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Hoffman S, Voss JA, Hendrickx L, Gibson N. Effect of Emergency Severity Index Annual Competency Assessment on Mistriage. J Nurs Care Qual 2022; 37:356-361. [PMID: 35947860 DOI: 10.1097/ncq.0000000000000638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is limited evidence identifying best practices to promote competency of accurate assignment of the Emergency Severity Index (ESI) acuity level to patients who present to the emergency department (ED) triage. LOCAL PROBLEM Triage-trained nurses do not receive competency training in an ESI triage tool. METHODS A retrospective chart review of 150 patients was completed to evaluate mistriage rates before and after triage-trained nurses completed an ESI competency assessment. RESULTS The retrospective chart review showed no statistically significant difference in mistriage from pre- to postintervention (P = .8535). CONCLUSIONS Implementation of an ESI annual competency assessment aligns well with an emerging theme in the literature that ED nurses should be provided with ongoing education that reinforces knowledge and implementation of ESI triaging.
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Affiliation(s)
- Stefanie Hoffman
- Sanford Acute Care, Sanford Sports Complex Acute Care, Sioux Falls, South Dakota (Dr Hoffman); College of Nursing, South Dakota State University, Rapid City (Dr Voss); South Dakota State University College of Nursing-Aberdeen Campus, Aberdeen (Dr Hendrickx); and North Central Heart Institute, Sioux Falls, South Dakota (Dr Gibson)
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Amissah M, Lahiri S. Modelling Granular Process Flow Information to Reduce Bottlenecks in the Emergency Department. Healthcare (Basel) 2022; 10:healthcare10050942. [PMID: 35628079 PMCID: PMC9140672 DOI: 10.3390/healthcare10050942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/25/2022] [Accepted: 05/10/2022] [Indexed: 02/01/2023] Open
Abstract
Increasing demand and changing case-mix have resulted in bottlenecks and longer waiting times in emergency departments (ED). However, many process improvement efforts addressing the bottlenecks have limitations, as they lack accurate models of the real system as input accounting for operational complexities. To understand the limitation, this research modelled granular procedural information, to analyse processes in a Level-1 ED of a 1200-bed teaching hospital in the UK. Semi-structured interviews with 21 clinicians and direct observations provided the necessary information. Results identified Majors as the most crowded area, hence, a systems modelling technique, role activity diagram, was used to derive highly granular process maps illustrating care in Majors which were further validated by 6 additional clinicians. Bottlenecks observed in Majors included awaiting specialist input, tests outside the ED, awaiting transportation, bed search, and inpatient handover. Process mapping revealed opportunities for using precedence information to reduce repeat tests; informed alerting; and provisioning for operational complexity into ED processes as steps to potentially alleviate bottlenecks. Another result is that this is the first study to map care processes in Majors, the area within the ED that treats complex patients whose care journeys are susceptible to variations. Findings have implications on the development of improvement approaches for managing bottlenecks.
