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Use of video recorders in auditing initial assessment times
Use of video recorders in auditing initial assessment times I. Wood
Staffordshire Hospital NHS Trust; an average daily attendance of approximately 255. Of these: approximately 70% were considered to have attended with ‘minor injuries.’ These patients were formally assessed upon their arrival by a triage nurse. This nurse occupies a desk which is situated in the waiting area and is adjacent to the entrance to the department. This position enables the nurse to see patients the moment they arrive. After assessing the nature of the patient’s problem, the nurse writes their assessment on a preprinted sheet and the patient proceeds to the registration desk. Nurses are allocated to triage as part of the shift allocation and as such triage is in operation in the department 24 hours per day.
LITERATURE The Patient’s Charter (Department of Health 1992) states that patients attending Accident and Emergency departments will ‘be seen immediately’ and have ‘their need for treatment assessed’. This paper describes a research project aimed at gathering accurate and reliable information regarding initial assessment times in a busy Emergency department. The use of closed circuit cameras and video recordings will be described. Ethical considerations will be highlighted along with the results of the study.
Gorton (1993) conducted a study using observational techniques to investigate initial assessment times in 31 A & E departments across England and Wales. Amongst her findings were that data collection methods were ‘diverse’, often fragmented and ‘inconsistent’. Data presented to the NHSME from such sources was found to be ‘variable’ and ‘usually unreliable.’ Crouch (1994) confirms this diversity and inconsistency when he describes the ‘controversy’ surrounding the publication of national league tables of Patient’s Charter Standard achievements.
METHODOLOGY INTRODUCTION
Ian Wood RGN, ENB 199, TNCC(P). Charge Nurse, Emergency Department. North Staffordshire Hospital NHS Trust. Princes Road, Hartshill. Stoke on Trent, ST4 7LN, UK
The aim of this research project was to develop a consistent and reliable method of data collection to enable accurate measurement of patients’ waiting time for initial assessment upon their arrival in an Accident and Emergency (A & E) department. In 1992, the Department of Health published ‘The Patient’s Charter’. Within this document, Charter Standard number 5 stated that patients attending an A & E department ‘will be seen immediately’ and their ‘need for treatment assessed.’ Further clarification of this Standard was provided by the National Health Services Management Executive (NHSME) when it was stated that ‘immediate’ was to be taken to mean within 5 minutes of the patient’s arrival in the department. In 1993, over 93000 new patients attended the Emergency department at the North
Amdent and EmergencyNuning (I 995) 3, 62-64 0 Pearson Professional Ltd I995
REVIEW
AND
SAMPLE
The study used an observational technique to measure the time taken from the patient’s arrival in the Emergency department to the time they are formally assessed by the triage nurse. Data was gathered by using an existing closed circuit video security camera to make a recording of the patient’s arrival and their assessment by the nurse. The time from arrival to initial assessment was then measured by retrospective viewing of the taped data. This method was chosen to allow a relatively large number of patients to be observed in a short space of time using existing video facilities. Nurses in the department were aware that this method of data collection was being employed and that they may be recorded at the triage desk. However, individual nurses were unaware which periods of taped data were being used for analysis, thereby reducing the likelihood of them modifying their behaviour to reduce waiting times. The sample of patients taken comprised all patients arriving at the triage desk over 3 periods
Use of video
of 8 hours within a quarterly 3-month period. Each g-hour period of video taping was undertaken on a randomly selected day but was taped to correspond with an early shift, a late shift and a night shift. It was anticipated that by using these 3 shift times, the taping would involve a moderately busy shift, a busy shift and a quiet shift respectively. It was predicted that over the 24 hours of data recorded, a sample of approximately 300 patients would have their arrival and assessment taped. Data was collected by using a long play VHS video recorder connected by closed circuit to the security camera in the waiting area. The tapes used were 4-hour VHS tapes which doubled up to give 8 hours of recording time using long play video. The security camera gave a full view of the triage desk and the entrance to the department. Patients arriving by ambulance were not observed using this method. Retrospective viewing of the recorded data allowed the observer to measure the time from the patient walking through the entrance to the time they met the triage nurse and had their formal assessment documented. During quiet periods, the tape was ‘fast forwarded’ to save time for the observer, In the event of a queue of patients waiting to be assessed, the tape was re-wound and each individual patient’s length of wait measured. Likewise, if a queue had developed and a seriously ill or injured patient walked in, the nurse interrupted her existing assessment to deal with the newly arrived patient. In this case, the waiting time for the patients in the queue continued to be measured from the time of their arrival. In short, the arrival of a seriously ill or injured patient was likely to increase the time that existing patients were waiting to be assessed. This fact was to be measured accurately during data analysis in order to gain a true representation of assessment times. Data gathered from the recorded tapes was analysed and the times that patients wait divided into those who wait less than 5 minutes, those who wait 5-10 minutes and those who wait more than 10 minutes. From these categories, the number of patients in each was calculated as a percentage of the total number of patients whose arrival and assessment was recorded.
