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The aim of this study was to evaluate and describe the three-stage triage method used in a child and adolescent psychiatry outpatient clinic.
The study investigated the new allocation process of 1482 children and adolescents who were assessed using this triage system for the duration of one year, in the year 2005. Data of 1423 children and adolescents who presented in 2003 regarding the waiting time for the first appointment and the rate of nonattendance at the first appointment were used for the comparison. In triage system, new patients presenting to the outpatient clinic in the morning four days a week were assessed by a three-stage procedure: An initial Strengths and Difficulties Questionnaire screening and a structured interview administered by an intern was then followed by a clinical interview.
Of the 1482 children and adolescents who presented to the outpatient clinic during the study period, 1291 were given further appointments. Among patients who presented in 2005, the 207 non-attendant patients were significantly more likely to have longer waiting times than the 1084 attendant patients. When compared to year 2003, it was found that there was a significant decrease in the median waiting time for the first appointment and the rate of nonattendance at the first appointment among patients who presented in 2005.
The triage procedure used in this study may constitute a model for developing countries with limited health care resources.
Bu çalışmanın amacı bir çocuk ve ergen psikiyatrisi polikliniğinde kullanılan üç aşamalı triyaj yönteminin değerlendirilmesi ve tanıtılmasıdır.
Bu çalışmada, 2005’te bir yıl boyunca yeni triyaj yöntemiyle değerlendirilen 1482 çocuk ve ergenin “rutin”, “öncelikli” ve “acil” olmak üzere öncelik gruplarına ayrılma süreçleri araştırılmıştır. Karşılaştırmak amacıyla, 2003 yılında başvuran 1423 çocuk ve ergenin ilk randevu için bekleme süresi ve randevu devamsızlığı verileri kullanılmıştır. Triyaj uygulamasında, haftada dört gün sabah kliniğe başvuran yeni hastalar üç aşamalı işlem ile değerlendirilmiştir: Güçler ve Güçlükler Anketi verilmesinden sonra bir intörn yapılandırılmış görüşme uygulamış ve son aşamada klinik görüşme yapılmıştır.
Çalışma döneminde, polikliniğe başvuran 1482 çocuk ve ergenin 1291’i için randevu önerilmiştir. 2005 yılı başvurularından, verilen randevusuna gelmeyen 207 hastanın randevu bekleme süreleri randevusuna gelen 1084 hastanınkinden anlamlı olarak daha uzundur. 2003 yılı ile karşılaştırıldığında, 2005 yılında başvuran hastaların ilk randevu için bekleme sürelerinin medyanı ve randevuya gelmeme oranının anlamlı düşük olduğu saptanmıştır.
Bu çalışmada kullanılan triyaj işlemi sağlık olanakları sınırlı gelişmekte olan ülkeler için bir model olabilir.
The World Health Organization predicts that childhood neuropsychiatric diseases will be one of the five most common causes of morbidity, mortality, and disability among youth in 2020 (1). Untreated psychiatric diseases of children and adolescents become more severe and treatment resistant in the subsequent periods of life and may lead to important problems, including school failure, early pregnancies, and early marriages. It has been stated that severe individual, social, and economic costs of psychiatric diseases of children and adolescents can be reduced by early treatment in addition to preventive interventions. However, for each treatment to be effective, it should be primarily initiated and secondarily maintained (2). Therefore, approaches that are directed to early recognition, evaluation, and treatment of psychiatric diseases in children are important.
