Factors contributing to patient safety during triage process in the emergency department: A systematic review

Root causes behind patient safety incidents in the emergency department and suggestions for improving patient safety - an analysis in a Finnish teaching hospital

BACKGROUND

Adverse events occur frequently at emergency departments (ED) because of several risk factors related to varying conditions. It is still unclear, which factors lead to patient safety incident reports. The aim of this study was to explore the root causes behind ED-associated patient safety incidents reported by personnel, and based on the findings, to suggest learning objectives for improving patient safety.

METHODS

The study material included incident reports (n = 340) which concerned the ED of a teaching hospital over one year. We used a mixed method combining quantitative descriptive statistics and qualitative research by inductive content analysis and deductive Ishikawa root cause analysis.

RESULTS

Most (76.5%) incidents were reported after patient transfer from the ED. Nurses reported 70% of incidents and physicians 7.4%. Of the reports, 40% were related to information flow or management. Incidents were evaluated as no harm (29.4%), mild (46%), moderate (19.7%), and severe (1.2%) harm to the patient. The main consequences for the organization were reputation loss (44.1%) and extra work (38.9%). In the qualitative analysis, nine specific problem groups were found: insufficient introduction, adherence to guidelines and protocols, insufficient human resources, deficient professional skills, medication management deficiencies, incomplete information transfer from the ED, language proficiency, unprofessional behaviour, identification error, and patient-dependent problems. Six organizational themes were identified: medical staff orientation, onboarding and competence requirements; human resources; electronic medical records and information transfer; medication documentation system; interprofessional collaboration; resources for specific patient groups such as geriatric, mental health, and patients with substance abuse disorder. Entirely human factor-related themes could not be defined because their associations with system factors were complex and multifaceted. Individual and organizational learning objectives were addressed, such as adherence to the proper use of instructions and adequate onboarding.

CONCLUSIONS

System factors caused most of the patient safety incidents reported concerning ED. The introduction and training of ED -processes is elementary, as is multiprofessional collaboration. More research is needed about teamwork skills, patients with special needs and non-critical patients, and the reporting of severe incidents.

Nurses' Perception on the Hindrances of Triage System in Emergency Unit

Background: Despite the fact that several triage tools have been implemented globally, emergency care, including the triage system, is often one of the weakest parts of the health system in developing countries, as compared to developed countries. Moreover, emergency centers in African countries are very busy, often flooded by high load of trauma patients, chronic medical conditions, acute medical emergencies, and HIV-related conditions. These disease conditions precipitate the reasons for the prioritization of patients. In South Africa, studies conducted on the use of triage by nurses revealed that most patients are satisfied with the Nurse-led triage service provided in emergency departments (EDs). At the same time, some Nurses also see the South African Triage Scale (SATS) as one of the easiest Nurse-led triage tools. Aim: The study aimed at identifying the factors hindering the effective process of triage during care provision at a selected public hospital in KwaZulu-Natal (KZN). Methods: This study utilized a cross-sectional survey, employing a nonprobability convenience sampling to recruit its respondents. The recognition primed decision model formed the framework of the study. Ethical clearance was obtained from the University of KwaZulu-Natal Ethics Review Board, and ethics principles were carefully observed throughout the study. Results: Out of the 100 respondents, 89% (89) of the respondents perceived that various factors still impede the progress of triage, while 11% (11) of the respondents perceived that no factor impedes the progress of triage. Conclusion: The study indicates that several factors still hinder the effective process of triage. Based on the findings of the study, factors like overcrowding, Nurses waiting for doctors when they know what to do, lack of continuous professional development on triage system, inadequate experience, lack of confidence, and lack of adequate training on triage still impede the efficient triage system.

Factors influencing the classification accuracy of triage nurses in emergency department: analysis of triage nurses' characteristics

BACKGROUND

Triage nurses play a vital role in emergency departments (Eds), with the accuracy of the triage nurse significantly impacting patient care and departmental efficiency. However, there is a lack of exploration into whether the time it takes for triage nurses to triage patients affects accuracy.

METHOD

This study analyzed the electronic medical records of 787 patients and the characteristics of triage nurses, using statistical methods to determine factors affecting classification accuracy. Data were collected from a single general hospital between November 1 and November 30, 2023.

