Triage Drift: A Workplace Study in a Pediatric ... - Semantic Scholar

Computer Supported Cooperative Work (2008) 17:395–419 DOI 10.1007/s10606-008-9079-2

© Springer 2008

Triage Drift: A Workplace Study in a Pediatric Emergency Department Pernille Bjørn1,2 & Kjetil Rødje1 1 Simon Fraser University, Burnaby, Canada; 2IT University, Copenhagen, Denmark (E-mail: [email protected])

Abstract. This paper presents a workplace study of triage work practices within an emergency department (ED). We examine the practices, procedures, and organization in which ED staff uses tools and technologies when coordinating the essential activity of assessing and sorting patients arriving at the ED. The paper provides in-depth empirical observations describing the situated work practices of triage work, and the complex collaborative nature of the triage process. We identify and conceptualize triage work practices as comprising patient trajectories, triage nurse activities, coordinative artefacts and exception handling; we also articulate how these four features of triage practices constitute and connect workflows, organize and re-organize time and space during the triage process. Finally we conceptualize these connections as an assessing and sorting mechanism in collaborative work. We argue that the complexities involved in this mechanism are a necessary asset of triage work, which calls for a reassessment of the concept of triage drift. Key words: emergency work, health care, triage, coordinative artefacts, exception handling, workplace study, assessing and sorting mechanism, triage drift

1. Introduction Implementation failures of IT-systems have lead to a growing skepticism towards technology amongst the general public (Heath et al. 2000). Nevertheless, large electronic IT-systems are entering the medical professions. Designing electronic IT-systems for any kind of setting requires that the designer has an understanding of the work performed so that the IT-system enables rather than constrains the work practices (Clarke et al. 2006; Orlikowski 1995). In many cases involving health care IT-systems, the model of work is based upon a simplistic perspective (Tjora 2000), where work is represented by its rules and protocols. However, there are immense differences between plans for practice and the actual situated actions (Suchman 1987), and many failures of digital systems within health care are grounded in IT designers’ perspective of work as merely plans (Berg 1998). Addressing this issue, there is an immediate need for workplace studies of work practices and use of technology in various health care settings (Goorman and Berg 2000; Heath et al. 2003). Workplace studies are concerned with the practical accomplishment of workplace activities, and in particular, with how tools and

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artefacts feature in everyday work. These studies involve an underlying interest with the design of complex collaborative systems and how these systems feature, or may turn out to feature, in organizational activities and actions (Clarke et al. 2006; Heath et al. 2000). Workplace studies position the emergent and reflexive character of practical action at the center of analysis. In simple terms, triage is the sorting or prioritizing of patients. Triage is “the process of sorting people based on their need for immediate medical treatment as compared to their chance of benefiting from such care. Triage is done in emergency rooms, disasters and wars when limited medical resources must be allocated to maximize the number of survivors” (MedicineNet.com 2007). The Canadian Triage & Acuity Scale (CTAS) is an instrument1 indicating criteria and categories for triage in EDs (Beveridge et al. 1998). Similar attempts to construct standardized criteria and categories for triage work also exist outside the Canadian context, such as the Norwegian Index for Medical Emergency Assistance (Tjora 2000). The primary operational objective of the CTAS scale is to indicate the maximum allowed wait time for patients entering a Canadian ED based upon their level of urgency. Sorting patients thus involves assessing their level of urgency. As such, triage work can be described as an assessing and sorting mechanism. The CTAS scale has five levels of urgency, ranging from CTAS 1 (Resuscitation) indicating immediate need for treatment to CTAS 5 (Non Urgent) indicating that the patient should be seen by a physician within 2 h. The CTAS scale lists characteristics and criteria for nurses’ triage assessment. Triage work according to the CTAS guidelines thus comprises assessing each patient individually, based upon objective indicators, and assigning them respective urgency levels with designated maximum wait times. In Canada, there is an increased public awareness of ED wait times (Eggertson 2004), which has furthered an interest in developing standardized procedures guided by electronic triage systems (Beveridge et al. 1998; Grafstein et al. 2006; Jiménez et al. 2003). Addressing these demands, EDs all over Canada are currently at different stages implementing electronic triage systems (Bjørn 2008). This process is reflected in national reports, emphasizing the need for standardized and objective triage criteria (Ospina et al. 2006). This has implications for triage work, as standardized and objective criteria also imply standardized work procedures. A triage nurse’s most important function is to decide on the correct clinical prioritization, which requires excellent skills based upon experience, knowledge, and intuition (Andersson et al. 2006). The concept triage drift refers to the seemingly unstructured and heterogeneous aspects implicit in triage work when performed by experienced triage nurses acting on their experience and intuition. Triage drift is a known factor in triage work (Jiménez et al. 2003), however it is perceived as a problem to be countered by the standardized procedures (Dong et al. 2006b). This perspective on triage work risks overlooking key tasks and activities missing in standardized procedures. As

