Effect of vital signs on triage decisions

Triage in the emergency department - a qualitative study of the factors which nurses consider when making decisions

Triage, as a concept, is relatively new in Sweden and means 'sorting'. The triage process was developed to grade patients who needed immediate care. Triage is currently important for the emergency treatment system, and nurses are expected to work with it professionally. The aim of this study is to describe how nurses implement triage when patients arrive at the emergency department of a county hospital, situated in a rural area of Sweden, as well as to highlight the factors considered when prioritizing, in connection with nurses' decision-making. The method used was observations of 19 nurses, with minimal disturbance in their triage work, followed by a short tape-recorded interview, during which the nurses were asked to reflect upon their decision of priorities. Qualitative content analysis of data has been used. The results were divided into two areas, internal factors and external factors. The internal factors reflect the nurse skills and personal capacity. The external factors reflect work environment, including high workload and practical arrangements, and should always be perceived and taken into consideration. Using these factors as a basis, the patients' clinical condition, clinical history, various examinations and tests form an assessment, which subsequently results in a prioritization.

Comparison of the Emergency Severity Index (ESI) and the Taiwan Triage System in Predicting Resource Utilization

BACKGROUND/PURPOSE

The importance of accurate triage in Taiwan is becoming more apparent with the increasing number of emergency department (ED) patients, and resources for the National Health Insurance becoming constrained. This study compared the ability of the Taiwan triage system (TTS) and the standardized 5-level Emergency Severity Index (ESI) triage system to predict ED resource utilization.

METHODS

Patients arriving at the ED were triaged by both TTS and by using a two-page checklist of ESI criteria during the 3-month study period. The ESI triage level was calculated independently to avoid bias. Disease category (trauma vs. nontrauma), length of stay (LOS) and hospitalization data were evaluated.

RESULTS

A total of 3172 patients with both ESI and TWN evaluation were included. The distributions of ESI ratings within TTS level 1 were: ESI 1, 21.1%; ESI 2, 68.1%; ESI 3, 7.4%; ESI 4, 3.4%; ESI 5, 0%. For TTS level 3, they were: ESI 1, 0.1%; ESI 2, 26.2%; ESI 3, 39.5%; ESI 4, 27.5%; ESI 5, 6.8%. Hospitalization rates were 74.5%, 40.9% and 22.2% in TTS levels 1, 2 and 3, respectively; and were 96.2%, 47.0%, 30.9%, 6.7%and 6.6% in ESI levels 1, 2, 3, 4 and 5, respectively. TTS triaged more trauma patients as life-threatening/emergent condition than nontrauma patients (68.8% vs. 48.4%, p < 0.001). Triage by ESI, however, showed no significant difference in the percentage of trauma and nontrauma patients with highly acute conditions (44.2% vs. 46.6%, p = 0.230). Patients with ESI level 4 or 5 have significantly shorter ED LOS than those with ESI level 3.

CONCLUSION

ESI produces more accurate discriminating patient acuity, ED LOS and hospitalization rate than TTS. Adopting a standardized 5-level triage tool might improve resource utilization planning of ED practice.

An educational framework for triage nursing based on gatekeeping, timekeeping and decision-making processes

INTRODUCTION

The role of the triage nurse has emerged in response to growing community demand for a more accessible and efficient emergency department (ED) service. The focus of triage research has been on measuring outcomes and improving the delivery of emergency care. This has meant that the context of care, and triage processes and practices have remained concealed. Thus, little evidence about the role and ways to prepare nurses for this role is available. The aim of this study was to provide insight and understanding needed to educate and support the triage nursing role in Australian EDs.

METHODS

A 12-month ethnographic study of triage nursing practice was conducted in Sydney metropolitan EDs. Data were then collected from participant observation in four EDs and interviews with 10 triage nurses. Analysis used standard content and thematic analysis techniques.

FINDINGS

Findings reveal that notions of timeliness, efficiency and equity are embedded in a culture of ED care. This sustains a particular cadence of care to which triage nurses are culturally oriented. Triage nurses maintain, negotiate and restore this cadence of emergency care by using gatekeeping, timekeeping and decision-making processes.

