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Triage nurses’ decisions using the National Triage Scale for Australian emergency departments
Original article
Triage nurses’ decisions using the National Triage Scale for Australian emergency departments Julie Considine RN, RM, BN, CertAcuteCareNsg (Emerg), GradDipNsg(Acute Care), MN, PhD candidate, Clinical Nurse Educator, Emergency Department, Dandenong Hospital, David Street, Dandenong, 3175, Victoria, Australia. Tel.: +03 9554 1000; E-mail: jconsidine@alphali nk.com.au Professor Lerma Ung RN, MN, DipAppSc (N Ed), BSc(Med), MHSc, PhD, Chair, Acute Care Nursing, Cabrini/Deakin Professorial Unit, Cabrini Hospital, 183 Wattletree Rd, Malvern, 3144 Victoria, Australia Shane Thomas BA(Hons), Dip Public Policy, PhD, Adjunct Professor, Faculty of Health and Behavioural Sciences, Deakin University, Cabrini/Deakin Professorial Unit, Cabrini Hospital, 183 Wattletree Rd Malvern, 3144 Victoria, Australia Correspondence to: Julie Considine Manuscript accepted: 12 July 2000
J. Considine, L. Ung, S. Thomas
The initiation of emergency care primarily depends on the decisions made by the triage nurse. Triage decisions can therefore have a profound effect on the health outcomes of patients who present for emergency care. If the National Triage Scale (NTS) was effective in providing a standardized approach to triage, a patient with a specific problem should be allocated to the same triage category, irrespective of the institution to which they present or the personnel performing the role of triage. This study examines triage nurses’ level of agreement in their allocation of triage categories to patients with specific presenting problems using the NTS. Relationships between demographic characteristics of participants and triage decisions are examined and implications of any variation for triage practice and patient outcomes are explored. © 2000 Harcourt Publishers Ltd
Introduction The triage role differentiates emergency nursing from other nursing specialities. Triage begins when a patient presents to an emergency department (ED) (Australasian College for Emergency Medicine 1993b, Dilley & Standen 1998). As EDs are often faced with more patients than their staffing and physical resources can manage, a process of prioritizing patients must occur. During the triage process patients are categorized according to severity of illness or injury. Staff and resources are then allocated firstly to those with life threatening illness or injury and other patients are seen in order of their need for emergency care. An effective triage system aims to ensure that patients receive ‘… appropriate attention, in a suitable location, with the requisite degree of urgency …’ on the basis of a rapid, accurate initial assessment (George et al. 1993).
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In Australia, triage is predominantly a nursing role. During the triage process, nurses are required not only to rapidly identify and respond to actual life threatening states, but also assess the potential for such states to occur (Brillman et al. 1996, Monitor, 1985). The initiation of emergency care primarily depends on the decisions made by the triage nurse. Triage decisions therefore can have a profound effect on the health outcomes of ED patients (Commonwealth Department of Health and Family Services and the Australasian College for Emergency Medicine 1997, Williams 1992). The National Triage Scale (NTS) for Australian Emergency Departments is used by most ED’s to establish patient care priorities. The NTS is a five point scale designed by the Australasian College for Emergency Medicine in 1993 with the aim of promoting a standardized approach to triage. Every patient who presents to an ED is assigned a triage category based on the nature of their
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Table 1 National Triage Scale for Australian Emergency Departments adapted from: Australasian College for Emergency Medicine, 1993b, p10. Triage Code
Treatment Acuity*
National Triage Scale
Category 1
Immediate
Resuscitation
Category 2
Within 10 minutes
Emergency
Category 3
Half Hour
Urgent
Category 4
One Hour
Semi Urgent
Category 5
Two Hours
Non Urgent
* for medical care
presenting problem and the need for medical care (Australasian College for Emergency Medicine 1993b, Commonwealth Department of Health and Family Services and the Australasian College for Emergency Medicine 1997). The categories used in the NTS are shown in Table 1. If the NTS was effective in providing a standardized approach to triage, a patient with a specific problem should be allocated to the same triage category, irrespective of the institution to which they present or the personnel performing the role of triage (Doherty 1996, Commonwealth Department of Health and Family Services and the Australasian College for Emergency Medicine 1997, Dilley & Standen 1998). In simple terms, a patient should be able to present to any triage nurse, in any ED, at any time of the day or night, with a specific problem and be allocated to the same triage category. The consequence of variation in triage decisions is discrepancy in the length of time that a patient must wait before receiving medical intervention. This has implications both for the patient being triaged, and the ability of the ED to function effectively. In general, there are three outcomes of triage decisions. A patient may present and be allocated to a triage category that is appropriate to his or her presenting problem. This patient is seen by a doctor within a suitable time frame and should have a positive health outcome. Problems occur if the same patient is allocated to a triage category of higher or lower acuity than required. If a triage category of higher acuity is selected, the patient’s waiting time until medical intervention is shorter than anticipated. Although this is not detrimental to the patient in question, the effect of
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inappropriate allocation of resources has the potential to adversely affect other patients in the ED. This type of triage decision is referred to as ‘overtriage’. If a triage category of lower acuity is selected, the patient’s waiting time until medical intervention would be prolonged and the risk of an adverse patient outcome is increased. There is the potential for patients to deteriorate or develop life threatening complications whilst waiting and patients may be subjected to prolonged pain or suffering. This type of triage decision is referred to as ‘undertriage’ (Considine 1998, Hollis & Sprivulis 1996). Although the NTS was designed for the purpose of prioritizing patient care in the ED context, lack of consensus regarding the application of the NTS still exists. Of concern is the fact that the NTS is now used in the context of ‘… workload and performance indicators …’ (Fitzgerald 1996, p.206) and has ‘… formed the basis of the Australian Council on Health Care Standards Clinical Indicators for Emergency Medicine’ (Jelinek & Little 1996, p229). It is also being used in some states as a funding determinant with ‘… Medicare Performance Funding and Incentive Package Funding … dependent on the percentage of patients seen within the required time intervals of the NTS’ (Jelinek & Little 1996, p.229, Health and Community Services 1995). The use of the NTS for funding, resource allocation and measurement of ED performance contradicts the National Triage Scale User Manual which clearly states that ‘Triage requires a clinical decision, which has regard only to the patient’s individual need for care.’ (Commonwealth Department of
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Health and Family Services and the Australasian College for Emergency Medicine 1997, p.5). The importance of the need for uniform application of the NTS is well recognized. Adjustment of triage practice to ‘… optimise financial outcomes under various funding models or incentives programs …’ has been labelled as unethical (Commonwealth Department of Health and Family Services and the Australasian College for Emergency Medicine, 1997, p.6). The decisions made by triage nurses now have significant administrative, political, economic and health care implications. As triage is predominantly a nursing role, it is imperative that the application of the NTS by nurses is closely examined.
from non-English-speaking backgrounds and of low socioeconomic status. The other ED was in a Victorian rural base hospital that provides general adult and paediatric services and operates an accident retrieval service. This hospital is situated in a large country town that is surrounded by isolated farming properties. These EDs were selected as they have diversity of presentations and they serve very different populations. As the environments in which triage nurses practice vary between institutions, the features of these EDs allowed for a greater representation of triage nurses.