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previous research shows, implementing standardized triage systems within EDs is highly complex and can risk failure because of conflicting demands between the collection of triage data and the work practices of triage nurses (Balka and Whitehouse 2007), or because of the clashes between the standardized model for triage work embedded within the electronic system and the actual situated practices of triage nurses (Bjørn and Balka 2007; Tjora 2000). We have conducted a workplace study within a Canadian pediatric ED, and examined ED staff’s practices and procedures when coordinating triage activity of patients entering the ED. This paper provides empirical observations describing the situated triage work practices, and discusses how these practices constitute a mechanism for assessing and sorting patients. We identify and conceptualize triage work practices as comprising patients’ trajectories, triage nurses’ activities, coordinative artefacts, and exception handling. We argue that the heterogeneous complexities involved in triage are necessary assets of this work, which implies a reevaluation of the seemingly chaotic phenomena of triage drift. We will discuss how triage drift needs to be readdressed in order to accommodate the necessarily unstructured and heterogeneous character of triage work practices. In the following section we outline the methodological approach of workplace studies and present our data sources and analytical approach. Next, we present each of the four features of triage work practices: patient trajectories, triage nurse activities, coordinative artefacts, and exception handling. A discussion of our theoretical findings follows and finally we conclude. 2. The empirical setting: the emergency department The empirical setting investigated is a pediatric ED within a Canadian provincial tertiary hospital facility. The ED sees about 38,000 children yearly and operates with two parallel patient areas: acute area for high urgency patients and fast track area resembling a walk in clinic. The acute area comprises 13 beds, two trauma/ resuscitation beds, and two psychiatric assessment rooms and the fast track area comprises six examination beds. The two areas share two procedure rooms for suturing, cast placement, and conscious sedation procedures (Figure 1). The acute area has one attending physician 24/7 working in 8 h shift together with one MD fellow, one MD resident and one medical student2. The fast track area has one attending physician from 10 A.M. to midnight every day of the year working together with up to one fellow, two to three residents and a number of medical students. There are 64 RN nurses in the ED plus 12 NRT (nursing resource team) nurses working 24/7 mostly in 12 h shifts. There is a triage nurse 24/7, located by the entrance facing the door. The triage nurse’s main job is to determine the level of urgency of any patient, using the PCTAS3 guidelines, and divide patients between the acute and fast track area. Behind the triage counter is a desk. At one side of the desk is a blue bench used for triage assessments, and on the other side are two

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Acute area

Paramedic ambulance entrance

Nurse station

Registratio n

Acute waiting room

Triage area

Fast track area Fast track waiting room

Front-end

Back-end

Figure 1 The layout of the ED.

chairs. Various equipment sit behind the desk, such as weight scales, IV-poles, blood pressure and blood sugar measurement machines. The triage nurse has a chair in the middle of the triage area and behind the chair is a curtain in front of a small nook with a bed. The nook is used for more private assessments of patients. To the one side of the triage area is the waiting room area for fast track patients and to the other side is the waiting room area for acute patients. Opposite the acute waiting area sits the registration clerk 24/7. The back-end of the ED comprise the acute and fast track area. The charge nurse is placed 24/7 at the nurses’ station located in the centre of the acute side. It is the charge nurse who coordinates and manages the workflow in the back-end of the ED, including assigning patients to rooms, assigning nursing tasks and addressing physicians’ orders. Each nursing shift comprises seven to nine nurses from 10 A.M. to midnight (when fast track is open): one charge nurse4, four to six bedside nurses,


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one triage nurse, a break nurse, and a fast track nurse. At really busy times (typically weekends 5 P.M.–12 A.M. or during winter session) there will be an additional float nurse. The unit clerk is placed next to the charge nurse at the nurses’ station 24/7. The unit clerk is responsible for discharge of patients as well as transferring really sick patients from the ED to an in-patient bed at the hospital. Moreover, the unit clerk supports the charge nurse handing physician orders and keeping track of patients. Finally there is a porter and housekeeper present in the ED 24/7 with the responsibility of making sure patients is followed to e.g., radiology, CT scans, or nuclear imaging; they also check that all rooms and equipments are clean and sometimes bring various blood or specimen samples to the lab. From 12–11 P.M. there are also a volunteer at the entrance door, with the primary assignment to make sure the triage nurse is not interrupted by all kinds of inquiries not related to the ED. 3. Method The work presented here is part of a larger ED study which takes up the challenge articulated by Timmermans and Berg (2003) to move beyond criticism of existing medical technologies and, in a constructive manner, try to influence specific aspects of the creation and implementation of medical technologies. After receiving ethical consent from three committees: the hospital committee, the hospital’s affiliated university committee, and the Simon Fraser University ethical board, the study began in the summer of 2006 and is still ongoing. The research method is an empirical workplace study (Heath et al. 2003; Luff et al. 2000; Plowman et al. 1995; Schmidt 1998) and can be divided into three analytical phases all with different focuses but highly interlinked. Because the study has evolved over time it is impossible to clearly distinguish research activities into phases. Rather, many of the research activities have been overlapping in focus, so that parts of each phase also influence findings in other phases. The three phases are: 1. Investigation of the former electronic triage system eTRIAGE 2. Investigations of the triage work practices 3. Investigation of the design, re-configuration and implementation of the new electronic triage and tracking system Cerner Firstnet Even though this paper focuses on the second phase, empirical observations from all three parts of the study constitute the empirical foundation for this paper. In the first phase the focus was to investigate the challenges and problems experienced by the triage nurses in the ED during an 18-month period of using the electronic triage system eTRIAGE. One of the main findings from the first phase was that the model of work embedded within the design of eTRIAGE was not compliant with the actual work practices of triage nurses and in some cases was directly constraining for conducting triage. The focus of the second phase