Number
Day Day I Day 2 Day 3
In less than 5 mins IO7 (98.2%) I38 (97.2%) 60( 100%)
ETHICAL
in auditing
initial
assessment
times
63
CONSIDERATIONS
The issue of consent to participate in a research project was considered by the researcher. As this method of data collection involves many patients, the researcher felt that it was impractical to ask each patient for their consent to participate in the research project. It should be added that patients’ faces could not be easily seen on the recordings and their conversations could not be heard. As the closed circuit camera and video recorder were in operation 24 hours per day as a routine security measure, the nursing staff did not feel that their formal consent to participate was required. Analysis of the taped data was conducted within 1 week of the recording being made. Only the researcher had access to the tapes and once analysed, the tapes were erased. At no time were the tapes used for other purposes. Use of this method of data collection and, indeed, the use of closed circuit security cameras in general, raised the following ethical dilemma: prior to conducting the research, consideration must be given to the course of action to be taken if the researcher observes poor nursing practice or negligent act. This issue had not been highlighted prior to the project described and is now under consideration by the senior staff in the department.
RESULTS The arrival of patients into the department was recorded over 3 separate B-hour periods on different days of the week. The total number of attendances for each period were 109 (day 1: early shift), 142 (day 2: late shift) and 60 (day 3: night shift). These samples were taken to represent moderately busy, busy and quiet shifts respectively. On day 1, 98.2% (107 patients) were assessed within 5 minutes of their arrival with the remaining 2 patients being assessed in under 10 minutes. On day 2, 97.2% (138 patients) were assessed in less than 5 minutes with the remaining 4 being seen in less than 10 minutes and on day 3, 100% (60 patients) were assessed within the 5 minutes standard (Table).
of patients Between
recorders
assessed 5 and IO mins
2 (1.8%) 4 (2.8%) 0
More
than 0 0 0
IO mins
64
Accident
and Emergency
Nursing
By taking an average of the 3 sample periods, of the 311 patients assessed, 98.1% (305 patients) were assessed within the Patient’s Charter standard of 5 minutes.
CONCLUSION The author is of the opinion that the retrospective viewing of taped data provides an accurate measurement of the time that patients wait to be initially assessed at triage. The study described is limited by the small size of its sample. However, recent guidance from the West Midlands Regional Health Authority (WMRHA) has suggested that the sample size
quoted in this study is satisfactory for an accurate reflection of assessment times. This method of observation continues to be used to gather data for submission to the WMRHA for inclusion in national league tables.
REFERENCES Crouch
R 1994 Triage:past,
present
and future.
Emergency Nurse 2(l)+6 Department of Health 1992 The Patient’s HMSO,
Charter.