RESULTS

Findings revealed an 84.9% accuracy rate. Longer clinical experience (p = .001, CI = 1.094-2.052), as well as extended classification time (p = .002, CI = 1.338-2.916), significantly improved accuracy. Age and gender had no notable effect.

CONCLUSION

Enhancing triage nurse experience and allowing adequate classification time can improve accuracy, optimizing patient care and ED operations.

Emergency department staff opinion on newly introduced phlebotomy services in the department. A cross-sectional study incorporating thematic analysis

OBJECTIVES

The demand for ED services, both in terms of patient numbers and complexity has risen over the past decades. According to reports, there has been an increase in the ED patient presentation rate from 330 per 1000 to 334 per 1000 between 2018-2019 and 2022-2023. Consequently, new care models have been introduced to address this surge in demand, mitigate associated risks and improve overall safety. Among these models is the concept of 'front loading' clinical care, involving the initiation of interventions at the point of arrival. The present study evaluates the impact of introducing phlebotomists at triage.

METHODS

We conducted a cross-sectional survey using purposive sampling at a single quaternary metropolitan ED with an annual census of greater than 90 000, encompassing all clinical staff in the ED. The survey data were analysed quantitatively and complemented by a thematic analysis.

RESULTS

The response rate for the questionnaire was 61% (n = 207), with good representation from all ED craft groups. Nearly all the staff (99.5%) reported being aware of the presence of phlebotomists in the ED, whereas only 57% of the staff reported working in triage (P = 0.05, 0.00 to 0.04). 'Valuable/vital resource' featured as a common response. Early decision-making, patient safety, staff and patient satisfaction emerged as consistent themes.

CONCLUSIONS

Staff expressed satisfaction that patient care now begins in the waiting room, especially after extended waiting periods prior to cubicle allocation. They assert that this improvement significantly enhances timely treatment and disposition decisions, as well as overall patient satisfaction.

Activity, triage levels and impact of the pandemic on hospital emergency departments: A multicentre cross-sectional study

AIM

Describe the activity of hospital emergency departments (EDs) and the sociodemographic profile of patients in the eight public hospitals in Spain, according to the different triage levels, and to analyse the impact of the SARS-CoV-2 pandemic on patient flow.

DESIGN

An observational, descriptive, cross-sectional and retrospective study was carried out.

METHODS

Three high-tech public hospitals and five low-tech hospitals consecutively included 2,332,654 adult patients seen in hospital EDs from January 2018 to December 2021. Hospitals belonging to the Catalan Institute of Health. The main variable was triage level, classified according to a standard for the Spanish structured triage system known as Sistema Español de Triaje. For each of the five triage levels, a negative binomial regression model adjusted for year and hospital was performed. The analysis was performed with the R 4.2.2 software.

RESULTS

The mean age was 55.4 years. 51.4% were women. The distribution of patients according to the five triage levels was: level 1, 0.41% (n = 9565); level 2, 6.10% (n = 142,187); level 3, 40.2% (n = 938,203); level 4, 42.6% (n = 994,281); level 5, 10.6% (n = 248,418). The sociodemographic profile was similar in terms of gender and age: as the level of severity decreased, the number of women, mostly young, increased. In the period 2020-2021, the emergency rate increased for levels 1, 2 and 3, but levels 4 and 5 remained stable.

CONCLUSION

More than half of the patients attended in high-technology hospital EDs were of low severity. The profile of these patients was that of a young, middle-aged population, mostly female. The SARS-CoV2 pandemic did not change this pattern, but an increase in the level of severity was observed.

IMPACT

What problem did the study address? There is overcrowding in hospital EDs. What were the main findings? This study found that more than half of the patients attended in high-technology hospital EDs in Spain have low or very low levels of severity. Young, middle-aged women were more likely to visit EDs with low levels of severity. The SARS-CoV2 pandemic did not change this pattern, but an increase in severity was observed. Where and on whom will the research have an impact? The research will have an impact on the functioning of hospital EDs and their staff.

PATIENT OR PUBLIC CONTRIBUTION

Not applicable.