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was to examine and describe the work practices of triage nurses, which clearly had not been in addressed in the design of eTRIAGE (Bjørn and Balka 2007). The third phase of the empirical study was initiated in late spring 2007 when a decision was made to reconfigure and implement a new electronic tracking and triage system in the ED. Here the main focus was to investigate the process of reconfiguring an existing electronic triage and tracking system to accommodate the existing work practices in the ED. In this work the results and findings of the first and second phase were valuable. The empirical study presented in this paper relates to the second phase and comprises in-depth analysis of the invisible and tacit work practices embedded within triage work in EDs. We focus on the essential articulation work which makes the emergency unit function. Understanding the invisible and tacit work practices is immensely important when constructing technology because it is exactly the articulation of these practices IT-systems should be designed to support (Schmidt and Bannon 1992). We seek to bring awareness of “important conceptual issues and questioning taken-for-granted assumptions about work activities and how they should be supported” (Plowman et al. 1995, p. 12), by placing the practical circumstances in which tools and technology are deployed in triage work at the forefront of the analytic agenda (Heath et al. 2003). This paper contributes to the conceptual foundation for research on the complex nature of collaborative work, which is an essential role of workplace studies (Schmidt 1998). More specifically, this involves a focus on the collaborative nature of assessing and sorting activities, which are key practices in many forms of collaborative work. The primary data used in this paper comprises various research activities which together contribute to an understanding of the work practices of triage nurses in the ED. The primary activities comprise observations of work practices, informal and formal interviews with ED staff, analysis of various artefacts in use, and participation in design workshops where the ED staff (mainly nurses and clerks) articulated their work with the aim of reconfiguring the new electronic system. The observations of work practices took place during 12 observations between November 2006 and August 2007, where the first author was located in the triage area, at the nurse station, or at fast track, observing the work while having informal interviews with staff about their work practices. Six of the observations were conducted in the front-end of the ED mainly focusing on the triage nurse and registration clerk, while the remaining six were conducted in the back-end of the ED mainly focusing on the charge nurse, unit clerk, fast track nurse and bedside nurses including their use of whiteboards, clipboards and chart racks (parts of the observations were done at the acute side and parts at the fast track). In total the front-end was observed for 24.25 h and the back-end for 31.75 h. For each observation activity in the front-end one to five triage nurses were observed (at busy times there can be up to three active triage nurses triaging at the same time; also other nurses might take over during breaks


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etc), and one to two registration clerks would also be part of any front-end observations. It was also during the front-end observations that the triage nurses’ encounters with paramedics were recorded. Observations at the back-end would either take place at the nurse station or at the fast track area. Observations at the nurse station would mainly focus on the coordination of work between the charge nurse, unit clerk, and the five bedside/ break nurses working each shift. Observations in the back-end also include recordings of the coordination and management of physicians’ orders for treatments and examinations, as well as the work of the porter (bringing samples to the lab) and housekeeping (cleaning rooms between patients). Observations at fast track in the back-end of the ED focused mainly on the fast track nurse’s coordination of patients between rooms and waiting room as well as handling of physician orders including the use of clipboards, chart racks, and whiteboard. During all observations informal interviews were conducted with 29 different ED staff members in total, mainly comprising 25 different nurses (triage, charge, break, float and bedside nurses), two clerks (one registration and one unit clerk), and two physicians. Some staff members were observed more than once. Digital images of a wide range of artefacts and copies of various paper forms have been collected during observations. In addition, four formal interviews were conducted, two with the clinical nurse educator and two with the emergency program manager. Three of the formal interviews were recorded and transcribed. Moreover, a large number of informal conversations have been made with the clinical nurse educator and the emergency program manager, as well as with various nurses, clerks, and physicians between July 2007 and January 2008, where the first author has been present at the hospital on average 2.5 full days each month. The other main part of the empirical investigation of work practices within the ED has been through participation in 22 design workshops between July 2007 and February 2008. Each design workshop have been focusing on articulating existing work practices and re-configuring the electronic triage and tracking system, which was implemented in the Spring of 2008. Participation in these design workshops resulted in detailed descriptions of various patient, work, and communication flows within the ED. Each workshop lasted between 4–8 h and included three to 12 participants. The participants comprise representatives of the different nursing functions (triage, charge, bedside), clinical nurse coordinator, the clinical nurse educator, the clerks, the emergency program manager, the patient safety liaison, the physicians, and the vendor. In general there were a core group of participants which included a clinical nurse educator, a clinical nurse coordinator, a charge/triage nurse, a unit clerk, the ED program manager, a vendor representative, a minute taker, and the first author. In total the first author spent approximately 132 h participating in design workshops. Finally the secondary data material includes a field trip to two regional hospitals together with the core group observing triage work using the electronic

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triage and tracking application in two adult EDs; as well as a smaller separate study comprising survey phone interviews with eight out of the ten pediatric EDs in Canada about triage practices and use of electronic triage systems (Bjørn 2008). Each interview was either conducted with the ED manager or the clinical nurse educator from the hospital using a structured interview guide. The analysis of the empirical findings presented in this paper was inspired by the grounded theory approach (Glaser and Strauss 1967; Orlikowski 1993). All transcriptions, observations notes etc. were imported into the software program Nvivo and closely examined while developing and connecting low level categories in the material. Low level categories used as codes were e.g., document handling; paper forms; pre-triage; re-ordering patient; room configuration; rules and protocols; coordination. All low level categories were written on a whiteboard and connections were captured while constructing a coherent perspective including high level categories on the empirical material. Finally, the description of the triage work practices as an assessing and sorting mechanism emerged as constituted by the four features: patient trajectories; triage nurse activities; coordinative artefacts; and exception handling. On this basis empirical observations from both interviews and observations were selected and combined into coherent small vignettes illustrating how the triage work is enacted. All descriptions of work provided in this paper are thus grounded directly in either the informal or formal interviews with the ED staff and/or in observations of the activities in the ED. To ensure reliability of our interpretations of the ED work the emergency program manager and the clinical nurse educator read our descriptions of the ED work as presented in this paper and provided comments and small corrections, but in general they experienced that our descriptions captured essential aspects of their work which they themselves had difficulties in articulating.

