Effect of a triage course on quality of rating triage codes in a group of university nursing students:a before-after observational study

BACKGROUND:

Most current triage tools have been tested among hospital nurses groups but there are not similar studies in university setting. In this study we analyzed if a course on a new four-level triage model, triage emergency method (TEM), could improve the quality of rating in a group of nursing students.

METHODS:

This observational study was conducted with paper scenarios at the University of Parma, Italy. Fifty students were assigned a triage level to 105 paper scenarios before and after a course on triage and TEM. We used weighted kappa statistics to measure the inter-rater reliability of TEM and assessed its validity by comparing the students’ predictions with the triage code rating of a reference standard (a panel of five experts in the new triage method).

RESULTS:

Inter-rater reliability was K=0.42 (95%CI: 0.37–0.46) before the course on TEM, and K=0.61 (95%CI: 0.56–0.67) after. The accuracy of students’ triage rating for the reference standard triage code was good: 81% (95%CI: 71–90). After the TEM course, the proportion of cases assigned to each acuity triage level was similar for the student group and the panel of experts.

CONCLUSION:

Among the group of nursing students, a brief course on triage and on a new in-hospital triage method seems to improve the quality of rating codes. The new triage method shows good inter-rater reliability for rating triage acuity and good accuracy in predicting the triage code rating of the reference standard.KEY WORDS: Emergency, Reliability, Triage, Triage system, Validity     

A systematic review on the validity and reliability of an emergency department triage scale,the Manchester Triage System

Objective

To conduct a systematic review to check the level of validity and reliability of the Manchester Triage System and the quality of reporting of literature on this topic.

Design

This is a systematic review based on the PRISMA guideline on reporting systematic reviews.

Data sources

The systematic search of the international literature published from 1997 through 30 November 2012 in the PubMed, Embase, Cochrane Library, Cinahl, Web of Knowledge, and Scopus databases.

Review methods

This review included quantitative and qualitative research investigating the reliability and validity of the Manchester Triage System for the broad population of adults and children visiting the emergency department.After a systematic selection process, included studies were assessed on their quality by three researchers using the STARD guidelines.

Results

Twelve studies were included in the review. The studies investigated the inter- and intra-rater reliability using the “kappa” statistic; the validity was tested with many measures: validity in predicting mortality, hospital admission, under- and overtriage, used resources, and length of stay in the emergency department, as well as a reference standard rating.

Conclusions

In this review, the Manchester Triage System shows a wide inter-rater agreement range with a prevalence of good and very good agreement. Its safety was low because of the high rate of undertriage and the low sensitivity in predicting higher urgency levels. The high rate of overtriage could cause unnecessarily high use of resources in the emergency department. The quality of the reporting in studies of the reliability and validity of the Manchester Triage System is good.     

Application of emergency severity index in pediatric emergency department

BACKGROUND:

The purpose of triage is to identify patients needing immediate resuscitation, to assign patients to a pre-designed patient care area, and to initiate diagnostic/therapeutic measures as appropriate. This study aimed to use emergency severity index (ESI) in a pediatric emergency room.

METHODS:

From July 2006 to August 2010, a total of 21 904 patients visited the International Department of Beijing Children’s Hospital. The ESI was measured by nurses and physicians, and compared using SPSS.

RESULTS:

Nurses of the hospital took approximately 2 minutes for triage. The results of triage made by nurses were similar to those made by doctors for ESI in levels 1-3 patients. This finding indicated that the nurses are able to identify severe pediatric cases.

CONCLUSION:

In pediatric emergency rooms, ESI is a suitable tool for identifying severe cases and then immediate interventions can be performed accordingly.KEY WORDS: Pediatrics, Emergency Department, Triage, Emergency severity index     

Translation,cross-cultural adaptation to Brazilian- Portuguese and reliability analysis of the instrument Rapid Entire Body Assessment-REBA

Background:

Observational instruments, such as the Rapid Entire Body Assessment, quickly assess biomechanical risks present in the workplace. However, in order to use these instruments, it is necessary to conduct the translational/cross-cultural adaptation of the instrument and test its measurement properties.

Objectives:

To perform the translation and the cross-cultural adaptation to Brazilian-Portuguese and test the reliability of the REBA instrument.

Method:

The procedures of translation and cross-cultural adaptation to Brazilian-Portuguese were conducted following proposed guidelines that involved translation, synthesis of translations, back translation, committee review and testing of the pre-final version. In addition, reliability and the intra- and inter-rater percent agreement were obtained with the Linear Weighted Kappa Coefficient that was associated with the 95% Confidence Interval and the cross tabulation 2×2.

