Factors influencing consistency of triage using the Australasian Triage Scale: Implications for guideline development

Objective: To examine the influence of the nurse, the type of patient presentation and the level of hospital service on consistency of triage using the Australasian Triage Scale. Methods: A secondary analysis of survey data was conducted. The main study was undertaken to measure the reliability of 237 scenarios for inclusion in a national training programme. Nurses were recruited from a quota sample of Australian ED according to peer group. Analysis was performed to determine concordance: the percentage of responses in the modal triage category. Analysis of variance (anova ) and Pearson correlations were used to investigate associations between the explanatory variables and concordance. Results: A total of 42/50 (84%) participants returned questionnaires, providing 9946 scenario responses for analysis. Significant differences in concordance were observed by variables describing the type of patient presentation and level of urgency. Mean scores for the comparison group (adult pain; 70.7%) were higher than the groups involving a mental health or pregnancy presentations (61.4%; P≤ 0.001; 65.0%; P= 0.02). Modal responses at the extreme ends of the scale were higher than in the middle categories (P≤ 0.001). There was a significant main effect on concordance by type of service according to peer group (P= 0.03). Of the nine variables that described nurse characteristics, age was the only factor to influence the outcome (P= 0.05). Conclusion: We identified significant problems with the consistency of triage for mental health and pregnancy presentations. Further research is needed to improve the guidelines on the implementation of the Australasian Triage Scale for these populations.     

Optimizing triage consistency in Australian emergency departments: The Emergency Triage Education Kit

Objective: The Emergency Triage Education Kit was designed to optimize consistency of triage using the Australasian Triage Scale. The present study was conducted to determine the interrater reliability of a set of scenarios for inclusion in the programme. Methods: A postal survey of 237 paper‐based triage scenarios was utilized. A quota sample of triage nurses (n = 42) rated each scenario using the Australasian Triage Scale. The scenarios were analysed for concordance and agreement. The criterion for inclusion of the scenarios in the programme was κ ≥ 0.6. Results: Data were collected during 2 April to 14 May 2007. Agreement for the set was κ = 0.412 (95% CI 0.410–0.415). Of the initial set: 92/237 (38.8%, 95% CI 32.6–45.3) showed concordance ≥70% to the modal triage category (κ = 0.632, 95% CI 0.629–0.636) and 155/237 (65.4%, 95% CI 59.3–71.5) showed concordance ≥60% to the modal triage category (κ = 0.507, 95% CI 0.504–0.510). Scenarios involving mental health and pregnancy presentations showed lower levels of agreement (κ = 0.243, 95% CI 0.237–0.249; κ = 0.319, 95% CI 0.310–0.328). Conclusion: All scenarios that showed good levels of agreement have been included in the Emergency Triage Education Kit and are recommended for testing purposes; those that showed moderate agreement have been incorporated for teaching purposes. Both scenario sets are accompanied by explanatory notes that link the decision outcome to the Australasian College for Emergency Medicine Guidelines on the Implementation of the Australasian Triage Scale. Future analysis of the scenarios is required to identify how task‐related factors influence consistency of triage.     

Do Knowledge and Experience Have Specific Roles in Triage Decision‐making?

Accuracy of triage decisions is a major influence on patient outcomes. Triage nurses' knowledge and experience have been cited as influential factors in triage decision-making. The aim of this article is to examine the independent roles of factual knowledge and experience in triage decisions. All of the articles cited in this review were research papers that examined the relationship between triage decisions and knowledge and/or experience of triage nurses. Numerous studies have shown that factual knowledge is an important factor in improving triage decisions. Although a number of studies have examined the role of experience as an independent influence on triage decisions, none have found a significant relationship between experience and triage decision-making. Factual knowledge appears to be more important than years of emergency nursing or triage experience in triage decision accuracy. Many triage education programs are underpinned by the assumption that knowledge acquisition will result in improved triage decisions. A better understanding of the relationships between clinical decisions, knowledge, and experience is pivotal for the rigorous evaluation of education programs.     