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Salvato M, Solbiati M, Bosco P, Casazza G, Binda F, Iotti M, Calegari J, Laquintana D, Costantino G. Prospective comparison of AMB, GAP AND START scores and triage nurse clinical judgement for predicting admission from an ED: a single-centre prospective study. Emerg Med J 2021; 39:897-902. [PMID: 34969662 DOI: 10.1136/emermed-2020-210814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/14/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND It is postulated that early determination of the need for admission can improve flow through EDs. There are several scoring systems which have been developed for predicting patient admission at triage, although they have not been directly compared. In addition, it is not known if these scoring systems perform better than clinical judgement. Therefore, the aim of this study was to validate existing tools in predicting hospital admission during triage and then compare them with the clinical judgement of triage nurses. METHODS To conduct this prospective, single-centre observational study, we enrolled consecutive adult patients who presented between 30 September 2019 and 25 October 2019 at the ED of a large teaching hospital in Milan, Italy. For each patient, triage nurses recorded all of the variables needed to perform Ambulatory (AMB), Glasgow Admission Prediction (GAP) and Sydney Triage to Admission Risk Tool (START) scoring. The probability of admission was estimated by the triage nurses using clinical judgement and expressed as a percentage from 0 to 100 with intervals of 5. Nurse estimates were dichotomised for analysis, with ≥50% likelihood being a prediction of admission. Receiver operating characteristic curves were generated for accuracy of the predictions. Area under the curve (AUC) with 95% CI for each of the scores and for the nursing judgements was also calculated. RESULTS A total of 1710 patients (844 men; median age, 54 years (IQR: 34-75)) and 35 nurses (15 men; median age, 37 years (IQR: 33-48)) were included in this study. Among these patients, 310 (18%) were admitted to hospital from the ED. AUC values for AMB, GAP and START scores were 0.77 (95% CI: 0.74 to 0.79), 0.72 (95% CI: 0.69 to 0.75) and 0.61 (95% CI: 0.58 to 0.64), respectively. The AUC for nurse clinical judgement was 0.86 (95% CI: 0.84 to 0.89). CONCLUSION AMB, GAP and START scores provided moderate accuracy in predicting patient admission. However, all of the scores were significantly worse than the clinical judgement of the triage nurses.
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Affiliation(s)
- Mauro Salvato
- UOC Pronto Soccorso e Medicina d'Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Monica Solbiati
- UOC Pronto Soccorso e Medicina d'Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
| | - Paola Bosco
- UOC Pronto Soccorso e Medicina d'Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,UOC Direzione delle Professioni Sanitarie, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Casazza
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
| | - Filippo Binda
- UOC Direzione delle Professioni Sanitarie, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Iotti
- UO Comparto Operatorio, Columbus Clinic Center, Milan, Italy
| | - Jessica Calegari
- UOC Pronto Soccorso e Medicina d'Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Dario Laquintana
- UOC Direzione delle Professioni Sanitarie, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Costantino
- UOC Pronto Soccorso e Medicina d'Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
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Trotzky D, Shopen N, Mosery J, Negri Galam N, Mimran Y, Fordham DE, Avisar S, Cohen A, Katz Shalhav M, Pachys G. Real-time prediction of patient disposition and the impact of reporter confidence on mid-level triage accuracies: an observational study in Israel. BMJ Open 2021; 11:e050026. [PMID: 34887272 PMCID: PMC8663100 DOI: 10.1136/bmjopen-2021-050026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
AIM The emergency department (ED) is the first port-of-call for most patients receiving hospital care and as such acts as a gatekeeper to the wards, directing patient flow through the hospital. ED overcrowding is a well-researched field and negatively affects patient outcome, staff well-being and hospital reputation. An accurate, real-time model capable of predicting ED overcrowding has obvious merit in a world becoming increasingly computational, although the complicated dynamics of the department have hindered international efforts to design such a model. Triage nurses' assessments have been shown to be accurate predictors of patient disposition and could, therefore, be useful input for overcrowding and patient flow models. METHODS In this study, we assess the prediction capabilities of triage nurses in a level 1 urban hospital in central Israeli. ED settings included both acute and ambulatory wings. Nurses were asked to predict admission or discharge for each patient over a 3-month period as well as exact admission destination. Prediction confidence was used as an optimisation variable. RESULT Triage nurses accurately predicted whether the patient would be admitted or discharged in 77% of patients in the acute wing, rising to 88% when their prediction certainty was high. Accuracies were higher still for patients in the ambulatory wing. In particular, negative predictive values for admission were highly accurate at 90%, irrespective of area or certainty levels. CONCLUSION Nurses prediction of disposition should be considered for input for real-time ED models.