Instrument
Aims of the study The aims of this study were: • to determine the level of agreement or variation that occurred between triage nurses in their allocation of triage categories to patients with specific presenting problems using the NTS • to examine the relationships (if any) between participants’ demographic characteristics and triage decisions • to explore the implications of any variation for triage practice and patient outcomes.
Method A correlational design using survey methods was employed in this study. A correlational design was selected as it allowed for the identification of relationships between variables. Survey methods were selected as this allowed answers to be sought from participants based on the same amount of information.
Setting This study was conducted in two Victorian EDs. One ED was in a large Melbourne teaching hospital that provided a wide range of general and specialist adult services as well as being a major health care provider for the poor and disadvantaged. The area surrounding this hospital is high density inner city housing and the patient population served by this hospital has a high proportion of persons who are homeless,
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At the time of this study, there was very little published research on the NTS and there were no validated data collection instruments in existence. In response to the need to develop a data collection instrument, a self administered questionnaire was developed by the researcher. The first section of the instrument required participants to complete demographic details and the second section presented participants with 10 adult patient scenarios. Each scenario required the participant to allocate a NTS category. Specialty scenarios, such as paediatrics and obstetrics, were not included as these presentations were only seen routinely at one of the two participating EDs. Written patient scenarios have been widely used in clinical decision making research. They have been validated for use in measuring the problem solving skills of nurses and have been considered useful in evaluating analytical skills and decision making (Holzemer et al 1981, Carroll & Johnson 1990). Patient scenarios were used in this study because they ensured that participants’ responses were based on the same information. There was also no way to replicate the same patient presentation to many different triage nurses and any risk to real patients was eliminated. The questionnaire was examined by nominated expert triage nurses to establish face and content validity, to assess clarity and ease of administration, and to judge the degree of fidelity of each scenario to real triage situations. Each of the expert triage nurses had post graduate qualifications in emergency nursing, a Bachelor
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Patient Scenario 1: A 78-year-old male presents to triage with his friend following falling down 1 step, landing on concrete, 15 minutes ago. He complains only of a 2 cm laceration to the centre of his forehead. He has good recall of events and his friend states that he had no loss of consciousness. He is alert, his laceration is not bleeding and he is not bothered by the placement of a dressing over his laceration. Patient Scenario 2: A 76-year-old female presents to triage with a referring letter from her local medical officer general practitioner. He states that she has a cellulitic area on her left lower leg that developed after an insect bite 1 week ago. She has taken oral antibiotics with poor effect and he states that she will need admission for intravenous antibiotics. On examination she has a warm, reddened area on her left lower leg, although she states it is not painful. Her temperature at triage is 37.2°C. Patient Scenario 3: A 24-year-old female presents with a two day history of increasing right iliac fossa pain. She has had associated nausea and anorexia, but no vomiting or diarrhoea. She denies any urinary symptoms and states that she had a normal bowel action yesterday. Her last normal menstrual period was 2 weeks ago. Her temperature is 37.60°C, heart rate 98 bpm, and respiratory rate 22/min. She rates her pain as 5/10 and her pain increases with movement. Patient Scenario 4: A 42-year-old male presents to triage complaining of central chest pain. He states the pain is “crushing” in nature and began after heavy physical labour approximately one hour prior to arrival. He states that the pain does not radiate and does not change with movement or inspiration. He states that he has never had chest pain before. His only associated symptom is dyspnoea and his skin is pale, cool and moist. Patient Scenario 5: A 20-year-old male presents by ambulance following a motor car accident. He was the driver of a vehicle that was struck on the driver’s side by a truck that ran a red light. The ambulance officers state that the vehicle was pushed approximately 20 m and the damage to the vehicle was such that the door had to be cut off to remove the driver. He was wearing a seatbelt and there was no loss of consciousness. On arrival his skin is pale, cool and moist with capillary refill of 4 s. The ambulance officers report that his pulse is 156 bpm, blood pressure 100/70 mmHg, respiratory rate 32/min and his SaO2 is 90%. He is orientated to time, place and person. His only complaint is of severe right lower chest pain that increases on inspiration. He is being administered oxygen at 10 L/min and has a cervical collar in situ from the ambulance service. Patient Scenario 6: A 16-year-old male presents by ambulance following a fall at school. He has a history of intellectual disability and although he requires only minimal assistance in his activities of daily living, he is unable to communicate verbally. He is accompanied by a carer from the school who informs you that he is allergic to penicillin, and his only medical history is asthma for which he uses a Ventolin puffer. She states that he was knocked over by another student, falling onto a concrete path. There was a brief period of LOC lasting only a 2–3 min. Enroute he had a clonictonic seizure that resolved simultaneously after 3–4 min. On arrival his skin is pink, warm and dry. His eyes are open, he does not respond verbally, but does obey command and smiles to name. Patient Scenario 7: A 56-year-old male walks through the ambulance doors. He is centrally cyanosed and is unable to speak. His skin is cool and moist. His wife tells you that he has asthma and that he has been using his Ventolin puffer every 15 min for the last 2 h. He has maximal use of his accessory muscles, but has no audible wheeze. Patient Scenario 8: A 22-year-old male presents to triage stating that he has ‘vomited blood’ twice in the last 6 h. He describes dark bowel actions for the past 3 days and states he drinks at least 12 cans of beer a day. His skin is pale, warm and dry with capillary refill of less than 2 s, his heart rate is 108 bpm and his respiratory rate is 20/min. He states he does not have any pain but complains of nausea. Patient Scenario 9: An 80-year-old female presents by ambulance following a fall whilst doing the vacuuming. She states she placed her hand out to break her fall and now complains of a painful (L) wrist. Her (L) wrist appears swollen, deformed and is painful to touch. She has a splint insitu, applied by the ambulance officers, and has normal color, warmth, movement and sensation in the fingers of her (L) hand. Her (L) radial pulse is palpable. Patient Scenario 10: A 55-year-old female presents to triage complaining of a ‘cold’ for 4 days. She presents because of 2 days of increasing right upper quadrant and right thoracic back pain. She states that she has had no vomiting, diarrhoea or urinary symptoms but describes 1 day of increasing dyspnoea. Her skin is pale, hot and moist and she has normal respiratory effort without the use of accessory muscles. Her temperature is 38. 80°C, heart rate 112 bpm, and respiratory rate 26/min. She rates her pain as 7/10 and her pain increases with movement and deep inspiration. Fig. 1
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Examples of Patient Scenarios used in the Study
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of Nursing and a Graduate Diploma related to acute care nursing. Two of the expert triage nurses were also currently undertaking Master of Nursing qualifications and both were undertaking research projects relating to triage. All expert triage nurses judged the scenarios as having a high level of fidelity to real triage situations. In order to test the scenarios, the expert triage nurses were asked to complete each of the patient scenarios. Their responses were compared with the response expected by the researcher and 100% agreement was reached on the most appropriate triage category for each scenario. The agreed triage category for each patient scenario was referred to as the ‘expected triage category’ and this was used for judging the appropriateness of the participants’ triage category allocation and level of agreement between participants. Examples of the patient scenarios used in the study are seen in Figure 1.
