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

Feasibility and acceptability of a serious game to study the effects of environmental distractors on emergency room nurse triage accuracy: A pilot study

BACKGROUND

Emergency triage, which involves complex decision-making under stress and time constraints, may suffer from inaccuracies due to workplace distractions. A serious game was developed to simulate the triage process and environment. A pilot study was undertaken to collect preliminary data on the effects of distractors on emergency nurse triage accuracy.

METHOD

A 2 × 2 factorial randomized controlled trial (RCT) was designed for the study. A sample of 70 emergency room nurses was randomly assigned to three experimental groups exposed to different distractors (noise, task interruptions, and both) and one control group. Nurses had two hours to complete a series of 20 clinical vignettes, in which they had to establish a chief complaint and assign an emergency level.

RESULTS

Fifty-five nurses completed approximately 15 vignettes each during the allotted time. No intergroup differences emerged in terms of triage performance. Nurses had a very favorable appreciation of the serious game focusing on triage.

CONCLUSION

The results show that both the structure of our study and the serious game can be used to carry out a future RCT on a larger scale. The lack of a distractor effect raises questions about the frequency and intensity required to find a significant impact on triage performance.

Characteristics of undertriaged older patients in the emergency department: Retrospective study

BACKGROUND

Older patients are more likely to be undertriaged as they often suffer from multiple diseases and complain of non-specific symptoms. Therefore, it is necessary to identify the characteristics of undertriaged older patients in emergency departments.

METHODS

This descriptive study retrospectively reviewed and analyzed the electronic medical records of older patients who visited the emergency department of a general hospital in Seoul between January and December 2019.

RESULTS

Approximately 29 % (n = 4,823) of older patients who visited the emergency department during the study period were classified as Korean Triage and Acuity Scale (KTAS) level 4 or 5, and approximately 8 % (n = 397) were undertriaged. Approximately 73 % (n = 288) of patients were hospitalized after visiting the emergency department. The undertriaged older patients exhibited nervous system symptoms such as dizziness and headache (28.8 %), cardiopulmonary symptoms such as chest discomfort, palpitations, and abdominal pain (28.4 %), head trauma (12.8 %), and respiratory symptoms such as cough and dyspnea (12.5 %).

CONCLUSION

Triage nurses in emergency departments should carefully triage older patients as their chief complaints can be non-specific. In particular, when older patients visit the emergency department and exhibit symptoms such as dizziness, abnormal pain, chest discomfort, palpitations, and head trauma, they are more likely to be admitted to the intensive care unit. Therefore, meticulous care for older patients showing these symptoms is essential.

Seeking Care for Children with Intellectual and/or Developmental Disabilities in the Emergency Department: A Mixed Methods Systematic Review of Parents' Experiences and Information Needs

The objective of this review was to explore parents' experiences and information needs regarding management of their child with an intellectual and/or developmental disability (IDD) in the emergency department (ED). We searched six electronic databases and grey literature to identify primary studies in English published since 2000. We synthesized quantitative and qualitative outcome data simultaneously using a convergent integrated approach and used a Mixed Methods Appraisal Tool (MMAT) to assess methodological quality of the included studies. Nine articles derived from seven studies were included (3 qualitative, 3 quantitative, 1 mixed method). Four main themes related to parents' self-reported experiences were identified: 1) appropriateness of the ED to manage and support their child; 2) acknowledgement/recognition of their child's IDD and incorporation of those considerations into overall care and management; 3) managing and navigating the ED environment; and 4) decision to disclose their child's condition when visiting the ED. Two articles provided data relevant to information needs, highlighting parents' desire to have resources supporting ED orientation and access to services within and outside of the ED setting. From the limited number of studies, it was evident that parents wanted better communication with healthcare providers and a greater understanding by ED staff around physical space settings needed to support their child. Resources supporting ED staff and parents to communicate effectively and work together can ensure that children with IDDs care needs are met. Further research into understanding parents' experiences and information needs related to managing a child with an IDD in the ED is needed to guide the development of effective resources.

Experiences of implementing and working with obstetric emergency triage: A qualitative study among Swedish midwifes, auxiliary nurses, and obstetricians

INTRODUCTION

Obstetric emergency triage is a relatively new form of emergency triage and is not yet implemented in Sweden. Adaptations enables safe assessment of the childbearing woman, fetus and labor status. Failure to identify severely ill childbearing women and women post childbirth has repeatedly led to adverse outcomes. Introducing obstetric emergency triage constitutes a profound alteration in management that may challenge preconceived notions on how to provide best care. This study aimed at exploring and describing obstetric staff's experiences of working with obstetric emergency triage.

MATERIALS AND METHODS

Thirteen obstetricians, midwives and auxiliary nurses at an obstetric emergency department in eastern Sweden were recruited by purposeful sampling. Individual qualitative interviews underwent inductive qualitative content analysis according to Graneheim and Lundman.

RESULTS

An overarching theme - A new mindset - emerged from the analysis, comprising the four categories: Implications for the individual caregiver's own work, An improved organization, Improved patient care. Initial skepticism to triage changed towards a positive attitude during implementation, identifying barriers and facilitators for successful implementation.

CONCLUSIONS

This first study exploring Swedish obstetric staff's perception of obstetric emergency triage as a working method suggests that, given time for implementation, a new mindset in obstetric emergency care might develop. Triage provides structure and a sense of control through a clear and quick overview of childbearing women seeking emergency care and enhances teamwork by improving communication. Triage directs attention toward aberrations and promotes reflection and action, improving patient safety.

Understanding triage assessment of acuity by emergency nurses at initial adult patient presentation: A qualitative systematic review

BACKGROUND

Nurses make complex triage decisions within emergency departments, which significantly affect patient outcomes. Understanding how nurses make these decisions and why they deviate from triage algorithms facilitates interventions that work with their decision-making processes, increasing acceptability and effectiveness.

AIMS

This qualitative systematic review aimed to understand decision-making processes emergency nurses use to make acuity decisions during triage assessment at initial patient presentation.

METHODOLOGY

Medline, CINAHL and Academic Search Complete were systematically searched to 15th December 2022. Data were analysed using thematic synthesis. Established themes were reviewed with GRADE-CERQual to evaluate certainty of evidence.

RESULTS

28 studies were included in the review. Data analysis uncovered three superordinate themes of holistic reasoning, situational awareness, and informed decision-making. The findings show nurses value holistic assessments over algorithms and rely on knowledge and experience. They also assess the wider situation in the emergency department.

CONCLUSIONS

This review presents new perspectives on nurses' decision-making processes about patient's acuity. Nurses holistically gather information about patients before translating that information into acuity scores. These actions are informed by their knowledge and experience; however, the wider situation also impacts their decisions. In turn, the nurses use interpretations of patients' acuity to control the wider situation.

The obstetric and gynecological service providers' and recipients' perception and experience of the quality of obstetric triage services during the COVID-19 pandemic in Iran

BACKGROUND

Enhancing the quality of obstetric triage services requires a clear perception of the current situations and problems, this issue gained more importance during the COVID-19 pandemic. The purpose of this study was to explore the obstetric and gynecological service providers' and recipients' perception and experience of the quality of obstetric triage services during the COVID-19 pandemic.

