The Triage Experiment

One of the rules of blogging is that it’s best to try and have frequent short, sharp posts. We’ve broken that today, as unfortunately we’ve been having real problems with the internet recently. So apologies for unanswered emails of late and length of post. Please forgive us...

Our brand new flag pole in JTH

Today is a very special day- it is our millennium edition. Yes, the blog now has a readership that numbers over 1000 unique individuals. So may I begin by thanking you all for your interest and ongoing support. Today I thought we would tell you about a little experiment that James and I did on Tuesday.

Triage

We all know how important triage is. It is a system that gets the sickest people to doctors first so that they can be seen earlier and sorted out. Never has triage been more important than in JTH when over 500 patients come through our doors every day, a mixture between primary care, hospital follow-up and the critically ill.

To set the scene, what appears "the obvious way to do things" to us in the UK is that the sickest patients, i.e. the closest to death, need to be seen most urgently by a doctor. You can say what you like about A&E waiting times in the NHS, but that fact is we’re pretty good at this. Our "obvious" way of doing things is of course an entirely culturally conditioned phenomenon, and is exactly the kind of assumption on which you cannot rely to be "self evident" in other cultural settings. In JTH, for better of for worse, the queue is managed by medically-untrained security staff guarding the doors to the doctor's offices. It’s a first come, first served system where the patient’s condition in irrelevant. If you’re unlucky enough to be unconscious on the floor (as many often are) then you tend to be stepped over by the well, thus effectively going backwards in the queue.

So with the Hospital Director's permission and encouragement, James and I set up shop outside the reception window. We were armed with the Triage Early Warning Score (TEWS) a triage model based on simple vital signs designed in South Africa, which was simple to use and designed specifically for resource poor countries. If you were well, you got a green colour. Yellow people were slightly more sick. Orange or red patients were the sickest. The purpose of the experiment was to ask two important questions:

1) Was the triage model any good?

2) How many staff are needed for triage in outpatients?

The answer was more than myself and James. As fast as we were triaging, (and it was fast, believe me!) they were coming. For some reason there is a mad dash for the hospital between the hours of 9:00 - 11:00 am. After that, it settles steadily to a trickle. We probably did core obs on and categorised around 300 patients that morning.

We have taken many photos of the chaos at outpatients. For the first time ever, the chaos turned to order. Patients were no longer blocking the doors and corridors. An ordered queue formed behind us. However, every five minutes we had to sub-triage the queue: there was no point in the sick people normally at the queue in the door waiting in the queue for triage! But crucially, we were processing the queue far quicker than the receptionist would have.

There were some low points during our stint. At one stage mother appeared carrying a limp child and we had to tell her that the she had died. The child was still warm.

However, that day, the sick folk got to the doctors early. The doctors on duty in outpatients loved it. That same day, the Paediatricians reported the highest Paediatric mortality on the wards for a long time. Six children died. The sick patients were getting to the wards, but there were still not enough doctors to monitor them on the emergency wards. We know that otherwise they would have died in the waiting room in the queue. It is clear that a triage system forms part of the solution but there are many other problems to deal with. One step at a time though eh?

Could this be the world's largest name badge?

On a lighter note, I thought I would leave you with a rather amusing photo of a wonderful man, a good friend, and a fine Consultant Physician, Dr Magdhy. He is a man of pure heart and his mind overflows with hope. He is passionate about his job and you can see his determination to do good in his eyes when he talks. A true inspiration. James caught site of the scene and took the photo the other day. (He gave his permission to put it on the website hoping it might make him famous.)

All the best,

David and James