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BMC Emergency Medicine
Published in: BMC Emergency Medicine 1/2011

Open Access 01-12-2011 | Debate

Emergency department triage: an ethical analysis

Authors: Ramesh P Aacharya, Chris Gastmans, Yvonne Denier

Published in: BMC Emergency Medicine | Issue 1/2011

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Abstract

Background

Emergency departments across the globe follow a triage system in order to cope with overcrowding. The intention behind triage is to improve the emergency care and to prioritize cases in terms of clinical urgency.

Discussion

In emergency department triage, medical care might lead to adverse consequences like delay in providing care, compromise in privacy and confidentiality, poor physician-patient communication, failing to provide the necessary care altogether, or even having to decide whose life to save when not everyone can be saved. These consequences challenge the ethical quality of emergency care. This article provides an ethical analysis of "routine" emergency department triage. The four principles of biomedical ethics - viz. respect for autonomy, beneficence, nonmaleficence and justice provide the starting point and help us to identify the ethical challenges of emergency department triage. However, they do not offer a comprehensive ethical view. To address the ethical issues of emergency department triage from a more comprehensive ethical view, the care ethics perspective offers additional insights.

Summary

We integrate the results from the analysis using four principles of biomedical ethics into care ethics perspective on triage and propose an integrated clinically and ethically based framework of emergency department triage planning, as seen from a comprehensive ethics perspective that incorporates both the principles-based and care-oriented approach.
Appendix
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Literature
1.
Moskop JC, Sklar DP, Geiderman JM, Schears RM, Bookman KJ: Emergency department crowding, part 1- concept, causes, and moral consequences. Ann Emerg Med. 2009, 53 (5): 605-11. 10.1016/j.annemergmed.2008.09.019.CrossRefPubMed
2.
Australasian College for Emergency Medicine: Policy document -- standard terminology. Emerg Med (Fremantle). 2002, 14: 337-340.
3.
Carrus B, Corbett S, Kandelwai D: A hospital-wide strategy for fixing ED overcrowding. Health International. 2009, 9: 6-17.
4.
Carret ML, Fassa AC, Domingues MR: Inappropriate use of emergency services: a systematic review of prevalence and associated factors. Cad Saude Publica. 2009, 25 (1): 7-28. 10.1590/S0102-311X2009000100002.CrossRefPubMed
5.
Ben-Isaac E, Schrager SM, Keefer M, Chen AY: National profile of nonemergent pediatric emergency department visits. Pediatrics. 2010, 125 (3): 454-9. 10.1542/peds.2009-0544. Epub 2010 Feb 1CrossRefPubMed
6.
Sturm JJ, Hirsh DA, Lee EK, Massey R, Weselman B, Simon HK: Practice characteristics that influence nonurgent pediatric emergency department utilization. Acad Pediatr. 2010, 10 (1): 70-4. 10.1016/j.acap.2009.10.001.CrossRefPubMed
7.
Gentile S, Vignally P, Durand AC, Gainotti S, Sambuc R, Gerbeaux P: Nonurgent patients in the emergency department? A French formula to prevent misuse. BMC Health Serv Res. 2010, 10: 66-10.1186/1472-6963-10-66.CrossRefPubMedPubMedCentral