Results

: The procedures for translation and adaptation were adequate and the necessary adjustments were conducted on the instrument. The intra- and inter-rater reliability showed values of 0.104 to 0.504, respectively, ranging from very poor to moderate. The percentage agreement values ranged from 5.66% to 69.81%. The percentage agreement was closer to 100% at the item ''upper arm'' (69.81%) for the Intra-rater 1 and at the items ''legs'' and ''upper arm'' for the Intra-rater 2 (62.26%).

Conclusions:

The processes of translation and cross-cultural adaptation were conducted on the REBA instrument and the Brazilian version of the instrument was obtained. However, despite the reliability of the tests used to correct the translated and adapted version, the reliability values are unacceptable according to the guidelines standard, indicating that the reliability must be re-evaluated. Therefore, caution in the interpretation of the biomechanical risks measured by this instrument should be taken.     

Brazilian version of the instrument of environmental assessment Craig Hospital Inventory of Environmental Factors (CHIEF): translation,cross-cultural adaptation and reliability

Background:

Environmental factors are essential for the characterization of human functioning and disability; however, the shortage of standardized instruments to assess environmental factors has limited the design of scientific investigations directed at identifying barriers to and facilitators of social participation of people with disabilities.

Objectives

: To translate to Brazilian Portuguese, cross-culturally adapt, and verify the reliability of an environmental assessment questionnaire, entitled Craig Hospital Inventory of Environmental Factors (CHIEF).

Method

: The questionnaire was translated to Portuguese, analyzed, translated back to English, and compared with the original version. The final version (CHIEF-BR) was submitted to 47 caregivers of children and adolescents with cerebral palsy (CP). The intra-rater reliability was tested using quadratic kappa and intraclass correlation coefficients (ICC), through interviews of 23 caregivers drawn from the total sample, on two occasions 10 days apart.

Results

: During submission of the questionnaires, it was observed that examples were needed in order to facilitate the understanding of the questions related to the politics sub-scale. Quadratic kappa showed that test-retest reliability of each question varied from 0.28 to 1.0 for the frequency score and from 0.30 to 0.98 for the magnitude score. Intraclass correlation coefficients for total scores showed high consistency indices (ICC≥0.92) for test-retest.

Conclusion

: The Brazilian version of the CHIEF was reproducible and applicable to the study sample. It may serve as an instrument to characterize the environmental barriers as well as a way to document the effects of interventions aimed at minimizing the impact of such barriers on the participation of children and adolescents with CP.     

Manual Ability Classification System (MACS): reliability between therapists and parents in Brazil

BACKGROUND:

The Manual Ability Classification System (MACS) has been widely used to describe the manual ability of children with cerebral palsy (CP); however its reliability has not been verified in Brazil.

OBJECTIVE:

To establish the inter- and intra-rater reliability of the Portuguese-Brazil version of the MACS by comparing the classifications given by therapists and parents of children with CP.

METHOD:

Data were obtained from 90 children with CP between the ages of 4 and 18 years, who were treated at the neurology and rehabilitation clinics of a Brazilian hospital. Therapists (an occupational therapist and a student) classified manual ability (MACS) through direct observation and information provided by parents. Therapists and parents used the Portuguese-Brazil version of the MACS. Intra- and inter-rater reliability was obtained using unweighted Kappa coefficient (k) and intra-class correlation coefficient (ICC). The Chi-square test was used to identify the predominance of disagreements in the classification of parents and therapists.

RESULTS:

An almost perfect agreement resulted among therapists [K=0.90 (95% CI 0.83-0.97); ICC=0.97 (95%CI 0.96-0.98)], as well as with intra-rater (therapists), with Kappa ranging between 0.83 and 0.95 and ICC between 0.96 and 0.99 for the evaluator with more and less experience in rehabilitation, respectively. The agreement between therapists and parents was fair [K=0.36 (95% CI 0.22-0.50); ICC=0.79 (95% CI 0.70-0.86)].

CONCLUSIONS:

The Portuguese version of the MACS is a reliable instrument to be used jointly by parents and therapists.     

THE NAVICULAR POSITION TEST – A RELIABLE MEASURE OF THE NAVICULAR BONE POSITION DURING REST AND LOADING

Background:

Lower limb injuries are a large problem in athletes. However, there is a paucity of knowledge on the relationship between alignment of the medial longitudinal arch (MLA) of the foot and development of such injuries. A reliable and valid test to quantify foot type is needed to be able to investigate the relationship between arch type and injury likelihood. Feiss Line is a valid clinical measure of the MLA. However, no study has investigated the reliability of the test.