CONCLUSION

The comprehensive study of triage nursing has led to the development of an educational framework based on the processes of gatekeeping, timekeeping and decision-making.

An exploration of accident and emergency nurse experiences of triage decision making in Hong Kong

This study used a descriptive qualitative design to explore emergency nurse experiences of decision making about triage in Hong Kong. Seven experienced nurses who were working in three different accident and emergency departments participated in the study. Unstructured interviews were used to provide the nurses with opportunities to describe their experiences. The findings fall into three main categories, including the experience of triage decision making, the use of information in the triage decision-making process, and the factors that influence triage decision making. Although the experience of triage was generally positive, the nurses felt frustrated and uncertain in some circumstances. In addition, triage decision making was influenced by a series of factors that occur in daily practice. The findings of this study have implications for the development of formal triage training and triage decision-making protocols in accident and emergency nursing. They also provide positive reinforcement and support to triage nurses that will enhance their ability to make decisions about triage. Avenues for further research in the area are recommended.

Can wrist blood pressure oscillometer be used for triage in an adult emergency department?

STUDY OBJECTIVE

We compare the performance of a wrist blood pressure oscillometer with the mercury standard in the triage process of an emergency department (ED) and evaluate the impact of wrist blood pressure measurement on triage decision.

METHODS

Blood pressure was successively measured with the standard mercury sphygmomanometer and with the OMRON-RX-I wrist oscillometer in a convenience sample of 2,493 adult patients presenting to the ED with non-life-threatening emergencies. Wrist and mercury measures were compared using criteria of the Association for the Advancement of Medical Instrumentation (AAMI) and the British Hypertension Society (BHS). The impact on triage decisions was evaluated by estimating the rate of changes in triage decisions attributable to blood pressure results obtained with the wrist device.

RESULTS

Wrist oscillometer failed to meet the minimal requirements for recommendation by underestimating diastolic and systolic blood pressure. Mean (+/-SD) differences between mercury and wrist devices were 8.0 mm Hg (+/-14.7) for systolic and 4.2 mm Hg (+/-12.0) for diastolic measures. The cumulative percentage of blood pressure readings within 5, 10, and 15 mm Hg of the mercury standard was 32%, 58%, and 72% for systolic, and 40%, 67%, and 83% for diastolic measures, respectively. Using the wrist device would have erroneously influenced the triage decision in 7.6% of the situations. The acuity level would have been overestimated in 2.2% and underestimated in 5.4% of the triage situations.

CONCLUSION

The performance of the OMRON-RX-I wrist oscillometer does not fulfill the minimum criteria of AAMI and BHS compared with mercury standard in the ED triage setting.

Shock index in diagnosing early acute hypovolemia

OBJECTIVE

The aim of this study was to determine the hemodynamic response and calculated shock index (SI=heart rate [HR]/systolic blood pressure [SBP]) in early acute blood loss.

METHODS

This was a prospective observational study that enrolled healthy blood donors. Patients were excluded if not eligible for blood donation. Baseline vital signs were obtained, 450 mL of blood was removed over 20 minutes, and vital signs were repeated immediately postdonation while lying and after 1 and 5 minutes of standing. Difference was tested using a paired t test with P<.01 set for significance.

RESULTS

Forty-six patients were enrolled; means for each time interval are shown below with 95% confidence intervals.

CONCLUSIONS

A significant elevation in mean SI was observed in healthy volunteers after standing for 1 and 5 minutes. Although significant changes in HR and SBP were observed, these indices were still within "normal" limits. The SI may be more useful in early hemorrhage than either the HR or SBP alone.

Making an IMPACT on emergency department flow: improving patient processing assisted by consultant at triage

OBJECTIVES

To assess whether initial patient consult by senior clinicians reduces numbers of patients waiting to be seen as an indirect measure of waiting time throughout the emergency department (ED).

METHODS

An emergency medicine consultant and a senior ED nurse (G or F grade), known as the IMPACT team, staffed the triage area for four periods of four hours per week, Monday to Friday between 9 am to 5 pm for three months between December 2001 and February 2002 when staffing levels permitted. Patients normally triaged by a nurse in this area instead had an early consultation with the IMPACT team. Data were collected prospectively on all patients seen by the IMPACT team. The number of patients waiting to be seen (for triage, in majors and in minors) was assessed every two hours during the IMPACT sessions and at corresponding times when no IMPACT team was operational.