高职学生急诊分诊评估教学实践与效果观察

目的探讨急诊分诊评估实践在急救护理教学中的应用及效果。方法对护理高职2年级学生开展急诊分诊评估临床实践,经过分诊实践培训,在临床带教老师指导下参与分诊工作,急诊分诊实践前后分别对学生分诊理论知识掌握程度和教学效果进行测评。结果①实践后高职学生的分诊知识应用评价成绩明显提高(P0.01);②高职学生对教学效果的评价总分为(101.31±5.29)分,各条目均值均大于4.00分。结论通过急诊分诊评估临床实践,有效地提高高职学生对急诊知识的实践应用能力,提升了高职学生自主学习的主观能动性,有利于高职学生进入临床实习时,更快地实现角色转变。     

智能急诊分诊诊断治疗系统的研发与应用

目的 探讨智能急诊分诊诊断治疗系统在急诊科分诊中的应用效果。方法 采取便利抽样的方法,选择某三级甲等医院400例急诊科就诊患者为研究对象,根据入院时间先后顺序将其分为对照组和观察组各200例,对照组采用常规人工预检分诊,观察组应用智能急诊分诊诊断治疗系统预检分诊,比较2组患者病情资料收集时间、分诊时间、过度分诊率及患者对护士分诊工作的满意度。结果 观察组的病情资料收集时间、分诊时间均比对照组短,差异有统计学意义（P<0.05）;观察组护士过度分诊率比对照组低,差异有统计学意义（P<0.05）;同时,观察组患者对护士分诊工作表示满意的有196例,对照组中40例患者认为分诊较慢、流程繁琐等原因,表示不满意,2组满意度的比较差异有统计学意义（P<0.05）。结论 在急诊科,结合应用智能急诊分诊诊断治疗系统,优化急诊分诊流程,快速对患者病情进行分类和归纳,减少了分诊时间,保障护士的分诊效率,从而进一步保障患者安全,提高患者的满意度。     

Exploring the complex interactions of baseline patient factors to improve nursing triage of acute coronary syndrome

Emergency department (ED) nurses need to identify patients with potential acute coronary syndrome (ACS) rapidly because treatment delay could impact patient outcomes. Aims of this secondary analysis were to identify key patient factors that could be available at initial ED nurse triage that predict ACS. Consecutive patients with chest pain who called 9-1-1, received a 12-lead electrocardiogram in the prehospital setting, and were transported via emergency medical service were included in the study. A total of 750 patients were recruited. The sample had an average age of 59 years old, was 57% male, and 40% Black. One hundred and fifteen patients were diagnosed with ACS. Older age, non-Caucasian race, and faster respiratory rate were independent predictors of ACS. There was an interaction between heart rate by Type II diabetes receiving insulin in the context of ACS. Type II diabetics requiring insulin for better glycemic control manifested a faster heart rate. By identifying patient factors at ED nurse triage that could be predictive of ACS, accuracy rates of triage may improve, thus impacting patient outcomes.     

The Emergency Severity Index Triage Algorithm Version 2 Is Reliable and Valid

OBJECTIVES: Initial studies have shown improved reliability and validity of a new triage tool, the Emergency Severity Index (ESI), over conventional three-level scales at two university medical centers. After pilot implementation and validation, the ESI was revised to include pediatric and updated vital signs criteria. The goal of this study was to assess ESI version (v.) 2 reliability and validity at seven emergency departments (EDs) in three states. METHODS: In part 1, interrater reliability was assessed using weighted kappa analysis of written training cases and postimplementation by a random sampling of actual patient triages. In part 2, validity was analyzed using a prospective cohort with stratified random sampling at each site. The ESI was compared with outcomes including resource consumption, inpatient admission, ED length of stay, and 60-day all-cause mortality. RESULTS: Weighted kappa analysis of interrater reliability ranged from 0.70 to 0.80 for the written scenarios (n = 3289) and 0.69 to 0.87 for patient triages (n = 386). Outcomes for the validity cohort (n = 1042) included hospitalization rates by ESI triage level: level 1, 83%; 2, 67%; 3, 42%; 4, 8%; level 5, 4%. Sixty-day all-cause mortality by triage level was as follows: level 1, 25%; 2, 4%; 3, 2%; 4, 1%; and 5, 0%. CONCLUSIONS: ESI v. 2 triage produced reliable, valid stratification of patients across seven sites. ESI triage should be evaluated as an ED casemix identification system for uniform data collection in the United States and compared with other major ED triage methods.     

急诊分诊、急救护理质量评价指标初探

目的:对急诊分诊、急救护理质量评价指标进行初步研究。方法:采用Delphi法。结果:在访谈、回顾大量文献和发放预调查问卷的基础上先确立备选指标,包括一级指标3项,二级指标15项,三级指标52项。采用Delphi法对遴选专家进行两轮问卷调查后,一级指标仍为3项,二级指标增加为16项,三级指标增加为67项。两轮问卷专家回复率分别为86.67%和100.00%,专家权威系数为0.815。结论:通过对急诊分诊、急救护理质量评价的初步研究,得出了急诊分诊、急救护理质量评价涵盖的主要内容,同时作为专科护理质量评价体系之一,为以后进一步探索研究急诊科护理质量评价体系奠定了基础。     

Evaluating outcomes of the emergency nurse practitioner role in a major urban emergency department, Melbourne, Australia

