Physicians-in-triage: Understanding your role and managing medico-legal risk

Hospitals in Canada continue to develop innovations aimed at providing the best possible care for their patients in an environment where resources are stretched thin and emergency departments reach a new breaking point.

To improve patient flow and potentially reduce wait times in emergency departments, some hospitals have adopted a “physicians-in-triage” model. ¹In this model, a physician acts as a secondary triage provider, working alongside triage nurses.

Physicians in this role may be exposed to medico-legal risk, much as they would when providing other types of care. This risk may be reduced when patients have an understanding of the triage physician’s limited role and their duty of care. It is up to the courts to determine liability in specific cases, based on what a reasonable physician would do in similar circumstances. For example, a court may expect a physician to inform a patient of what actions to take if the patient’s condition worsens while they wait for a full assessment.

What does a physician-in-triage do?

A triage physician typically performs brief, focused assessments in the emergency department, but does not usually perform a full assessment of a patient. Specifically, the triage physician:

• Identifies patients who may need expedited care.
• Initiates early diagnostics (e.g. labs, imaging, ECGs).
• Facilitates specialty consults if appropriate.
• Reassesses patients in the waiting room whose conditions may be evolving.

What medico-legal risks do triage physicians face?

Triage physicians may worry about their medico-legal risk in various situations, such as:

• A patient might choose to leave without being seen (i.e. no clinical assessment).
• A patient might leave after being assessed but before receiving test results or treatment (i.e. leave against medical advice).
• A patient’s condition might change or worsen after being assessed in triage and returning to the waiting room.
• A serious condition might be missed during the triage assessment, or treatment might be delayed due to access block.

The underlying medico-legal risks for triage physicians are broadly the same as for other practising physicians. If a patient suffers harm and initiates a regulatory authority (College) complaint or legal action, anyone involved in the patient’s care may be named in the complaint or action, including the triage physician, nursing staff, and hospital.

The legal responsibility of a physician will be determined, in part, by whether the physician owes a duty of care to the patient. A duty of care generally arises where there is a doctor-patient relationship. In Québec, similar obligations stem from the principles of general civil liability.

When a physician participates in the triage of a patient, performs an initial assessment, makes a clinical decision regarding the patient’s acuity, orders tests, or initiates treatment, the physician will likely be found to have entered into a doctor-patient relationship and thus to owe a duty of care. This duty may exist even without direct patient contact if decisions are made that influence care.

Physicians are expected to provide an accepted standard of care, which is typically determined by the College or court examining a medical negligence case. The decisions and actions of a physician are evaluated considering the circumstances at the time the care was provided, including available facilities, equipment, and personnel. A physician would be expected to attempt to do the best they can for their patients and to act reasonably in the circumstances.

Who is the “most responsible physician”?

Triage physicians may be concerned that, because they are making a clinical assessment, they could then be regarded as the “most responsible physician” (MRP). ²

In general, a triage physician would not be considered the MRP, unless the care involved decisions or actions that extend beyond the rapid initial assessment. Even if the triage physician is not the MRP, they nevertheless have a duty of care, that is, they are responsible for the care and decisions made during their interaction with the patient.

How to reduce medico-legal risk

If your hospital adopts or expands a physicians-in-triage system, you may consider taking steps to reduce your medico-legal risk:

1. Communicate clearly with patients
• Explain the limited nature of your role (i.e. you are only triaging the patient).
• Inform the patient of the expected wait time to see an emergency physician, and what symptoms should prompt the patient to seek immediate help while waiting.
• Document this discussion and use hospital-approved triage notes if available.
  
2. Communicate with the ED team and other treating physicians
• Help promote continuity of care by communicating and working collaboratively with other treating physicians.
  
3. Advocate for clear protocols
   Work with hospital leadership to ensure policies include:
• Defined roles and responsibilities for triage physicians, nurses, and receiving physicians.
• Clear expectations regarding transitions in care (handovers).
• Reliable systems for tracking and following up on investigations ordered at triage.
4. Consult with your ED colleagues
• If you have concerns about the emergency triage system in your hospital, raise them early and often. Your insights can help identify safety gaps.
• Consult with colleagues in other institutions who may have experience with physicians-in-triage models to learn and share best practices.
• Consider engaging the Canadian Association of Emergency Physicians concerning physicians-in-triage models.

More reading

• Article: Ambulance offload delay at the emergency department: Clarifying your duty of care
• Article: Who is the most responsible physician? Check your knowledge
• CMPA Good practices: Transitions in care

1. 1. 
   The physicians-in-triage (PIT) model goes by various alternative names in hospitals, including for example, Early Physician Assessment (EPA), and Reducing Access Block at Triage (RABAT) physician assessment.
2. 2. 
   The most responsible physician (MRP) is the physician who has overall responsibility for directing and coordinating the care of a patient at a specific point in time, which is typically the attending or admitting physician. Physicians should consult their hospital policies for specific guidance on the role of the MRP in their institution.