METHODS

This research was a qualitative study carried out using conventional content analysis. Participants were selected through purposive sampling, and data collection was conducted using in-depth semi-structured interviews. Data were analyzed using MAXQDA software and conventional content analysis. Validity of the data was approved based on four criteria: credibility, dependability, conformability and transferability.

RESULTS

Five themes emerged through analysis: "unpreparedness to deal with the COVID-19 resulting in disorganized triage", "threat to the physical and mental health of personnel during the COVID-19 pandemic", "degradation of the quality of services due to improper triage structure during the COVID-19 pandemic", "communicating with patients which is neglected during the COVID-19 pandemic" and finally "accountability required to improve the provision of services during the COVID-19 pandemic.

CONCLUSION

Obstetrics and gynecology service providers and recipients faced formidable challenges in the triage department during this pandemic caused by the complex and ambiguous nature of the Coronavirus. Identifying the problems, barriers and challenges in providing services to patients in this situation especially in triage, can lead to an improvement in the outcome of services.

Experiences of primary health care practitioners dealing with emergencies - 'We are on our own'

BACKGROUND

Primary health care (PHC) focuses on health promotion and disease prevention; however, acute episodes and emergencies still occur at this level of care. The World Health Organization (WHO) proposes strengthening emergency care at a PHC level as a way of lessening the burden of disease on the overall health system. It is not known how health care practitioners at the PHC level experience management of emergencies.

AIM

To explore and describe the experiences of PHC practitioners dealing with emergencies at PHC facilities in Gauteng, South Africa.

SETTING

The study was conducted in the District Health Services of Gauteng province in South Africa, including clinics, community health care centres and district hospitals.

METHODS

Using a qualitative approach, semi-structured interviews were conducted with a purposively selected sample of professional nurses and doctors from various levels of the district health care system. Data were transcribed and analysed using qualitative thematic analysis.

RESULTS

Various themes were identified related to the individual confidence and competence of the PHC practitioner, the team approach, the process of role and task allocation and the need for training.

CONCLUSION

The study provided a voice for the needs of health care practitioners dealing with emergencies at the PHC level. The designing of a targeted and contextually appropriate approach to emergency care training of health care practitioners in the PHC setting that improves team dynamics and team performance, is recommended.Contribution: The insights of PHC practitioners dealing with emergencies contribute contextual relevance to any strategic improvement of care at this level.

A multicenter survey of patients’ favorite type of nursing care and associated factors in Hebei Province, China

Background

Nursing care service is an important part of the healthcare system; however, patients’ favorite type of nursing care remains unknown. This study aims to investigate inpatients’ and nurses’ favorite types of nursing care and identify nurses’ learning needs.

Method

The study selected a province-representative sample of inpatients and nurses using a stratified random sampling method from 18 selected hospitals, including 9 Level Ⅱ hospitals and 9 Level Ⅲ hospitals in 9 cities of Hebei province. All participants were personally interviewed about their favorite type of nursing care. Multinomial logistic regression analysis was applied to analyze the potential associations between favorite nursing care and factors about inpatients and nurses.

Results

Data from 3,642 inpatients and 371 nurses were included for the final analysis during this survey. Among inpatients, the proportions who selected good attitude-centered, good nursing skill-centered, good environment-centered and good health education guidance-centered as their favorite types of nursing care were 49.9%, 31.8%, 5.8%, and 12.5%, respectively. Concurrently, among nurses, the proportions were 49.9%, 29.6%, 19.1%, and 1.3%, respectively. Multivariate analysis showed that most patients selected good attitude-centered nursing care as their favorite type of nursing care. However, patients who did not live with guardians and had more than one hospitalization per year were more likely to select other nursing care types.

Conclusion

Attitude-centered nursing care service was the favorite type of nursing care for most inpatients and nurses. Health education guidance was another main concern of inpatients. The main factors affecting the patients’ choice of favorite nursing care included patients’ living status and the number of hospitalization events per year. Nursing education should focus on nurse attitude as well as on health education guidance.

Effect of the Strategic Thinking, Problem Solving Skills, and Grit on the Disaster Triage Ability of Emergency Room Nurses

In this descriptive study, we aimed to identify factors related to emergency room nurses’ disaster triage ability. A total of 166 nurses who worked for emergency departments of general hospitals completed a structured questionnaire consisting of the Disaster Triage Ability Scale (DTAS), the Strategic Thinking Scale (STS), the Problem-Solving Inventory (PSI), and the Original Grit Scale (Grit-O). The data were analyzed using SPSS/WIN 25.0 by means of descriptive statistics, t-test, one-way ANOVA, the Scheffé post hoc test, Pearson’s correlation coefficients, and stepwise multiple regression. Participants’ DTAS averaged 14.03 ± 4.28 (Range 0–20) and showed a statistically significant difference according to their experience of triage education (t = 2.26, p = 0.022) as a disaster triage-related attribute. There were significant correlations among DTAS and confidence in the PSI (r = 0.30, p < 0.001), the approach-avoidance style in the PSI (r = −0.28, p < 0.001), and futurism in the STS (r = 0.19, p = 0.019). The strongest predictor was confidence in the PSI; in addition, 14.1% of the DTAS was explained by confidence in the PSI, approach-avoidance in the PSI, and futurism in the STS. Emergency room nurses who received triage education showed a higher level of the DTAS and their DTAS could be explained by problem-solving skills and strategic thinking. Therefore, it is necessary to develop and implement triage education programs integrated with stress management to improve the approach-avoidance style to ensure better problem-solving skills and to utilize various training methods to enhance confidence to improve problem-solving skills and futurism as part of strategic thinking.

Pediatric triage variations among nurses, pediatric and emergency residents using the Canadian triage and acuity scale

Background

Emergency care continues to be a challenge, since patients’ arrival is unscheduled and could occur at the same time which may fill the Emergency Department with non-urgent patients. Triaging is an integral part of every busy ED. The Canadian Triage and Acuity Scale (CTAS) is considered an accurate tool to be used outside Canada. This study aims to identify the chosen triage level and compare the variation between registered nurses, pediatric and adult emergency residents by using CTAS cases.

Method

This study was conducted at King Abdulaziz Medical City,Saudi Arabia. A cross-sectional self-administered questionnaire was used, and which contains 15 case scenarios with different triage levels. All cases were adopted from a Canadian triage course after receiving permission. Each case provides the patient’s symptoms, clinical signs and mode of arrival to the ED. The participants were instructed to assign a triage level using the following scale. A non-random sampling technique was used for this study. The rates of agreement between residents were calculated using kappa statistics (weighted-kappa) (95%CI).

Result

A total of 151 participants completed the study questionnaire which include 15 case scenarios. 73 were nurses and 78 were residents. The results showed 51.3, 56.6, and 59.9% mis-triaged the cases among the nurses, emergency residents, and pediatric residents respectively. Triage scores were compared using the Kruskal Wallis test and were statistically significant with a p value of 0.006. The mean ranks for nurses, emergency residents and pediatric residents were 86.41, 73.6 and 59.96, respectively. The Kruskal Wallis Post-Hoc test was performed to see which groups were statistically significant, and it was found that there was a significant difference between nurses and pediatrics residents (P value = 0.005). Moreover, there were no significant differences found between nurses and ER residents (P value> 0.05).

