Evaluating implementation of the emergency severity index in a Belgian hospital

Evaluating the effects of triage education on triage accuracy within the emergency department: An integrative review

INTRODUCTION

Triage accuracy can affect patient outcomes. Education to ensure nurses provide the most accurate triage scores is paramount for patient safety.The objective was to investigate whether ongoing triage education increases triage accuracy, knowledge or behaviour.

METHOD

An integrative review was conducted by searching five databases to identify studies that included triage-based education. A systematic search strategy was completed followed by analysis with critical appraisal using the Critical Appraisal Skills Programme, a TIDieR Checklist and thematic analysis.

FINDINGS

Four thousand five hundred seventy-six studies were retrieved, with 34 studies selected for inclusion. Thirty-one studies were quantitative, and three were mixed methods. 18 out of 34 studies showed improvement in triage accuracy. Seven showed increased knowledge. Six studies showed no improvement in triage accuracy. Sixteen studies assessed triage behaviour and showed improvement post-intervention, with five showing no changes. Only three studies compared interventions. Fifty-three opportunities for changes to triage accuracy, knowledge or behaviour were found, 41 showed improvements.

CONCLUSION

Triage education interventions can improve accuracy, knowledge and behaviour, but whether improvements are sustained needs further research.

FRENCH versus ESI: comparison between two nurse triage emergency scales with referent scenarios

OBJECTIVES

Acute triage is needed to prioritize care and achieve optimal resource allocation in busy emergency departments. The main objective is to compare the FRench Emergency Nurse Classification in Hospital scale (FRENCH) to the American scale Emergency Severity Index (ESI). Secondary objectives are to compare for each scale the over and under-triage, the triage matching to the gold standard and the inter-individual sorting reproducibility between the nurses.

METHODS

This is a prospective observational study conducting among the nursing staffs and nursing students, selected from Caen University College Hospital and Lisieux Hospital Center emergency departments between two months. Each group individually rank 60 referent clinical cases composed by scales designers. An assessment of scale practicality is collected after for each tool. The collected parameters are analyzed by a Cohen kappa concordance test (κ).

RESULTS

With 8151 triage results of gold standard scenarios sorting in two scales by the same nurses, the FRENCH scale seems to give better triage results than the US ESI scale (nurse: FRENCH 60% and ESI 53%, p = 0.003 ; nursing students: FRENCH 49% and ESI 42%, p < 0.001). In the two groups ESI has also a big tendency to under-sort (p = 0.01), particularly for the most severe patients (p < 0.01). The interobserver sorting concordance for any experience gives good results for the FRENCH and the ESI without any difference (nurses : FRENCH K_PQ=0.72 ESI K_PQ=0.78; p = 0.32 ; students K_PQ=0.44 K_PQ=0.55; p = 0.22).

CONCLUSION

The ESI and FRENCH scales comparison on 8151 sorting results shows direct validity in favor of FRENCH one and similar interobserver agreement for both scales.

Educational intervention in triage with the Swedish triage scale RETTS©, with focus on specialist nurse students in ambulance and emergency care - A cross-sectional study

AIM

To determine the reliability of application of the RETTS© triage scale after an educational intervention using paper-based scenarios in emergency care education.

BACKGROUND

Knowledge about and education in triage are important factors in triagescale implementation. Presenting students with a large number of triage scenarios is a common part of triage education.

METHODS

In this prospective cross-sectional study at two universities students undergoing education in emergency care used RETTS© to assess triage level in 46 paper-based scenarios.

RESULTS

57 students in the study made 2590 final triage decisions. Fleiss Kappa for final triage was 0.411 which is in the lower range of moderate agreement. In 25 of 46 (53.4%) scenarios, final triage levels did not agree about whether the case was stable or unstable.

CONCLUSION/IMPLICATIONS

Application of the RETTS© triage scale after an educational intervention with paper-based simulation in emergency care education resulted in moderate agreement about the final levels of triage.

Comparison between Emergency Severity Index and Heart Failure Triage Scale in heart failure patients: A randomized clinical trial

BACKGROUND

It is not clear whether Emergency Severity Index (ESI) is valid to triage heart failure (HF) patients and if HF patients benefit more from a customized triage scale or not. The aim of study is to compare the effect of Heart Failure Triage Scale (HFTS) and ESI on mistriage among patients with HF who present to the emergency department (ED).