Objectives:

The purpose was to describe a modified version of the Feiss Line test and to determine the intra- and inter-tester reliability of this new foot alignment test. To emphasize the purpose of the modified test, the authors have named it The Navicular Position Test.

Methods:

Intra- and inter-tester reliability were evaluated of The Navicular Position Test with the use of ICC (interclass correlation coefficient) and Bland-Altman limits of agreement on 43 healthy, young, subjects.

Results:

Inter-tester mean difference -0.35 degrees [–1.32; 0.62] p = 0.47. Bland-Altman limits of agreement –6.55 to 5.85 degrees, ICC = 0.94. Intra-tester mean difference 0.47 degrees [–0.57; 1.50] p = 0.37. Bland-Altman limits of agreement –6.15 to 7.08 degrees, ICC = 0.91.

Discussion:

The present data support The Navicular Position Test as a reliable test of the navicular bone position during rest and loading measured in a simple test set-up.

Conclusion:

The Navicular Position Test was shown to have a high intraday-, intra- and inter-tester reliability. When cut off values to categorize the MLA into planus, rectus, or cavus feet, has been determined and presented, the test could be used in prospective observational studies investigating the role of the arch type on the development of various lower limb injuries.     

Lean techniques for the improvement of patients’ flow in emergency department

BACKGROUND:

Emergency departments (EDs) face problems with overcrowding, access block, cost containment, and increasing demand from patients. In order to resolve these problems, there is rising interest to an approach called “lean” management. This study aims to (1) evaluate the current patient flow in ED, (2) to identify and eliminate the non-valued added process, and (3) to modify the existing process.

METHODS:

It was a quantitative, pre- and post-lean design study with a series of lean management work implemented to improve the admission and blood result waiting time. These included structured re-design process, priority admission triage (PAT) program, enhanced communication with medical department, and use of new high sensitivity troponin-T (hsTnT) blood test. Triage waiting time, consultation waiting time, blood result time, admission waiting time, total processing time and ED length of stay were compared.

RESULTS:

Among all the processes carried out in ED, the most time consuming processes were to wait for an admission bed (38.24 minutes; SD 66.35) and blood testing result (mean 52.73 minutes, SD 24.03). The triage waiting time and end waiting time for consultation were significantly decreased. The admission waiting time of emergency medical ward (EMW) was significantly decreased from 54.76 minutes to 24.45 minutes after implementation of PAT program (P<0.05).

CONCLUSION:

The application of lean management can improve the patient flow in ED. Acquiescence to the principle of lean is crucial to enhance high quality emergency care and patient satisfaction.KEYWORDS: Lean, Triage, Waiting time, Patient flow, Emergency department     

Development and psychometric evaluation of an information literacy self-efficacy survey and an information literacy knowledge test

Objective

To develop and psychometrically evaluate an information literacy (IL) self-efficacy survey and an IL knowledge test.

Methods

In this test–retest reliability study, a 25-item IL self-efficacy survey and a 50-item IL knowledge test were developed and administered to a convenience sample of 53 chiropractic students. Item analyses were performed on all questions.

Results

The IL self-efficacy survey demonstrated good reliability (test–retest correlation = 0.81) and good/very good internal consistency (mean κ = .56 and Cronbach''s α = .92). A total of 25 questions with the best item analysis characteristics were chosen from the 50-item IL knowledge test, resulting in a 25-item IL knowledge test that demonstrated good reliability (test–retest correlation = 0.87), very good internal consistency (mean κ = .69, KR20 = 0.85), and good item discrimination (mean point-biserial = 0.48).

Conclusions

This study resulted in the development of three instruments: a 25-item IL self-efficacy survey, a 50-item IL knowledge test, and a 25-item IL knowledge test. The information literacy self-efficacy survey and the 25-item version of the information literacy knowledge test have shown preliminary evidence of adequate reliability and validity to justify continuing study with these instruments.Key Indexing Terms: Chiropractic, Evidence-Based Practice, Information Literacy, Psychometrics, Questionnaire Design     

Inter-examiner reliability of diplomats in the mechanical diagnosis and therapy system in assessing patients with shoulder pain

Objective:

To investigate the inter-examiner reliability of Mechanical Diagnosis and Therapy (MDT)-trained diplomats in classifying patients with shoulder disorders. The MDT system has demonstrated acceptable reliability when used in patients with spinal disorders; however, little is known about its utility when used for appendicular conditions.

Methods:

Fifty-four clinical scenarios were created by a group of 11 MDT diploma holders based on their clinical experience with patients with shoulder pain. The vignettes were made anonymous, and their clinical diagnoses sections were left blank. The vignettes were sent to a second group of six international McKenzie Institute diploma holders who were asked to classify each vignette according to the MDT categories for upper extremity. Inter-examiner agreement was evaluated with kappa statistics.