Conclusion

The triaging system was found to be a very important tool to prioritize patients based on their complaints. The results showed that nurses had the greatest experience in implementing patients on the right triage level. On the other hand, ER and pediatric residents need to develop more knowledge about CTAS and become exposed more to the triaging system during their training.

Fair prioritization of casualties in disaster triage: a qualitative study

Background

Disasters may result in mass casualties and an imbalance between health care demands and supplies. This imbalance necessitates the prioritization of the victims based on the severity of their condition. Contributing factors and their effect on decision-making is a challenging issue in disaster triage. The present study seeks to address criteria for ethical decision-making in the prioritization of patients in disaster triage.

Methods

This conventional content analysis study was conducted in 2017. Subjects were selected from among Iranian experts using purposeful and snowball sampling methods. Data were collected using semi-structured interviews and were analyzed by the content analysis.

Results

Efficient and effective triage and priority-oriented triage were the main categories. These categories summarized a number of medical and nonmedical factors that should be considered in the prioritization of the victims in disaster triage.

Conclusion

A combination of measures should be considered to maximize the benefits of the prioritization of causalities in disasters. None of these measures alone would suffice to explain all aspects of ethical decision-making in disaster triage. Further investigations are needed to elaborate on these criteria in decision-making.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00515-2.

An interrater reliability study on the Gothenburg obstetric triage system- a new obstetric triage system

BACKGROUND

Triage, identifying patients with critical and time-sensitive disorders, is an integrated process in general emergency medicine. Obstetric triage is more specialised, requiring assessment of both woman, fetus and labour status. Failure to identify severely ill obstetric patients has repeatedly led to maternal morbidity and mortality. Reliable triage systems, adapted to obstetric patients as well as local conditions, are thus essential. The study aims to assess the interrater reliability (IRR) of the Gothenburg Obstetric Triage System (GOTS).

METHODS

Midwives (n = 6) and registered nurses with no experience in managing obstetric patients (n = 7), assessed 30 paper cases based on actual real-life cases, using the GOTS. Furthermore, a reference group consisting of two midwives and two obstetricians, with extensive experience in obstetric care, determined the correct triage level in order to enable analysis of over- and undertriage. IRR was assessed, both with percentage of absolute agreement and with intra-class correlation coefficients (ICC) with 95% confidence intervals (CI).

RESULTS

A total of 388 assessments were performed, comprising all five levels of acuity in the GOTS. Absolute agreement was found in 69.6% of the assessments. The overall IRR was good, with a Kappa value of 0.78 (0.69-0.87, 95% CI) for final triage level. Comparison with reference group assessments established that over- and undertriage had occurred in 9% and 21% of the cases, respectively. The main reasons for undertriage were "not acknowledging abnormal vital sign parameters" and "limitations in study design".

CONCLUSION

The GOTS is a reliable tool for triaging obstetric patients. It enables a standardized triage process unrelated to the assessors' level of experience in assessing and managing obstetric patients and is applicable for triaging obstetric patients presenting for emergency care at obstetric or emergency units.

Establishing Research Priorities for the Emergency Severity Index Using a Modified Delphi Approach

INTRODUCTION

The accuracy of an initial ED triage decision has been reported to drive the clinical trajectory for ED patients, and, therefore, this assessment is critical to patient safety. The Emergency Severity Index-a 5-point score assigned by a triage nurse and based on disease acuity, patient potential for decompensation, and anticipated resource use-is used both in the United States and internationally. In the US, the Emergency Severity Index is used by up to 94% of the academic medical center emergency departments. In 2020, the Emergency Nurses Association acquired the intellectual property rights to the Emergency Severity Index and is responsible for its maintenance and improvement.

OBJECTIVE

The purpose of this study was to establish a research agenda for the improvement of individual and institutional understanding and use of the Emergency Severity Index.

METHODS

Modified Delphi process was used with 3 rounds of data collection.

RESULTS

Round 1 yielded 112 issues, which were collapsed into 18 potential research questions in 4 general categories: education and training (6 questions), workplace environment (3 questions), emergency care services (7 questions), and special populations (2 questions). These questions were used in round 2 to establish importance. Round 3 yielded a rank ordering of both categories and research questions.

DISCUSSION

The research priorities as set through the use of this modified Delphi process align well with current gaps in the literature. Research in these areas should be encouraged to improve the understanding of educational, environmental, and process challenges to emergency nurses' triage decisions and accuracy of Emergency Severity Index assignments.

An Australian Cross-Sectional Survey of Parents' Experiences of Emergency Department Visits Among Children with Autism Spectrum Disorder

Parents of children with ASD who had attended an Australian emergency department (ED; n = 421) completed a questionnaire relating to their experiences in the ED, including (1) child's reason for presentation and existing comorbidities, (2) quality of care during the visit (3) child's behaviour during visit, e.g. sensory responses to the ED environment, and disruptive behaviours. Children with comorbid ASD and intellectual disability were more likely to present with gastrointestinal issues and seizures, while those with comorbid ASD and oppositional defiant disorder were more likely to present with self-injury. ED staff awareness of ASD-related issues, including communication and expression of pain, were common difficulties for parents. The ED environment (e.g. lights, sounds, waiting areas), exacerbated child anxiety and led to disruptive behaviour.

Improving ED Emergency Severity Index Acuity Assignment Using Machine Learning and Clinical Natural Language Processing

INTRODUCTION

Triage is critical to mitigating the effect of increased volume by determining patient acuity, need for resources, and establishing acuity-based patient prioritization. The purpose of this retrospective study was to determine whether historical EHR data can be used with clinical natural language processing and machine learning algorithms (KATE) to produce accurate ESI predictive models.

METHODS

The KATE triage model was developed using 166,175 patient encounters from two participating hospitals. The model was tested against a random sample of encounters that were correctly assigned an acuity by study clinicians using the Emergency Severity Index (ESI) standard as a guide.

RESULTS

At the study sites, KATE predicted accurate ESI acuity assignments 75.7% of the time compared with nurses (59.8%) and the average of individual study clinicians (75.3%). KATE's accuracy was 26.9% higher than the average nurse accuracy (P <.001). On the boundary between ESI 2 and ESI 3 acuity assignments, which relates to the risk of decompensation, KATE's accuracy was 93.2% higher, with 80% accuracy compared with triage nurses 41.4% accuracy (P <.001).

DISCUSSION

KATE provides a triage acuity assignment more accurate than the triage nurses in this study sample. KATE operates independently of contextual factors, unaffected by the external pressures that can cause under triage and may mitigate biases that can negatively affect triage accuracy. Future research should focus on the impact of KATE providing feedback to triage nurses in real time, on mortality and morbidity, ED throughput, resource optimization, and nursing outcomes.

Coupling Wearable Devices and Decision Theory in the United States Emergency Department Triage Process: A Narrative Review

This research was motivated by the nurses' decision-making process in the current emergency department (ED) triage process in the United States. It explores how continuous vital signs monitoring can be integrated into the ED. The article presents four shortcomings on current ED triage systems and proposes a new conceptual clinical decision support model that exploits the benefits of combining wireless wearable devices with Multi-Attribute Utility Theory to address those shortcomings. A literature review was conducted using various engineering and medical research databases, analyzing current practices and identifying potential improvement opportunities. The results from the literature review show that advancements in wireless wearable devices provide opportunities to enhance current ED processes by monitoring patients while they wait after triage and, therefore, reduce the risk of an adverse event. A dynamic mathematical decision support model to prioritize patients is presented, creating a feedback loop in the ED. The coupling of wearable devices (to collect data) with decision theory (to synthesize and organize the information) can assist in reducing sources of uncertainty inherent to ED systems. The authors also address the feasibility of the proposed conceptual model.