Aims and objectives. The aim of this study was to evaluate the impact of the introduction of Emergency Nurse Practitioner Candidates (ENPC) on waiting times and length of stay of patients presenting to a major urban Emergency Department (ED) in Melbourne, Australia. Background. As part of a Victorian state funded initiative to improve patient outcomes, the role of the Emergency Nurse Practitioner has been developed. The integration and implementation of this role, is not only new to the Alfred Emergency and Trauma Centre but to EDs in Melbourne, Australia, with aims of providing holistic and comprehensive care for patients. Design. A retrospective case series of all patients with common ED diagnostic subgroups were included. The ENPC group (n = 572) included all patients managed by the ENPC and the Traditional Model (TM) group (n = 2584) included all patients managed by the traditional medical ED model of care. Outcome measures included waiting times and length of stay. Results. Statistically significant differences were evident between the two groups in waiting times and length of stay in the ED. The overall median waiting time for emergency patients to be seen by the ENPC was less than for the TM group [median (IQR): ENPC 12 (5·5–28) minutes; TM 31 (11·5–76) minutes (Wilcoxon p < 0·001)]. Length of stay in the ED was also significantly reduced in the ENPC group [median (IQR): ENPC 94 (53·5–163·5) minutes; TM 170 (100–274) minutes (Wilcoxon p < 0·001)]. The comparison of overall waiting times for ENPC shifts vs. non‐ENPC shifts revealed significant differences [median (IQR): ENPC rostered 24 (9–52) minutes; ENPC not rostered 33 (13–80·5) minutes (Wilcoxon p < 0·001)]. Conclusions. This study has demonstrated that ENPCs implementation in Melbourne, Australia were associated with significantly reduced waiting times and length of stay for emergency patients. Emergency Nurse Practitioners should be considered as a potential long term strategy to manage increased service demands on EDs. Relevance to clinical practice. This study is the first in Australia with a significant sample size to vigorously compare ENPC waiting times and length of stay outcomes with the TM model of care in the ED. The study suggests that ENPCs can have a favourable impact on patient outcomes with regard to waiting times and length of stay.     

“SOAP”分诊法优化口腔急诊预检分诊管理实践

目的：通过运用“SOAP”分诊法,探讨口腔专科医院急诊科分诊模式与规范。方法：采用“SOAP”分诊法并结合澳大利亚预检系统、美国牙科协会（ADA）和美国口腔颌面外科协会（AAOMS）所定义的口腔急症进行分诊。结果：制定了口腔急诊预检分诊系统。结论：运用“S OA P”分诊法,提高了护士正确判断口腔急症的能力,为抢救赢得了时间,取得了患者和医生的满意,为完善口腔急诊患者服务开辟了一条新的途径,从而促进了口腔急诊护理水平的提高。     

我国二级及以上医院急诊分诊依据现状调查

目的调查国内急诊分诊执行情况及分诊依据的现状。方法采用自制调查问卷,对国内113所医院的274名急诊科护士进行急诊分诊执行情况及分诊依据现状的调查。结果目前急诊分诊护士要求不统一,急诊分诊标准存在不足,急诊分诊护士现有培训不能满足临床需要。结论我国在急诊分诊护士培养和急诊分诊标准的建立等方面尚不完善,建立统一规范的分诊标准和专职分诊护士将成为急诊分诊发展的趋势。     

Current status of emergency department triage in mainland China: A narrative review of the literature

In this review, the current status of emergency department triage in mainland China is explored, with the purpose of generating a deeper understanding of the topic. Literature was identified through electronic databases, and was included for review if published between 2002 and 2012, included significant discussion of daily emergency department triage in mainland China, was peer reviewed, and published in English or Chinese. Thematic analysis was used to identify themes which emerged from the reviewed literature. This resulted in 21 articles included for review. Four themes emerged from the review: triage process, triage training, qualification of triage nurses, and quality of triage. The review demonstrates that there is currently not a unified approach to emergency department triage in mainland China. Additionally, there are limitations in triage training for nurses and confusion around the role of triage nurses. This review highlights that emergency department triage in mainland China is still in its infancy and that more research is needed to further develop the role of triage.     

Emergency Department Triage: Do Experienced Nurses Agree on Triage Scores?

Background

The reproducibility of the Canadian Triage &; Acuity Scale (CTAS), designed and introduced in the late 1990s in all Canadian emergency departments (EDs), has been studied mostly using measures of interrater agreement. However, each of these studies shares a common limitation: the nurses had received fresh CTAS training, which is likely to have led to an overestimation of the reproducibility of CTAS.