London
Gorton B 1993 Those first five minutes: a report on responses and problems associated with the Patient’s Charter accident Salford.
standard of Immediate Initial Assessment in & emergency departments. Hope Hospital,
Staffordshire Hospital NHS Trust; an average daily attendance of approximately 255. Of these: approximately 70% were considered to have attended with ‘minor injuries.’ These patients were formally assessed upon their arrival by a triage nurse. This nurse occupies a desk which is situated in the waiting area and is adjacent to the entrance to the department. This position enables the nurse to see patients the moment they arrive. After assessing the nature of the patient’s problem, the nurse writes their assessment on a preprinted sheet and the patient proceeds to the registration desk. Nurses are allocated to triage as part of the shift allocation and as such triage is in operation in the department 24 hours per day.
LITERATURE The Patient’s Charter (Department of Health 1992) states that patients attending Accident and Emergency departments will ‘be seen immediately’ and have ‘their need for treatment assessed’. This paper describes a research project aimed at gathering accurate and reliable information regarding initial assessment times in a busy Emergency department. The use of closed circuit cameras and video recordings will be described. Ethical considerations will be highlighted along with the results of the study.
Gorton (1993) conducted a study using observational techniques to investigate initial assessment times in 31 A & E departments across England and Wales. Amongst her findings were that data collection methods were ‘diverse’, often fragmented and ‘inconsistent’. Data presented to the NHSME from such sources was found to be ‘variable’ and ‘usually unreliable.’ Crouch (1994) confirms this diversity and inconsistency when he describes the ‘controversy’ surrounding the publication of national league tables of Patient’s Charter Standard achievements.
METHODOLOGY INTRODUCTION
Ian Wood RGN, ENB 199, TNCC(P). Charge Nurse, Emergency Department. North Staffordshire Hospital NHS Trust. Princes Road, Hartshill. Stoke on Trent, ST4 7LN, UK
The aim of this research project was to develop a consistent and reliable method of data collection to enable accurate measurement of patients’ waiting time for initial assessment upon their arrival in an Accident and Emergency (A & E) department. In 1992, the Department of Health published ‘The Patient’s Charter’. Within this document, Charter Standard number 5 stated that patients attending an A & E department ‘will be seen immediately’ and their ‘need for treatment assessed.’ Further clarification of this Standard was provided by the National Health Services Management Executive (NHSME) when it was stated that ‘immediate’ was to be taken to mean within 5 minutes of the patient’s arrival in the department. In 1993, over 93000 new patients attended the Emergency department at the North
Amdent and EmergencyNuning (I 995) 3, 62-64 0 Pearson Professional Ltd I995
REVIEW
AND
SAMPLE
The study used an observational technique to measure the time taken from the patient’s arrival in the Emergency department to the time they are formally assessed by the triage nurse. Data was gathered by using an existing closed circuit video security camera to make a recording of the patient’s arrival and their assessment by the nurse. The time from arrival to initial assessment was then measured by retrospective viewing of the taped data. This method was chosen to allow a relatively large number of patients to be observed in a short space of time using existing video facilities. Nurses in the department were aware that this method of data collection was being employed and that they may be recorded at the triage desk. However, individual nurses were unaware which periods of taped data were being used for analysis, thereby reducing the likelihood of them modifying their behaviour to reduce waiting times. The sample of patients taken comprised all patients arriving at the triage desk over 3 periods
Use of video
of 8 hours within a quarterly 3-month period. Each g-hour period of video taping was undertaken on a randomly selected day but was taped to correspond with an early shift, a late shift and a night shift. It was anticipated that by using these 3 shift times, the taping would involve a moderately busy shift, a busy shift and a quiet shift respectively. It was predicted that over the 24 hours of data recorded, a sample of approximately 300 patients would have their arrival and assessment taped. Data was collected by using a long play VHS video recorder connected by closed circuit to the security camera in the waiting area. The tapes used were 4-hour VHS tapes which doubled up to give 8 hours of recording time using long play video. The security camera gave a full view of the triage desk and the entrance to the department. Patients arriving by ambulance were not observed using this method. Retrospective viewing of the recorded data allowed the observer to measure the time from the patient walking through the entrance to the time they met the triage nurse and had their formal assessment documented. During quiet periods, the tape was ‘fast forwarded’ to save time for the observer, In the event of a queue of patients waiting to be assessed, the tape was re-wound and each individual patient’s length of wait measured. Likewise, if a queue had developed and a seriously ill or injured patient walked in, the nurse interrupted her existing assessment to deal with the newly arrived patient. In this case, the waiting time for the patients in the queue continued to be measured from the time of their arrival. In short, the arrival of a seriously ill or injured patient was likely to increase the time that existing patients were waiting to be assessed. This fact was to be measured accurately during data analysis in order to gain a true representation of assessment times. Data gathered from the recorded tapes was analysed and the times that patients wait divided into those who wait less than 5 minutes, those who wait 5-10 minutes and those who wait more than 10 minutes. From these categories, the number of patients in each was calculated as a percentage of the total number of patients whose arrival and assessment was recorded.
