Optimizing Triage and Hospitalisation In Adult General Medical Emergency Patients: the TRIAGE Study
Optimizing Triage and Hospitalisation In Adult General Medical Emergency Patients: the TRIAGE Study
Patients presenting to the emergency department (ED) currently face inacceptable delays in
 initial treatment, and long and costly hospital stays due to suboptimal initial triage.
 Accurate ED triage should focus not only on initial treatment priority, but also on
 prediction of medical risk and nursing needs to improve site of care decision and to simplify
 early discharge management. Herein, we propose a large prospective cohort study to optimize
 initial patient triage for (a) better determination of initial treatment priority, (b)
 overall risk and need for inhospital treatment and (c) early assessment of post-acute nursing
 needs.
Background: Patients presenting to the emergency department (ED) currently face inacceptable
 delays in initial treatment, and long and costly hospital stays due to suboptimal initial
 triage. Accurate ED triage should focus not only on initial treatment priority, but also on
 prediction of medical risk and nursing needs to improve site of care decision and to simplify
 early discharge management. Different triage scores have been proposed, such as the
 Manchester Triage Score (MTS). Yet, these scores focus only on treatment priority, have
 suboptimal performance and lack validation in the Swiss Health care system. Because the MTS
 will be introduced into clinical routine of the Kantonsspital Aarau, we propose a large
 prospective cohort study to optimize initial patient triage. Specifically, the aim of this
 trial is to derive a three part triage algorithm to better predict (a) treatment priority;
 (b) medical risk and thus need for inhospital treatment; (c) post-acute care needs of
 patient's at the most proximal time point of ED admission.

 Methods / Design: Prospective, observational, cohort study. We will include all consecutive
 medical patients seeking ED care into this observational registry. There will be no
 exclusions except for non-adult and non-medical patients. Vital signs will be recorded and
 left over blood samples will be stored for later batch analysis of blood markers. Upon ED
 discharge, the post-acute care score will be recorded. Attending ED physicians will
 adjudicate triage priority based on all available results at the time of discharge. Patients
 will be reassessed daily during the hospital course for medical and nursing stability. To
 assess outcomes, data from electronic medical records will be used and all patient will be
 contacted 30 days after hospital admission to assess vital status, rehospitalisation and
 quality of life measures.

 We aim to include between 5000 and 7000 patients over one year of recruitment to derive the
 three part triage algorithm. The respective main endpoints were defined as (a) initial triage
 priority (high vs. low priority) adjudicated by the attending ED physician at ED discharge,
 (b) adverse 30 day outcome (death or intensive care unit admission) within 30 days following
 ED admission to assess patients risk and thus need for inhospital treatment and (c) care
 needs after hospital discharge, defined as transfer of patients to a post-acute care
 institution, for early recognition and planning of post-acute care needs. Other outcomes are
 time to first physician contact, time to initiation of adequate medical therapy, length of
 hospital stay, patient's satisfaction with care and overall hospital costs.

 Discussion: Using a reliable initial triage system for estimating initial treatment priority,
 need for inhospital treatment and post-acute care needs is an innovative and persuasive
 approach for a more targeted management of medical patients in the ED. Our group has proven
 feasibility with a track record of several completed and ongoing trials. The proposed
 interdisciplinary project has unprecedented potential to improve initial triage decisions and
 optimize resource allocation to the sickest patients from admission to discharge. The
 algorithms derived in this study will be compared in a later randomized controlled trial
 against a usual care control group in terms of resource use, length of hospital stay, overall
 costs and patient's outcomes in terms of mortality, rehospitalisation, quality of life and
 satisfaction with care.
Inclusion Criteria:

 -  All consecutive medical patients seeking ED care

 Exclusion Criteria:

 -  age below 18 years