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Affiliation(s)
- Daniel Trotzky
- Department of Emergency Medicine, Yitzhak Shamir Medical Center Assaf Harofeh, Zerifin, Israel
| | - Noaa Shopen
- Department of Emergency Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Jonathan Mosery
- Department of Emergency Medicine, Yitzhak Shamir Medical Center Assaf Harofeh, Zerifin, Israel
| | - Neta Negri Galam
- Department of Emergency Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yizhaq Mimran
- Department of Emergency Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Daniel Edward Fordham
- Department of Emergency Medicine, Yitzhak Shamir Medical Center Assaf Harofeh, Zerifin, Israel
| | - Shiran Avisar
- Department of Emergency Medicine, Yitzhak Shamir Medical Center Assaf Harofeh, Zerifin, Israel
| | - Aya Cohen
- Department of Emergency Medicine, Yitzhak Shamir Medical Center Assaf Harofeh, Zerifin, Israel
| | - Malka Katz Shalhav
- Department of Emergency Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Gal Pachys
- Department of Emergency Medicine, Yitzhak Shamir Medical Center Assaf Harofeh, Zerifin, Israel
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Moura BRS, Nogueira LDS. Performance of the rapid triage conducted by nurses at the emergency entrance. Rev Lat Am Enfermagem 2020; 28:e3378. [PMID: 33084778 PMCID: PMC7575239 DOI: 10.1590/1518-8345.3467.3378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 06/28/2020] [Indexed: 11/29/2022] Open
Abstract
Objective: to compare the performance of the rapid triage conducted by nurses at the
emergency entrance and of the Manchester Triage System (MTS) in identifying
the priority level of care for patients with spontaneous demand and
predicting variables related to hospitalization. Method: a cross-sectional study carried out in an Emergency Department (ED) of a
university hospital in São Paulo. The priority levels established in the
rapid triage performed by nurses were high priority (patients of spontaneous
demand directed to the emergency room) or low priority (those referred to
the institution’s usual flow). Diagnostic accuracy measures were calculated
to assess the performance of the indexes. Results: of the 173 patients (52.0% female, with mean age of 60.4 ± 21.2 years old)
evaluated, it was observed that rapid triage was more inclusive for high
priority and had better sensitivity and worse specificity than the MTS. The
probability of non-severe patients being admitted to the emergency
observation unit was lower due to the rapid triage. For the prediction of
the other variables, the systems presented unsatisfactory results. Conclusion: the nurses overestimated the classification of patients as high priority, and
rapid triage performed better than MTS in predicting admission to the
emergency observation unit.
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Afnan MAM, Netke T, Singh P, Worthington H, Ali F, Kajamuhan C, Nagra A. Ability of triage nurses to predict, at the time of triage, the eventual disposition of patients attending the emergency department (ED): a systematic literature review and meta-analysis. Emerg Med J 2020; 38:694-700. [DOI: 10.1136/emermed-2019-208910] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 05/03/2020] [Accepted: 05/08/2020] [Indexed: 11/03/2022]
Abstract
IntroductionExit block is the most significant cause of poor patient flow and crowding in the emergency department (ED). One proposed strategy to reduce exit block is early admission predictions by triage nurses to allow proactive bed management. We report a systematic review and meta-analysis of the accuracy of nurse prediction of admission at triage.MethodologyWe searched MEDLINE, Cochrane, Embase, CINAHL and grey literature, up to and including February 2019. Our criteria were as follows: prospective studies analysing the accuracy of triage nurse intuition—after gathering standard triage information—for predicting disposition for adult ED patients. We analysed the results of this test—nurse prediction of disposition—in a diagnostic test analysis review style, assessing methodology with the Quality Assessment of Diagnostic Accuracy Studies 2 checklist. We generated sensitivity, specificity and likelihood ratios (LRs). We used LRs and pretest probability of admission (baseline admission rate) to find positive and negative post-test probabilities.ResultsWe reviewed 10 articles. Of these, seven had meta-analysable data (12 282 participants). The studies varied in participant selection and admission rate, but the majority were of moderate quality and exclusion of each in sensitivity analyses made little difference. Sensitivity was 72% and specificity was 83%. Pretest probability of admission was 29%. Positive and negative post-test probabilities of admission were 63% and 12%, respectively.ConclusionTriage nurse prediction of disposition is not accurate enough to expedite admission for ED patients on a one-to-one basis. Future research should explore the benefit, and best method, of predicting total demand.
