Impact of a Nursing Triage Line on the Use of Emergency Department Services in a Military Hospital, The

Military Medicine, Dec 2003 by O'Rourke, Kathleen M, Roddy, Mary, King, Rosemary, Custer, Michael, Et al

Further research has been conducted to examine the impact of telephone triage on ED usage. In the late 1970s, retrospective studies of patients directed to an ED or clinic by telephone nurses found from 72 to 84% appropriate referrals.12-14 In addition to making use of a telephone line to minimize the over use of the ER for nonurgent conditions, the accuracy of triage disposition is important given the potential consequences of delaying treatment for urgent problems. Lowe et al.15 found that a third of the patients who were refused ER care on the basis of triage guidelines had legitimate diagnostic or therapeutic reasons for seeking ER care. In a later study, Lowe and Bindman16 compared assessments of appropriateness of ED use for 596 patients made by the patients themselves, triage nurses, and physician review of charts. Approximately 90% of patients reported that their acuity level was appropriate for ED care, but only 22 to 31% of nurse triage ratings and 20 to 34% of physician chart review of the patients met criteria for ED care. A study of 86,000 patients managed by telephone consultation found "no clinically significant, untoward patient outcome as a result of the telephone advice" occurred.17 However, adverse outcomes as a result of triage "errors" may be underestimated due to difficulties in obtaining follow-up.4

Two studies have specifically addressed the impact of telephone triage on the inappropriate use of EDs. A 1997 study by Franco et al.18 compared the appropriateness of ED visits by a patient population before and after the implementation of the telephone triage system. ED visits dropped from 10.1 to 7.6% of the patient population with an increase in appropriateness from 59 to 93%. Similarly, Barber et al.19 evaluated appropriateness of telephone nurse triage-referred patients and randomly selected nonreferred control patients to a pediatric emergency room. Pediatric emergency medicine physicians determined an appropriateness rate of 80.2% for telephone triage-referred patients compared with a rate of 60.5% for the control group. In the 2.5 years of use of the telephone triage system, there were no reports of adverse outcome in patients denied an ED referral. The authors observed that the ideal rate of appropriate referrals cannot be determined but that it is unlikely that it is much more than the 80% appropriateness found in their study because telephone triage systems should be designed to over-refer patients.

Nursing triage lines can be cost-effective as well. An earlier retrospective study found that the cost of care for triaging and treating patients in a clinic was less than one-half of the cost if comparable patients were treated in the ED.20 In reviewing the benefits of pediatric call centers, Schuman21 estimated that the average cost of medical care for children of parents who do not have access to a call center is three times greater than for those who do have access.

This study evaluates the impact of the TAN triage program on ED use among callers receiving care at a military hospital. TAN nurses use computerized protocols to identify the best level of care for their callers and direct them to appropriate services. There are a number of potential dispositions: 911, ED, urgent clinic appointments, nonurgent clinic appointments, home care, and health information only. This study focuses on the subset of patients who were directed to the ED and assesses the appropriateness of these referrals by comparing the acuity level of patients referred to the ED by the TAN line with those who self-refer.