4. Triage work practices 4.1. Patient trajectories The first main feature in triage work is patient trajectories (Strauss et al. 1985). Patient trajectories refer to the pathophysiological unfolding of patients’ medical status, as well as to the total organization of work processes surrounding the patient including the impact of these processes on the people involved with the work and its organization (Goorman and Berg 2000) (Figure 2). The patient typically enters the pediatric ED together with a parent or guardian. The patient is either carried, arrives by foot, by wheelchair, or by ambulance with paramedics. When patient and parent/guardian come through the glass doors, they see a waiting room and a triage desk with a large sign stating: “Have you checked in with nurse?” The patient will then go to the counter and the triage nurse will ask: “are you here for emergency and what seems to be the problem?”


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Figure 2 Patient view of triage area.

The parent/guardian will present the chief complaint and they are sent to the waiting room if there is a line up. When first in line, the patient is called up for the triage interview at the blue bench beside the triage counter. Here the patient will be asked various questions about immunization, health history, and medication while the nurse performs examinations such as stethoscoping, measuring temperature, weight, and blood pressure. When the triage interview is completed, the patient is directed to the registration clerk, where name, address, personal health number etc. are provided. After registration high urgency patients are directed to an examination room by the charge nurse while low urgency patients are directed to the waiting room. Waiting room patients will stay here until the charge nurse calls them into an examination room and a doctor enters. From the perspective of a patient, this whole triage process might seem straight forward and without complex coordination work. The work practices are ‘black boxed’, as they should be because “the better the work is done, the less visible it is to those who benefit from it” (Suchman 1995, p. 58). The triage activity appears as a singularity, as a “definite, limited, and therefore single, sets of processes in the world” (Law 2004, p. 163). For the outsider triage work appears as a singularity performed by one triage nurse assessing one patient accordantly to one set of objective rules. This visible singularity black boxes triage work, which means that the inherent multiplicity of triage becomes invisible from the outside. Multiplicity refers to the simultaneous enactment in different practices of objects said to be the same (Law 2004, p. 162). However, the complexity is revealed when we open the black box of triage nurse activities. 4.2. Triage nurse activities From the triage nurse perspective triaging patients is not a singularity; rather, it is a multiplicity where various patients and their conditions are continuously

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assessed and related to each other as well as to the available resources of the ED, determining the current context which affects the sorting of patients. In this section we illustrate this multiplicity by providing detailed descriptions of the triage work in the ED. Our intention is to represent the high level of complexity faced by the triage nurse during an ordinary day, while illustrating that everyday ED activities do not adhere strictly to a standardized script (Figure 3). At the blue bench sit a mom and her 5 year old daughter with burned hands. The story of how this happened is not clear. The mom explains that the daughter is at a foster home 2 days a week, and when she returned home 2 days ago, her hands were burned. They saw a family doctor who bandaged the girl’s hands and sent them to the ED. Meanwhile, the glass door to the parking lot opens and two parents enter, the father carrying their 6-year-old son. The triage nurse interrupts the interview with the girl with burned hands and addresses the newcomers: “Are you here for emergency and what seems to be the problem?” The parents explain their son had a penis operation 2 days ago and now has severe pain. The triage nurse preassesses the new patient to a higher level of urgency than the patient at the bench and decides to push the new patient ahead of the queue. The new family is directed behind the curtain covering the nook at the triage area, so the triage nurse can examine the patient in a more private manner. Once the triage nurse completes her examination the patient is directed to registration while the triage nurse phones the nurses’ station alerting the charge nurse that a CTAS 2 needs a room immediately. The charge nurse tells the triage nurse to send the patient to examination room 2. The triage nurse leaves the triage desk, walks to registration and tells the father, still carrying the 6-year-old son, to go directly to room 2 while the mother registers.

Figure 3 Triage nurse view of entrance.


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When the triage nurse returns to the triage desk, she continues the assessment of the child with burned hands but is soon interrupted by a new patient entering the ED. A mom is very concerned about her 3-week-old baby. Right now, four patients wait to be triaged (laceration, cough, diarrhea, and broken ankle). The nurse walks around the counter, does a quick assessment of the baby using her stethoscope and decides she will finish the assessment in progress before taking in the baby. She tells the mom not to go far, because she and her baby will be next. The triage nurse returns to the interview, finishes it, directs the mother and daughter to registration, and then calls up the mother with her 3-week-old baby. A new nurse enters the triage area to take over while the triage nurse takes her break. However, the triage area is so busy that instead of simply taking over, the new nurse starts calling patients up for interviews. She uses the two chairs on the other side of the counter. The child with diarrhea is called up. Now triage interviews are executed on both ends of the counter and more patients enter through the front door. The triage nurse interrupts her interview, quickly assesses the urgency of the new patients, and sends them to the waiting area until there is time to interview them. The triage nurse finishes her assessment of the 3-weekold baby, but she does not want the baby to be contaminated by other patients while waiting. No more rooms are available, so she directs the mother to the psychiatric area, since there are no psychiatric patients at this moment. A man enters behind the triage desk. He is there to repair the blood pressure machine. The triage nurse is weighing a child about age 4, who has a laceration in the forehead however the child is crying and does not want to stand on the scale. In the end, the guardian stands on the scale holding the child, and the nurse then subtracts the weight of the guardian to calculate the weight of the child. An ambulance arrives and two paramedics enter with a stretcher. People are everywhere in the ED, and the paramedics end up being placed in the middle of the room with the stretcher. The triage nurse goes to the stretcher and examines the child while getting the story from the paramedics about a seizure. Patients arriving by ambulance are not necessary more urgent than patients arriving otherwise, however in cases where the paramedics point to the trauma room upon entry the triage nurse interrupts everything and runs towards the patient right away. Yet another nurse enters the triage area due to the hectic situation and begins calling in patients for interviews. The third nurse puts on a mask, glasses, and gloves while examining a child around the age of 3 because the child is coughing a lot. She does not want to be contaminated and pass on infections to other patients. Now triage interviews take place on both ends of the triage counter, as well as in the middle of the room, while patients keep entering. A couple enters. The woman is 5 months pregnant and in risk of miscarrying. They arrived to the province only recently and are looking for an adult ED. The pediatric ED can only take in patients under the age of 17, and pregnancy is dealt with at the