Sample and sampling process The population for the study consisted of all the registered nurses working in the two EDs selected. As this study focused on triage decision making, only those nurses who could be rostered to the triage role were eligible to participate in the study. The total number of registered nurses who could be rostered to triage, and therefore met the inclusion criteria for the study, was 42. Given the small numbers of triage nurses, random sampling was not employed and convenience sampling was used. All 42 triage nurses were invited to participate in the study and 31 triage nurses responded by completing and returning the questionnaire. This gave a response rate of 74%.
Data collection The questionnaires were distributed to the triage nurses and a covering letter was included, explaining the nature of the study and assuring confidentiality and anonymity. The participants were asked to return the questionnaires to a nominated point in the ED within a 2-week time frame. The researcher then collected the questionnaires from each ED.
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Results The computer software package SPSS® Version 6.1 was used for statistical analysis. Frequency and descriptive statistics were obtained and the level of agreement between triage nurses using the NTS examined. As the data was predominantly ordinal data, non-parametric correlation measures were used. The Spearman correlation coefficient (rs) was used with two-tailed significance as it indicates both the strength and direction of identified associations. Significance was identified by a probability of less than 5% (P < 0.05).
Participants’ demographic characteristics When participants’ years of experience in emergency nursing were examined, 29.1% of participants had two or fewer years experience and 32.2% of participants had 10 or more years of emergency nursing experience. Examination of participants’ years of triage experience revealed that 32.3% of participants had 2 or fewer years of triage experience, almost half of the participants (48.4%) had 3 to 6 years triage experience and 19.3% reported 10 or more years of triage experience. Examination of participants’ level of appointment revealed that 64.54% were employed as registered nurses (staff nurses), 22.6% were clinical nurse specialists and 12.9% were employed in unit management (associate unit manager or unit manager). When participants were asked to indicate how many shifts per month they were rostered to triage, almost half (45.2%) reported that 21–60% of their ED shifts were spent at triage.
Relationships between demographic characteristics Statistically significant positive correlations were identified between the age of the triage nurse and experience in both emergency nursing (P <0.001) and triage (P <0.001) indicating that the older triage nurses were also more experienced. Experience in emergency nursing was positively correlated with triage experience (P <0.001) demonstrating that experienced triage nurses are also experienced emergency nurses. No correlation was identified between the number of
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shifts rostered to the triage role and either triage or emergency nursing experience. This raises a question as to whether triage nurses with more experience in emergency nursing and triage are being under rostered to this role. Higher level of appointment demonstrated positive correlations with increasing age (P = 0.003) and more years of experience in emergency nursing (P <0.001) and triage (P <0.001). These findings indicate that triage nurses who are employed in unit management or as clinical nurse specialists are older and more experienced.
Participants’ triage decisions Participants’ allocation of triage categories using the NTS were examined for each patient scenario. The ‘expected triage category’ was used as the standard by which to judge participants’ triage category allocation. In addition, participants’ responses were also examined to determine the most frequently allocated triage category for each patient scenario and this was referred to as the ‘modal triage category’. Table 2 shows participants’ triage category allocation for each patient scenario.
Table 2
The ‘expected triage category’ and the ‘modal triage category’ were the same for 7 of the 10 scenarios (patient scenarios 3, 4, 5, 7, 8, 9 and 10). The difference between the ‘expected triage category’ and the ‘modal triage category’ for the remaining patient scenarios was one adjacent triage category. The frequency with which the ‘expected triage category’ was selected for each patient scenario ranged from 10 (32.2%) to 26 (83.8%). The frequency with which the ‘modal triage category’ was selected for each patient scenario ranged from 51.6% to 83.8%. There was no patient scenario in which all participants responded with the same triage category. Six scenarios (patient scenarios 3, 5, 6, 7, 8 and 10) had responses across two adjacent triage categories and four scenarios (patient scenarios 1, 2, 4 and 9) had triage categories allocated across three adjacent categories. The four scenarios in which the triage responses spanned three different triage categories all contained a small number of participants who allocated triage categories of unusually high or unusually low acuity. The number of participants who responded across two triage categories for these scenarios ranged from 26 (83.8%) to 30 (96.8%). The number of participants whose
Participants’ Triage Category Allocation for each Patient Scenario
Patient Scenario
Cat 1 n
Cat 2 n
Cat 3 n
Cat 4 n
Cat 5 N
Patient Scenario 1 – Fall
2
19
10**
Patient Scenario 2 – Localised cellulitis
1
16
14**
Patient Scenario 3 – RIF Pain Patient Scenario 4 – Chest Pain Patient Scenario 5 – Multiple trauma
15 2 21**
Patient Scenario 6 – Head injury & seizure Patient Scenario 7 – Asthma
26**
3
10 10**
16**
16**
21
15
Patient Scenario 8 – Haematemesis & Malaena
25**
Patient Scenario 9 – Colles#
10
Patient Scenario 10 – RUQ Pain
24**
6 18**
3
7
** expected response for each patient scenario
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responses entered a third triage category ranged from 1 (3.2%) to 3 (9.7%). Each of the 31 participants completed 10 patient scenarios resulting in a total of 310 triage episodes. The total number of ‘expected triage category’ responses was 180 (58%) and the total number of ‘modal triage category’ responses was 202 (65.2%). The overall level of agreement of triage nurses using the NTS ranged from 58% (‘expected triage category’) to 65.2% (‘modal triage category’).
Relationships between triage decisions and demographic characteristics No correlation was found between participants’ triage decisions and age or years of experience in emergency nursing or triage. A positive correlation was found between ‘overtriage’ decisions and increased frequency of shifts rostered to the triage role (P = 0.041) suggesting that triage nurses who had a higher number of shifts rostered to triage were more likely to make ‘overtriage’ decisions. No relationship was identified between the percentage of shifts rostered to triage and ‘expected triage’ or ‘undertriage’ decisions. A negative correlation was identified between ‘overtriage’ decisions and higher level of appointment (P = 0.021). This finding suggests that clinical nurse specialists and those in unit management were less likely to ‘overtriage’ than their more junior counterparts.
