Speaker 1: The difference between streaming and triage is that streaming is choosing the correct pathway for the patient and triaging is assessing a patient's priority and needs once you've done the initial assessment. Here at Sherwood Forest Trust Hospitals we implement streaming and triaging as a combined process so a patient will present to A&E and we assess that patient's need, stream as appropriate and prioritise as the need necessary. So for example if a patient is presented to A&E with a complaint of a sore throat I would shout the patient in, get a general overview of the complaint, find out their comorbidities, do a quick set of observations. If they were in the acceptable and agreed parameters I would stream the patient to primary care, relieving the pressure on A&E so it would be able to deal with the more acutely unwell patients.

Speaker 2: The purpose of streaming is to put people as quickly as possible into the correct part of the hospital or the health service and it's to make sure they get treated right place first time and we actually avoid the emergency department for people who don't need to be here. Streaming should occur as early as possible on the patient pathway. It can be pre-hospital with GPs or ambulance services, telephone triage, straight away on arrival in the emergency department, also from ambulance arrivals. It could also occur after they've been seen by a clinician to get them to the appropriate place. Over a quarter of patients attending an emergency department can be streamed to alternative providers like to GP, to dental services, to co-located primary care services, ambulatory care, early pregnancy assessment unit, surgical assessment unit and actually often directly to certain specialties. People returning from who are post-op with problems go directly to surgical units. We have also developed specific pathways outside of the normal high INR, high potassium anaemia patients going to primary care where they are dealt with and discharged with support from the emergency department if needed. The system has to agree the right place for patients to go, they have to agree what kind of patients will go and they have to agree timescales and pathways for that. It's really important there's an open door policy so patients aren't pushed around between different areas and repeated times. It's really important to have an experienced streaming person who's appropriately trained with a really good knowledge of all the pathways and which patients to go where and it has to be done in a really rapid fashion, it's a quick eyeball with or without a set of observations and a quick decision to get the patients to the right place quickly. To deliver this consistently, staff need to be trained, they need to be aware of pathways, they also need to be aware of any updates in the pathways if pathways may change and they need to be aware of any incidents or feedback that come back when things don't go quite as planned. Sometimes patients won't end up on the best pathway as more information becomes available. At that point, it's really important processes are in place to get them back onto the best pathway to get their care in the right place. The governance between partner organisations should always involve agreement from both sides, should involve joint processes where everyone follows the same rules for each patient regardless of which unit they present to. As an example of the governance structure we use in our primary care stream, we have monthly meetings where we review cases that are either handed back or where patients may deteriorate or change. We also make sure once that's done, we learn from the case, we disseminate that learning to both staff groups. We also encourage positive learning about things that went really well, so staff can ensure that patients get to the appropriate place. The other thing we would do is monitor the numbers, the timings, the potentials of patients to make sure the standard is maintained.

Speaker 1: I feel the benefits of streaming and triaging for patients is fantastic. It means that the patients are appropriately streamed to the correct place, which alleviates the pressure on the A&E, which in turn allows A&E doctors and nurses to concentrate on the more acutely unwell patients and avoids overcrowding in A&E, which means that we can essentially concentrate on the patients with the greater clinical need to be here. www.cdc.gc.ca www.cdc.gov.au