Objectives

This study aims to assess the interrater reliability of the CTAS in current clinical practice, that is, as used by experienced ED nurses without recent certification or recertification.

Methods

A prospective sample of 100 patients arriving by ambulance was identified and yielded a set of 100 written scenarios. Five experienced ED nurses reviewed and blindly assigned a CTAS score to each scenario. The agreement among nurses was measured using the Kappa statistic calculated with quadratic weights. Kappa values were generated for each pair of nurses and a global Kappa coefficient was calculated to measure overall agreement.

Results

Overall interrater agreement was moderate, with a global Kappa of 0.44 (95% confidence interval 0.40–0.48). However, pairwise, Kappa values were heterogeneous (0.30 to 0.61, p = 0.0013).

Conclusions

The moderate interrater agreement observed in this study is disappointingly low and suggests that CTAS reliability may be lower than expected, and this warrants further research. Intra-observer reliability of CTAS should be ascertained more extensively among experienced nurses, and a future evaluation should involve several institutions.     

急诊分诊管理的研究进展

院内急救是急诊医疗服务中的复杂而又非常重要的中间环节,是完善急诊救治链的重要环节。在急诊医学飞速发展的今天,预检分诊的概念已经从简单的“分科分诊”发展到根据患者病情的轻重缓急决定提供医疗服务的优先顺序,从而帮助临床提高救治效率和成功率阻。目前,正确的应用合适的病情评估工具,迅速收集患者信息,测量相关生命体征,在最短的时间内,获得最有价值的病情信息,综合分析,作出正确的判断,按照分级标准,     

Reliability and Validity of a New Five-level Triage Instrument

OBJECTIVES: Triage is the initial clinical sorting process in hospital emergency departments (EDs). Because of poor reproducibility and validity of three-level triage, the authors developed and validated a new five-level triage instrument, the Emergency Severity Index (ESI). The study objectives were: 1) to validate the triage instrument against ED patients' clinical resource and hospitalization needs, and 2) to measure the interrater reliability (reproducibility) of the instrument. METHODS: This was a prospective, observational cohort study of a population-based convenience sample of adult patients triaged during 100 hours at two urban referral hospitals. Validation by resource use and hospitalization (criterion standards) and reproducibility by blinded paired triage assignments compared with weighted kappa analysis were assessed. RESULTS: Five hundred thirty-eight patients were enrolled; 45 were excluded due to incomplete evaluations. The resulting cohort of 493 patients was 52% female, was 26% nonwhite, and had a median age of 40 years (range 16-95); overall, 159 (32%) patients were hospitalized. Weighted kappa for triage assignment was 0.80 (95% CI = 0.76 to 0.84). Resource use and hospitalization rates were strongly associated with triage level. For patients in category 5, only one-fourth (17/67) required any diagnostic test or procedure, and none were hospitalized (upper confidence limit, 5%). Conversely, in category 1, one of twelve patients was discharged (upper confidence limit, 25%), and none required fewer than two resources. CONCLUSIONS: This five-level triage instrument was shown to be both valid and reliable in the authors' practice settings. It reproducibly triages patients into five distinct strata, from very high hospitalization/resource intensity to very low hospitalization/resource intensity.     

Implementation and Refinement of the Emergency Severity Index

OBJECTIVES: To implement a new five-level emergency department (ED) triage algorithm, the Emergency Severity Index (ESI), into nursing practice, and validate the instrument with a population-based cohort using hospitalization and ED length of stay as outcome measures. METHODS: The five-level ESI algorithm was introduced to triage nurses at two university hospital EDs, and implemented into practice with reinforcement and change management strategies. Interrater reliability was assessed by a posttest and by a series of independent paired patient triage assignments, and a staff survey was performed. A cohort validation study of all adult patients registered during a one-month period immediately following implementation was performed. RESULTS: Eight thousand two hundred fifty-one ED patients were studied. Weighted kappa for reproducibility of triage assignments was 0.80 for the posttest (n = 62 nurses), and 0.73 for patient triages (n = 219). Hospitalization was 28% overall and was strongly associated with triage level, decreasing from 58/63 (92%) of patients in triage category 1, to 12/739 (2%) in triage category 5. Median lengths of stay were two hours shorter at either triage extreme (high and low acuity) than in intermediate categories. Outcomes followed a-priori predictions. Staff nurses rated the new program easier to use, and more useful as a triage instrument than previous three-level triage. They provided feedback, which resulted in significant revisions to the algorithm and educational materials. CONCLUSIONS: Triage nurses at these two hospitals successfully implemented the ESI algorithm and provided useful feedback for further refinement of the instrument. Emergency Severity Index triage reproducibly stratifies patients into five groups with distinct clinical outcomes.