Triage Performance Across Large Language Models, ChatGPT, and Untrained Doctors in Emergency Medicine: Comparative Study

BACKGROUND

Large language models (LLMs) have demonstrated impressive performances in various medical domains, prompting an exploration of their potential utility within the high-demand setting of emergency department (ED) triage. This study evaluated the triage proficiency of different LLMs and ChatGPT, an LLM-based chatbot, compared to professionally trained ED staff and untrained personnel. We further explored whether LLM responses could guide untrained staff in effective triage.

OBJECTIVE

This study aimed to assess the efficacy of LLMs and the associated product ChatGPT in ED triage compared to personnel of varying training status and to investigate if the models' responses can enhance the triage proficiency of untrained personnel.

METHODS

A total of 124 anonymized case vignettes were triaged by untrained doctors; different versions of currently available LLMs; ChatGPT; and professionally trained raters, who subsequently agreed on a consensus set according to the Manchester Triage System (MTS). The prototypical vignettes were adapted from cases at a tertiary ED in Germany. The main outcome was the level of agreement between raters' MTS level assignments, measured via quadratic-weighted Cohen κ. The extent of over- and undertriage was also determined. Notably, instances of ChatGPT were prompted using zero-shot approaches without extensive background information on the MTS. The tested LLMs included raw GPT-4, Llama 3 70B, Gemini 1.5, and Mixtral 8x7b.

RESULTS

GPT-4-based ChatGPT and untrained doctors showed substantial agreement with the consensus triage of professional raters (κ=mean 0.67, SD 0.037 and κ=mean 0.68, SD 0.056, respectively), significantly exceeding the performance of GPT-3.5-based ChatGPT (κ=mean 0.54, SD 0.024; P<.001). When untrained doctors used this LLM for second-opinion triage, there was a slight but statistically insignificant performance increase (κ=mean 0.70, SD 0.047; P=.97). Other tested LLMs performed similar to or worse than GPT-4-based ChatGPT or showed odd triaging behavior with the used parameters. LLMs and ChatGPT models tended toward overtriage, whereas untrained doctors undertriaged.

CONCLUSIONS

While LLMs and the LLM-based product ChatGPT do not yet match professionally trained raters, their best models' triage proficiency equals that of untrained ED doctors. In its current form, LLMs or ChatGPT thus did not demonstrate gold-standard performance in ED triage and, in the setting of this study, failed to significantly improve untrained doctors' triage when used as decision support. Notable performance enhancements in newer LLM versions over older ones hint at future improvements with further technological development and specific training.

Use of Mobile Technologies to Streamline Pretriage Patient Flow in the Emergency Department: Observational Usability Study

BACKGROUND

In emergency departments (EDs), triage nurses are under tremendous daily pressure to rapidly assess the acuity level of patients and log the collected information into computers. With self-service technologies, patients could complete data entry on their own, allowing nurses to focus on higher-order tasks. Kiosks are a popular working example of such self-service technologies; however, placing a sufficient number of unwieldy and fixed machines demands a spatial change in the greeting area and affects pretriage flow. Mobile technologies could offer a solution to these issues.

OBJECTIVE

The aim of this study was to investigate the use of mobile technologies to improve pretriage flow in EDs.

METHODS

The proposed stack of mobile technologies includes patient-carried smartphones and QR technology. The web address of the self-registration app is encoded into a QR code, which was posted directly outside the walk-in entrance to be seen by every ambulatory arrival. Registration is initiated immediately after patients or their proxies scan the code using their smartphones. Patients could complete data entry at any site on the way to the triage area. Upon completion, the result is saved locally on smartphones. At the triage area, the result is automatically decoded by a portable code reader and then loaded into the triage computer. This system was implemented in three busy metropolitan EDs in Shanghai, China. Both kiosks and smartphones were evaluated randomly while being used to direct pretriage patient flow. Data were collected during a 20-day period in each center. Timeliness and usability of medical students simulating ED arrivals were assessed with the After-Scenario Questionnaire. Usability was assessed by triage nurses with the Net Promoter Score (NPS). Observations made during system implementation were subject to qualitative thematic analysis.