8.
Domres B, Koch M, Manger A, Becker HD: Ethics and triage. Prehospital Disaster Med. 2001, 16: 53-8.CrossRefPubMed
9.
Iserson KV, Moskop JC: Triage in medicine, Part I: Concept, history and types. Ann Emerg Med. 2007, 49 (3): 275-81. 10.1016/j.annemergmed.2006.05.019.CrossRefPubMed
10.
Moskop JC, Iserson KV: Triage in medicine, part II: Underlying values and principles. Ann Emerg Med. 2007, 49 (3): 282-7. 10.1016/j.annemergmed.2006.07.012.CrossRefPubMed
11.
Hartman RG: Tripartite triage concerns: issues for law and ethics. Crit Care Med. 2003, 31 (suppl): S358-S361. 10.1097/01.CCM.0000065130.18337.05.CrossRefPubMed
12.
Beauchamp TL, Childress JF: Principles of Biomedical Ethics. 2009, New York: Oxford University Press, 6
13.
Anderson-Shaw L, Ahrens W, Fetzer M: Ethics Consultation in the Emergency Department. JONA's Healthcare Law, Ethics, and Regulation. 2007, 9 (1): 32-35. 10.1097/01.NHL.0000262491.15783.cd.CrossRef
14.
Bell NK: Triage in medical practices: an unacceptable model?. Soc Sci Med F. 1981, 15 (4): 151-6.PubMed
15.
16.
Bodansky DMS: Ethical dilemmas in triage: a perspective from the Jewish philosophical tradition. Ethics & Medicine: an international journal of Bioethics. 2009, 25 (1): 49-56.
17.
Mackway-Jones K, Marsden J, Windle J: Emergency Triage: Manchester Triage Group. 2006, BMJ Book. Blackwell Publishing Limited, 2
18.
SAEM Ethics Committee (Society for Academic Emergency Medicine): Ethics of emergency department triage: SAEM position statement. Acad Emerg Med. 1995, 2 (11): 990-5.CrossRef
19.
Weinerman ER, Ratner RS, Robbins A, Lavenhar MA: Yale studies in ambulatory care V: determinants of use of hospital emergency services. Am J Public Health. 1966, 56: 1037-1056. 10.2105/AJPH.56.7.1037.CrossRef
20.
Jones J, Playforth MJ: The effect of the introduction of NHS Direct on requests for telephone triage advice from an accident and emergency department. Emergency Medicine Journal. 2001, 18: 300-301. 10.1136/emj.18.4.300.CrossRefPubMedPubMedCentral
21.
Thompson AK, Faith K, Gibson JL, Upshur RE: Pandemic influenza preparedness: an ethical framework to guide decision-making. BMC Med Ethics. 2006, 7: E12-10.1186/1472-6939-7-12.CrossRefPubMed
22.
Christian MD, Hawryluck L, Wax RS, Cook T, Lazar NM, Herridge MS, Muller MP, Gowans DR, Fortier W, Burkle FM: Development of a triage protocol for critical care during an influenza pandemic. CMAJ. 2006, 175 (11): 1377-81. 10.1503/cmaj.060911.CrossRefPubMedPubMedCentral
23.
Verweij M: Moral principles for allocating scarce medical resources in an influenza pandemic. Bioethical Inquiry. 2009, 6: 159-169. 10.1007/s11673-009-9161-6.CrossRef
24.
Society of Critical Care Medicine Ethics Committee: Consensus statement on the triage of critically ill patients. JAMA. 1994, 271: 1200-3.CrossRef
25.
Travers DA, Waller AE, Bowling JM, Flowers D, Tintinalli J: Five-level triage system more effective than three-level in tertiary emergency department. J Emerg Nurs. 2002, 28 (5): 395-400. 10.1067/men.2002.127184.CrossRefPubMed
26.
Wuerz RC, Milne LW, Eitel DR, Travers D, Gilboy N: Reliability and validity of a new five-level triage instrument. Acad Emerg Med. 2000, 7 (3): 236-42. 10.1111/j.1553-2712.2000.tb01066.x.CrossRefPubMed
27.
