As a society, we learn from a young age how most lines work: we stand behind the person in front of us until it’s our turn, whether it’s at school, the bank, or the movie theatre. Most lines operate on a first-come, first-served basis.

However, one place lines don’t work this way is the emergency department (ED) at the hospital. The first thing that happens at the ED is triage, which is the sorting of patients according to the urgency of their need for care; he or she with the most immediate need will be seen first. So just because you arrived at the ED before someone else doesn’t necessarily mean you’ll receive treatment before them. 

The triage station at one of Saskatoon's emergency departments.

The triage station at one of Saskatoon’s emergency departments.

“Emergency departments in Saskatoon Health Region use the Canadian Triage and Acuity Scale,” explained Dr. James Stempien, head of emergency medicine for Saskatoon Health Region.

This scale ranges from 1 to 5, with one signifying the sickest patients and five the least sick.

Those designated CTAS 1 – needing resuscitation – don’t wait at all to be seen, Stempien explained. When they come into the emergency department, they usually arrive by ambulance, and go into a treatment area immediately. These are the people who have been in a trauma, have abnormal vital signs, are in cardiac arrest or are not breathing well.

“It’s someone who is in imminent danger,” Stempien said.

Those designated CTAS 2 need emergency care but can wait a short time for treatment, with the team trying to see them in about 15 minutes.

“This is, let’s say, an elderly man who comes in with chest pain, and we’re worried about his heart,” Stempien noted.

CTAS 3 patients – those classified as needing urgent care – are the most varied bunch. It could be someone having an asthma attack or someone with abdominal pain.

“These are the people we try to see within 30 minutes, although it’s not always easy,” Stempien said. “Often we need a place where they can be examined, so we can better determine why they are feeling the way they are feeling.”

Finding a place to do the examination can be tricky at times, especially when the emergency department is full. What staff and physicians try to do in these situations is pull these patients into an exam room very quickly to start an examination. Depending on what the physician finds, and the availability of beds, the patient may be asked to go back to the waiting room.

CTAS 4 patients are those who have less urgent issues.

“This might be someone who presents with symptoms of a skin infection, mild shortness of breath, minor belly pain, minor cuts that need stitches, that kind of thing,” Stempien explained. “These are the walking wounded; they’re stable and not in too much pain. We try to see them within 60 minutes.”

CTAS 5 patients are those who are not urgent – those with sprained ankles, a rash or who need a prescription renewal. ED staff tries to see these non-critical patients within 120 minutes.

There are, of course, many factors that move patients up or down the triage scale – age and vital signs are two.

“The whole point of triage is not to make people wait, but to see the people who need to be seen first,” Stempien said. “It wouldn’t exist if there was always room and physicians enough to see everyone who walks in right away. But we have limited beds and resources, and so we have to see certain people first. It’s the safest thing for our population.”

Triage is a dynamic process, and a patient’s status can change rapidly. This is why the concept of triage captains is being trialed. These captains watch the lineup for triage and pull out people they believe are in immediate danger. They also keep an eye on the waiting room, and reassess those whose conditions start to worsen suddenly. The triage captain process is currently active at the Royal University Hospital ED, with plans to replicate to St. Paul’s Hospital Emergency room in the future.

Triage staff at all emergency rooms are there for people to talk to if someone feels their own situation or that of their loved one is changing, as the timeliness of their care could be escalated.

“Patients should let us know if they feel they are getting worse. We’ll reassess and expedite their care as necessary,” Stempien explained.

ED staff knows it can be frustrating to wait for care if your concern is more minor and believe it could only take a couple of minutes for a physician to deal with. To help address this frustration, there are now “low acuity” rooms in the ED, for those who are triaged as a CTAS 4 or 5.

“These rooms allow physicians to see people with lower acuity quickly, when we have a minute or two between heavy cases. It’s become part of our streamlining plan for less urgent cases, so they don’t have to wait too long,” said Stempien.

This is one of a number of initiatives Saskatoon Health Region is undertaking to improve how patients flow through the health care system in the Region.

If I don’t think my complaint is serious, should I just go to a clinic?

“Sometimes, patients need the tests, the X-rays and the expertise an ED can provide,” he said, “so it doesn’t necessarily make sense for them to go to a clinic first.”

Sometimes, people come to the ED because they’ve had a problem for two or three weeks and can’t get an appointment with their family doctor. This isn’t the best use of the emergency department as it’s often preferable for a patient to see the doctor who knows them best for minor or chronic problems, Stempien suggested. Prescription renewals that aren’t urgent also fall into this category.

“But we trust our patients,” he said. “We don’t send anyone away. If you feel you have an emergency, you should come to the emergency department.”

After the waiting room

Once you get into a bed in the ED from the waiting room, the nursing staff will reassess your condition, and will start communicating with one of the ED physicians, who could be dealing with up to 20 patients who need their attention at any time. The physician will then come and see you.

“That initial visit from a physician usually lasts between five and 10 minutes,” Stempien explained. “We try and get a focused history, and perform an exam based on their complaint. We might order medications or tests, depending on what the patient needs.”

If tests are ordered, you will likely have to wait for results, and for the physician to review them.

“You have to take your turn there, too,” Stempien said.

And if you need a bed in the hospital, you may have to wait in the ED for that.

Sometimes, the initial wait for care in the ED is due to how full ED beds are. And often, a full ED is due to the number of patients who have been admitted to a unit for in-hospital care, but there’s no bed available in the appropriate unit.

“Getting patients into the right bed is extremely important – it means that they will get the right resources and the right care to get better,” explained Graham Blue, Director of Adult Medicine and Complex Care for Saskatoon Health Region. “But sometimes it means a wait for the right bed.”

Many different departments in the Region, including the ED, are working towards improving the flow of patients from the emergency department into inpatient beds.

“We are constantly working to make things better,” said Dr. Stempien. “For our part, in the ED, we will see people out of the waiting room, out of back halls, and we’ve put some nurse protocols in place so they can start certain treatments right away.”

The EDs in Saskatoon are under mounting pressure, there is no doubt.

“No matter how hard we try, there are new challenges presented every day,” Stempien said. “We’re not just sitting in the back while you wait, I promise. We’re trying to see everyone as quickly as we can.”