METHODS

A randomized clinical trial was conducted from April to June 2017. HF patients with dyspnea were randomly assigned to HFTS or ESI groups. Triage level, used resources and time to electrocardiogram (ECG) were compared between both groups among HF patients who were admitted to coronary care unit (CCU), cardiac unit (CU) and discharged patients from the ED. Content validity was examined using Kappa designating agreement on relevance (K*). Reliability of both scale was evaluated using inter-observer agreement (Kappa).

RESULTS

Seventy-three and 74 HF patients were assigned to HFTS and ESI groups respectively. Time to ECG in HFTS group was significantly shorter than that of ESI group (2.05 vs. 16.82 minutes). Triage level between HFTS and ESI groups was significantly different among patients admitted to CCU (1.0 vs. 2.8), cardiac unit (2.26 vs. 3.06) and discharged patients from the ED (3.53 vs. 2.86). Used resources in HFTS group was significantly different among triage levels (H=25.89; df=3; P<0.001).

CONCLUSION

HFTS is associated with less mistriage than ESI for triaging HF patients. It is recommended to make use of HFTS to triage HF patients in the ED.

Comparison between Emergency Severity Index plus peak flow meter and Emergency Severity Index in the dyspneic patients with chronic obstructive pulmonary disease: A randomized clinical trial

Introduction

It is unclear whether the Emergency Severity Index (ESI) can identify high-risk patients with Chronic Obstructive Pulmonary Disease (COPD). This study aims to compare the mistriage rates of the ESI plus the Peak Expiratory Flowmeter (PEF) approach and ESI approach among dyspneic patients with COPD.

Methods

This study was a randomized clinical trial conducted between July and October 2018. We randomly assigned COPD patients with dyspnea to the ESI + PEF or ESI groups. Triage levels, disposition rates, number of resources used, and time to first physician contact were compared in patients admitted to the Intensive Care Unit (ICU), the Pulmonary Care Unit (PU), or discharged from the ED. Reliability of the ESI was evaluated by using the interobserver agreement (Kappa).

Results

Seventy COPD patients were equally assigned to the ESI + PEF and ESI groups. The under-triage rates were 11.42% and 0%, the over-triage rates were 31.42% and 2.85% in the ESI and ESI + PEF groups, respectively. The triage levels of the patients admitted to the ICU (2 vs. 3), the PU (2 vs. 4), or discharged from the ED (3 vs. 2) were significantly different between the ESI + PEF and ESI groups.

Conclusions

Addition of PEF to the ESI provides a more accurate method for triaging COPD patients compared to ESI alone. We recommend using PEF for the triage of COPD patients in the ED.

Reliability of the revised Swiss Emergency Triage Scale: a computer simulation study

Background

The Swiss Emergency Triage Scale (SETS) is a four-level emergency scale that previously showed moderate reliability and high rates of undertriage due to a lack of standardization. It was revised to better standardize the measurement and interpretation of vital signs during the triage process.

Objective

The aim of this study was to explore the inter-rater and test–retest reliability, and the rate of correct triage of the revised SETS.

Patients and methods

Thirty clinical scenarios were evaluated twice at a 3-month interval using an interactive computerized triage simulator by 58 triage nurses at an urban teaching emergency department admitting 60 000 patients a year. Inter-rater and test–retest reliabilities were determined using κ statistics. Triage decisions were compared with a gold standard attributed by an expert panel. Rates of correct triage, undertriage, and overtriage were computed. A logistic regression model was used to identify the predictors of correct triage.

Results

A total of 3387 triage situations were analyzed. Inter-rater reliability showed substantial agreement [mean κ: 0.68; 95% confidence interval (CI): 0.60–0.78] and test–retest almost perfect agreement (mean κ: 0.86; 95% CI: 0.84–0.88). The rate of correct triage was 84.1%, and rates of undertriage and overtriage were 7.2 and 8.7%, respectively. Vital sign measurement was an independent predictor of correct triage (odds ratios for correct triage: 1.29 for each additional vital sign measured, 95% CI: 1.20–1.39).

Conclusion

The revised SETS incorporating standardized vital sign measurement and interpretation during the triage process resulted in high reliability and low rates of mistriage.

Outcome-Based Validity and Reliability Assessment of Raters Regarding the Admission Triage Level in the Emergency Department: a Cross-Sectional Study

INTRODUCTION

Emergency department (ED) is usually the first line of healthcare supply to patients in non-urgent to critical situations and, if necessary, provides hospital admission. A dynamic system to evaluate patients and allocate priorities is necessary. Such a structure that facilitates patients' flow in the ED is termed triage.