Results:

There was ‘very good’ agreement among the six MDT diplomats for classifying the McKenzie syndromes in patients with shoulder pain (kappa = 0.90, SE = 0.018). The raw overall level of multi-rater agreement among the six clinicians in classifying the vignettes was 96%. After accounting for the actual MDT category for each vignette, kappa and the raw overall level of agreement decreased negligibly (0.89 and 95%, respectively).

Discussion:

Using clinical vignettes, the McKenzie system of MDT has very good reliability in classifying patients with shoulder pain. As an alternative, future reliability studies could use real patients instead of written vignettes.     

THE FUNCTIONAL MOVEMENT SCREENING (FMS)?: AN INTER‐RATER RELIABILITY STUDY BETWEEN RATERS OF VARIED EXPERIENCE

Background:

Previous researchers have reported on the reliability of the scoring of the FMS™ movement screens. Those authors have reported good to excellent inter‐rater reliability between paired raters of similar experience level (either novice or expert), but no comparisons of inter‐rater reliability exist between a novice and an expert.

Purpose:

The purpose of this investigation was to examine the inter‐rater reliability of the scoring of the FMS™ between trained novices and an expert rater using video records.

Methods:

Twenty healthy college students participated. Each participant performed the series of seven functional movement screens. Four raters (three novices and one expert) independently scored the seven FMS™ tests by watching video recordings of the movements..

Results:

The mean total FMS™ score for all subjects was 14.6 ± 1.9, and was not significantly different between raters (p = 0.136). For the individual tests, half of them had perfect agreement, while the other half ranged from slight to moderate agreement (33‐66%).

Conclusion:

Conclusion: Total FMS™ scores were similar among the raters, and the inter‐rater reliability for a majority of the individual tests had as strong agreement despite the various level of experience of the raters scoring the FMS™ tests.

Clinical Relevance:

Although there was mostly moderate to perfect agreement among raters, the level of experience of the rater scoring the FMS™ should be considered, as it appears that the expert rater was more critical than novice raters in the interpretation of the scoring criteria.

Level of Evidence:

Level 3     

Analysis of Test-Retest Reliability,Construct Validity,and Internal Consistency of the Brazilian Version of the Pelvic Girdle Questionnaire

Objective

The purpose of this study was to evaluate test-retest reliability, construct validity, and internal consistency of the Brazilian version of the Pelvic Girdle Questionnaire (PGQ-Brazil).

Instrumented Measurement of Spinal Stiffness: A Systematic Literature Review of Reliability

Objective

The purpose of this review was to critically appraise the quality of studies evaluating the reliability of spinal stiffness assessment devices.

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.     

Medial Longitudinal Arch: Accuracy,Reliability, and Correlation Between Navicular Drop Test and Footprint Parameters

Objective

The purpose of this study was to evaluate the correlation among the navicular drop test, the arch angle, the Staheli index and the Chippaux-Smirak index. The reliability and the correlation among the footprint parameters were also estimated.

EVALUATING CHANGE IN CLINICAL STATUS: RELIABILITY AND MEASURES OF AGREEMENT FOR THE ASSESSMENT OF GLENOHUMERAL RANGE OF MOTION

Objectives:

To evaluate intra-rater and inter-rater reliability and measurement error in glenohumeral range of motion (ROM) measurements using a standard goniometer.

Study design:

17 adult subjects with and without shoulder pathology were evaluated for active and passive range of motion. Fifteen shoulder motions were assessed by two raters to determine reliability. The intra-class correlation coefficients (ICC) were calculated and examined to determine if reliability of ICC ≥ 0.70 existed. The standard error of measurement (SEM) and the minimal clinical difference (MCD) were also calculated.

Results:

Thxe criterion reliability was achieved in both groups for intra-rater reliability of standing AROM abduction; supine AROM and PROM abduction, flexion, external rotation at 0° abduction; and for inter-rater reliability of supine AROM and PROM abduction, external rotation at 0° abduction. The SEM ranged from 4°-7° for intra-rater and 6°-9° for inter-rater agreement on movements that achieved the criterion reliability. The MCD ranged from 11°-16° for a single evaluator and 14°-24° for two evaluators.

Conclusions:

Assessment of AROM and PROM in supine achieves superior reliability. The use of either a single or multiple raters affects the number of movements that achieved clinically meaningful reliability. Some movements consistently did not achieve the criterion and may not be the best movements to monitor treatment outcome.     