The challenge of interprofessional collaboration in emergency department team triage - An interpretive description

AIMS

To explore emergency nurses' and physicians' experience of collaboration and collective decision-making when triaging older Emergency Department patients within the interprofessional team triage system.

DESIGN

Qualitative.

METHODS

Semi-structured interviews were conducted with seven nurses and five physicians. Transcripts were analysed via Interpretive Description between September 2016-May 2017.

RESULTS

'Negotiating collaboration' was developed as the main theme. Three subthemes influenced the negotiation process: Participants described divergent opinions on how an optimal triage system should work ('preferences for triage systems'); they had conflicting perceptions of each profession's role ('role perceptions'); and they expressed different coping strategies regarding 'perceived time pressure'. The compatibility of participants' views on these sub-themes determined whether the nurse and physician were able to successfully negotiate their collaboration. These themes became more evident when the team triaged older ED patients.

CONCLUSION

Improving interprofessional team triage requires working with the involved nurses' and physicians' values and beliefs. The strengths of both professions need to be considered and a flexible approach to collaboration established according to the patients' situations.

IMPACT

Emergency Department leaders need to consider nurses' and physicians' values and beliefs to promote interprofessional collaboration in team triage.

Effects of environmental distractors on nurse emergency triage accuracy: a pilot study protocol

Background

The clinical decisions of emergency department triage nurses need to be of the highest accuracy. However, studies have found repeatedly that these nurses over- or underestimate the severity of patient health conditions. This has major consequences for patient safety and patient flow management. Workplace distractors such as noise and task interruptions have been pointed to as factors that might explain this inaccuracy. The use of a serious game reproducing the work environment during triage affords the opportunity to explore the impact of these distractors on nurse emergency triage accuracy, in a safe setting.

Methods/design

A pilot study with a factorial design will be carried out to test the acceptability and feasibility of a serious game developed specifically to simulate the triage process in emergency departments and to explore the primary effects of distractors on nurse emergency triage accuracy. Eighty emergency nurses will be randomized into four groups: three groups exposed to different distractors (A, noise; B, task interruptions; C, noise and task interruptions) and one control group. All nurses will have to complete 20 clinical vignettes within 2 h. For each vignette, a gold standard assessment will be determined by experts. Pre-tests will be conducted with clinicians and certified emergency nurses to evaluate the appeal of the serious game.

Discussion

Study results will inform the design of large-scale investigations and will help identify teaching, training, and research areas that require further development.

Exploring the concept and structure of obstetric triage: a qualitative content analysis

BACKGROUND

Obstetric triage is a new idea, so the design and implementation of it requires identification of its concept and structure. The aim of this qualitative study was to explore the concept and structure of the obstetric triage in Iran.

METHODS

The purposive sampling was done and it continued until reaching the theoretical saturation. Thirty-seven semi-structured interviews were conducted individually and face-to-face. Interviews were audio recorded, transcribed, and analyzed using conventional content analysis.

RESULTS

Two themes, 8 main categories, and 16 subcategories emerged from the content analysis of the interviews and observations. The themes were the concept and structure of obstetric triage. The concept of obstetric triage consisted of three categories of nature, process, and philosophy of obstetric triage. The structure of obstetric triage included five categories of assessment criteria, emergency grading, determining the appropriate location for patient guidance, initiation of diagnostic and therapeutic measures, and timeframe for initial assessment and reassessment.

CONCLUSION

Findings highlighted that obstetric triage is a process with a dual and dynamic nature. This process involves clinical decision making to prioritize the pregnant mother and her fetus based on the severity and acuity of the disease in order to allocate medical resources and care for providing appropriate treatment at the right time and place to the right patient. The results of this study could be used for the design and implementation of the obstetric triage system.

Factors affecting emergency nurses' perceptions of the triage systems

Background: Emergency services use a triage system to prioritize patients according to their level of diagnosis. Triage is one of the mandated skills to be owned by an emergency unit nurse. This research aims to identify factors affecting emergency nurses’ perceptions of the triage systems.

Design and Methods: 90 nurses were chosen based on quota sampling. Data were analyzed using Chi Square test (α 0.05) and logistic regression analysis.

Results: The results show that nurses perceptions were influenced by knowledge (p = 0.017), working experience (p = 0.023), and training (p = 0.041). The factor that had the strongest influence in the formation of nurses’ perceptions was knowledge (p = 0.020 and OR = 3.19).

Conclusions: It can be concluded that knowledge, working experience and training influenced emergency nurses’ perceptions on triage systems.

Explaining challenges of obstetric triage structure: A qualitative study

Aim

The purpose of this study was to explain the challenges of the obstetric triage structure.

Design

The present qualitative research was conducted with directed content analysis approach on 21 members of the triage team and the key informant using purposeful sampling in 2018.

Methods

The method of data collection was semi-structured interviews. Then, the accuracy and rigour of the qualitative data were examined.

Results

In this study, the most important challenges in the structure of obstetric triage were identified as pattern and standard, equipment, physical space, human resource and triage procedure and process. Correction and revision in the obstetric triage structure is important to provide high-quality services. Therefore, the quality of the structure can be developed and maintained accounting for the corresponding challenges.

The Quality of the Maternity Triage Process: a Qualitative Study

Introduction:

There is no consensus on what the bases and criteria are for the dynamic process of maternity triage. Properly performing the maternity triage process requires reliable data to ensure the correct implementation of this process and the identification of existing deficiencies, and find strategies to modify, improve and enhance the quality of this process.

Objective:

The present study was conducted to explain the quality of the maternity triage process.

Methods:

The present qualitative study performed a directed content analysis on 19 maternity triage service providers and key informants selected through purposive sampling. The data were collected through semi-structured interviews in 2018 and analyzed using directed content analysis based on the Donabedian’s model. The accuracy and rigor of the qualitative data were then investigated and confirmed.

Results:

The participants identified the most important factors affecting the quality of the services provided in maternity triage as two categories of measures and care, and interactions and communication. The category of measures and care included two subcategories of examinations and obtaining a medical history.

Conclusion:

The present study comprehensively identified different dimensions of the quality of maternity triage services at different levels. The participants identified the quality of the maternity triage process as a multi-dimensional and important concept. Different dimensions of the maternity triage process are recommended that be addressed when designing and implementing maternity triage guidelines and instructions so as to maintain the quality of this process and satisfy their needs.

Triage emergency nurse decision-making: Incidental findings from a focus group study

INTRODUCTION

Emergency Department (ED) triage decision-making is a complex process. Triage scales are used to determine patient acuity level, however, they do not provide information on how nurses make triage decisions. This focus group study was part of a larger project to develop a psychometrically sound instrument to measure triage decision-making by nurses; the Triage Decision-Making Instrument. We report important incidental findings that emerged during the study that the participants identified as factors impeding triage decision-making.

METHODS

Three focus groups were conducted with 11 triage Registered Nurses. They commented on the instrument items and identified factors that influence triage decision-making. Transcripts were analyzed using thematic analysis.