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women’s hospital. The triage nurse makes a quick visual assessment of the woman and walks to the back-end of the ED, presumably to consult with the back-end personnel. The triage nurse returns, calls a porter and finds a wheelchair for the woman. The porter arrives and follows the couple to the women’s hospital next door. A closer look at the triage nurse activities nuances the seemingly singular and straightforward patient trajectory. The multiplicity of activities involved in triage work illustrates a far more complex and collaborative process, where multiple tasks are performed simultaneously, across the space of the ED, and where new patients and incidents relentlessly call for attention interrupting one another. 4.3. Coordinative artefacts As the preceding descriptions show, triage work in the ED comprises highly complex collaborative tasks involving not only one individual triage nurse but multiple professions including triage nurses, charge nurses, registration clerks, and paramedics. Also, triage work is influenced by the current status of the ED and other factors such as the number of patients present and the space available. Aligning and integrating interdependent activities, also referred to as coordination work, is one of the core activities in collaborative work (Bardram 2000). Various coordinative artefacts such as whiteboards, telephones, and documents can support coordination work. Coordinative artefacts comprise a symbolic construct objectifying an integrated set of procedures and conventions stipulating the articulation of interdependent activities (Schmidt and Simone 1996). In expert work, these procedures and conventions are typically invisible and tacit through workarounds and only become salient in situations of breakdowns (Gerson and Star 1986; Kobayashi et al. 2005). ED staff use various coordinative artefacts e.g., folders, clipboards, whiteboards, telephones, and chart racks to keep track of patients, wait times, assessments, treatments etc (Figure 4). Each time a patient enters the ED, the triage nurse interrupts ongoing activities and conducts what is referred to as ‘pre-triage’ or ‘triage-across the room’, while grabbing a yellow note paper from the pad on the table and stamping it with the time of arrival. When the patient reaches the triage counter, the triage nurse has already done a visual pre-assessment, has at hand a yellow piece of paper stamped with time of entry to the ED, and is ready to write down the patient’s name and chief complaint. In many cases the triage nurse will also stethoscope the patient during pre-triage assessment. If there is a lineup of patients waiting for triage interviews and the new patient is not in an urgent state, the triage nurse will put the yellow note on the table and place the patient’s care card on top of the yellow note and send the patient to the waiting room. For each patient waiting to be interviewed, a corresponding yellow note sits on the triage table with information about the patient’s time of arrival and chief complaint. The yellow notes on the desk are organized in a queue


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Figure 4 Triage desk with yellow notes, time stamp machine and patient follow up folder.

according to time of arrival and level of urgency, based upon pre-triage assessment. Before calling up the next patient for triage interview, the triage nurse gets an overview of all patients waiting by looking at the yellow notes on the desk, and in some cases the yellow notes are reorganized. This occurs when a new patient enters with a higher level of urgency than some of the patients already waiting. The nurse will then position the new yellow note according to the level of urgency and not at the end of the queue. An additional function of the yellow notes is that other nurses passing the triage desk can estimate the busyness at the ED by simply noticing the number of yellow notes. When a patient is called up for an interview, a new coordinative artefact enters the work practice, namely the triage interview form. There are three triage interview templates5: Emergent/Urgent patients (CTAS 2/3), who are treated at the acute side; Less/non urgent patients (CTAS 4/5), who are treated at fast track; and psychiatric patients (CTAS 2/3), who are treated at the psychiatric area on the acute side. The three main templates differ in length, questions, and examinations required. All forms are placed on built-in shelves in the triage counter. In the beginning of each interview the triage nurse reaches for the appropriate form, time stamps it, and then begins examinations. Thus, at the very beginning of a triage interview, the triage nurse makes an initial assessment of the patient’s urgency and chief complaint in order to select the right triage form. Selecting the appropriate triage template is a key part of the triage process, with several artefacts and work practices at play. The fundamental decision for the triage nurse is to make the distinction between CTAS 3s and 4s, whether the patient should be seen in the acute or fast track area. In situations where the triage nurse conducting the interview also did pre-triage (producing the yellow note) of the patient, the previous encounter plays a part in determining the level of urgency. In situations where a different triage nurse did the pre-triage, the triage nurse conducting the interview lacks previous experience with the patient, which

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makes it more difficult and time-consuming to decide whether the patient is a 3 or 4 and thus which form to choose. Choosing the correct form at this initial stage requires a high level of triage nursing skills. As indicated by previous triage work studies, key skills for triage nurses are experience, knowledge and intuition (Andersson et al. 2006), and these skills are vital in processing these complex work tasks. To accommodate the difficulties, less experienced nurses start the interview before choosing the form. They write the information they collect (e.g. vital signs) on the yellow note and then transfer this information to the correct triage form at a later stage in the interview. Other nurses start on one form, and if they realize they chose the wrong form, switch during the interview, transferring all the information onto the new form. Other nurses choose to keep two piles of forms on the desk, instead of in the built-in shelves, to make it easier to choose the form at a later stage of the interview. When the interview is finished, the triage form, the yellow note, and the care card are given to the registration clerk, who, after receiving the documents6, will call the patients for registration. When the ED is less busy, the patient/guardian hands over the documents to the registration clerk; however, during busy times, the triage nurse will leave the triage desk and personally hands the documents to the clerk directly. To an outsider, it might seem strange that the triage nurses, while busy, do the extra work of handing over the documents in person. However, during busy times a queue is most likely to form at the registration counter. By handing the documents over to the clerk in person, the nurses ensure patients are registered in the same order as they left the triage desk. Also, it allows sick patients to sit down while waiting, instead of standing in line. During more quiet periods, patients can usually go directly to the registration clerk after the triage interview without having to stand in line, thus they can hand over the documents themselves. At registration, the clerk types the patient’s information and demographics into the electronic Admitting, Discharge and Transfer system (ADT). This includes the patient’s time of arrival found on the yellow note. In situations where the yellow note is not time stamped, the clerk will register the time stamp on the triage form instead, which resembles the time of the triage interview. The time stamp is used for the national statistics on ED wait times. In this way the time stamp on the yellow note serves two functions: it supports the triage in organizing and reorganizing pre-triage patients as well as creating statistics on ED wait times. The chief complaint written on the yellow note is also registered in the ADT system. After typing in all information, the clerk throws the yellow notes into the recycling bin for shredding and disposal. After typing the information, the registration clerk prints four SSP copies (Short Stay Paper: Physician’s chart), one for the health records, one for the physician, one for consulting physicians, and one for the patient/parent. The clerk then carries all documents together with the triage form, which also serves as the bedside nursing chart when used in the back-end of the ED, to either the tray at acute side or the tray at the fast track side.


