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Using clinical based vignettes to further develop a mass gathering event triage tool
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AUEC-455; No. of Pages 4
Australasian Emergency Care xxx (2019) xxx–xxx
Contents lists available at ScienceDirect
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Research paper
Using clinical based vignettes to further develop a mass gathering event triage tool Jamie Ranse a,b,∗ , Matt Cannon c,d , Rebecca Roitman d , Julia Morphet e a
Department of Emergency Medicine, Gold Coast Health, Southport, Queensland, Australia Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia St John Ambulance Papua New Guinea, Port Morsbey, Papua New Guinea d St John Ambulance Australia (NSW), Sydney, New South Wales, Australia e Nursing & Midwifery, Monash University, Victoria, Australia b c
a r t i c l e
i n f o
Article history: Received 26 October 2019 Received in revised form 20 December 2019 Accepted 23 December 2019 Keywords: Emergency medical services Health Mass gathering Planned event Triage
a b s t r a c t Background: Previously published triage tools for use at mass gathering events (MGE) lack real-world validation. Non-health care professionals, such as first aiders, first responders, and advanced responders often undertake a triage role at MGEs. This research aimed to determine consistency in the decisionmaking of a MGE triage tool. Method: Volunteer members of St John Ambulance Australia were recruited. Surveys included participant demographics and real-world clinical vignettes. Participants determined a triage category based on the vignettes and supplied triage tool. Demographics were analysed using descriptive statistics and responses to vignettes were analysed using Fleiss Kappa [p-bar]. Results: There were 110 participants, the majority male (60%), having completed a Bachelor or higher degree (53.6%), and were non-health care professionals (70%). Of the vignettes, there was a slightly better than moderate agreement (items: 18, p-bar: 0.55). There was an excellent level of agreeance for the resuscitation category (items: 3, b-par 0.69), and moderate level of agreeance for the urgent (items: 10, b-par 0.52) and minor (items: 5, b-par 0.52) categories. Conclusions: This research demonstrated similar findings to that of emergency department triage tool validation. Multi-country, multi-site, multi-type, real-world testing at MGEs is the next step to progress the development of this tool. © 2019 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
Introduction A mass gathering event (MGE) can be defined as an event where a group of people come together for a common purpose within a particular space or venue [1]. Participants, spectators and/or officials who attend a MGE may become unwell or obtain an injury, requiring health care. This health care may be provided by local ambulance services and/or hospital emergency departments (EDs) [2]. However, patients may require ‘in-event’ healthcare in the first instance. In-event health services are often provided in temporary facilities and are well-established as standard requirements at various types of MGEs, such as outdoor music festivals [3], marathons [4], religious gatherings [5], and agricultural shows [6]. In-event health care delivery models may consist of health care profession-
∗ Corresponding author. E-mail address: [email protected] (J. Ranse).