The number of patients waiting for their initial appointment at child mental health services is gradually incresing due to high patient demand for appointments, long follow-up periods and insufficient number of doctors. Long waiting times decrease the rate of attendance and lead to waste of time for the staff, delayed solution of problems, and inability to evaluate priority cases in time (3,4,5). It has been stated that psychopathology becomes more severe during long waiting periods in many patients (6). Different methods are being applied to cope with these problems (4). The return of questionnaires sent to cases on the waiting list was considered to be useful method in predicting attendance at the planned appointments (7). Asking families to confirm ahead of time their intention to attend scheduled appointments has been reported to be an effective method for reducing the non-attendance rate. This approach, however, does not provide sufficient information to make a decision on the placement of the individual at the appropriate level of priority on the patient list (4). It was considered that referral letters would be useful in determining urgent cases and intervening in these cases in time; however, it was found that they were insufficient because of the lack of appropriate information (8). In managing waiting lists, methods, including utilizing multidisciplinary teams, shortening the consultation periods, increasing efficiency by intervening with non-attendance, and appropriately allocating referrals, are applied (6).
Triage is another method recommended to solve the problems mentioned above (4). Triage that originates from military medicine means dividing the wounded into three groups in the basis of a preliminary examination: the ones who require urgent intervention, ones who can wait, and ones who will not benefit from the treatment. In the triage system, patients are directed to appropriate treatments according to their clinical requirements, the possibility of benefitting from the treatment, and urgency level (4). In child and adolescent mental health services, triage can be used in determining priority cases requiring urgent intervention or in psychiatric assessment in emergencies (for example, abuse, suicide, violent behaviors, and severe psychopathology) or under extraordinary conditions (disasters) (4,9) as well as in arranging routine appointments (3,8). Triage assessment is useful in preventing inappropriate appointment requests and prevents patients requiring urgent intervention from waiting for prolonged periods. With triage, some cases are closed at the first appointment or initial interventions are realized. It has been reported that triage improves the rates of non-attendance and patient and clinician satisfaction (4). When triage is used while providing limited resources in healthcare services, the ones who require resources with the highest priority and who will benefit with the highest rate are specified (10).
In Turkey, approximately 200 child and adolescent psychiatrists, including residents, provided service to approximately 25 million children under the age of 18 years, which constituted 36% of the population (11) at the time when this study was conducted. It is clear that the number of child and adolescent psychiatrists is insufficient in our country considering the fact that the prevalence of psychiatric disorders has been found to be approximately 14% in epidemiological studies (12). In our country, it is common for families to overlook and even neglect the psychological needs and problems of their children due to educational and socioeconomical factors. Because one third of children do not attend subsequent appointments after their first appointment with the child and adolescent psychiatrist (13), the first appointment may be the only opportunity for some children to receive psychological assistance. A comprehensive assessment and referral to appropriate service (if possible) by the child and adolescent psychiatrist at the initial presentation may be a useful approach for these children to receive appropriate psychological assistance. Although child and adolescent psychiatry clinics should be considered as the last resort in the treatment of children with psychological problems, it is common in our country for parents to bring their children directly to these clinics without the referral of other physicians. Because of inadequacies in the monitoring of child development, some children with developmental problems (pervasive developmental disorders, hearing impairement, mental retardation, etc.) may be forced to wait for child and adolescent psychiatry clinic appointments without having had a complete physical examination by a physician. Children with severe mental and developmental disorders as well as children with simple problems that can be easily solved at the primary care level present to these clinics. Because of these factors, it is important to rapidly make the first assessment in order to identify priority cases and manage problems that can be easily resolved or that require early intervention.
In this study, the three-stage triage system that was applied in the admission of patients in a child and adolescent psychiatry clinic was addressed along with the conditions requiring this approach. It was aimed to examine the characteristics of the patients whose initial assessment was made using triage for a period of one year and to compare the three-stage triage method with the previous method used before in terms of appointment non-attendance and appointment waiting times.