Gilboy N, Tanabe P, Travers DA, Rosenau AM, Eitel DR: Emergency Severity Index, Version 4: Implementation Handbook. 2005, AHRQ Publication No. 05-0046-2. Rockville, MD: Agency for Healthcare Research and Quality
28.
Cronin JG: The introduction of the Manchester triage scale to an emergency department in the Republic of Ireland. Accid Emerg Nurs. 2003, 11 (2): 121-5. 10.1016/S0965-2302(02)00218-7.CrossRefPubMed
29.
Zimmermann PG: The case for a universal, valid, reliable 5-tier triage acuity scale for US emergency departments. J Emerg Nurs. 2001, 27 (3): 246-54. 10.1067/men.2001.115284.CrossRefPubMed
30.
Bullard MJ, Unger B, Spence J, Grafstein E, CTAS National Working Group: Revisions to the Canadian Emergency Department Triage and Acuity Scale (CTAS) adult guidelines. CJEM. 2008, 10 (2): 136-51.PubMed
31.
Warren DW, Jarvis A, LeBlanc L, Gravel J, CTAS National Working Group, Canadian Association of Emergency Physicians, National Emergency Nurses Affiliation, Association des Médecins d'Urgence du Québec, Canadian Paediatric Society, Society of Rural Physicians of Canada: Revisions to the Canadian Triage and Acuity Scale paediatric guidelines (PaedCTAS). CJEM. 2008, 10 (3): 224-43.PubMed
32.
Yousif K, Bebbington J, Foley B: Impact on patients triage distribution utilizing the Australasian Triage Scale compared with its predecessor the National Triage Scale. Emerg Med Australas. 2005, 17 (5-6): 429-33. 10.1111/j.1742-6723.2005.00773.x.CrossRefPubMed
33.
Wallis LA, Gottschalk SB, Wood D, Bruijns S, Vries S, Balfour C: The Cape Triage Score - a triage system for South Africa. S Afr Med J. 2006, 96: 53-56.PubMed
34.
Travers DA: Triage: How long does it take? How long should it take?. J Emerg Nurs. 1999, 25 (3): 238-40. 10.1016/S0099-1767(99)70213-8.CrossRefPubMed
35.
Lerner E Brooke, Schwartz Richard, Coule Phillip, Weinstein Eric, Cone David, Hunt Richard, Sasser Scott, Liu J Marc, Nudell Nikiah, Wedmore Ian, Hammond Jeffrey, Bulger Eileen, Salomone Jeffrey, Sanddal Teri, Lord Graydon, Markenson David, O'Connor Robert: Mass Casualty Triage: An Evaluation of the Data and Development of a Proposed National Guideline. Disaster Med Public Health Preparedness. 2008, 2 (Suppl 1): S25-S34.CrossRef
36.
Larkin GL, Arnold J: Ethical considerations in emergency planning, preparedness, and response to acts of terrorism. Prehosp Disaster Med. 2003, 18 (3): 170-8.PubMed
37.
Kellermann AL, Isakov AP, Parker R, Handrigan MT, Foldy S: Web-based self-triage of influenza-like illness during the 2009 H1N1 influenza pandemic. Ann Emerg Med. 2010, 56 (3): 288-294. 10.1016/j.annemergmed.2010.04.005.CrossRefPubMed
38.
Sacco WJ, Navin DM, Waddell RK, Fiedler KE, Long WB, Buckman RF: A new resource-constrained triage method applied to victims of penetrating injury. J Trauma. 2007, 63 (2): 316-25. 10.1097/TA.0b013e31806bf212.CrossRefPubMed
39.
Jecker NS, Reich WT: Contemporary Ethics of care. Encyclopedia of bioethics. Edited by: Post SG. 2004, New York: Macmillan, 367-74.
40.
Held V: The ethics of care: personal, political and global. 2006, Oxford: Oxford University Press
41.
Gastmans C: The care perspective in health care ethics. Essentials of Teaching and Learning in Nursing Ethics: Perspectives and methods. Edited by: Davis A, Tchudin V, de Raeve L. 2006, Elsevier, Edinburgh, 135-148.