RESULTS

Three powerful inter-related themes emerged central to encumbering triage decision-making: competing systems (pre-hospital versus the ED), fluctuating patient volume resulting in 'intra-Canadian Triage and Acuity Scale' triaging, and personal capacity including experience and 'triage fatigue'.

DISCUSSION

The findings demonstrate how interrelated system factors impede nurses triage decision-making. Triage nurses require support in their role and initiatives are needed to reduce the pressure they feel in relation to resolving system issues. Larger system issues and the capacity of the individual decision-makers must be accounted for within the context of increasing effectiveness and safety of ED triage.

Triage in Australian emergency departments: Results of a New South Wales survey

AIM

To describe current models of triage, the preparation and education of triage nurses, and methods of auditing triage practice in New South Wales emergency departments.

BACKGROUND

Triage is a critical component of emergency department practice; affecting patient safety and access to emergency care. Within Australia, triage is an autonomous role predominantly conducted by trained emergency nurses. Patient safety and timely access to emergency care relies upon the experience, education and training of emergency triage nurses. To date, little is known about triage models of care, the preparation and education of triage nurses, and assessment of triage practice and decision accuracy.

METHOD

Descriptive, exploratory study design employing a self-reporting cross-sectional survey of clinical nurse consultants and educators in New South Wales.

RESULTS

The survey results reveal variability in models of triage, and the eligibility, preparation and education requirements of triage nurses; that appear geographically related. Auditing of triage practice was commonly undertaken retrospectively; feedback to triage nurses was infrequent. The survey found evidence of locally developed guidelines directing triage category allocation for specific conditions or symptoms.

CONCLUSION

The purpose of triage is to ensure that the level of emergency care provided is commensurate with clinical urgency. Variability in the preparation, education and evaluation of triage nurses may in and of itself, contribute to poor patient outcomes. Further, workforce size and geography may impede auditing and the provision of feedback, which are critical to improving triage practice and triage nurse performance. It is imperative that the Emergency Triage Education Kit be revised and maintained in tandem with future revisions of the Australasian Triage Scale.

Responsibility-Evading Performance: The Experiences of Healthcare Staff about Triage in Emergency Departments: A Qualitative Study

Background:

Correct triage is one of the most important issues in delivering proper healthcare in the emergency department. Despite the availability of various triage guidelines, triage is not still appropriately implemented. Therefore, this study was conducted to investigate the role of different underlying factors in triaging emergency patients through a qualitative approach.

Materials and Methods:

This study was conducted by conventional content analysis. For this purpose, 30 interviews were conducted with 25 participants. The participants included triage nurses, emergency general physicians, emergency medicine specialists, and expert managers at different position rankings in hospitals and educational and administrative centers in Yazd, selected by purposeful sampling. Data were collected through in-depth and unstructured interviews from April 2017 to January 2018, and then analyzed by inductive content analysis.

Results:

Four categories of profit triage, exhibitive triage, enigmatic, and tentative performance triage were drawn from the data, collectively comprising the main theme of responsibility-evading performance.

Conclusions:

The dominant approach to the triage in the emergency departments in a central city of Iran is responsibility evasion; however, the triage is performed tentatively, especially in critical cases. To achieve a better implementation of triage, consideration of the underlying factors and prevention of their involvement in triage decision-making is necessary.

Triage Nurses Decision-Support Application Design

In this paper, we will present the planning and design process of a triage decision-support application, aimed to be used for both research data gathering and real-time triage decision-making. Triage is an initial classification of emergency department (ED) patients, according to the severity level of their medical condition. The need of fast and accurate triage decision-making, lead to the development of widely used triage algorithms, such as ESI (Emergency Severity Index).

Observations and interviews with triage personnel exposed difficulties of triage process and helped us create an ESI-based decision making model. Next, we built a multiple-choice questioner to characterize the application and required features. 40 triage nurses completed the questioner. Results indicated that the most highly requested feature was an automated severity grade calculator, which became the core of the proposed design.

While current design focuses on the analytical decision model, statistical analysis of the questioner results indicated that it is often insufficient when facing medical reality complexities, dictating nurse’s frequent use of intuition. Using triage systems data analysis and modern machine-learning methodologies, we inspire to develop a second version of the application that will integrate intuitive insights into triage scale algorithmic decision process.

Prognostic performance of Emergency Severity Index (ESI) combined with qSOFA score

OBJECTIVE

We conducted this study to investigate whether ESI combined with qSOFA score (ESI+qSOFA) predicts hospital outcome better than ESI alone in the emergency department (ED).

METHODS

This was a retrospective study for patients aged over 15years who visited an ED of a tertiary referral hospital from January 1st, 2015 to December 31st, 2015. We calculated and compared predictive performances of ESI alone and ESI+qSOFA for prespecified outcomes. The primary outcome was hospital mortality, and the secondary outcome was composite outcome of in-hospital mortality and ICU admission. We calculated in-hospital mortality rates by positive qSOFA in each subgroup divided according to ESI levels (1, 2, 3, 4+5).

RESULTS

43,748 patients were enrolled. The area under receiver-operating characteristics curves were higher in ESI+qSOFA than in ESI alone for both mortality and composite outcome (0.786 vs. 0.777, P<.001 for mortality; 0.778 vs. 0.774, P<.001 for composite outcome). In each subgroup divided by ESI levels, patients with positive qSOFA had significantly higher in-hospital mortality rate compared to those with negative qSOFA (20.4% vs. 14.7%, P=.117 in ESI level 1 subgroup; 11.3% vs. 2.7%, P=.001 in ESI level 2 subgroup; 2.3% vs. 0.4%, P<.001 in ESI level 3 subgroup; 0.0% vs. 0.0% in ESI level 4 or 5 subgroup).

CONCLUSION

The prognostic performance of ESI+qSOFA for in-hospital mortality was significantly higher than that of ESI alone. Within each subgroup, patients with positive qSOFA had higher in-hospital mortality compared to those with negative qSOFA.

Troponin Testing in the Emergency Department: Real world experience

Objectives

The aim of this study was to examine patterns of troponin testing in the emergency department of a large tertiary care hospital in Oman and to determine its effect on patient management, including length of hospital stay (LOS).

Methods

This retrospective study analysed the medical records of all adult patients undergoing troponin testing in the emergency department of the Sultan Qaboos University Hospital, Muscat, Oman, during the month of July 2015. Patients who presented with an ST-elevation myocardial infarction were excluded.

Results

A total of 4,845 patients attended the emergency department during the study period; of these, troponin tests were ordered for 588 patients. The majority of the patients had negative troponin test results (81.3%). Chest pain, palpitations and breathlessness were the most common presenting complaints for those with positive troponin results. However, 41.8% of patients did not have any cardiac symptoms. Individuals with positive troponin tests had a significantly longer LOS compared to those with negative tests (mean: three versus one day; P = 0.001). In total, only 28.2% of those with positive troponin test results had final diagnoses associated with a cardiac condition, such as heart failure, an acute coronary syndrome (ACS), atrial fibrillation or other types of arrhythmia.

Conclusion

A positive troponin test was associated with increased LOS; however, only a small proportion of these patients had a final diagnosis associated with a cardiac condition. Guidelines should be provided to ensure that troponin testing is performed only in cases where an ACS is suspected.