In this study, the three-stage triage method was applied in the İzmir Dokuz Eylül University Faculty of Medicine, Child and Adolescent Psychiatry Outpatient Clinic. In setting up this triage system the resources of the clinic and the main features and inadequacies of the health care system in our country were taken into account. Since the majority of patients were self-referrals by parents, the triage assessment was designed to be as comprehensive as possible. The objective of the triage system applied included the following:
The metropolitan population of İzmir, which is the third largest province of Turkey and the largest province in the Egean region, was 2 732 669 at the time when this study was conducted (11). Child and adolescent psychiatry services were provided by two universities and one public hospital. Patients from the other parts of the Egean region were being referred to these clinics because of the insufficiency of the number of child and adolescent psychiatrists. Assessment and treatment services have been provided to children under the age of 18 years in the Dokuz Eylül University, Faculty of Medicine, Child and Adolescent Psychiatry Clinic since its establishment in 1986. In 2003 and 2005, outpatient services were provided by two child and adolescent psychiatrists and 5–7 residents.
Urgent cases are instantly addressed in the Dokuz Eylül University, Faculty of Medicine, Child and Adolescent Psychiatry Outpatient Clinic. Different approaches have been tried and applied in arranging routine appointment requests to adapt with the changing conditions in time. Previously, before September 2001, appointments for patients who telephoned or came to the clinic (except emergencies) were made by the secretary on a first-come, first-served basis. In September 2001, a new method of patient assignment was introduced. In this new method, a child development specialist filled in patient forms by interviewing patients (parents/caregivers) face to face or by phone at certain hours of the day. At regular weekly team meetings (including child and adolescent psychiatrists), these patient forms that included demographic data, complaints, time of complaints, and previous diagnoses were evaluated, and the patients whose priority levels were specified were assigned into one of the two groups, including the “priority” and “routine” groups. Immediately after the team meetings, appointments were given to the patients in the “priority” group. The patients in the “routine” group waited for their appointment without any intervention. When the patients in the routine waiting list, whose turns came, were called by phone, they were asked if they would attend their appointments. However, the rates of non-attendance were high and the waiting times were long. In addition, problems occurred while prioritizing patients due to inadequate evaluation.
The benefits of this time-consuming and burdensome approach in which patients’ forms were used in the evaluation of priority were limited. Conclusively, the three stage-triage assessment system, which is still being used, was started in July 2004.
Patients with emergent conditions and patients who have been seen by the consultation team during hospitalization are cared for on a priority basis without triage assessment. In the triage practice, the first 10 patients presenting in the morning on Monday, Tuesday, Thursday, and Friday are evaluated on a first-come first-serve basis. The three stages of triage assessment are shown in Figure 1. Primarily, the parent(s)/adolescents fill the Strengths and Difficulties Questionnaire (SDQ). Afterwards, the demographic properties, presentation complaints, developmental history, and familial history of the patient are recorded in a structured form by interns who interview the parent(s) for approximately 20 min. Subsequently, a child and adolescent psychiatrist reviews the responses provided to SDQ and to a structured form and interviews with the child/adolescent and parent(s).
The complaints, history, background, and risk factors are rapidly evaluated (in 30 min) using the forms prepared for three different age groups (“preschool,” “school,” and “adolescent”). The priority needs of patients are determined according to the preliminary diagnoses by evaluating the severity of symptoms, functionality level, and risks. In dividing the patients into triage groups, algorithms designed to help physicians in their decision of triage are utilized. The main preliminary diagnoses placed in the “urgent” group include acute mania or psychosis, carrying a risk of dangerousness to self or others, organic mental disorders, school refusal, eating disorders, psychosocial crises, and child abuse and neglect. These patients who require urgent interventions are referred to the related units. In the waiting list, priority is given to patients who will benefit from early diagnosis and intensive intervention. The main preliminary diagnoses in this group include psychosis, depressive disorders, bipolar disorder, and pervasive developmental disorders. The necessary examinations and consultations (hearing test or developmental test, etc.) are planned for these patients. Solutions are found for simple problems (giving advices to parents to handle these problems or sending child to kindergarten, etc.) and main questions of parents are answered. In this way, some cases can be closed quickly. The patients are added to the waiting list after their preliminary diagnoses are determined and priority interventions and examinations are planned.