als, such as medical officers, nurses and/or paramedics. Further, depending on the clinical governance arrangements within individual organizations, non-health care professionals may provide health care at MGEs. Non-health care professional’s level of training may vary and include, first aider, first responder or advanced responder. Both health care professionals and non-health care professionals may be required to triage patients at MGEs and determine appropriate levels of care for patients. Triage is used in a variety of health care contexts with the principle concept being to do the greatest good for the greatest number of people. Doing the greatest good is a concept that relates to the prioritizing of both human and physical resources for patients within the health care context [7]. Triage processes exist, underpinned by triage tools and systems within both the pre-hospital and ED environments. Trained ambulance paramedics use tools and systems in the pre-hospital environment such as ‘triage sieve and sort’ and ‘simple triage and rapid treat’ (START) systems [8]. In the ED environment, nurses commonly use triage tools and systems such as the
https://doi.org/10.1016/j.auec.2019.12.010 2588-994X/© 2019 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Ranse J, et al. Using clinical based vignettes to further develop a mass gathering event triage tool. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.12.010
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Australasian Triage Scale (ATS) in Australia, the Canadian Triage and Acuity Scale (CTAS) in Canada, the Manchester Triage Scale (MTS) in the United Kingdom, and the Emergency Severity Index (ESI) in the United States [9]. Internationally, triage is becoming gold standard in EDs to assess injury and illness severity to inform patient clinical management priorities [9]. However, how non-health care professionals apply triage tools and systems in unknown. There is limited literature pertaining to triage undertaken relating to MGEs. One study explored ambulance paramedic decision making using a triage criteria to determine which patients required transport from MGEs to hospital and which patients could remain at the MGE [10]. It was demonstrated that this triage criteria had 100% sensitivity and 90% specificity, with appropriate decisions by paramedics on 78% of occasions [10]. A University of British Columbia Mass Gathering Medical (UBC MGM) Triage Acuity Scale/Discharge Acuity Scale (TAS/DAS) has been discussed in the literature [11]. The TAS/DAS is based on the START triage system and incorporates the CTAS [11]. However, the actual TAS/DAS triage tool has not been published. From an Australian perspective, a previously developed and published triage tool for MGEs was developed by Cannon, et al. [12]. This triage tool was “based on: (1) the principles of triage; (2) previous mass-gathering triage tools; (3) existing Australian triage tools, such as SMART Triage and the ATS; (4) Australian contextual considerations, such as ‘between the flags’; and (5) the target population of first responders” (p. 2) [12]. This Australian tool was developed for non-health care professional first responders within MGEs (see Fig. 1).
Table 1 Example of vignette. Patient 1 Age: 26 Gender: Male Presenting problem: Decreased level of consciousness, history of presenting problem: “Sudden onset of decreased level of consciousness. Friends report patient has taken ‘multiple drugs’ - ETOH (alcohol), MDMA, GHB.” Observations RR: 18 HR: 101 BP: 133/100 GCS: 3/ AVPU: U SpO2: 94% RA Temp: 36.5C
The aim of this research was to determine consistency in decision-making of the previously designed MGE triage tool (Fig. 1) [12] prior to real world testing.
presentation including the patient’s demographics, such as age, gender; presenting problem; and observations, such as respiratory rate, heart rate, blood pressure, neurological status, SpO [2] and temperature. See Table 1 for an example of a vignette triage case scenario. Overall, 48 triage case vignettes were developed. Three of the researchers (JR, MC, RR) independently applied the triage tool to these 48 cases, in a blind manner. A blinded approach ensured that the individual researchers did not know of each other’s responses to the cases, until all had completed the application of the triage tool. On 18 occasions, the three researchers had agreeance on the triage category. These 18 vignettes were then used in the online survey. These scenarios varied in triage categories, such as category one (resuscitation), category two (urgent), or category three (minor). Category four (self-help) scenarios were not included in the survey as category four (self-help) includes requests for minor items, such as ‘Band-Aids’ and sun lotion, rather than a clinical assessment or management.
Methods
Data collection
Design
Volunteer members of St John Ambulance Australia, with different clinical qualifications were recruited via closed social media pages, such as Facebook groups. Interested members were directed to the survey directly from the Facebook groups, as such, completing the survey at the time of accepting the invitation. Members were recruited on the basis that they were either a first responder for at least one year, were an advanced responder, or were a health care professional including nurses, doctors and paramedics. The survey, hosted by Survey MonkeyTM , was open from 10th May 2016 to 14th July 2016.