42.
Vanlaere L, Gastmans C: A Personalist Approach to Care Ethics. Nursing Ethics. 2011, 18: 161-173. 10.1177/0969733010388924.CrossRefPubMed
43.
Gilligan C: In a different voice: psychological theory and women's development. 1982, Cambridge: Harvard University Press
44.
Tronto J: Moral Boundaries, a Political Argument for an Ethic of Care. 1993, Routledge, New York
45.
American College of Emergency Physicians: Definition of an emergency service. Ann Emerg Med. 1991, 23: 1397-
46.
Lowe RA, Bindman AB, Ulrich SK, Norman G, Scaletta TA, Keane D, Washington D, Grumbach K: Refusing care to emergency department of patients: evaluation of published triage guidelines. Ann Emerg Med. 1994, 23 (2): 286-93. 10.1016/S0196-0644(94)70042-7.CrossRefPubMed
47.
48.
Leung WC: Consent to treatment in the A&E department. Accid Emerg Nurs. 2002, 10 (1): 17-25. 10.1054/aaen.2001.0303.CrossRefPubMed
49.
Davis MA, Hoffman JR, Hsu J: Impact of patient acuity on preference for information and autonomy in decision making. Acad Emerg Med. 1999, 6 (8): 781-5. 10.1111/j.1553-2712.1999.tb01206.x.CrossRefPubMed
50.
Rhodes KV, Vieth T, He T, Miller A, Howes DS, Bailey O, Walter J, Frankel R, Levinson W: Resuscitating the physician-patient relationship: emergency department communication in an academic medical center. Ann Emerg Med. 2004, 44 (3): 262-7. 10.1016/j.annemergmed.2004.02.035.CrossRefPubMed
51.
52.
Goransson KE, Rosen AV: Patient experience of the triage encounter in a Swedish emergency department. Int Emerg Nursing. 2010, 18: 36-40. 10.1016/j.ienj.2009.10.001.CrossRef
53.
Knopp R, Rosenzweig S, Bernstein E, Totten V: Physician-patient communication in the emergency department, part 1. Acad Emerg Med. 1996, 3 (11): 1065-9. 10.1111/j.1553-2712.1996.tb03357.x.CrossRefPubMed
54.
Altevogt BM, Stroud C, Hanson SL, Hanfling D, Gostin LO: Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. 2009, Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations; Institute of Medicine
55.
Bernstein SL, Aronsky D, Duseja R, Epstein S, Handel D, Hwang U, McCarthy M, John McConnell K, Pines JM, Rathlev N, Schafermeyer R, Zwemer F, Schull M, Asplin BR, SAEM Emergency Department Crowding Task Force: The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med. 2009, 16: 1-10. 10.1111/j.1553-2712.2008.00295.x.CrossRefPubMed
56.
Cooke T, Watt D, Wertzler W, Quan H: Patient expectations of emergency department care: phase II - a cross-sectional survey. Can J Emerg Med. 2006, 8 (3): 148-57.
57.
Hodge AN, Marshall AP: Violence and aggression in the emergency department: A critical care perspective. Aust Crit Care. 2007, 20: 61-67. 10.1016/j.aucc.2007.03.001.CrossRefPubMed
58.
Crilly J, Chaboyer W, Creedy D: Violence towards emergency department nurses by patients. Accid Emerg Nurs. 2004, 12: 67-73. 10.1016/j.aaen.2003.11.003.CrossRefPubMed
59.
Ekwall A, Gerdtz M, Manias E: The influence of patient acuity on satisfaction with emergency care: perspectives of family, friends and carers. J Clin Nurs. 2008, 17 (6): 800-9. 10.1111/j.1365-2702.2007.02052.x.CrossRefPubMed
60.
Cook Charles, Muscarella Peter, Praba Anant, Melvin W Scott, Martin Larry: Reducing Overtriage Without Compromising Outcomes in Trauma Patients. Arch Surg. 2001, 136: 752-756. 10.1001/archsurg.136.7.752.CrossRefPubMed