Discussion At the time of this study, little published research on the NTS was available. Despite this, the findings of this study with regard to participants’ triage decisions resemble those of the other available studies in this area. A study by Jelinek and Little (1996) had 115 participants triage 100 written patient profiles. All (100%) patient profiles were triaged to within one category of the modal response by 86% of participants and over half the participants agreed with the modal response for 89% of the patient profiles. Doherty (1996) had 24 participants complete 12 patient scenarios. He reported that there was no scenario in which all participants agreed and responses for 10 of the 12 (83.3%) scenarios spanned three or more NTS categories. A study by Dilley and
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Standen (1998) involved 188 participants who completed 20 patient scenarios and again, there was no scenario in which the patient was triaged to the same category by all participants. Seventeen (85%) patient scenarios were triaged across two triage categories by more than 90% of participants. There were triage responses spanning three triage categories for four (20%) scenarios and 15 (75%) scenarios elicited triage responses across four triage categories. The results of this study are an improvement on previous studies with six (60%) patient scenarios being triaged to two triage categories and only four (40%) scenarios eliciting responses across three triage categories. No scenario in this study had triage responses across four different triage categories. This variability of allocation of triage categories raises concerns about patient waiting times and the health outcomes of patients who present for emergency care. The fact that there was not one scenario in which all participants responded with the same triage category has vast implications for emergency nursing practice. In terms of patient outcomes, the findings of this study would mean gross variation in waiting times depending on who was the triage nurse when the patient presented. As participants’ triage decisions in this study were based on the same information, this is not acceptable. For example, patient scenario 4 was a 42-year-old male with 1 h of crushing central chest pain that began after heavy physical labour. His skin was pale, cool and moist and he was complaining of dyspnoea. The triage categories allocated to this patient varied from category 1 which implies that this patient warrants immediate medical intervention to category 3 which is associated with up to a 30 min wait for medical intervention. This variation in waiting time poses a degree of risk to this patient if a triage category of lower acuity is selected and if a triage category of higher acuity is selected, there is the potential to affect resource allocation for other patients within the ED. The findings of this study with regard to the relationships between participants’ demographic characteristics and their triage decisions using the NTS also resembled the findings of other clinical decision making studies. Jelinek and Little (1996) concluded that triage responses were unaffected
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by triage nurse experience. Similarly, a study of critical care nurses’ clinical decision making by Sims and Fought (1989) also reported no relationship between accuracy of decision making and length of experience. In this study, there was no identifiable correlation between triage decisions and years of experience in either emergency nursing or triage. The positive correlation between ‘overtriage’ decisions and frequency of shifts rostered to triage in this study bears a resemblance to the findings of Hughes and Young (1990) who reported that nurses who work more hours were more likely to make similar clinical decisions than nurses who worked fewer hours. Hughes and Young (1990) postulated that the nurses who worked more hours had greater exposure to clinical problems and therefore had to repeatedly utilize problem solving and decision making strategies. It may be argued that these findings could be applied to the triage context where repeated exposure to specific types of presentations may result in familiarity with presentations of a serious nature. As a consequence, the triage nurse forms templates and uses these in making triage decisions. The negative correlation identified between higher levels of appointment and ‘overtriage’ decisions suggests that triage nurses of lower levels of appointment were more likely to make ‘overtriage’ decisions. Possible explanations for this finding are factors such as increased caution, less triage experience or familiarity with certain presentations all of which may affect the clinical decision making of less experienced triage nurses. As a result, this group of triage nurses may be ‘erring on the side of caution’ and choosing to allocate a triage category of higher acuity knowing that this will decrease the time until a doctor sees the patient. ‘Experience’ is often equated with better clinical decision making in nursing (Watson 1994, Pardue 1987, del Bueno 1983), but the term ‘experience’ is often not quantified. The inability of this study to identify a correlation between ‘expected triage’ decisions and years of experience, frequency of triage shifts or level of appointment raises questions about the criteria used to measure ‘experience’ in the triage context. The assumption that chronological experience or task repetition correlates with better clinical decisions is challenged, as is the identification of
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‘experienced’ triage nurses by virtue of chronology, cumulative number of triage shifts or level of appointment. The criteria by which nurses are selected as role models or mentors for the clinical and educational preparation of triage nurses is also now open to wider debate. The primary intention of the NTS is to prioritize the emergency care of many patients who present concurrently to an ED. If there is gross variation in triage category allocation when the NTS is being used for the purpose for which it was originally designed, questions may be raised as to the appropriateness of using the NTS to allocate funding and measure ED performance. The results of this study increase the need for further formal evaluation of the NTS in the context of patient care. Arguments by others that the validity of the use of the NTS to determine funding, measure ED performance and as a model for the comparison of hospitals is questionable are also strengthened by the findings of this study (Doherty 1996, Dilley & Standen 1998).
Conclusion As the overall level of agreement of triage nurses using the NTS ranged from 58% (‘expected triage category’) to 65.2% (‘modal triage category’), it may be said that the level of agreement between triage nurses using the NTS remains variable. Variability in triage category allocation relates directly to variability in patient waiting times. It is not acceptable that a specific patient may be allocated varying triage categories, depending on who the triage nurse was when that patient presented to the ED. Although each patient scenario in this study was triaged to two or three categories, it must be remembered that the NTS is only a five category scale. The level of agreement of triage nurses using the NTS has far reaching implications. The NTS was intended to promote a standardized approach to triage in the context of prioritizing patient care. The current level of agreement amongst triage nurses using the NTS raises concerns regarding patient risk, potential adverse patient outcomes and the inappropriate allocation of staff and ED resources. The lack of agreement regarding the application of the NTS in the patient care context makes the use of the NTS for funding, resource allocation and measurement of ED performance questionable.
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These factors also widen the implications of the decisions made by triage nurses.
References
Recommendations The few studies that have examined uniformity and levels of agreement in users of the NTS have, to date, been performed within local populations. Further research into the use of the NTS by nurses should be undertaken at a national level to overcome these limitations. Further examination of the effect of care provided by emergency nurses on patient outcomes is also warranted. Consideration should be given to amendment of the NTS to acknowledge the emergency care provided by nurses. Triage category allocation according to the need for emergency care rather than the need for medical care removes the debate about which aspects of care are in the medical domain and which comprise emergency nursing practice. As practice in the emergency care setting is one of collaboration, this amendment may improve uniformity in the application of the NTS by ensuring that patients receive a high standard of emergency care within a suitable time frame, irrespective of who provides that care. The call for more comprehensive guidelines with a statewide or national approach in order to improve uniformity of application of the NTS by triage nurses is well-founded (Doherty, 1996, Dilley & Standen 1998). Anecdotal evidence suggests wide diversity in the way that novice triage nurses are taught and orientated to the triage role. Whilst this is occurring, it is little wonder that there is variation in the application of the NTS. As triage is primarily a nursing role, consideration needs to be given to the use of the NTS by nurses. There is danger in assuming that a high level of agreement amongst medical staff will translate to nursing staff and variables in application of these two groups need to be identified. Only when triage nurses have attained an acceptable level of agreement in the use of the NTS, for the purpose of prioritizing patient care, should consideration be given to extending the uses of the NTS. Validation of the use of the NTS for funding, resource allocation and measurement of ED performance should also be undertaken. This is the only way to determine if the NTS is an appropriate and equitable tool for these purposes.