Spinal cord stimulation for patients with inoperable chronic critical leg ischemia

BACKGROUND:

Because of the prevalence of diabetes, the treatment of diabetic foot is still challenging. Even an exactly proved effective and practical method can’t be listed except vascular surgery which is not a long-term way for it. Spinal cord stimulation (SCS) is a very promising option in the treatment algorithm of inoperable chronic critical leg ischemia (CLI).

DATA SOURCES:

We searched Pubmed database with key words or terms such as “spinal cord stimulation”, “ischemic pain” and “limb ischemia” appeared in the last five years.

RESULTS:

The mechanism of SCS is unclear. Two theories have emerged to interpret the benefits of SCS. Pain relief from SCS can be confirmed by a majority of the studies, while limb salvage and other more ambitious improvements have not come to an agreement. The complications of SCS are not fatal, but most of them are lead migration, lead connection failure, and local infection.

CONCLUSIONS:

SCS is a safe, promising treatment for patients with inoperable CLI. It is effective in pain reduction compared with traditional medical treatment.KEY WORDS: Spinal cord stimulation, Critical leg ischemia, Pain reduction     

Testing the Simple Lifestyle Indicator Questionnaire: Initial psychometric study

OBJECTIVE

To carry out initial psychometric testing on the Simple Lifestyle Indicator Questionnaire (SLIQ).

DESIGN

Self-administered questionnaire to obtain data for test-retest reliability, for Cronbach α testing on completed questionnaires, and for blinded external validity testing.

SETTING

Kingston, Ont, and surrounding area.

PARTICIPANTS

One hundred thirty-six family practice patients with an mean age of 68 years; 58% were women. Subjects were primarily white and living in a small city and itsrural surroundings.

MAIN OUTCOME MEASURES

Test-retest coefficients, Cronbach α values, and correlation coefficients.

RESULTS

Test-retest reliability on the 12 questions ranged from 0.63 to 0.97. The Cronbach α was 0.58 for questions on diet and 0.6 for questions on physical activity. We found a correlation coefficient of 0.77 between participants’ and blinded raters’ scores on the SLIQ.

CONCLUSION

The SLIQ, as currently tested, is likely suitable for use in research on people who are at least similar to those in our study population. It probably should not be used in clinical settings until further testing has been carried out.     

Acute hyperlipidemic pancreatitis in a pregnant woman

BACKGROUND:

Acute pancreatitis is a serious complication during pregnancy, however the incidence of hyperlipidemia induced by pancreatitis is lower.

METHODS:

We treated a pregnant woman with hypertriglyceridemia-associated acute gestational pancreatitis who simultaneously developed hypoxemic acute respiratory failure (ARF).

RESULTS:

The woman was successfully treated through noninvasive positive pressure ventilation (NPPV), emergent caesarean delivery, drainage of chylous ascites, and peritoneal lavage.

CONCLUSION:

The signs and symptoms of ARF were greatly improved in this patient after NPPV and conventional therapies. Early NPPV may be related to good prognosis of the disease.KEY WORDS: Hyperlipidemia, Pancreatitis, Pregnancy     

Assessing Electronic Note Quality Using the Physician Documentation Quality Instrument (PDQI-9)

Objective

To refine the Physician Documentation Quality Instrument (PDQI) and test the validity and reliability of the 9-item version (PDQI-9).

Methods

Three sets each of admission notes, progress notes and discharge summaries were evaluated by two groups of physicians using the PDQI-9 and an overall general assessment: one gold standard group consisting of program or assistant program directors (n = 7), and the other of attending physicians or chief residents (n = 24). The main measures were criterion-related validity (correlation coefficients between Total PDQI-9 scores and 1-item General Impression scores for each note), discriminant validity (comparison of PDQI-9 scores on notes rated as best and worst using 1-item General Impression score), internal consistency reliability (Cronbach’s alpha), and inter-rater reliability (intraclass correlation coefficient (ICC)).

Results

The results were criterion-related validity (r = –0.678 to 0.856), discriminant validity (best versus worst note, t = 9.3, p = 0.003), internal consistency reliability (Cronbach’s alphas = 0.87–0.94), and inter-rater reliability (ICC = 0.83, CI = 0.72–0.91).

Conclusion

The results support the criterion-related and discriminant validity, internal consistency reliability, and inter-rater reliability of the PDQI-9 for rating the quality of electronic physician notes. Tools for assessing note redundancy are required to complement use of PDQI-9. Trials of the PDQI-9 at other institutions, of different size, using different EHRs, and incorporating additional physician specialties and notes of other healthcare providers are needed to confirm its generalizability.