Based Real Time Remote Health Monitoring Systems: A Review on Patients Prioritization and Related "Big Data" Using Body Sensors information and Communication Technology

The growing worldwide population has increased the need for technologies, computerised software algorithms and smart devices that can monitor and assist patients anytime and anywhere and thus enable them to lead independent lives. The real-time remote monitoring of patients is an important issue in telemedicine. In the provision of healthcare services, patient prioritisation poses a significant challenge because of the complex decision-making process it involves when patients are considered 'big data'. To our knowledge, no study has highlighted the link between 'big data' characteristics and real-time remote healthcare monitoring in the patient prioritisation process, as well as the inherent challenges involved. Thus, we present comprehensive insights into the elements of big data characteristics according to the six 'Vs': volume, velocity, variety, veracity, value and variability. Each of these elements is presented and connected to a related part in the study of the connection between patient prioritisation and real-time remote healthcare monitoring systems. Then, we determine the weak points and recommend solutions as potential future work. This study makes the following contributions. (1) The link between big data characteristics and real-time remote healthcare monitoring in the patient prioritisation process is described. (2) The open issues and challenges for big data used in the patient prioritisation process are emphasised. (3) As a recommended solution, decision making using multiple criteria, such as vital signs and chief complaints, is utilised to prioritise the big data of patients with chronic diseases on the basis of the most urgent cases.

Benner's Framework and Clinical Decision-Making in the Critical Care Environment

Completed as part of a larger dissertational study, the purpose of this portion of this descriptive correlational study was to examine the relationships among registered nurses' clinical experiences and clinical decision-making processes in the critical care environment. The results indicated that there is no strong correlation between clinical experience in general and clinical experience in critical care and clinical decision-making. There were no differences found in any of the Benner stages of clinical experience in relation to the overall clinical decision-making process.

Modeling the Length of Stay of Respiratory Patients in Emergency Department Using Coxian Phase-Type Distributions With Covariates

Variability and unpredictability are typical features of emergency departments (EDs) where patients randomly arrive with diverse conditions. Patient length of stay (LOS) represents the consumption level of hospital resources, and it is positively skewed and heterogeneous. Both accurate modeling of patient ED LOS and analysis of potential blocking causes are especially useful for patient scheduling and resource management. To tackle the uncertainty of ED LOS, this paper introduces two methods: statistical modeling and distribution fitting. The models are applied to 894 respiratory diseases patients data in the year 2014 from ED of a Chinese public tertiary hospital. Covariates recorded include patient region, gender, age, arrival time, arrival mode, triage category, and treatment area. A Coxian phase-type (PH) distribution model with covariates is proposed as an alternative method for modeling ED LOS. The expectation-maximization (EM) algorithm is used to implement parameter estimation. The results show that ED LOS data can be modeled well by the proposed models. Distributions of ED LOS differ significantly with respect to patients' gender, arrival mode, and treatment area. Using the fitted Coxian PH model will assist ED managers in identifying patients who are most likely to have an extreme ED LOS and in predicting the forthcoming workload for resources.

Measuring Fatigue in Triage: A Pilot Study

: Given the critical nature of triage in facilitating emergency department (ED) functions, an understanding of the factors that impact triage nurses' ability to accurately assign triage scores and the ways in which these factors may affect various patient outcomes is extremely important; yet, there exists a paucity of such research in the literature. To further develop this knowledge base, an investigation of triage nurse fatigue and the role it may play in the ability to accurately assign triage scores was developed. The purpose of this pilot study was to determine how the length of a triage shift affects perceived fatigue levels among triage nurses. This pilot study was conducted using a prospective, descriptive cohort design with 28 registered nurses at a university-affiliated community hospital in the southeastern United States. Fatigue data were collected every 2 hr while the subject was in triage over the course of eighteen 24-hr periods between November 2015 and April 2016. Fatigue was measured using a self-reported fatigue questionnaire that included 2 validated fatigue scales: Karolinska Sleepiness Scale and Samn-Perelli Seven-Point Fatigue Scale. Data were analyzed using SPSS and Microsoft Excel. Results indicate a strong correlation between the amount of time spent in triage and fatigue scores, with average fatigue scores increasing by 64.4%-75.2% over the course of a 12-hr shift. Findings suggest that there was a positive correlation between the length of a triage shift and perceived fatigue levels among triage nurses in the ED. The biggest percent increase in fatigue scores is between hours 4 and 8. Further studies are needed to determine optimal triage shift length as well as the effect of nursing fatigue on triage accuracy.

The reliability of the Manchester Triage System (MTS): a meta-analysis

OBJECTIVE

Although the Manchester Triage System (MTS) was first developed two decades ago, the reliability of the MTS has not been questioned through comparison with a moderating variable; therefore, the aim of this study is to determine the extent of the reliability of MTS using a meta-analytic review.

METHOD

Electronic databases were searched up to 1 March 2014. Studies were only included if they had reported sample sizes, reliability coefficients, and adequate description of the reliability assessment. The Guidelines for Reporting Reliability and Agreement Studies was used. Two reviewers independently examined abstracts and extracted data. The effect size was obtained by the z-transformation of reliability coefficients. Data were pooled with random-effects models, and meta-regression was performed based on the method-of-moments estimator.

RESULTS

Seven studies were included. The pooled coefficient for the MTS was substantial at 0.751 (CI 95%: 0.677 to 0.810); the incidence of mistriage is greater than 50%. Agreement is higher for the latest version of MTS (for adults) among nurse-experts and in countries in closer proximity to the country of MTS origin (the UK, in Manchester) than for the oldest (pediatric) version, nurse-nurse raters, and countries at a greater distance from the UK.

CONCLUSION

The MTS showed an acceptable level of overall reliability in the emergency department, but more development is required to attain almost perfect agreement.

Acute coronary syndrome in relation to the occurrence of associated symptoms: A quantitative study in prehospital emergency care

INTRODUCTION

Acute chest pain is a common symptom among prehospital emergency care patients. Therefore, it is crucial that ambulance nurses (ANs) have the ability to identify symptoms and assess patients suffering from acute coronary syndrome (ACS). The aim of this study is to explore the occurrence of dyspnoea and nausea and/or vomiting in the prehospital phase of a suspected ACS and the associations with patients' outcome.

METHODS

This study has a quantitative design based on data from hospital records and from a previous interventional study (randomised controlled trial) including five Emergency Medical Service (EMS) systems in western Sweden in the years 2008-2010.

RESULTS

In all, 1836 patients were included in the interventional study. Dyspnoea was reported in 38% and nausea and/or vomiting in 26% of patients. The risk of death within one year increased with the presence of dyspnoea. The presence of nausea and/or vomiting increased the likelihood of a final diagnosis of acute myocardial infarction (AMI).

CONCLUSION

This study shows that dyspnoea, nausea and/or vomiting increase the risk of death and serious diagnosis among ACS patients. This means that dyspnoea, nausea and/or vomiting should influence the ANs' assessment and that special education in cardiovascular nursing is required.