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The charge nurse regularly checks the tray at the acute side and coordinates which patient to call into which room and uses various types of chart racks together with a whiteboard to coordinate waiting patients as well as patients in treatment. The whiteboard is among other things used to keep track of which patients are in which examination rooms, having which kind of treatment, looked after by which nurse and treated by which ED physician and/or consultants. For CTAS 2 patients the charge nurse will know in advance that the patient is coming because the triage nurse will phone the charge nurse in advance. Also in cases where the patient has been exposed to e.g., mums or chickenpox or is MRSA positive the triage nurse requests an isolation room by calling up the charge nurse. Because the hospital is a tertiary facility other hospitals within the province transfer pediatric patients with severe conditions to the pediatric ED by ambulance and/or helicopter. In these situations the attending physician from the other hospital will call in advance. When the charge nurse receives information about an expected patient he or she will write the information on a white phone message, which is handed to the triage nurse. The white phone message is also used in other cases where a patient is expected in the ED; such as when a patient is told by a consulting physician from one of the ambulatory clinics (e.g. oncology or metabolic diseases) that he or she will examine the patient using the ED facility and therefore the patient needs to go to the ED. Because the pediatric ED is an open ED, the facilities are often used by physicians from other parts of the hospital. However all patients entering the ED must be triaged by the triage nurse. In all cases where the charge nurse knows about an expected patient and writes on a white phone message, he or she will personally hand the white phone message over to the triage nurse, who then places the note in the folder called “Patient expected and/or follow ups” at the triage desk. The name of the arriving patient is also listed in this folder. By handling over the white phone messages in person the charge nurse also gets to monitor the busyness of the ED by glancing at the yellow notes on the table. When the expected patient (consultant only, transfer from other facilities) actually arrives in the ED, the normal triage procedures will be performed, now also including searching for the patient in the patient-expected/follow-up folder on the table, locating the white phone message and cross the patient’s name from the list. Then the triage nurse will write the consulting physician’s name from the white note onto the yellow note. The white phone note adds to the pile of paper going first to registration and then to the back-end. When entering information into the ADT system and printing the SSP in cases where a consulting physician is expected, the registration clerk will enter the name of the consulting physician on the form instead of leaving a blank field for the ED physician to write his or her name. A special category of expected patients are the re-check patients. Re-check patients are patients who have been asked by the ED physician to return to the

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ED for further treatment such as getting IV-antibiotic treatments in severe infection cases. Re-check patients are triaged in the same way as all other patients using an appropriate triage form, however in cases of re-check patients, the triage nurse also locates the patient’s re-check folder in the chart rack on the triage table. The re-check folder contains the original SSP, as well as all the former original documentation including nursing charts and triage forms on the patient. When the patient is registered after triage a new SSP will be printed and attached to the front of the re-check folder together with the new triage form. The re-check folder is then used as a clipboard moving around between the different chart racks in the back-end of the ED coordinating the whereabouts and treatment of the patient. After registration all documents on expected patients, including the white phone message and/or the re-check folder, are then placed in the tray at the acute side or fast track depending on the level of urgency, and then processed by either the charge nurse (all acute patients) or by the fast track nurse (all fast track patients). Handling the patient flow at the back-end is managed through the use of special assigned whiteboards, chart racks, and clipboards. However it is beyond the scope of this paper to go into details about patient handling in the back-end of the ED. So what happens between triage, registration, and the back-end handling of patients is that the one queue of patients entering through the door is assessed and re-sorted into a new queue managed by the triage nurse. This queue is sent through registration as one but then split into two smaller queues of patients: one for acute and one for fast track patients, both pre-sorted by the triage nurse. The two queues is then handled by either the charge nurse or the fast track nurse in the back-end and all these processes are coordinated by various coordinative artefacts (e.g. yellow notes, white phone messages, trays, clipboards, and chart racks). 4.4. Exception handling Triage work is a highly complex collaborative task of coordinating the patient flow within the ED based upon the patients’ level of urgency and the status of the department. This work includes managing people’s whereabouts within the physical space of the department using various coordinative artefacts. In particular, papers of different color are used in the process of handling the articulation work. Articulation work is the additional work required to manage collaborative work, and comprises all tasks involved in such activities as dividing, allocating, scheduling, and monitoring work between mutual interdependent collaborators (Gerson and Star 1986; Schmidt and Bannon 1992; Strauss et al. 1985). We have described the complexity of triage work practices in the situations where the processes follow the ‘standards’. However, triage work also includes handling exceptions. Exceptions in emergency work come in different forms and are connected to space, coordination artefacts, and patients. These incidents typically happen when the department is extremely busy.


