GREYFRIARS MEDICAL CENTRE

TRIAGE

'Triage' is a word we hear more often nowadays in the health service, especially in general practice.  It is also normal practice in any busy hospital casualty department.

'Triage' comes from the French word 'trier' - to sort into different groups or categories.  In 1792 during the Napoleonic Wars, a twenty-six year old French surgeon, Baron Dominique Jean Larrey, devised the system of 'triage' to sort out which casualties should be treated first.  A doctor on a battlefield would go round the hundreds of injured soldiers, knowing that he could never treat every single one instantly; they had to be given priority in order to make the best use of limited resources.

He would identify three categories.  One would be poor devils who were dead or so nearly dead that there was no realistic hope of saving their lives.  They would be given something to ease their suffering (if they were lucky) and left to their fate.  At the other extreme there would be injuries that obviously did not threaten life, like a superficial wound, where some first aid for their comfort and then proper treatment later in the fullness of time was all that they needed.  Finally there would be those with life-threatening injuries who could be saved with prompt action.  They would be tagged with a mark telling the stretcher bearers to take them straight to the field hospital for immediate treatment.  For this he devised 'ambulances volante' - 'flying ambulances' (actually light artillery wagons used to bring the surgeons to the battlefield in the first place) in order to evacuate the injured quickly to get medical help.  Prior to that, it was not uncommon for wounded soldiers to have to wait for more than twenty-four hours before receiving medical attention.  Many of them died as a consequence and the suffering doesn't bear thinking about.

It is sad to have to equate our treasured NHS with a battlefield, but with limited resources, there are similarities.  GPs have always 'triaged' or sorted referrals to specialists into three possible categories of priority stated on their referral letter:  'urgent' - it might be cancer so please act immediately;  'soon' - my patient is suffering so much that they deserve to be seen quickly;  and 'routine' - no priority can be clearly justified.  There is a story of some GPs always categorising their patients as higher priority because they wanted to get a better service from the hospital.  All that happened, of course, was that consultants got to know this and would ignore the priority because they would wish to be fair for everyone.  But then the 'cry wolf' scenario would lead to the occasional disaster so his patients in the end lost out.

Formal triage is now normal practice in Primary Care.  Over the past several years in Dumfries & Galloway most surgeries have used a triage system out of normal hours.  If a patient phoned for help, a doctor or nurse would speak with them first to determine what was needed - telephone advice, consultation at the Primary Care Centre, home visit by doctor or district nurse, or immediate ambulance to hospital.  This is going to continue and in fact will become more structured with nurses working to a computerised series of questions with NHS 24 having now taken over the triaging of out of hours calls.

During normal hours, because of increasing demand, we cannot see every single case on the same day that the patient reports sick.  At the moment you have to wait for some months to see an orthopaedic surgeon because of a painful hip or a cardiologist because of angina.  For a routine appointment to see a particular GP you now might have to wait for some days, especially if you can only come at certain times or it is a doctor with a particularly large or demanding list of patients.  This is fine if it is only for a routine blood pressure check or review of an on-going problem but it is obviously not good enough if you are ill and need to be seen.

In the old days we used to rely on the common sense and experience of our receptionists who would fit extra cases into our surgeries as needed.  However we recognise that this is much better done by someone with clinical training.  So now in many surgeries, if a patient is offered a routine appointment and they feel that whatever they are offered is too long a wait, they are told that their request will be passed to the triage nurse or doctor.  If it is obviously more serious, like someone with chest pain, the call would then be dealt with even more urgently.

This means that every case is given appropriate attention.  Often a triage doctor or nurse can actually provide the necessary care on the basis of the telephone consultation alone - some problems do not need a face to face encounter.  For example a simple cold does not actually need any examination - it all hangs on the patient's history, so advice is usually all that is needed.  If things don't go according to plan, of course, the patient will know that all they have to do is to phone up again (preferably in the morning) to be put through triage to be seen that day if need be.

So triage is now the norm.  It means that a limited resource, doctor or nurse consulting time, is made available to those that need it urgently without undue delay.  For the rest of us with non-urgent problems, we will all have to learn to plan ahead for those routine appointments such as a review of an on-going problem.  Maybe it will all become unnecessary if the number of GPs increases substantially, but I do not hold out too much hope for that.