The Role Descriptions of Triage Nurse in Emergency Department: A Delphi Study

Background. Triage nurses play a pivotal role in the emergency department. However some researchers have attempted to expand triage nurse's role; remarkable discrepancies exist among scholarly communities. The aim was to develop a role description of triage nurse relying on the experts. Methods. A modified Delphi study consisting of 3 rounds was performed from March to October 2014. In the first round, an extensive review of the literature was conducted. Expert selection was conducted through a purposeful sample of 38 emergency medicine experts. Results. Response rates for the second and third rounds were 37% and 58%. Average age of panelists was (38.42 ± 5.94) years. Thirty-nine out of 54 items reached to the final round. Prioritizing had the higher agreement rate and least agreement on triage related interventions. Conclusion. Triage nursing as a relatively new role for nurses needs significant development to be practiced. Comprehensive educational programs and developmental research are required to support diagnostic and therapeutic interventions in triage practice by nurses.

Decision Making in Nursing Practice: A Concept Analysis

PURPOSE

The study aims to gain an understanding of the concept of decision making as it relates to the nurse practice environment.

METHODS

Rodgers' evolutionary method on concept analysis was used as a framework for the study of the concept. Articles from 1952 to 2014 were reviewed from PsycINFO, Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), JSTOR, PubMed, and Science Direct.

FINDINGS

Findings suggest that decision making in the nurse practice environment is a complex process, integral to the nursing profession. The definition of decision making, and the attributes, antecedents, and consequences, are discussed. Contextual factors that influence the process are also discussed. An exemplar is presented to illustrate the concept.

CONCLUSION

Decision making in the nurse practice environment is a dynamic conceptual process that may affect patient outcomes. Nurses need to call upon ways of knowing to make sound decisions and should be self-reflective in order to develop the process further in the professional arena. The need for further research is discussed.

Canadian Triage and Acuity Scale: testing the mental health categories

PURPOSE

The study tested the inter-rater reliability and accuracy of triage nurses' assignment of urgency ratings for mental health patient scenarios based on the 2008 Canadian Triage and Acuity Scale (CTAS) guidelines, using a standardized triage tool. The influence of triage experience, educational preparation, and comfort level with mental health presentations on the accuracy of urgency ratings was also explored.

METHODS

Study participants assigned urgency ratings to 20 mental health patient scenarios in randomized order using the CTAS. The scenarios were developed using actual triage notes and were reviewed by an expert panel of emergency and mental health clinicians for face and content validity.

RESULTS

The overall Fleiss' kappa, the measure of inter-rater reliability for this sample of triage nurses (n=18), was 0.312, representing only fair albeit statistically significant (P<0.0001) agreement. Kendall's coefficient of concordance for the sample was calculated to be 0.680 (P<0.0001), which signifies moderate agreement. Although the sample reported high levels of education, comfort with mental health presentations, and experience, accuracy in urgency ratings measured by the percentage of correct responses ranged from 0.05% to 94% (mean: 54%). Greater accuracy in urgency ratings was recorded for triage nurses who used second-order modifiers and avoided the use of override.

CONCLUSION

Specific focus on the use of second-order modifiers in orientation and ongoing education of triage nurses may improve the reliability and validity of the CTAS when used to assign urgency ratings to mental health presentations.

The Reliability of the Canadian Triage and Acuity Scale: Meta-analysis

Background:

Although the Canadian Triage and Acuity Scale (CTAS) have been developed since two decades ago, the reliability of the CTAS has not been questioned comparing to moderating variable.

Aims:

The study was to provide a meta-analytic review of the reliability of the CTAS in order to reveal to what extent the CTAS is reliable.

Materials and Methods:

Electronic databases were searched to March 2014. Only studies were included that had reported samples size, reliability coefficients, adequate description of the CTAS reliability assessment. The guidelines for reporting reliability and agreement studies (GRRAS) were used. Two reviewers independently examined abstracts and extracted data. The effect size was obtained by the z-transformation of reliability coefficients. Data were pooled with random-effects models and meta-regression was done based on method of moments estimator.

Results:

Fourteen studies were included. Pooled coefficient for the CTAS was substantial 0.672 (CI 95%: 0.599-0.735). Mistriage is less than 50%. Agreement upon the adult version, among nurse-physician and near countries is higher than pediatrics version, other raters and farther countries, respectively.

Conclusion:

The CTAS showed acceptable level of overall reliability in the emergency department but need more development to reach almost perfect agreement.

The reliability of the Australasian Triage Scale: a meta-analysis

BACKGROUND

Although the Australasian Triage Scale (ATS) has been developed two decades ago, its reliability has not been defined; therefore, we present a meta-analyis of the reliability of the ATS in order to reveal to what extent the ATS is reliable.

DATA SOURCES

Electronic databases were searched to March 2014. The included studies were those that reported samples size, reliability coefficients, and adequate description of the ATS reliability assessment. The guidelines for reporting reliability and agreement studies (GRRAS) were used. Two reviewers independently examined abstracts and extracted data. The effect size was obtained by the z-transformation of reliability coefficients. Data were pooled with random-effects models, and meta-regression was done based on the method of moment's estimator.

RESULTS

Six studies were included in this study at last. Pooled coefficient for the ATS was substantial 0.428 (95%CI 0.340-0.509). The rate of mis-triage was less than fifty percent. The agreement upon the adult version is higher than the pediatric version.

CONCLUSION

The ATS has shown an acceptable level of overall reliability in the emergency department, but it needs more development to reach an almost perfect agreement.

Outcomes for emergency severity index triage implementation in the emergency department

INTRODUCTION

Hospital triage scale in emergency departments needs to be valid and reliable. Lack of sufficient data exists on triage scale rigor in emergency departments of Iran. This study aimed to determine the impact of the emergency severity index (ESI) triage scale in the emergency department.

MATERIALS AND METHODS

A single-center study was conducted. Proportion of triage categories allocated to high-risk patients admitted to high-acuity departments was examined in observational period in June 2012 and May 2013. True triage score was reported based on patients` paper- based scenario questionnaire. Interrater reliability was assessed using unweighted kappa. Concordance among experts, nurses and physicians was examined. The Chi-square test and Kappa statistics was used for statistical analysis.

RESULTS

Triage decisions regarding high-risk patients before and after implementation period are independent from each other (χ2= 22.254; df=1; p<0.05) and more high-risk patients were recognized after implementation of the ESI. Overall agreement and concordance were (79%) and (κ=0.54) among nurses; (71%) and (κ=0.45) among physicians, (85%) and (κ=0.81) among experts, respectively. Correct triage decisions among clinicians were increased after implementation of the ESI.

CONCLUSION

The ESI as valid and reliable tool improving desirable outcomes` in the emergency department has been recommended but it may not reveal optimal outcomes in developing countries comparing to what have been achieved in the developed countries. In addition, patient influx in ESI level II could create considerable controversy with clinicians.

The effect of supportive emergency department nursing care on pain reduction of patients with Red Sea marine wildlife injuries

INTRODUCTION

The emergency department at Yoseftal hospital in Eilat is on the shore of the Red Sea, and it is visited by patients with marine wildlife injuries. The purpose of this study was to examine the effects of supportive nursing care on the pain level of patients with Red Sea marine wildlife injuries.

METHOD

A prospective quantitative study including 102 patients admitted to the emergency department. The study included a study group (N = 50) and a control group (N = 52). Both groups rated their pain level on the VAS before and after receiving treatment. The control group received the usual treatment, and the study group received the usual nursing treatment along with structured patient guidance and support.