OBJECTIVE

This study was conducted to investigate the validity and reliability of implementation of Emergency Severity Index (ESI) system version 4 by triage nurses in an overcrowded referral hospital with more than 80000 patient admissions per year and an average emergency department occupancy rate of more than 80%.

METHOD

This prospective cross-sectional study was conducted in a tertiary care teaching hospital and trauma center with an emergency medicine residency program. Seven participating expert nurses were asked to assess the ESI level of patients in 30 written scenarios twice within a three-week interval to evaluate the inter-rater and intra-rater reliability. Patients were randomly selected to participate in the study, and the triage level assigned by the nurses was compared with that by the emergency physicians. Finally, based on the patients' charts, an expert panel evaluated the validity of the triage level.

RESULTS

During the study period, 527 patients with mean age of 54 ± 7 years, including 253 (48%) women and 274 (52%) men, were assessed by seven trained triage nurses. The degree of retrograde agreement between the collaborated expert panel's evaluation and the actual triage scales by the nurses and physicians for all 5 levels was excellent, with the Cohen's weighted kappa being 0.966 (CI 0.985-0.946, p < 0.001) and 0.813 (CI 0.856-0.769, p<0.001), respectively. The intra-rater reliability was 0.94 (p < 0.0001), and the inter-rater reliability for all the nurses was in perfect agreement with the test result (Cohen's weighted kappa were as follows: 0.919, 0.956, 0.911, 0.955, 0.860, 0.956, and 0.868; p < 0.001).

CONCLUSION

The study findings showed that there was perfect reliability and, overall, almost perfect validity for the triage performed by the studied nurses.

Nursing Perceptions of the Emergency Severity Index as a Triage Tool in the United Arab Emirates: A Qualitative Analysis

INTRODUCTION

With emergency department crowding becoming an increasing problem across the globe, nursing triage to prioritize patients receiving care is ever more important. ESI is the most common triage system used in the United States and is increasingly used worldwide. This qualitative study that explores emergency nursing perceptions of the ESI identifies strengths, weaknesses, and barriers to implementation of the ESI internationally.

METHODS

We conducted a cross-sectional qualitative analysis using semistructured interviews of 27 emergency triage nurses. Content analysis was performed by 2 independent coders, using NVivo software to identify and analyze important themes.

RESULTS

Interview coding revealed 7 core themes related to use of the ESI (frequencies indicated in parentheses): ease of use (90), speed and efficiency (135), patient safety (12), accuracy and reliability (30), challenging patient characteristics (123), subjectivity and variability (173), and effect of triage system on team dynamics (100). Intercoder agreement was excellent (Cohen's unweighted kappa = 0.84). Subjectivity and variability in ESI score assignment consistently emerged in all interviews and included variability in number and use of resources, definition of "high risk," nursing experience, and subjectivity in pain assessment.

DISCUSSION

Although emergency nurses perceive the ESI as easy to use, there are concerns about the subjectivity and variability inherent in the ESI that can lead to a functional lack of triage and a burden of undifferentiated ESI level 3 patients. These limitations in separating critically ill patients and in stratifying patients based on anticipated required resources points to the need for improvement in the ESI algorithm or a more objective triage system that can predict patient outcomes.

Emergency Severity Index: accuracy in risk classification

OBJECTIVE

To verify agreement between estimative of predicted resources using the adapted Emergency Severity Index and the real amount of resources used by patients. To analyze the variables number of years since graduation, years of work experience and years of experience in emergency services especially with accurate anticipation of resources need.

METHODS

This retrospective analytical study with a quantitative approach included 538 medical records of patients assisted by 11 triage nurses. Data collected were related to assistances carried out from December 2012 to February 2013.

RESULTS

There was no significant association between the adequacy of the number of resources used, based on Emergency Severity Index score, number of years since graduation, year of work experience or years of experience in emergency services. Kappa agreement coefficient (0.34) showed that agreement was low between predicted and real used number of resources.

CONCLUSION

Nurses' accuracy index to predict resources for patients care from emergency room using the adapted Emergency Severity Index was lower than results reported in the studies in the literature that used the original scale. There was low agreement of diagnostic exams predicted by nurses and those really performed. There was no association among correct prediction of resources needed, number of years since graduation, years of experience in emergency services and years of work experience in the unit where the study was done.