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A clear indication of the status and busyness of the ED is the line-up of yellow notes on the triage desk. The triage area easily becomes crowded, with triage interviews taking place on both ends of the counter as well as behind the curtain. This means that a large number of people are passing by the triage desk, increasing the risk of a yellow note falling to the floor. When the triage nurse notices the yellow note on the floor, the question becomes where in the queue does this note belong? Since all yellow notes are time stamped, it is easy for the triage nurse to put it back according to chronological order. However, if the triage nurse notices the queue has already passed the time of the misplaced yellow note, the patient will be called to the triage interview immediately. After registration and the charge nurse or fast track nurse have managed the first part of the papers, attaching them to clipboards and placing them in the correct chart rack, the triage nurse will leave the triage desk, approach the chart rack, and rearrange the charts to ensure that the patient with the misplaced yellow note is back in the correct order of the queue. The small incident of a piece of paper falling to the floor has a huge impact on the work flows throughout the ED. However, the exception handling ensures that patient trajectories are not seriously disturbed by these incidents. Another indication of the busyness of the ED is the crowdedness of the frontend area of the ED, comprising the triage area, the acute waiting area, the fast track waiting area, and the registration area. Managing the front-end space of the ED is an essential work activity of the triage nurse and includes separating patients from each other. The triage nurse isolates contagious conditions, keeping apart patients with fragile health to avoid infections. Separating the patients becomes a challenging assignment in situations where there are no more rooms available. Sometimes the triage nurse will use the psychiatric examination room for waiting patients with fragile health, such as young babies and oncology patients. However, there is not always available space to separate patients. In one of the empirical observations, a mother arrived with her 5-year-old son, who she during pre-triage explained was MRSA-positive. Being MRSA positive is not dangerous for the boy but can be extremely dangerous for other patients with fragile health. No rooms were available and the psychiatric room was occupied so the triage nurse had to find a solution to isolate the boy. The triage nurse told the mother that they unfortunately had to wait in the parking lot until a room would become available. Exception handling is also related to the assignment of urgency. In situations where the acute side is very busy and the fast track staff is idle, patients will be seen faster if directed through fast track rather than through the acute track. One incident illustrating how this affects triage work practices was articulated during an informal interview with a triage nurse. A father brought his 16-year-old son to the ED with appendicitis and the son was in pain. Due to the status in the ED, the triage nurse knew that the patient would be seen sooner at the fast track than at the acute side, so the nurse deliberately assigned a lower acuity to the patient so that he would go to fast track and be seen faster.

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5. Discussion—triage as assessing and sorting Triage work is about assessing the urgency of patients and sorting them according to these assessments. From a distance, triage work might seem to be an individual activity of assessing the urgency of individual patients according to objective criteria. This perspective is highly embedded within the project of creating standardized acuity scores, which can be used by hospital management to control the finances of EDs (Innes et al. 2001). However, upon close inspection triage work appears quite different. Through multiple activities the triage nurse intermingle a number of work tasks, where patients are simultaneously assessed and sorted according to their level of urgency and the overall status of the ED. Thus assessing and sorting patients are not objectively managed according to standardized scores but rather a flexible activity operating according to the status of incoming patients and to the context of the ED. This aspect of triage work is well-known and also referred to as triage drift (Jiménez et al. 2003). However, while it is stated by prior research that triage drift is something that must be limited (Dong et al. 2006b), we will advocate that triage drift is naturally embedded within emergency work. There exists an inherent conflict between on the one hand managerial goals of transparency and standardization and on the other hand the unstructured and heterogeneous nature of triage work. Like in the case of hospital bed booking, where what seems as ‘bad’ bed management in fact is the normal, natural trouble involved with the activity (Clarke et al. 2006); presumably unstructured heterogeneous triage assessments involving triage drift in fact comprise the normal, natural trouble embedded within triage activities. Also, like triage work, in the case of hospital bed booking staff need to constantly reevaluate the current patient population in light of the resources currently available (personnel, space, equipment, etc). A match between patients and resources need to be found, and both patients and resources must be assessed and sorted accordingly. Thus, the complex nature of assessing and sorting is not necessarily unique to triage work, but can be found in a wide array of healthcare work involving the processing of information and constant rearrangement of activities according to available resources and unpredictable circumstances. The conflict between standardization and triage drift cannot be fully resolved, but rather needs to be acknowledged in order to find a balance between allowing for flexibility and complexity while maintaining a coherent structure. This is not a question of whether triage drift is good or bad, but instead about acknowledging that it is an inherent part of triage work. Triage drift is a feature of the collaborative activity of triaging and as such should be understood and taken seriously and not eliminated. A fine balancing-act is thus called for, where triage drift is an accepted part of triage nurses’ work. The triage process in the front-end of the ED is interlinked with the work performed at the back-end (acute and fast track). The collaboration between the front-end and back-end of the ED is an essential feature of triage work requiring