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Ibrahim MS. Validating Service Quality (SERVQUAL) in Healthcare: Measuring Patient Satisfaction Using their Perceptions in Jordan. JOURNAL OF INFORMATION & KNOWLEDGE MANAGEMENT 2020. [DOI: 10.1142/s0219649220400213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Patient satisfaction in the developing world has not received sufficient interest in the healthcare literature. More importantly, models predicting patient satisfaction seldom incorporates patient perspectives into their measurement providing ill-suited metrics for healthcare administrators to make decisive decisions concerning service quality improvements. The current analysis utilizes original data collected from 336 patients in Jordan. This paper tests whether service quality (SERVQUAL) is suitable to be used in the new context and concluded that SERVQUAL is reliable and valid in supplying stakeholders with reliable and valid information concerning patient satisfaction. Further, the analysis suggests a large gap between perceived and expected services performed by Jordanian hospitals signalling the need to service quality enhancement. The study calls for the adoption of agile and rapid patient screening models in emergency departments to reduce wait times and decrease the number of patients left without being seen. This study constitutes an emerging attempt at better understanding how service quality influences patient satisfaction, and more importantly, introduce affordable and cost-effective solutions capable of improving satisfaction in the short run.
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Schütze H, Rees R, Asha S, Eagar K. Development and evaluation of a code frame to identify potential primary care presentations in the hospital emergency department. Emerg Med Australas 2019; 31:982-988. [PMID: 31050197 PMCID: PMC6916150 DOI: 10.1111/1742-6723.13293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/14/2019] [Accepted: 03/15/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVE A major challenge in evaluating the appropriateness of ED presentations is the lack of a universal and workable definition of patients who could have received primary care instead. Our objective was to develop a standardised code frame to identify potential primary care patients in the ED. METHODS A standardised code frame to identify which patients could potentially be treated in a primary care setting was developed and tested on all patient episodes of care who presented to the ED of the St George Hospital, Sydney, between December 2016 and February 2017. Sensitivity and specificity of the code frame were performed. The code frame was then tested on all presentations from 2011 to 2016 in the St George Hospital and The Sutherland Hospital in Sydney. RESULTS Of 19 916 ED presentations, 5810 (29%) were potential primary care presentations. The code frame had a sensitivity of 99.9% and a specificity of 49.0%. Results were consistent (28%) when applied to 5 years of presentations (601 168 presentations). CONCLUSION This standardised code frame enables accurate retrospective local and national data estimations. The code frame could be used prospectively to evaluate interventions such as diverting patients to primary care settings, and to identify populations for specifically targeted interventions. The conservative nature of the code frame ensures that only those that can safely receive care in a primary care setting are identified as potential primary care.
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Affiliation(s)
- Heike Schütze
- School of Health and SocietyUniversity of WollongongWollongongNew South WalesAustralia
- Australian Health Services Research InstituteUniversity of WollongongWollongongNew South WalesAustralia
- St George HospitalSydneyNew South WalesAustralia
| | - Rhyannan Rees
- School of Health and SocietyUniversity of WollongongWollongongNew South WalesAustralia
- St George HospitalSydneyNew South WalesAustralia
| | - Stephen Asha
- St George HospitalSydneyNew South WalesAustralia
- St George Clinical SchoolThe University of New South WalesSydneyNew South WalesAustralia
| | - Kathy Eagar
- Australian Health Services Research InstituteUniversity of WollongongWollongongNew South WalesAustralia
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Affiliation(s)
- Dickson S Cheung
- Department of Emergency Medicine, University of Colorado, Aurora
| | - Joseph A Grubenhoff
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado, Aurora
- Children's Hospital Colorado, Aurora
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