RESULTS

There was an overall reduction in the number of patients waiting to be seen in the department from 18.3 to 5.5 (p<0.0001) at formal two hourly assessments. The largest difference was seen in minors. Of the patients seen at triage by the IMPACT team, 48.9% were discharged home immediately after assessment and treatment. With the IMPACT team present, no patient waited more than four hours for initial clinical consult.

CONCLUSIONS

By using a senior clinical team for initial patient consultation, the numbers of patients waiting fell dramatically throughout the ED. Many patients can be effectively treated and discharged after initial consult by the IMPACT team.

The validity of emergency department triage blood pressure measurements

OBJECTIVE

Automated blood pressure (ABP) devices are ubiquitous at emergency department (ED) triage. Previous studies failed to evaluate ABP devices against accepted reference standards or demonstrate triage readings as accurate reflections of blood pressure (BP). This study evaluated ED triage measurements made using an ABP device and assessed agreement between triage BP and BP taken under recommended conditions.

METHODS

A prospective study was conducted at an urban teaching hospital. Patients were enrolled by convenience sampling. Simultaneous automated and manual triage BPs were obtained using one BP cuff with a Y-tube connector. Research assistants were certified in obtaining manual BP as described by the British Hypertension Society (BHS). Patients were placed in a quiet setting, and manual BP was repeated by American Heart Association (AHA) standards. Data analysis was performed using methods described by Bland and Altman. The ABP device was assessed using Association for the Advancement of Medical Instrumentation (AAMI) and BHS criteria.

RESULTS

One hundred seventy-one patients were enrolled. Systolic BP (sBP) range was 81 to 218 mm Hg; diastolic BP (dBP) range was 43 to 130 mm Hg. Automated vs. manual sBP difference was 3.8 +/- 11.2 mm Hg (95% confidence interval [CI] = 2.1 to 5.4); dBP difference was 6.6 +/- 9.0 mm Hg (95% CI = -7.9 to -5.2). Manual triage BP vs. AHA standard SBP difference was 11.6 +/- 12.8 mm Hg (95% CI = 9.1 to 14.1); dBP difference was 9.9 +/- 10.4 mm Hg (95% CI = 7.9 to 12.0). The ABP device failed to meet AAMI criteria and received a BHS rating of "D." Poor operator technique and extraneous patient and operator movement appeared to hamper accuracy.

CONCLUSIONS

ABP triage measurements show significant discrepancies from a reference standard. Repeat measurements following AHA standards demonstrate significant decreases in the measured blood pressures.

Interobserver agreement in emergency department triage

STUDY OBJECTIVES

We measure the interobserver reliability of the triage process, examine the effect of vital signs on the triage process, and provide a context for the prior observation of poor interobserver agreement between in-person and telephonic interviews.

METHODS

We performed a prospective observational study using a randomized crossover design at a university teaching hospital emergency department. Patients were eligible if they spoke English, were not presenting for a reevaluation, and were unlikely to be harmed by the delay created by a second triage interview. Every eligible patient underwent 2 independent, sequential, in-person ED intake interviews conducted by experienced ED triage nurses. After taking a history, each nurse chose 1 of 5 hypothetic triage designations (ED by 911, ED within 2 hours, see a physician within 8 hours, see a physician within 24 hours, or home care-see a physician in >24 hours) and, after being told the patient's vital signs, again selected a designation.

RESULTS

Three hundred sixty-three patients presented during the study period: 113 were ineligible, 34 were missed by the investigators, and 15 refused to participate. Nineteen nurses participated in the triage of the 201 study patients. Agreement between 2 in-person designations made without knowledge of vital signs was poor (percent agreement 53%; kappa=0.30; tau(b)=0.50). Knowledge of vital signs did not improve agreement (percent agreement 49%; kappa=0.25; tau(b)=0.45).

CONCLUSION

There was poor interobserver agreement between certified triage nurses using a 5-item triage scale designed for telephonic triage. These findings suggest that only a small portion of the poor interobserver agreement observed in a prior study of telephonic versus in-person triage can be attributed to the use of the telephone.