In this study, the characteristics of 1482 patients who were initially assessed using the triage method in the child and adolescent psychiatry outpatient clinic in 2005 were evaluated. The process of the allocation of children and adolescents to treatment options and the variables affecting the rates of non-attendance for outpatient clinic appointments were investigated. The data of new patients who were assessed throughout 2005 with the three-stage triage system were compared with the data of 1423 new patients in 2003.
The data were analyzed using SPSS 11.0 program. Chi-square test was used to compare the sex ratios between attendant and non-attendant patients in 2005 and the non-attendance rates between years 2005 and 2003. Continuous variables, including age and waiting period, were compared using Mann-Whitney U test. A p value of <.05 was considered statistically significant.
The numbers of new patients who presented to the child and adolescent psychiatry outpatient clinic each month in 2003 and 2005 are shown in Figure 2. December is the month during which the highest number of patients presented for both years.
In this study, 907 (61.2%) of the 1482 new patients assessed by triage in 2005 were male and 575 (38.8%) were female. The ages of the patients ranged between 1 and 18 years, and the mean age was 9.2±4.5 years. The median age of the boys was found to be significantly lower (8 years) compared with that of the girls (10 years) (p<.001). In 2005, as a result of the initial assessment of 1482 patients, it was found that 347 patients (23.4%) had multiple preliminary diagnoses. The preliminary diagnoses of patients were grouped as follows:
Furthermore, the 1482 patients assessed by triage were allocated as follows based on preliminary diagnoses (Figure 3):
In the process of triage in 2005, 95 patients who were included in the routine or primary waiting list refused the appointment given when called by phone or could not be reached. Furthermore, 33 of a total of 1291 patients who were given appointment are patients whose appointments were planned after urgent treatment; 1084 (84.0%) of the 1291 patients attended the planned appointment, whereas 207 (16.0%) did not. The mean and median waiting times of the urgent, priority, and routine patients and the rates of non-attendance are shown in Table 1. The rate of non-attendance of 193 urgent/priority patients who were given an appointment in approximately 3 weeks was not found to be significantly different from the routine patients (14.5% and 16.3%, respectively; p=.603). There were only six patients who waited longer than 30 weeks to get an appointment. The patients who attended their planned appointments were compared with patients who did not in terms of age, gender, and waiting times. The median waiting time of patients who did not attend their appointments (31 days) was significantly longer compared with that of patients who attended their appointments (23.5 days) (p<.001). The median age of patients who attended their appointments (9 years) was not different from the median age of patients who did not attend their appointments (9 years) (p=.934). Furthermore, the gender rate of the group who attended their appointments (59.6% male, 40.4% female) was not significantly different from the gender rate of the group who did not attend their appointments (59.1% male, 40.9% female) (p=.339).
The data of the new patients who presented in 2005 were compared with the data of the new patients who presented in 2003 in order to evaluate the difference between the three-stage triage system and the previous patient allocation method. Appointment was planned for 1291 (87%) of the 1482 patients who presented in 2005 and for 1176 (83%) of the 1423 patients who presented in 2003. The median waiting time was 26 days in 2005 and 105 days in 2003. The median waiting time for patients who were seen in 2005 was significantly shorter compared with the median waiting time for patients who were seen in 2003 (p<.001). It was found that the rate of non-attendance in 2005 was significantly lower compared with that in 2003 (16.0% vs. 30.7%; p<.001) (Table 1).
In this study, the numbers of patients who were given an appointment was found to be similar when the three-stage triage method that was first applied in 2005 was compared with the previous evaluation method. Extension of the waiting list was prevented by handling the problems that could be solved by simple interventions. The rates of non-attendance for appointments in child and adolescent psychiatry have been reported to range between 14% and 35% (7). In a study conducted by Lai, it was found that triage was an efficient method in shortening the waiting times for children who had more urgent needs, and the rate of non-attendance was found to be 11.1% in 337 patients who were assessed by triage (8). In this study, the rate of non-attendance was found to be 16%. The median ages and gender distributions of the patients who did and did not attend their appointments were found to be similar. However, the waiting time of the patients who did not attend their appointments was significantly longer. A significant reduction occurred in the rate of non-attendance for patients who presented in 2005 with the three-stage triage practice.