RESULTS

Overall, 5928 of 8575 patients performed self-registration on kiosks, and 7330 of 8532 patients checked in on their smartphones. Referring effort was significantly reduced (43.7% vs 8.8%; P<.001) and mean pretriage waiting times were significantly reduced (4.4, SD 1.7 vs 2.9, SD 1.0 minutes; P<.001) with the use of smartphones compared to kiosks. There was a significant difference in mean usability scores for "ease of task completion" (4.4, SD 1.5 vs 6.7, SD 0.7; P<.001), "satisfaction with completion time" (4.5, SD 1.4 vs 6.8, SD 0.6; P<.001), and "satisfaction with support" (4.9, SD 1.9 vs 6.6, SD 1.2; P<.001). Triage nurses provided a higher NPS after implementation of mobile self-registration compared to the use of kiosks (13.3% vs 93.3%; P<.001). A modified queueing model was identified and qualitative findings were grouped by sequential steps.

CONCLUSIONS

This study suggests patient-carried smartphones as a useful tool for ED self-registration. With increased usability and a tailored queueing model, the proposed system is expected to minimize pretriage waiting for patients in the ED.

Understanding the mechanism of safety attitude mitigates the turnover intention novice nurses via the person-centred method: A theory-driven, deductive cross-sectional study

AIM

Examine profiles of safety attitudes among novices and explore whether profiles moderate the occupational identity-turnover pathway.

BACKGROUND

Novice nurses face unique challenges in adopting positive safety attitudes, which influence outcomes like turnover. However, past research found only average levels of safety attitudes among novices, ignoring possible heterogeneity. Exploring whether meaningful subgroups exist based on safety perspectives and factors shaping them can provide insights to improve safety attitudes and retention.

DESIGN

This study was designed as a cross-sectional investigation.

METHODS

Data were collected through the distribution of questionnaires. Descriptive statistics were first conducted, followed by latent profile analysis. We then carried out univariate analysis and ordinal multinomial regression to explore the factors shaping the different profiles. Finally, we examine the moderating effect of nurses' safety attitudes with different latent profiles on the relationship between professional identification and turnover intention.

RESULTS

A total of 816 novice nurses were included. Three profiles were identified: high, moderate and low safety attitudes - higher attitudes were associated with lower turnover intention. Interest in nursing, health status, identity and turnover predicted profile membership. Moderate profile had a stronger buffering effect on the identity-turnover link versus high profile.

CONCLUSION

Multiple safety attitude profiles exist among novice nurses. Certain factors like interest in nursing and occupational identity are associated with more positive safety profiles. Targeting these factors could potentially improve safety attitudes and reduce turnover among novice nurses. The moderating effects suggest that tailored interventions matching specific subgroups may maximize impact.

IMPACT

Assessing subgroup attitudes enables tailored training for novices' specific needs, nurturing continuous improvement. Supporting early career development and role identity may strengthen retention intentions.

Perceptions of Patient Safety Culture among Triage Nurses in the Emergency Department: A Cross-Sectional Study

The patient safety culture is key to ensuring patient safety in healthcare organizations. The triage environment is inherently demanding for patient safety and is characterized by high stress, rapid decision-making, and quick action. In several countries, including Slovenia, there is a lack of studies on the patient safety culture among triage nurses. This study aimed to assess the perceptions of the patient safety culture among triage nurses. A cross-sectional survey design was used. The Emergency Medical Services-Safety Attitudes Questionnaire, distributed to triage nurses, was used to collect data. A total of 201 triage nurses participated in this study. The results revealed that the overall average perception of the patient safety culture was 57.27% (SD = 57.27), indicating that the perception of the patient safety culture among triage nurses in the emergency department was non-positive and requires improvement. "Job Satisfaction" received the highest score (63.18%; SD = 17.19), while "Working Conditions" received the lowest (49.91%; SD = 17.37). The perception of positive and negative safety culture responses was statistically significant for age (χ2 (3) = 17.750, p ≤ 0.001), education (χ2 (2) = 6.957, p = 0.031) and length of working experience (χ2 (3) = 8.875, p = 0.031). The findings emphasize the significance of improving the safety culture in relation to several areas of patient care during the triage process. This research serves as a crucial foundation for enhancing patient safety in triage, providing quality care, and reducing adverse events.