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visibility and monitoring between the two sides. Awareness of expected patients is provided from the back-end to the front-end through the artefacts such as the white phone messages and re-check folder. Preparing a white phone message and handing it over to the triage nurse, the charge nurse makes the triage nurse aware that a severely ill patient will arrive, which provide the triage nurse with extra information about the current and future status of the ED. Likewise awareness is also provided from the front-end to the back-end using artefacts such as the telephone e.g. when requesting a room for a CTAS 2 or a isolation room for a contagious patient. Although it is the charge nurse’s responsibility to organize the use of rooms and beds, it is the triage nurse’s responsibility to make the charge nurse aware that a patient requires a room. In this way, specific tasks and responsibilities that might appear as individual are in practice organized interactively, just as was found in control rooms (Heath and Luff 1992, p. 86). The usage of various kinds of coordinative artefacts such as the patientexpected/follow-up folder, yellow notes, white phone messages, re-check folder, trays, and the chart racks relies upon highly complex tacit work practices, which coordinate the patient flow throughout the ED. The coordinative artefacts make pertinent information publicly visible for others to monitor. For instance, when the charge nurse enters the triage area with a white phone message, the charge nurse will also glance at the triage desk to monitor the busyness of the department based on the number of yellow notes lined up. While outsiders might view the charge nurse walking between the back-end and the triage desk as a disruptive activity, this ‘walk’ actually has a further purpose, in addition to simply handing over the white phone message, namely for the charge nurse to monitor the status of the front-end. The yellow notes make visible the number of waiting patients, who are not yet represented by the clipboards in the chart rack in the back-end, but who will be added to the chart racks in the near future. This kind of information, which will influence the future status of the back-end, is not visible by any other means within the ED. Collaborative work is distinct from individual work because it is constituted by multiple actors who, in their individual work, are mutually interdependent on the work of others, thus requiring articulation work (Schmidt and Bannon 1992). In Strauss et al. (1985) hospital study, the articulation work comprises coordination of the individual yet interdependent work, with the physician as the center figure and the head nurse as the key actor. In our study, the triage work is a collaborative effort, where various emergency staff (nurses, clerks, paramedics, physicians, etc.) is mutually engaged in their individual yet highly interdependent activities. They handle patients’ trajectories with the triage nurse as the center figure, but with a number of key actors involved in managing the articulation work. This triage articulation work comprises making pertinent information publically accessible to the relevant key actors when assessing and sorting patients according to their level of urgency, as well as to the current status of the ED constituted by the available time and space.

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As our data shows, the triage process is more complicated and complex than it appears at first glance. What appears as a singular event from the perspective of the patient—one individual patient triaged by one individual nurse at one singular moment in time, at one singular location in space, according to clearly defined and objective criteria (CTAS categories)—is in reality a multiplicity of practices and actors dispersed across time and space. As we have seen, the triage work has a collective and collaborative character, where more than one nurse often is involved in the triage work. Like in the cases where it is different nurses who pretriage and triage the same patient. Also, coordination artefacts such as yellow paper notes, white phone messages, clipboards, triage interview forms, folders, chart racks etc., are involved in the process of triaging the patients. Further, the triaging of each patient is often dispersed across time and space, from an initial pre-triage assessment as the patient enters the entrance of the ED and the yellow note is time stamped, to the triage-interview, which often is interrupted by other patients or work tasks, through registration until placed in either the queue for acute or queue for fast track. Rather than a one-off assessment, the patients are triaged in a stop-start manner, where each step of the process takes part in determining the final outcome, as well as the speed of the various patient trajectories. Based on the pre-triage and initial assessments, some patients are prioritized while others are put on hold. Patients may thus follow different trajectories, moving at different speeds. This not only happens as a final outcome of the triage assessment, but also during the triage process, as patients are constantly being arranged and rearranged, according to a wide array of seemingly invisible work tasks. The unforeseen and seemingly chaotic incidents and situations constantly emerging make exception handling a key component of triage work, enabling the fine-balancing act of triage drift, where ‘exceptional’ situations are a part of the everyday work flow. We do not see exception handling as caused by or independent on triage drift. Instead we see exception handling as a necessary component of triage work making triage drift work well. Exception handling is the flexibility required to conduct triage work which includes triage drift ensuring that the work in the ED functions. This demonstrates that triaging is a process where the work and assessments continuously undertaken inflict upon the future triage process itself, as well as the outcome of this process. This also shows that assessing and sorting are not separate activities, rather they constantly overlap and are carried out simultaneously. Thus, rather than occurring as a singular event, triage work is a multiplicity of bits and pieces that together produce the outcomes of assessing and sorting the patients first into one queue for registration and then into two queues: one for fast track and one for acute patient care. This multiplicity appears invisible, indeed it is supposed to appear invisible, as a result of the work practices that go on (Suchman 1995). As long as the end results are produced—that is, patients are assessed and sorted—the impression of singularity is kept intact. The invisible multiplicity of the triage unit comes across


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as a visible singularity (Law 2004, p. 66). When successful, the invisible work makes the visible outcomes appear singular and straightforward. This visible singularity is beneficial from a managerial point of view, where the unstructured and heterogeneous nature of triage work is turned into a black box where what matters is the input (incoming patients) and the output (patients assessed and sorted). Indeed, it needs to be black boxed in order for a managerial structure to run efficiently, as the visible results of triaging (patients to be treated, bills to be paid, records to be processed, etc) need to be able to travel easily across the hospital and further onwards. While this can demonstrate the success of the work practice system, it can be problematic if the singularity is taken at face value, without recognizing the invisible multiplicity constituting it. This is what happens when triage drift is perceived merely as an obstacle, without recognizing how the seemingly chaotic character of triage work in practice helps producing the outcomes which appear streamlined and singular. Thus, it is problematic if the visible singularity becomes a threat to the invisible multiplicity. That is, when triage drift is perceived as a problem to be eradicated in order for the system to run more smooth and efficient. Our conceptualization of triage drift has organizational implications for hospitals in the way that it questions the project of designing and implementing standardized electronic triage systems (Grafstein et al. 2006) based upon objective criteria for triage (Ospina et al. 2006), where collected data about CTAS levels are used by hospital management as an indicator to control the finances of EDs (Innes et al. 2001). “Compared with CTAS 3, the odds ratios for specialist consultation, CT scan, and admission were significantly higher in CTAS 1 and CTAS 2, and lower in CTAS 4 and 5 (p