Number
Day Day I Day 2 Day 3
In less than 5 mins IO7 (98.2%) I38 (97.2%) 60( 100%)
ETHICAL
in auditing
initial
assessment
times
63
CONSIDERATIONS
The issue of consent to participate in a research project was considered by the researcher. As this method of data collection involves many patients, the researcher felt that it was impractical to ask each patient for their consent to participate in the research project. It should be added that patients’ faces could not be easily seen on the recordings and their conversations could not be heard. As the closed circuit camera and video recorder were in operation 24 hours per day as a routine security measure, the nursing staff did not feel that their formal consent to participate was required. Analysis of the taped data was conducted within 1 week of the recording being made. Only the researcher had access to the tapes and once analysed, the tapes were erased. At no time were the tapes used for other purposes. Use of this method of data collection and, indeed, the use of closed circuit security cameras in general, raised the following ethical dilemma: prior to conducting the research, consideration must be given to the course of action to be taken if the researcher observes poor nursing practice or negligent act. This issue had not been highlighted prior to the project described and is now under consideration by the senior staff in the department.
RESULTS The arrival of patients into the department was recorded over 3 separate B-hour periods on different days of the week. The total number of attendances for each period were 109 (day 1: early shift), 142 (day 2: late shift) and 60 (day 3: night shift). These samples were taken to represent moderately busy, busy and quiet shifts respectively. On day 1, 98.2% (107 patients) were assessed within 5 minutes of their arrival with the remaining 2 patients being assessed in under 10 minutes. On day 2, 97.2% (138 patients) were assessed in less than 5 minutes with the remaining 4 being seen in less than 10 minutes and on day 3, 100% (60 patients) were assessed within the 5 minutes standard (Table).
of patients Between
recorders
assessed 5 and IO mins
2 (1.8%) 4 (2.8%) 0
More
than 0 0 0
IO mins
64
Accident
and Emergency
Nursing
By taking an average of the 3 sample periods, of the 311 patients assessed, 98.1% (305 patients) were assessed within the Patient’s Charter standard of 5 minutes.
CONCLUSION The author is of the opinion that the retrospective viewing of taped data provides an accurate measurement of the time that patients wait to be initially assessed at triage. The study described is limited by the small size of its sample. However, recent guidance from the West Midlands Regional Health Authority (WMRHA) has suggested that the sample size
quoted in this study is satisfactory for an accurate reflection of assessment times. This method of observation continues to be used to gather data for submission to the WMRHA for inclusion in national league tables.
REFERENCES Crouch
R 1994 Triage:past,
present
and future.
Emergency Nurse 2(l)+6 Department of Health 1992 The Patient’s HMSO,
Charter.
London
Gorton B 1993 Those first five minutes: a report on responses and problems associated with the Patient’s Charter accident Salford.
standard of Immediate Initial Assessment in & emergency departments. Hope Hospital,