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Triage nurses’ decisions using the National Triage Scale for Australian emergency departments Julie Considine RN, RM, BN, CertAcuteCareNsg (Emerg), GradDipNsg(Acute Care), MN, PhD candidate, Clinical Nurse Educator, Emergency Department, Dandenong Hospital, David Street, Dandenong, 3175, Victoria, Australia. Tel.: +03 9554 1000; E-mail: jconsidine@alphali nk.com.au Professor Lerma Ung RN, MN, DipAppSc (N Ed), BSc(Med), MHSc, PhD, Chair, Acute Care Nursing, Cabrini/Deakin Professorial Unit, Cabrini Hospital, 183 Wattletree Rd, Malvern, 3144 Victoria, Australia Shane Thomas BA(Hons), Dip Public Policy, PhD, Adjunct Professor, Faculty of Health and Behavioural Sciences, Deakin University, Cabrini/Deakin Professorial Unit, Cabrini Hospital, 183 Wattletree Rd Malvern, 3144 Victoria, Australia Correspondence to: Julie Considine Manuscript accepted: 12 July 2000
J. Considine, L. Ung, S. Thomas
The initiation of emergency care primarily depends on the decisions made by the triage nurse. Triage decisions can therefore have a profound effect on the health outcomes of patients who present for emergency care. If the National Triage Scale (NTS) was effective in providing a standardized approach to triage, a patient with a specific problem should be allocated to the same triage category, irrespective of the institution to which they present or the personnel performing the role of triage. This study examines triage nurses’ level of agreement in their allocation of triage categories to patients with specific presenting problems using the NTS. Relationships between demographic characteristics of participants and triage decisions are examined and implications of any variation for triage practice and patient outcomes are explored. © 2000 Harcourt Publishers Ltd
Introduction The triage role differentiates emergency nursing from other nursing specialities. Triage begins when a patient presents to an emergency department (ED) (Australasian College for Emergency Medicine 1993b, Dilley & Standen 1998). As EDs are often faced with more patients than their staffing and physical resources can manage, a process of prioritizing patients must occur. During the triage process patients are categorized according to severity of illness or injury. Staff and resources are then allocated firstly to those with life threatening illness or injury and other patients are seen in order of their need for emergency care. An effective triage system aims to ensure that patients receive ‘… appropriate attention, in a suitable location, with the requisite degree of urgency …’ on the basis of a rapid, accurate initial assessment (George et al. 1993).
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In Australia, triage is predominantly a nursing role. During the triage process, nurses are required not only to rapidly identify and respond to actual life threatening states, but also assess the potential for such states to occur (Brillman et al. 1996, Monitor, 1985). The initiation of emergency care primarily depends on the decisions made by the triage nurse. Triage decisions therefore can have a profound effect on the health outcomes of ED patients (Commonwealth Department of Health and Family Services and the Australasian College for Emergency Medicine 1997, Williams 1992). The National Triage Scale (NTS) for Australian Emergency Departments is used by most ED’s to establish patient care priorities. The NTS is a five point scale designed by the Australasian College for Emergency Medicine in 1993 with the aim of promoting a standardized approach to triage. Every patient who presents to an ED is assigned a triage category based on the nature of their
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Table 1 National Triage Scale for Australian Emergency Departments adapted from: Australasian College for Emergency Medicine, 1993b, p10. Triage Code
Treatment Acuity*
National Triage Scale
Category 1
Immediate
Resuscitation
Category 2
Within 10 minutes
Emergency
Category 3
Half Hour
Urgent
Category 4
One Hour
Semi Urgent
Category 5
Two Hours
Non Urgent
* for medical care
presenting problem and the need for medical care (Australasian College for Emergency Medicine 1993b, Commonwealth Department of Health and Family Services and the Australasian College for Emergency Medicine 1997). The categories used in the NTS are shown in Table 1. If the NTS was effective in providing a standardized approach to triage, a patient with a specific problem should be allocated to the same triage category, irrespective of the institution to which they present or the personnel performing the role of triage (Doherty 1996, Commonwealth Department of Health and Family Services and the Australasian College for Emergency Medicine 1997, Dilley & Standen 1998). In simple terms, a patient should be able to present to any triage nurse, in any ED, at any time of the day or night, with a specific problem and be allocated to the same triage category. The consequence of variation in triage decisions is discrepancy in the length of time that a patient must wait before receiving medical intervention. This has implications both for the patient being triaged, and the ability of the ED to function effectively. In general, there are three outcomes of triage decisions. A patient may present and be allocated to a triage category that is appropriate to his or her presenting problem. This patient is seen by a doctor within a suitable time frame and should have a positive health outcome. Problems occur if the same patient is allocated to a triage category of higher or lower acuity than required. If a triage category of higher acuity is selected, the patient’s waiting time until medical intervention is shorter than anticipated. Although this is not detrimental to the patient in question, the effect of
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inappropriate allocation of resources has the potential to adversely affect other patients in the ED. This type of triage decision is referred to as ‘overtriage’. If a triage category of lower acuity is selected, the patient’s waiting time until medical intervention would be prolonged and the risk of an adverse patient outcome is increased. There is the potential for patients to deteriorate or develop life threatening complications whilst waiting and patients may be subjected to prolonged pain or suffering. This type of triage decision is referred to as ‘undertriage’ (Considine 1998, Hollis & Sprivulis 1996). Although the NTS was designed for the purpose of prioritizing patient care in the ED context, lack of consensus regarding the application of the NTS still exists. Of concern is the fact that the NTS is now used in the context of ‘… workload and performance indicators …’ (Fitzgerald 1996, p.206) and has ‘… formed the basis of the Australian Council on Health Care Standards Clinical Indicators for Emergency Medicine’ (Jelinek & Little 1996, p229). It is also being used in some states as a funding determinant with ‘… Medicare Performance Funding and Incentive Package Funding … dependent on the percentage of patients seen within the required time intervals of the NTS’ (Jelinek & Little 1996, p.229, Health and Community Services 1995). The use of the NTS for funding, resource allocation and measurement of ED performance contradicts the National Triage Scale User Manual which clearly states that ‘Triage requires a clinical decision, which has regard only to the patient’s individual need for care.’ (Commonwealth Department of
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Health and Family Services and the Australasian College for Emergency Medicine 1997, p.5). The importance of the need for uniform application of the NTS is well recognized. Adjustment of triage practice to ‘… optimise financial outcomes under various funding models or incentives programs …’ has been labelled as unethical (Commonwealth Department of Health and Family Services and the Australasian College for Emergency Medicine, 1997, p.6). The decisions made by triage nurses now have significant administrative, political, economic and health care implications. As triage is predominantly a nursing role, it is imperative that the application of the NTS by nurses is closely examined.
from non-English-speaking backgrounds and of low socioeconomic status. The other ED was in a Victorian rural base hospital that provides general adult and paediatric services and operates an accident retrieval service. This hospital is situated in a large country town that is surrounded by isolated farming properties. These EDs were selected as they have diversity of presentations and they serve very different populations. As the environments in which triage nurses practice vary between institutions, the features of these EDs allowed for a greater representation of triage nurses.
