Is triage a dead end for health care? 

It is hard to escape bad news about wait times in health care these days. Across the developed world, health systems are under stress as populations age, exacerbated by the COVID pandemic that created long backlogs for care. Similarly in Canada, wait times that have been increasing for years are now severely limiting access to essential health services.

In response, we are increasingly turning to triage, hoping to prioritize our use of scarce health-care resources.

Gone are the days of being referred to a cardiologist, a psychiatrist, a gastroenterologist or pretty much any specialist service with an expectation of being seen in a reasonable amount of time. Instead, you are given a list of warning signs to look out for while waiting to be triaged and added to a wait list, with the risk that if you’re not deemed ill enough, you’ll keep getting bumped until you’re really sick – at which point you’re advised to visit an emergency department (ED). At least there they can’t refuse you, even if you have to wait all day. At the ED, where our fixation with triage first became firmly established, you are of course, triaged.

Wait lists grow when demand exceeds capacity. Demand for health care is increasing: We have an aging and increasing population, and older people have more complex health needs.

We don’t invest enough in preventive medicine and primary care, leading to more time and higher spending to treat advanced illnesses. The range of available treatment options has exploded, meaning that there’s almost always something more that can be done, and more that patients can expect will be done.

Chronic under-investment in primary care means we have fewer family physicians managing access to expensive specialty care, one of the few ways to manage demand in a health system that is supposed to be free for users.

To make matters worse, capacity is decreasing. Many health providers are reaching retirement age themselves. And those who remain are working less. We have among the lowest ratio of physicians per population, nurses per population and hospital beds per population of all Organization for Economic Co-operation and Development countries.

Until health-care demand and capacity are balanced, wait times will keep going up. But considering how ubiquitous triage has become as a response, we should be sure that it’s not doing more harm than good.

The Oxford dictionary defines triage as: “a preliminary assessment of a patient in order to determine the … urgency of treatment required. Sometimes used with the negative implication of withholding treatment from a patient, especially one who is considered unlikely to benefit from it.” The word originated in France in the 1800s to describe the assessment of soldiers wounded in the Napoleonic wars, categorizing patients into three groups:

1. Those who were likely to live, regardless of what care they received;
2. Those for whom immediate care might make a positive difference in outcome;
3. Those who were likely to die, regardless of what care they received.

Triage is a tool to be used during temporary conditions of extreme imbalance between demand and supply, such as the availability of medics on battlefields. It is intended to be a rapid and inherently imperfect assessment with life-and-death consequences. Triage doesn’t help you decide how long to delay necessary care. It helps you decide who is, and who isn’t, going to get any care at all.

Triage is imperfect. Triage is not  intended to be a perfect assessment tool. It is a partial assessment performed in a time-limited fashion. Therefore, it’s bound to result in more diagnostic errors than a full medical assessment. When triage is wrong, people can die.

Time spent triaging reduces time available for patient care. The ability of health providers to diagnose and treat patients develops in parallel – there is no such thing as a “triage-ist” specialty. Any health provider who can triage reasonably accurately also has some ability to treat patients, which is a better use of their time. The more triage, the less capacity to treat patients.

Delaying treatment leads to worse outcomes. Some conditions resolve without medical intervention. But many conditions worsen over time. Triaging delays patients until they are sick enough to warrant immediate treatment. Sicker patients have worse outcomes and consume more health resources because their treatment is more complex. This “death spiral of waiting” is obviously not a good foundation for a high-performance health system.

And this last point matters a lot. Battlefield medics know that the longer they wait to apply a tourniquet to someone who’s bleeding out, the harder it will be to keep them alive. There’s not much point triaging into a fourth category, say, “pretty sick and needs care but I’ll get back to you later when you’re closer to dying.” Yet this is exactly the category that most patients in Canada get put into when they are triaged in our health system.

The effect is not to speed up access for those who need it most, but rather to slow it down for everyone else. On the battlefield and in physicians’ offices, triage is used in response to overwhelming demand to justify denying care to those who need it least. But if we’re not withholding care, just delaying it, then triage is ultimately a dead end.