RESULTS

There was a significant difference in the level of pain after the intervention between the control and the study group. In the study group, the level of pain was significantly reduced compared with the control group (p < 0.001).

DISCUSSION

Nursing training and patient guidance contributed to increasing cooperation with patients and pain reduction. Therefore, training interventions should be structured and assimilated as an integral part of nursing practice.

Reliability of the Emergency Severity Index: Meta-analysis

OBJECTIVES

Although triage systems based on the Emergency Severity Index (ESI) have many advantages in terms of simplicity and clarity, previous research has questioned their reliability in practice. Therefore, the aim of this meta-analysis was to determine the reliability of ESI triage scales.

METHODS

This meta-analysis was performed in March 2014. Electronic research databases were searched and articles conforming to the Guidelines for Reporting Reliability and Agreement Studies were selected. Two researchers independently examined selected abstracts. Data were extracted in the following categories: version of scale (latest/older), participants (adult/paediatric), raters (nurse, physician or expert), method of reliability (intra/inter-rater), reliability statistics (weighted/unweighted kappa) and the origin and publication year of the study. The effect size was obtained by the Z-transformation of reliability coefficients. Data were pooled with random-effects models and a meta-regression was performed based on the method of moments estimator.

RESULTS

A total of 19 studies from six countries were included in the analysis. The pooled coefficient for the ESI triage scales was substantial at 0.791 (95% confidence interval: 0.787-0.795). Agreement was higher with the latest and adult versions of the scale and among expert raters, compared to agreement with older and paediatric versions of the scales and with other groups of raters, respectively.

CONCLUSION

ESI triage scales showed an acceptable level of overall reliability. However, ESI scales require more development in order to see full agreement from all rater groups. Further studies concentrating on other aspects of reliability assessment are needed.

A pathway care model allowing low-risk patients to gain direct admission to a hospital medical ward--a pilot study on ambulance nurses and Emergency Department physicians

A pathway care model allowing low-risk patients to gain rapid admission to a hospital medical ward - a pilot study on ambulance nurses and Emergency Department physicians.

BACKGROUND

Patients with non-urgent medical symptoms who nonetheless require inpatient hospital treatment often have to wait for an unacceptably long time at the Emergency Department (ED). The purpose of this study is to evaluate the feasibility and effect on length of delay of a pathway care model for low-risk patients who have undergone prehospital assessment by an ambulance nurse and ED assessment by a physician within 10 minutes of arrival at the ED.

METHODS

The pilot study comparing two low-risk groups took place in western Sweden from October 2011 until January 2012. The pathway model for low-risk patients was used prospectively in the rapid admission group (N = 51), who were admitted rapidly after being assessed by the nurse on scene and then assessed by the ED physician on ED admission. A retrospectively assembled control group (N = 51) received traditional care at the ED. All p-values are age-adjusted.

RESULTS

Patients in the rapid admission group were older (mean age 80 years old) than patients in the control group (mean age 73 years old) (p = 0.02). The median delay from arrival at the patient's side until arrival in a hospital medical ward was 57 minutes for the rapid admission group versus 4 hours 13 minutes for the control group (p < 0.0001). However, the median delay time from the ambulance's arrival at the patient's side until the nurse was free for a new assignment was 77 minutes for the rapid admission group versus 49 minutes for the control group (p < 0.0001). The 30-day mortality rate was 20% for the rapid admission group and only 4% for the control group (p = 0.16).

CONCLUSION

The pathway care model for low-risk patients gaining rapid admission to a hospital medical ward shortened length of delay from the first assessment until arrival at the ward. However, the result was achieved at the cost of an increased workload for the ambulance nurse. Furthermore patients who were rapidly admitted to a hospital ward had a high age level and a high early mortality rate. Patient safety in this new model of fast-track assessment needs to be further evaluated.

Dynamic patient grouping and prioritization: a new approach to emergency department flow improvement

The demand on emergency departments (ED) is variable and ever increasing, often leaving them overcrowded. Many hospitals are utilizing triage algorithms to rapidly sort and classify patients based on the severity of their injury or illness, however, most current triage methods are prone to over- or under-triage. In this paper, the group technology (GT) concept is applied to the triage process to develop a dynamic grouping and prioritization (DGP) algorithm. This algorithm identifies most appropriate patient groups and prioritizes them according to patient- and system-related information. Discrete event simulation (DES) has been implemented to investigate the impact of the DGP algorithm on the performance measures of the ED system. The impact was studied in comparison with the currently used triage algorithm, i.e., emergency severity index (ESI). The DGP algorithm outperforms the ESI algorithm by shortening patients' average length of stay (LOS), average time to bed (TTB), time in emergency room, and lowering the percentage of tardy patients and their associated risk in the system.

Registered nurses' experiences of their decision-making at an Emergency Medical Dispatch Centre

AIMS AND OBJECTIVES

To describe registered nurses' experiences at an Emergency Medical Dispatch Centre.

BACKGROUND

It is important that ambulances are urgently directed to patients who are in need of immediate help and of quick transportation to a hospital. Because resources are limited, Emergency Medical Dispatch centres cannot send ambulances with high priority to all callers. The efficiency of the system is therefore dependent on triage. Nurses worldwide are involved in patient triage, both before the patient's arrival to the hospital and in the subsequent emergency care. Ambulance dispatching is traditionally a duty for operators at Emergency Medical Dispatch centres, and in Sweden this duty has become increasingly performed by registered nurses.

DESIGN

A qualitative design was used for this study.

METHODS

Fifteen registered nurses with experience at Emergency Medical Dispatch centres were interviewed. The participants were asked to describe the content of their work and their experiences. They also described the most challenging and difficult situations according to the critical incidence technique. Content analysis was used.

RESULTS

Two themes emerged during the analysis: 'Having a profession with opportunities and obstacles' and 'Meeting serious and difficult situations', with eight sub-themes. The results showed that the decisions to dispatch ambulances were both challenging and difficult. Difficulties included conveying medical advice without seeing the patient, teaching cardio-pulmonary resuscitation via telephone and dealing with intoxicated and aggressive callers. Conflicts with colleagues and ambulance crews as well as fear of making wrong decisions were also mentioned.

CONCLUSIONS

Work at Emergency Medical Dispatch centres is a demanding but stimulating duty for registered nurses.

RELEVANCE TO CLINICAL PRACTICE

Great benefits can be achieved using experienced triage nurses, including increased patient safety and better use of medical resources. Improved internal support systems at Emergency Medical Dispatch centres and striving for a blame-free culture are important factors to attract and retain employees.

How clinicians manage access to opioid replacement therapy

In Australia, people wait to access opioid replacement therapy (ORT). The aim of this study was to examine how clinicians (n = 35) prioritize consumers for opioid replacement therapy (ORT). The study used a methodology informed by a constructivist approach to grounded theory. Based on a scenario related to two consumers seeking admission to opioid replacement therapy (ORT), participants were asked to prioritize one for preferential admission and questioned about their decision-making. Clinicians were neither confident nor unanimous in their decision-making. Team involvement and work experience influenced their judgment. Differences between clinicians in regard to understanding risks and protective factors were identified. To support uniformity in managing treatment requests, clearer policy direction to gui clinician practice, and further exploration of how models of care and team involvement influence consumer outcomes, are recommended.