC 4 Vomiting Recent mild pain Recent problem Warmth 32 -A triage system for dogs and cats: Is it significantly better than common sense?- Flowchart 6: Progression of known problem UC 1 Airway compromise/ inadequate breathing Currently fitting Hypoglycemia Exsanguinating hemorrhage Acutely distended abdomen Shock Unresponsive UC 2 Increased work of breathing Uncontrollable hemorrhage Continuous abnormal vocalizations Ketoacidosis Floppy Altered conscious level Severe dehydration (> 8%) Abnormal pulse (arrhythmia) Petechiae/ purpura/ ecchymosis Severe pain Very high fever Fever puppy/ kitten Cold UC 3 Vomiting blood Persistent vomiting Persistant straining Melena or hematochezia Mild dyspnea Acute neurologic deficit/ deterioration Ventroflexion of the head Dehydration (5 – 8%) Hyperglycemia Moderate pain Fever Anorexia puppy/ kitten UC 4 Vomiting Recent mild pain Recent problem Warmth 33 -A triage system for dogs and cats: Is it significantly better than common sense?- Flowchart 7: Abscesses, local inflammations and rashes Including eyes, ears, gingiva UC 1 Airway compromise/ inadequate breathing Stridor Shock Unresponsive UC 2 Continuous abnormal vocalizations Uncontrollable hemorrhage Altered conscious level Increased work of breathing Subcutaneous gas Oedema of the tongue Significant history of allergy Petechiae/ purpura/ ecchymosis Vascular compromise Severe pain Very high fever Fever puppy/ kitten Abnormal pulse (arrhythmia) UC 3 Uncontrollable minor hemorrhage Mild dyspnea Facial edema Widespread rashes or blistering Moderate pain Severe itch Fever Anorexia puppy/ kitten UC 4 Local inflammation Othematoma Head tilt Recent mild pain or itch Recent problem Swelling Warmth 34 -A triage system for dogs and cats: Is it significantly better than common sense?- Flowchart 8: Urinary problems UC 1 Airway compromise/ inadequate breathing Acutely distended abdomen Shock Unresponsive UC 2 Unable to urinate (large, tense bladder) Continuous abnormal vocalizations Severe dehydration (> 8%) Altered conscious level Severe pain Very high fever Fever puppy/ kitten Abnormal pulse (arrhythmia) Cold UC 3 Persistent straining (small bladder) Hematuria without straining Persistent vomiting Dehydration (5 – 8%) Moderate pain Fever UC 4 Vomiting Recent mild pain Recent problem Warmth 35 -A triage system for dogs and cats: Is it significantly better than common sense?- Flowchart 9: Abnormal posture and gait UC 1 Airway compromise/ inadequate breathing Exsanguinating hemorrhage Acutely distended abdomen Shock UC 2 Continuous abnormal vocalizations Increased work of breathing Vascular compromise Signs of meningism Unable to urinate (large, tense bladder) Petechiae/ purpura/ ecchymosis Uncontrollable hemorrhage Altered conscious level Severe pain Very high fever Fever puppy/ kitten UC 3 Open fracture/ gross deformity Mild dyspnea Acute neurologic deficit/ deterioration Uncontrollable minor hemorrhage History of unconsciousness or head trauma Persistent straining (small bladder) Ventroflexion of the head Moderate pain Fever Anorexia puppy/ kitten UC 4 Local inflammation Deformity Recent mild pain Recent problem Swelling Warmth 36 -A triage system for dogs and cats: Is it significantly better than common sense?- Flowchart 10: Collapse UC 1 Airway compromise/ inadequate breathing Unresponsive Exsanguinating hemorrhage Acutely distended abdomen Unproductive retching Hypoglycemia Currently fitting Shock UC 2 History of poisoning History of ingestion of foreign body Unable to urinate (large, tense bladder) Hyperglycemia with ketosis Increased work of breathing Uncontrollable hemorrhage Significant history of allergy Abnormal pulse (arrhythmia) Floppy Severe dehydration (> 8%) Altered conscious level Continuous abnormal vocalizations Petechiae/ purpura/ ecchymosis Severe pain Very high fever Fever puppy/ kitten Cold UC 3 Persistent straining (small bladder) Hyperglycemia Vomiting blood Persistent vomiting Melena or hematochezia Increased work of breathing Ventroflexion of the head Acute neurologic deficit/ deterioration History of unconsciousness or head trauma Dehydration (5 – 8%) Moderate pain Fever Anorexia puppy/ kitten UC 4 Vomiting Recent mild pain Recent problem Warmth 37 -A triage system for dogs and cats: Is it significantly better than common sense?- Flowchart 11: Pregnancy, parturition and sexual organs UC 1 Airway compromise/ inadequate breathing Unresponsive Exsanguinating hemorrhage Currently fitting Acutely distended abdomen Shock Presenting fetal parts UC 2 Continuous abnormal vocalizations In active labour History of fitting Heavy blood loss per vaginam Scrotal gangrene Phimosis Petechiae/ purpura/ ecchymosis Altered conscious level Severe pain Very high fever Cold UC 3 History of trauma (pregnancy) Abnormal blood loss per vaginam Persistent vomiting Moderate pain Fever UC 4 Local inflammation Recent mild pain Recent problem Warmth 38 -A triage system for dogs and cats: Is it significantly better than common sense?- Flowchart 12: Hemorrhage UC 1 Airway compromise/ inadequate breathing Exsanguinating hemorrhage Acutely distended abdomen Shock Unresponsive UC 2 Uncontrollable hemorrhage Heavy blood loss per vaginam Continuous abnormal vocalizations Heavy blood loss per vaginam Petechiae/ purpura/ ecchymosis Vascular compromise High lethality envenomation Increased work of breathing Severe pain Abnormal pulse (arrhythmia) Altered conscious level Very high fever Fever puppy/ kitten Cold UC 3 Vomiting blood Melena or hematochezia Hematuria without straining History of or suspected of bleeding disorder Uncontrollable minor hemorrhage Moderate lethality envenomation Mild dyspnea Moderate pain Fever UC 4 Recent mild pain Recent problem Warmth 39 -A triage system for dogs and cats: Is it significantly better than common sense?- Addendum 3: Assignment of patients Table 1: Assignment of patients to the 12 different presentation groups and distribution over urgency categories. Patient groups 1. Trauma patients 2. Gastrointestinal problems 3. Abnormal behaviour & Seizures 4. Respiratory problems 5. Suspicion poison/foreign body 6. Progression of known problem 7. Abscesses & local inflammations 8. Urinary problems 9. Abnormal posture & Gait 10. Collapse & Anorexia 11. Pregnancy & Genital problems 12. Haemmorhage Total Percentage 21.8% 18.6% 5.2% 5.6% 2.8% 3.6% 9.2% 9.6% 6.6% 15% 1.4% 0.6% 100% 40 Total 109 93 26 28 14 18 46 48 33 75 7 3 500 UC1 4 8 3 10 0 4 1 2 0 31 1 0 64 UC2 22 8 0 8 3 5 1 8 4 25 3 1 88 UC3 42 42 14 4 9 5 15 15 16 13 1 1 177 UC4 40 35 9 6 1 2 28 23 13 5 1 1 164 UC5 1 0 0 0 1 2 1 0 0 1 1 0 7