61.
Hupert Nathaniel, Hollingsworth Eric, Xiong Wei: Is Overtriage Associated With Increased Mortality? Insights From a Simulation Model of Mass Casualty Trauma Care. Disaster Med Public Health Prep. 2007, 1: S14-S24. 10.1097/DMP.0b013e31814cfa54.CrossRefPubMed
62.
Armstrong JH, Hammond J, Hirshberg A, Frykberg ER: Is overtriage associated with increased mortality? The evidence says "yes". Disaster Med Public Health Prep. 2008, 2 (1): 4-5. 10.1097/DMP.0b013e31816476c0. author reply 5-6.CrossRefPubMed
63.
Chung JYM: An exploration of accident and emergency nurse experiences of triage decision making in Hong Kong. Accid Emerg Nurs. 2005, 13: 206-213. 10.1016/j.aaen.2005.08.003.CrossRefPubMed
64.
Persad G, Wertheimer A, Emanuel EJ: Principles for allocation of scarce medical interventions. The Lancet. 2009, 373: 423-431. 10.1016/S0140-6736(09)60137-9.CrossRef
65.
Dworkin R: Sovereign Virtue. The Theory and Practice of Equality. 2000, Cambridge: Harvard University Press
66.
67.
Sevenhuijsen S: Citizenship and the ethics of care: feminist considerations on justice, morality and politics. 1998, London: RoutledgeCrossRef
68.
Gastmans C, Dierckx de Casterlé B, Schotsmans P: Nursing considered as a moral practice: a philosophical-ethical interpretation of nursing. The Kennedy Institute of Ethics Journal. 1998, 8: 43-69. 10.1353/ken.1998.0002.CrossRefPubMed
69.
van Hooft S: Acting from the virtue of caring in nursing. Nursing Ethics. 1999, 6: 192-193.CrossRef
70.
Widdershoven G: Care, cure, and interpersonal understanding. Journal of Advanced Nursing. 1999, 29: 1163-1169. 10.1046/j.1365-2648.1999.00985.x.CrossRefPubMed
71.
Verkerk M: A Care perspective on coercion and autonomy. Bioethics. 1999, 13: 358-369. 10.1111/1467-8519.00163.CrossRefPubMed
72.
Gatens-Robinson E: A defence of women's choice: abortion and the ethics of care. Southern Journal of Philosophy. 1992, 30: 39-66. 10.1111/j.2041-6962.1992.tb00637.x.CrossRefPubMed
73.
Loots C: Expecting a child with a disability: clinical ethical reflections on prenatal diagnosis and selective abortion. Between Technology and Humanity: the impact of technology on health care ethics. Edited by: Gastmans C. 2002, Leuven: Leuven University Press, 81-94.
74.
Lindemann K: The ethics of receiving. Theoretical Medicine. 2003, 24: 501-509.CrossRef
75.
Parks J: Envisioning a kinder, gentler world: on recognition and remuneration of care workers. Theoretical Medicine. 2003, 24: 489-499.CrossRef
76.
Gastmans C, De Lepeleire J: Living to the bitter end? A personalist approach to euthanasia in persons with severe dementia. Bioethics. 2010, 24: 78-86. 10.1111/j.1467-8519.2008.00708.x.CrossRefPubMed
77.
Edwards SD: Three versions of an ethics of care. Nurs Philos. 2009, 10 (4): 231-240. 10.1111/j.1466-769X.2009.00415.x.CrossRefPubMed
78.
Reiser SJ: The ethical life of health care organizations. Hastings Cent Rep. 1994, 24 (6): 28-35. 10.2307/3563464.CrossRefPubMed
Metadata
Title
Emergency department triage: an ethical analysis
Authors
Ramesh P Aacharya
Chris Gastmans
Yvonne Denier
Publication date
01-12-2011
Publisher
BioMed Central
Published in
BMC Emergency Medicine / Issue 1/2011
Electronic ISSN: 1471-227X
DOI
https://doi.org/10.1186/1471-227X-11-16

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