It has been reported that prolonged waiting time for the first appointment in child and adolescent psychiatry was among the main causes of non-attendance (7). In one study, it was reported that the rate of non-attendance increased by 1.4% each day after application (2). It is considered that a waiting period of shorter than 1 month is very short for transient problems to disappear; however, it has been found that families do not wish to or can not wait for longer than 30 weeks (7). It has been reported that a mean waiting period of 7–8 weeks is acceptable for families (4). In this study, it was found that the mean waiting time in 2005 was approximately 7 weeks, and very few patients waited for longer than 30 weeks. The rate of non-attendance of the “urgent” and “priority” patients who were given an appointment was not found to be different from the “routine” patients. A significant reduction occurred in the waiting time for the first appointment for patients who presented in 2005 with the three-stage triage practice.
In our country, triage is mostly used in pediatric emergency medicine (14). Although there are foreign studies (3,4,8,9) related with the use of triage in child and adolescent psychiatry, this is the first comprehensive study conducted in our country in this area. The fact that evaluation of priority was not performed using standard tools and lack of data of a recent study by which the study results could be compared is among the main limitations of our study.
Since there is an increasing demand for child and adolescent psychiatry in our country, the triage system used in this study is an approach that would lead to prolonged waiting times for patients who require psychiatric help but who are not defined as “urgent” or “priority” patients. Thus, delay in reaching appropriate service gradually increased for patients who were defined as “routine” patients in subsequent years during which the triage practice was continued.
Interventions directed to rapidly termination of patients evaluated to be “routine” in outpatient clinic using short term treatment approaches are continuing. Priority evaluation in the emergency applications and triage practice in outpatient clinic has been tried to be more objective since October 2008. For this purpose, a single form was created for the 5–18 year age group by renewing the “school age” and “adolescent” forms used in the triage assessment. In addition, an adaptation study for the Child Mental Health Priority Rating Tool, which is a standard tool used to determine priority (15), was conducted by obtaining permission from those concerned, and this tool began to be used in triage. Currently, eight patients who have made an appointment by online system are evaluated four days a week by the triage method in the outpatient clinic.
In a recent study, it was found that more than two-thirds of patients who presented to the outpatient clinic in which this study was performed had parents with high school or higher education and had health insurance for the family (13). The answer of the question if the triage method used in a university outpatient clinic where a patient group with these socioeconomic characteristics attends can be used in patients with a low socioeconomic level and in outpatient clinics the operation of which are shaped by economic and administrative pressures of the healthcare system depends on what is expected from triage. Triage has the function of arranging the waiting list rather than shortening it and if improvement in the quality of service is expected, triage can enable this.
Primarily, the quality of service in the clinics that provide residency training may affect the competence of the specialists who were trained. Therefore, using the triage method in education units is important.
In conclusion, the three-stage triage system that was used in this study was designed according to the needs of patients in our country and the resources of the clinic where the study was conducted. This system can create a model for developing countries that try to meet the increasing demand for child and adolescent psychiatry service with limited resources. By using triage, patients can be classified in terms of the appropriateness of the request and priority level. Problems which can be easily solved can be handled, and the necessary examinations and consultations can be planned. The triage system used in this study can be useful in managing patients who present with their own decisions without referral. The results of this study demonstrated that the three stage triage system was an efficient method in decreasing the waiting time for the initial assessment and providing an opportunity for early interventions for problems that may worsen during the waiting period. Review and adjustment of the triage process and evaluating the effects of triage on the rates of attendance for the first appointment, service efficiency, and patient satisfaction may help to improve this method.
Conflict of Interest: The authors reported no conflict of interest related to this article.
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