The Comprehensive Triage Acuity System to Improve Patient Outcomes in a Walk in ClinicNaomi Farkas, Lauren Hopkin, Michelle Lew, Elin Mogollon, Yaakov Perlstein, Nicole Reeger

Pace University, College of Health Professions, Lienhard School of NursingThe names and addresses of the associated institutions go here.

Will implementing the use of the Comprehensive Triage Acuity System by triage nurses in the Veterans Affairs New York Harbor Healthcare System walk-in clinic, improve patient flow and decrease the number of homeless veterans as compared to the absence of a triage protocol?

Background

EBP Recommendations

Evaluation & Conclusion

Implementation• Develop the Comprehensive Triage Acuity System which is a five-level triage scale that

assesses physical, social, and physiological health needs. This scale is adapted from the ESI triage system and a triage system developed by The National Health Care for the Homelessness Council (CITE).

• This triage system will be implemented for use by all triage nurses who are completing the initial assessment at the the Veterans Affairs New York Harbor Healthcare System walk-in-clinic.

• The triage system delineates those patients requiring emergent care, urgent care, and non-urgent care and the identification of homelessness.

• All staff in the walk-in-clinic will receive education sessions on the proper use of the Comprehensive Triage Acuity System. RNs will require competency.

• An easy-to-read visual flow chart of the Comprehensive Triage Acuity System will be posted in the triage areas of the walk-in-clinic for quick reference.

Search Strategy

References

Literature Review

• Compare utilization rates for various services provided at the VA from 2014 as baseline and quarterly after the implementation of the Comprehensive Triage Acuity System to measure patient flow

• Quarterly measure the number of homeless veterans in the VA system and compare with 2014 as baseline.

• A paired t-test will measure significance of implementation of the Comprehensive Triage Acuity System

• Implementing the Comprehensive Triage Acuity System will 1) decrease patient wait time and improve patient flow and outcomes and 2) reduce the number of homeless veterans.

• If successful, this triage assessment tool can be implemented in all VA primary walk- in clinics throughout the nation.

Emergency Severity Index (ESI) (McHugh, Tanabe, McClelland et al., 2012).•The ESI is the most commonly used triage system in the United States. •Acuity judgments are addressed first based on stability of vital functions or high-risk presentation. •For “stable” patients, the experienced triage nurse uses the ESI to predict the resources needed to move the patient to an appropriate disposition from the ED (admission, discharge or transfer).U.S. Department of Veteran Affairs•The Homeless Screening Clinical Reminder (HSCR) is a universal, two-question screener for current homelessness and imminent risk and is preformed annually at VA healthcare facilities (Fargo, Byrne, Montgomery et al., 2014).•Homeless Veteran Patient Aligned Care Teams (HPACT) use a multidisciplinary approach to address the chronic medical, mental, and behavioral health conditions among Veterans experiencing housing instability (Fargo, Byrne, Montgomery et al., 2014).

• Veterans comprise 12% of the adult homeless population and report an average of 5.77 years vs. 3.92 years of homeless compared to non-veterans (National Coalition for Homeless Veterans, 2015) (National Survey of Homeless Veterans in 100,000 Homes Campaign Communities, 2011).

• The 1.5 million Americans that experience homelessness per year are amongst the highest users of costly hospital based acute care (Burns, 2014).

• Emergency department (ED) crowding has been recognized as a growing problem. From 1995 through 2005, the annual number of ED visits in the United States increased nearly 20%, from 96.5 million to 115.3 million (Wiler, Gentle, Halfpenny, Heins, Mehrotra, Mikhail, & Fite, 2009).

• The walk-in clinic at the VA was established to alleviate high influx of patients in the ED; however, there is no standardized leveled triage tool in place

College ofHealth

ProfessionsLIENHARD SCHOOL

OF NURSING

PICO Question

PubMed, CINAHL, PSYCHinfo, and Up to Date databases were used to find relevant studies. The following keywords were used: triage tool, urgent care, walk-in-clinic, assessing emergency room patients, homelessness, and veterans. Original research articles, articles with keywords present in the abstract or the title, articles published between 2009 and 2015 were used. Eight publications including 1 systematic review and 1 clinical guideline met the inclusion criteria.

The Comprehensive Triage Acuity System

The most common triage systems used throughout emergency rooms are the Australian Triage Scale (ATS), the Manchester Triage Scale (MTS), the Canadian Emergency Department Triage and Acuity Scale (CTAS), and the Emergency Severity Index (ESI) (Lidal, Holte & Vist, 2013). Evidence supports the use of five level triage scales to effectively and efficiently manage the flow of patient care, improve the initial assessment of patients, manage resources in the acute care setting, and to increase the accuracy of prioritizing patient care (Lidal, Holte & Vist, 2013). Errors in the initial clinical evaluation of patients can potentially lead to severe consequences such as a misdiagnosis, delayed treatment, disproportionate health care resource utilization, and increased costs (Elias et al., 2015). Triage tools have been instituted in many emergency rooms to decrease these errors (Elias et al., 2015). A systematic review on the use of triage tools in the pre-hospital selling, such as a walk-in-clinic determined there is insufficient research on the use of triage tools in these settings.