Instrument
Aims of the study The aims of this study were: • to determine the level of agreement or variation that occurred between triage nurses in their allocation of triage categories to patients with specific presenting problems using the NTS • to examine the relationships (if any) between participants’ demographic characteristics and triage decisions • to explore the implications of any variation for triage practice and patient outcomes.
Method A correlational design using survey methods was employed in this study. A correlational design was selected as it allowed for the identification of relationships between variables. Survey methods were selected as this allowed answers to be sought from participants based on the same amount of information.
Setting This study was conducted in two Victorian EDs. One ED was in a large Melbourne teaching hospital that provided a wide range of general and specialist adult services as well as being a major health care provider for the poor and disadvantaged. The area surrounding this hospital is high density inner city housing and the patient population served by this hospital has a high proportion of persons who are homeless,
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At the time of this study, there was very little published research on the NTS and there were no validated data collection instruments in existence. In response to the need to develop a data collection instrument, a self administered questionnaire was developed by the researcher. The first section of the instrument required participants to complete demographic details and the second section presented participants with 10 adult patient scenarios. Each scenario required the participant to allocate a NTS category. Specialty scenarios, such as paediatrics and obstetrics, were not included as these presentations were only seen routinely at one of the two participating EDs. Written patient scenarios have been widely used in clinical decision making research. They have been validated for use in measuring the problem solving skills of nurses and have been considered useful in evaluating analytical skills and decision making (Holzemer et al 1981, Carroll & Johnson 1990). Patient scenarios were used in this study because they ensured that participants’ responses were based on the same information. There was also no way to replicate the same patient presentation to many different triage nurses and any risk to real patients was eliminated. The questionnaire was examined by nominated expert triage nurses to establish face and content validity, to assess clarity and ease of administration, and to judge the degree of fidelity of each scenario to real triage situations. Each of the expert triage nurses had post graduate qualifications in emergency nursing, a Bachelor
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Patient Scenario 1: A 78-year-old male presents to triage with his friend following falling down 1 step, landing on concrete, 15 minutes ago. He complains only of a 2 cm laceration to the centre of his forehead. He has good recall of events and his friend states that he had no loss of consciousness. He is alert, his laceration is not bleeding and he is not bothered by the placement of a dressing over his laceration. Patient Scenario 2: A 76-year-old female presents to triage with a referring letter from her local medical officer general practitioner. He states that she has a cellulitic area on her left lower leg that developed after an insect bite 1 week ago. She has taken oral antibiotics with poor effect and he states that she will need admission for intravenous antibiotics. On examination she has a warm, reddened area on her left lower leg, although she states it is not painful. Her temperature at triage is 37.2°C. Patient Scenario 3: A 24-year-old female presents with a two day history of increasing right iliac fossa pain. She has had associated nausea and anorexia, but no vomiting or diarrhoea. She denies any urinary symptoms and states that she had a normal bowel action yesterday. Her last normal menstrual period was 2 weeks ago. Her temperature is 37.60°C, heart rate 98 bpm, and respiratory rate 22/min. She rates her pain as 5/10 and her pain increases with movement. Patient Scenario 4: A 42-year-old male presents to triage complaining of central chest pain. He states the pain is “crushing” in nature and began after heavy physical labour approximately one hour prior to arrival. He states that the pain does not radiate and does not change with movement or inspiration. He states that he has never had chest pain before. His only associated symptom is dyspnoea and his skin is pale, cool and moist. Patient Scenario 5: A 20-year-old male presents by ambulance following a motor car accident. He was the driver of a vehicle that was struck on the driver’s side by a truck that ran a red light. The ambulance officers state that the vehicle was pushed approximately 20 m and the damage to the vehicle was such that the door had to be cut off to remove the driver. He was wearing a seatbelt and there was no loss of consciousness. On arrival his skin is pale, cool and moist with capillary refill of 4 s. The ambulance officers report that his pulse is 156 bpm, blood pressure 100/70 mmHg, respiratory rate 32/min and his SaO2 is 90%. He is orientated to time, place and person. His only complaint is of severe right lower chest pain that increases on inspiration. He is being administered oxygen at 10 L/min and has a cervical collar in situ from the ambulance service. Patient Scenario 6: A 16-year-old male presents by ambulance following a fall at school. He has a history of intellectual disability and although he requires only minimal assistance in his activities of daily living, he is unable to communicate verbally. He is accompanied by a carer from the school who informs you that he is allergic to penicillin, and his only medical history is asthma for which he uses a Ventolin puffer. She states that he was knocked over by another student, falling onto a concrete path. There was a brief period of LOC lasting only a 2–3 min. Enroute he had a clonictonic seizure that resolved simultaneously after 3–4 min. On arrival his skin is pink, warm and dry. His eyes are open, he does not respond verbally, but does obey command and smiles to name. Patient Scenario 7: A 56-year-old male walks through the ambulance doors. He is centrally cyanosed and is unable to speak. His skin is cool and moist. His wife tells you that he has asthma and that he has been using his Ventolin puffer every 15 min for the last 2 h. He has maximal use of his accessory muscles, but has no audible wheeze. Patient Scenario 8: A 22-year-old male presents to triage stating that he has ‘vomited blood’ twice in the last 6 h. He describes dark bowel actions for the past 3 days and states he drinks at least 12 cans of beer a day. His skin is pale, warm and dry with capillary refill of less than 2 s, his heart rate is 108 bpm and his respiratory rate is 20/min. He states he does not have any pain but complains of nausea. Patient Scenario 9: An 80-year-old female presents by ambulance following a fall whilst doing the vacuuming. She states she placed her hand out to break her fall and now complains of a painful (L) wrist. Her (L) wrist appears swollen, deformed and is painful to touch. She has a splint insitu, applied by the ambulance officers, and has normal color, warmth, movement and sensation in the fingers of her (L) hand. Her (L) radial pulse is palpable. Patient Scenario 10: A 55-year-old female presents to triage complaining of a ‘cold’ for 4 days. She presents because of 2 days of increasing right upper quadrant and right thoracic back pain. She states that she has had no vomiting, diarrhoea or urinary symptoms but describes 1 day of increasing dyspnoea. Her skin is pale, hot and moist and she has normal respiratory effort without the use of accessory muscles. Her temperature is 38. 80°C, heart rate 112 bpm, and respiratory rate 26/min. She rates her pain as 7/10 and her pain increases with movement and deep inspiration. Fig. 1
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Examples of Patient Scenarios used in the Study
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of Nursing and a Graduate Diploma related to acute care nursing. Two of the expert triage nurses were also currently undertaking Master of Nursing qualifications and both were undertaking research projects relating to triage. All expert triage nurses judged the scenarios as having a high level of fidelity to real triage situations. In order to test the scenarios, the expert triage nurses were asked to complete each of the patient scenarios. Their responses were compared with the response expected by the researcher and 100% agreement was reached on the most appropriate triage category for each scenario. The agreed triage category for each patient scenario was referred to as the ‘expected triage category’ and this was used for judging the appropriateness of the participants’ triage category allocation and level of agreement between participants. Examples of the patient scenarios used in the study are seen in Figure 1.
