Background: Hospitalists have increasingly engaged in admission decision-making for acute care medical patients. The role, duties, and impact of a Hospital Medicine Triage Attending (“triagist”) are emerging yet ill-defined. To our knowledge, no study thus far has catalogued the activities of these physicians in a comprehensive way. Our objectives were to 1) characterize the demands on the triagist by measuring the frequency and origin of admission calls to the acute care medical service, 2) better understand the triage decision-making process by delineating the sources of triage decision concordance/discordance encountered, and 3) identify the impact of the triagist with respect to ultimate disposition in the setting of triage discordance.
Methods: This is a descriptive study of cross-sectional data collected from May 1st 2018 through April 30th 2019 at a large, urban, safety-net, public teaching hospital. At our institution the triagist logs all calls into a central Triage Database with an assessment of admission appropriateness and reasoning. Using this database, we generated descriptive statistics for referral site, triage concordance (defined as the triagist assessment of “definitely appropriate” for acute care medical service) or discordance (defined as triagist assessment of anything other than “definitely appropriate” for acute care medical service), and ultimate disposition.
Results: Over the 12-month study period, 3724 requests for admission were logged. The majority came from the Emergency Department (n = 2448; 65.73%), followed by the Medical ICU (n = 790; 21.21%); few came from the Surgical ICU (n = 113; 3.0%) or clinics (n = 98; 2.63%). Overall, the triagist decision was concordant with a total of 2318 (62.24%) of all admission calls; the proportion and reason for discordance varied by site of admission referral. The triagist most commonly shared triage concordance with calls coming from the Medical ICU (78.8% agreement), followed by the outpatient clinics (69.1% agreement), ED (66.9% agreement), and least commonly from the Surgical ICU (44.6% agreement). For referrals from the Medical ICU, the most frequent reason for discordance was that the patient required ongoing ICU-level care (n = 121; 73.9%), while for those from outpatient clinics and ED the most frequent reason cited was that inpatient admission was not necessary given the lack of medical acuity of presenting issues (clinics: n=19; 67%; ED: n = 453; 58.7%), and for referrals from Surgical ICU that another service was felt to be more appropriate (n = 40; 64.5%).It does not appear that there is a consistent relationship between triagist assessment and ultimate disposition decisions. Take, for example, triage-discordant admission calls from the ED. For patients the triagist felt did not require inpatient admission, 75.5% were admitted to an acute care Medicine service; for patients the triagist felt would be better served on an alternate service, 46.7% were admitted to an acute care Medicine service. However, for patients the triagist assessed as requiring a higher level of care, 65.5% were admitted to an ICU.
Conclusions: The triagist handles a large volume of calls, primarily from the Emergency Department and Medical ICU, and encounters a relatively high proportion of triage discordance. The most common cause of discordance varies by referral site, and ultimate disposition is not always in alignment with triagist assessment. Additional exploration of these relationships and additional outcomes is warranted.