In The Netherlands, where I lived recently, health-care wait times were rarely in the news and I never had the personal experience of waiting to access health services. This anecdotal evidence is backed up by statistics. Wait times there are among the shortest internationally. An international survey conducted by The Commonwealth Fund in 2016 gives insight into our international performance. In The Netherlands, 77 per cent of patients reported that they could see a doctor or nurse the same or next day, compared to only 43 per cent in Canada, putting us dead last of countries surveyed. Only 7 per cent of Dutch patients waited more than two months to see a specialist, compared to 30 per cent of Canadians, again ranking us dead last.

Unfortunately, things don’t appear to have improved.

Unfortunately, things don’t appear to have improved. The Commonwealth Fund recently released its 2023 Primary Care survey results. Only 86 per cent of Canadians report they have a regular doctor or place to go for care, which is, again, the worst performance among 10 peer countries. The Netherlands has the best primary care access, with 99 per cent reporting they have a regular doctor.

The Netherlands spent slightly more per patient than Canada in 2022, although less as a share of GDP. Overall, it is achieving significantly better access to health care at similar costs. That experience suggests it is possible to balance health-care capacity and demand, and that long wait times are not an inevitable consequence of a publicly funded health system.

In EDs, there are times when urgent care needs can overwhelm resources, such as mass casualty events when patients with less serious problems have to wait until physicians can catch up again. But there are rarely opportunities to catch up anymore. We’ve taken an intervention designed for temporary, exceptional circumstances and are applying it inappropriately out of desperation to our normal, steady-state health-care processes.

Triage is a dead-end for our health system. The prevalence and pervasiveness of triage signals a serious imbalance in demand and supply that needs to be fixed. But triage is not the solution. Even in EDs, many hospitals are successfully reducing wait times by reducing triage. A focus on streamlining triage at North York General has helped it to achieve wait times below the provincial average despite being among the busiest hospitals in Toronto. We need to follow this lead across the entire health system by triaging only when absolutely necessary and streamlining triage when it is.

Seven steps to eliminate triage: 

1. Triage only when necessary

Triage only when two criteria are met:

1. There is a relationship between the speed of access to medical care and patient outcomes, and
2. Demand exceeds capacity.

In these situations, decisions to withhold non-urgent care are required. Triage is used to focus efforts where it will provide the greatest benefit. For instance, in an emergency department, triage ensures that an unstable trauma victim is seen before patients with non-urgent issues.

2. Triage in primary care, not in specialty care

In Canada, all patients presenting for non-emergent medical care are assessed by primary care providers before they are referred to specialists. Triage does not necessarily need to be repeated by specialists. Primary care providers can be assisted with their triage decisions if specialists provide them with referral advice, for instance a list of indications, contraindications and “red flags.”

3. Simplify triage

Triage is never perfect no matter how much time you put into it. Instead of striving for perfection, triage should be simplified so that it is “good enough”: rapid yet reasonably accurate. All time saved should be put into patient care, helping to reduce the wait list.

4. Manage urgent and non-urgent care differently

If triage is required, then only two triage categories should be defined: urgent and non-urgent. Patient demand and specialist capacity should be managed separately for these two groups of patients. For urgent patients, enough capacity should be reserved to meet the daily demand. If it’s not required, unused capacity can be released for non-urgent patients. For non-urgent patients, the average capacity should match the average demand. If demand temporarily exceeds capacity, non-urgent patients can safely be delayed.

5. Balance patient demand and clinical capacity to stabilize wait lists

Incentives for appropriate access to specialty care (or disincentives for inappropriate access) can reduce patient demand. There are options, including better patient education about the risks and benefits of treatment, financial incentives/disincentives for patients, positioning primary care providers as gatekeepers to secondary care and transferring care to the lowest-cost qualified care provider.

To increase clinical capacity, we either have to improve productivity or add additional resources. Applying process improvement tools and techniques can increase productivity and quality by helping clinicians to work smarter instead of just harder. And we need to retain our existing clinical workforce and train and hire more.

6. Work through the wait lists

Once average patient demand and specialist capacity are balanced, a temporary increase in capacity is required to work through the backlog of currently waiting patients. Once this is achieved, capacity can be matched to the average demand without increasing wait times.

7. Stop triaging

When there are no wait lists, there is no need to triage. Patients for whom it is appropriate can start treatment immediately, without being triaged.