Sample and sampling process The population for the study consisted of all the registered nurses working in the two EDs selected. As this study focused on triage decision making, only those nurses who could be rostered to the triage role were eligible to participate in the study. The total number of registered nurses who could be rostered to triage, and therefore met the inclusion criteria for the study, was 42. Given the small numbers of triage nurses, random sampling was not employed and convenience sampling was used. All 42 triage nurses were invited to participate in the study and 31 triage nurses responded by completing and returning the questionnaire. This gave a response rate of 74%.
Data collection The questionnaires were distributed to the triage nurses and a covering letter was included, explaining the nature of the study and assuring confidentiality and anonymity. The participants were asked to return the questionnaires to a nominated point in the ED within a 2-week time frame. The researcher then collected the questionnaires from each ED.
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Results The computer software package SPSS® Version 6.1 was used for statistical analysis. Frequency and descriptive statistics were obtained and the level of agreement between triage nurses using the NTS examined. As the data was predominantly ordinal data, non-parametric correlation measures were used. The Spearman correlation coefficient (rs) was used with two-tailed significance as it indicates both the strength and direction of identified associations. Significance was identified by a probability of less than 5% (P < 0.05).
Participants’ demographic characteristics When participants’ years of experience in emergency nursing were examined, 29.1% of participants had two or fewer years experience and 32.2% of participants had 10 or more years of emergency nursing experience. Examination of participants’ years of triage experience revealed that 32.3% of participants had 2 or fewer years of triage experience, almost half of the participants (48.4%) had 3 to 6 years triage experience and 19.3% reported 10 or more years of triage experience. Examination of participants’ level of appointment revealed that 64.54% were employed as registered nurses (staff nurses), 22.6% were clinical nurse specialists and 12.9% were employed in unit management (associate unit manager or unit manager). When participants were asked to indicate how many shifts per month they were rostered to triage, almost half (45.2%) reported that 21–60% of their ED shifts were spent at triage.
Relationships between demographic characteristics Statistically significant positive correlations were identified between the age of the triage nurse and experience in both emergency nursing (P <0.001) and triage (P <0.001) indicating that the older triage nurses were also more experienced. Experience in emergency nursing was positively correlated with triage experience (P <0.001) demonstrating that experienced triage nurses are also experienced emergency nurses. No correlation was identified between the number of
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shifts rostered to the triage role and either triage or emergency nursing experience. This raises a question as to whether triage nurses with more experience in emergency nursing and triage are being under rostered to this role. Higher level of appointment demonstrated positive correlations with increasing age (P = 0.003) and more years of experience in emergency nursing (P <0.001) and triage (P <0.001). These findings indicate that triage nurses who are employed in unit management or as clinical nurse specialists are older and more experienced.
Participants’ triage decisions Participants’ allocation of triage categories using the NTS were examined for each patient scenario. The ‘expected triage category’ was used as the standard by which to judge participants’ triage category allocation. In addition, participants’ responses were also examined to determine the most frequently allocated triage category for each patient scenario and this was referred to as the ‘modal triage category’. Table 2 shows participants’ triage category allocation for each patient scenario.
Table 2
The ‘expected triage category’ and the ‘modal triage category’ were the same for 7 of the 10 scenarios (patient scenarios 3, 4, 5, 7, 8, 9 and 10). The difference between the ‘expected triage category’ and the ‘modal triage category’ for the remaining patient scenarios was one adjacent triage category. The frequency with which the ‘expected triage category’ was selected for each patient scenario ranged from 10 (32.2%) to 26 (83.8%). The frequency with which the ‘modal triage category’ was selected for each patient scenario ranged from 51.6% to 83.8%. There was no patient scenario in which all participants responded with the same triage category. Six scenarios (patient scenarios 3, 5, 6, 7, 8 and 10) had responses across two adjacent triage categories and four scenarios (patient scenarios 1, 2, 4 and 9) had triage categories allocated across three adjacent categories. The four scenarios in which the triage responses spanned three different triage categories all contained a small number of participants who allocated triage categories of unusually high or unusually low acuity. The number of participants who responded across two triage categories for these scenarios ranged from 26 (83.8%) to 30 (96.8%). The number of participants whose
Participants’ Triage Category Allocation for each Patient Scenario
Patient Scenario
Cat 1 n
Cat 2 n
Cat 3 n
Cat 4 n
Cat 5 N
Patient Scenario 1 – Fall
2
19
10**
Patient Scenario 2 – Localised cellulitis
1
16
14**
Patient Scenario 3 – RIF Pain Patient Scenario 4 – Chest Pain Patient Scenario 5 – Multiple trauma
15 2 21**
Patient Scenario 6 – Head injury & seizure Patient Scenario 7 – Asthma
26**
3
10 10**
16**
16**
21
15
Patient Scenario 8 – Haematemesis & Malaena
25**
Patient Scenario 9 – Colles#
10
Patient Scenario 10 – RUQ Pain
24**
6 18**
3
7
** expected response for each patient scenario
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responses entered a third triage category ranged from 1 (3.2%) to 3 (9.7%). Each of the 31 participants completed 10 patient scenarios resulting in a total of 310 triage episodes. The total number of ‘expected triage category’ responses was 180 (58%) and the total number of ‘modal triage category’ responses was 202 (65.2%). The overall level of agreement of triage nurses using the NTS ranged from 58% (‘expected triage category’) to 65.2% (‘modal triage category’).
Relationships between triage decisions and demographic characteristics No correlation was found between participants’ triage decisions and age or years of experience in emergency nursing or triage. A positive correlation was found between ‘overtriage’ decisions and increased frequency of shifts rostered to the triage role (P = 0.041) suggesting that triage nurses who had a higher number of shifts rostered to triage were more likely to make ‘overtriage’ decisions. No relationship was identified between the percentage of shifts rostered to triage and ‘expected triage’ or ‘undertriage’ decisions. A negative correlation was identified between ‘overtriage’ decisions and higher level of appointment (P = 0.021). This finding suggests that clinical nurse specialists and those in unit management were less likely to ‘overtriage’ than their more junior counterparts.
Discussion At the time of this study, little published research on the NTS was available. Despite this, the findings of this study with regard to participants’ triage decisions resemble those of the other available studies in this area. A study by Jelinek and Little (1996) had 115 participants triage 100 written patient profiles. All (100%) patient profiles were triaged to within one category of the modal response by 86% of participants and over half the participants agreed with the modal response for 89% of the patient profiles. Doherty (1996) had 24 participants complete 12 patient scenarios. He reported that there was no scenario in which all participants agreed and responses for 10 of the 12 (83.3%) scenarios spanned three or more NTS categories. A study by Dilley and
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Standen (1998) involved 188 participants who completed 20 patient scenarios and again, there was no scenario in which the patient was triaged to the same category by all participants. Seventeen (85%) patient scenarios were triaged across two triage categories by more than 90% of participants. There were triage responses spanning three triage categories for four (20%) scenarios and 15 (75%) scenarios elicited triage responses across four triage categories. The results of this study are an improvement on previous studies with six (60%) patient scenarios being triaged to two triage categories and only four (40%) scenarios eliciting responses across three triage categories. No scenario in this study had triage responses across four different triage categories. This variability of allocation of triage categories raises concerns about patient waiting times and the health outcomes of patients who present for emergency care. The fact that there was not one scenario in which all participants responded with the same triage category has vast implications for emergency nursing practice. In terms of patient outcomes, the findings of this study would mean gross variation in waiting times depending on who was the triage nurse when the patient presented. As participants’ triage decisions in this study were based on the same information, this is not acceptable. For example, patient scenario 4 was a 42-year-old male with 1 h of crushing central chest pain that began after heavy physical labour. His skin was pale, cool and moist and he was complaining of dyspnoea. The triage categories allocated to this patient varied from category 1 which implies that this patient warrants immediate medical intervention to category 3 which is associated with up to a 30 min wait for medical intervention. This variation in waiting time poses a degree of risk to this patient if a triage category of lower acuity is selected and if a triage category of higher acuity is selected, there is the potential to affect resource allocation for other patients within the ED. The findings of this study with regard to the relationships between participants’ demographic characteristics and their triage decisions using the NTS also resembled the findings of other clinical decision making studies. Jelinek and Little (1996) concluded that triage responses were unaffected
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by triage nurse experience. Similarly, a study of critical care nurses’ clinical decision making by Sims and Fought (1989) also reported no relationship between accuracy of decision making and length of experience. In this study, there was no identifiable correlation between triage decisions and years of experience in either emergency nursing or triage. The positive correlation between ‘overtriage’ decisions and frequency of shifts rostered to triage in this study bears a resemblance to the findings of Hughes and Young (1990) who reported that nurses who work more hours were more likely to make similar clinical decisions than nurses who worked fewer hours. Hughes and Young (1990) postulated that the nurses who worked more hours had greater exposure to clinical problems and therefore had to repeatedly utilize problem solving and decision making strategies. It may be argued that these findings could be applied to the triage context where repeated exposure to specific types of presentations may result in familiarity with presentations of a serious nature. As a consequence, the triage nurse forms templates and uses these in making triage decisions. The negative correlation identified between higher levels of appointment and ‘overtriage’ decisions suggests that triage nurses of lower levels of appointment were more likely to make ‘overtriage’ decisions. Possible explanations for this finding are factors such as increased caution, less triage experience or familiarity with certain presentations all of which may affect the clinical decision making of less experienced triage nurses. As a result, this group of triage nurses may be ‘erring on the side of caution’ and choosing to allocate a triage category of higher acuity knowing that this will decrease the time until a doctor sees the patient. ‘Experience’ is often equated with better clinical decision making in nursing (Watson 1994, Pardue 1987, del Bueno 1983), but the term ‘experience’ is often not quantified. The inability of this study to identify a correlation between ‘expected triage’ decisions and years of experience, frequency of triage shifts or level of appointment raises questions about the criteria used to measure ‘experience’ in the triage context. The assumption that chronological experience or task repetition correlates with better clinical decisions is challenged, as is the identification of
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‘experienced’ triage nurses by virtue of chronology, cumulative number of triage shifts or level of appointment. The criteria by which nurses are selected as role models or mentors for the clinical and educational preparation of triage nurses is also now open to wider debate. The primary intention of the NTS is to prioritize the emergency care of many patients who present concurrently to an ED. If there is gross variation in triage category allocation when the NTS is being used for the purpose for which it was originally designed, questions may be raised as to the appropriateness of using the NTS to allocate funding and measure ED performance. The results of this study increase the need for further formal evaluation of the NTS in the context of patient care. Arguments by others that the validity of the use of the NTS to determine funding, measure ED performance and as a model for the comparison of hospitals is questionable are also strengthened by the findings of this study (Doherty 1996, Dilley & Standen 1998).
Conclusion As the overall level of agreement of triage nurses using the NTS ranged from 58% (‘expected triage category’) to 65.2% (‘modal triage category’), it may be said that the level of agreement between triage nurses using the NTS remains variable. Variability in triage category allocation relates directly to variability in patient waiting times. It is not acceptable that a specific patient may be allocated varying triage categories, depending on who the triage nurse was when that patient presented to the ED. Although each patient scenario in this study was triaged to two or three categories, it must be remembered that the NTS is only a five category scale. The level of agreement of triage nurses using the NTS has far reaching implications. The NTS was intended to promote a standardized approach to triage in the context of prioritizing patient care. The current level of agreement amongst triage nurses using the NTS raises concerns regarding patient risk, potential adverse patient outcomes and the inappropriate allocation of staff and ED resources. The lack of agreement regarding the application of the NTS in the patient care context makes the use of the NTS for funding, resource allocation and measurement of ED performance questionable.
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These factors also widen the implications of the decisions made by triage nurses.
References
Recommendations The few studies that have examined uniformity and levels of agreement in users of the NTS have, to date, been performed within local populations. Further research into the use of the NTS by nurses should be undertaken at a national level to overcome these limitations. Further examination of the effect of care provided by emergency nurses on patient outcomes is also warranted. Consideration should be given to amendment of the NTS to acknowledge the emergency care provided by nurses. Triage category allocation according to the need for emergency care rather than the need for medical care removes the debate about which aspects of care are in the medical domain and which comprise emergency nursing practice. As practice in the emergency care setting is one of collaboration, this amendment may improve uniformity in the application of the NTS by ensuring that patients receive a high standard of emergency care within a suitable time frame, irrespective of who provides that care. The call for more comprehensive guidelines with a statewide or national approach in order to improve uniformity of application of the NTS by triage nurses is well-founded (Doherty, 1996, Dilley & Standen 1998). Anecdotal evidence suggests wide diversity in the way that novice triage nurses are taught and orientated to the triage role. Whilst this is occurring, it is little wonder that there is variation in the application of the NTS. As triage is primarily a nursing role, consideration needs to be given to the use of the NTS by nurses. There is danger in assuming that a high level of agreement amongst medical staff will translate to nursing staff and variables in application of these two groups need to be identified. Only when triage nurses have attained an acceptable level of agreement in the use of the NTS, for the purpose of prioritizing patient care, should consideration be given to extending the uses of the NTS. Validation of the use of the NTS for funding, resource allocation and measurement of ED performance should also be undertaken. This is the only way to determine if the NTS is an appropriate and equitable tool for these purposes.
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