Aim
This research used clinical case vignettes (Evans, et al., 2015) to further develop an existing MGE triage tool. Population and sample The population of this research were volunteer members of St John Ambulance Australia. These members included health care professionals such as doctors, nurses and paramedics; and nonhealth care professionals, such as first aiders, first responders, and advanced responders. The first aider, first responder and advanced responder volunteers with St John Ambulance are lay people with additional training and have real-world experience of providing patient care at MGEs. The sample was purposive of the above population and included members who responded to an invitation to participate in this research, and voluntarily completed the online survey. Survey development The online survey was developed by the researchers and consisted of two parts. The first part was developed based on face validity between the researchers and consisted of questions relating to participant demographics. The second part consisted of triage case vignettes, of which participants were asked to allocate a triage category. Each triage case vignette was based on real-world scenarios by de-identifying real patient case sheets from MGEs covered by St John Ambulance Australia, New South Wales (NSW) in 201314. Each triage scenario included a short summary of the patient’s
Data analysis Demographic data were analysed using descriptive statistics, such as frequencies and means of central tendency. Fleiss Kappa [p-bar] (an adaption of Cohen’s kappa for 3 or more raters) was used to assess the reliability of agreement of individual responses against the various vignettes, and also measured as a total for the 18 vignettes. Using Fleiss Kappa, a score of 0.80 or more per vignette represents very good agreement between participants, a score of between 0.60 and 0.79 represents good agreement, a score between 0.40 and 0.59 represents a satisfactory agreement, and scores less than 0.40 represent poor agreement [9]. Analysis was undertaken using Microsoft Excel (Version: Microsoft Office 2016. Redmond, Washington, US). Protection of human participants Ethical approval was obtained for this research from the St John Ambulance Australian Human Research Ethics Committee.
Please cite this article in press as: Ranse J, et al. Using clinical based vignettes to further develop a mass gathering event triage tool. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.12.010
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Fig. 1. triage tool.
Table 2 Participant demographics. Number of participants Age, median (IQR) Gender, f (%) Male Female Highest achieved qualification, f (%) High School Certificate Diploma Bachelor Degree Postgraduate Degree Other Years as a St John Ambulance Australia member, median (IQR) Clinical skill level, f (%) First aider First Responder Advanced Responder Paramedic Enrolled Nurse Registered Nurse Medical Officer
110 28 (24–43.5) 66 (60) 44 (40) 19 (17.3) 28 (25.5) 38 (34.5) 21 (19.1) 4 (3.6) 7 (3–15) 3 (2.7) 42 (38.2) 32 (29) 16 (14.5) 2 (1.8) 16 (14.5) 4 (3.6)
f, frequency; IQR, interquartile range.
Findings There were 110 completed responses. From a broad perspective, the majority of participants were male (n = 66, 60%), having completed a Bachelors Degree (n = 38, 34.5%), and were currently holding the clinical skill level of ‘first responder’ with St John Ambulance Australia (n = 42, 38.2%). Additional, more detailed participant demographics are outlined in Table 2. Agreeance Of the 18 vignettes, there was a satisfactory agreement overall (items: 18, p-bar: 0.55). In addition to assessing the overall agreement, agreement was determined for each individual triage category against the participant responses. There was a good
level of agreeance amongst responses for the resuscitation category (items: 3, b-par 0.69), and there was satisfactory agreeance amongst responses for the urgent (items: 10, b-par 0.52) and minor (items: 5, b-par 0.52) categories.
Discussion This research provides insight into the decision-making and usage of a previously developed MGE triage tool. The findings from this research demonstrated an overall satisfactory reliability, which is similar to that of the in-hospital emergency department triage tool development. In a literature review of emergency department triage tools and systems, it was identified that there was good to very good reliability for the CTAS and ESI, whereas the ATS and MTS had satisfactory reliability [9]. When exploring the individual triage categories there is greater consistency in the application of the triage tool for higher priority patients, such as those requiring resuscitation [14,15]. Higher priority patients have less subjective presentations, including clear changes in vital signs or threats to life. In contrast, lower priority patients have fewer concrete variables to discriminate between triage categories. A recent systematic review concluded that triage systems internationally, are more reliable when patients present with higher acuity complaints [16]. When used across the broader population, the authors found that interrater reliability for paper-based vignettes ranged from 0.40 to 0.87 [16]. This was also the case for this research in which the resuscitation category had the highest level of agreement. The development of MGE triage tools have been descriptive to date [11,12], however, this research has added an element of reliability to the development of the presented MGE triage tool. Further development of this MGE triage tool should be undertaken at real-world MGEs, with multi-type and multi-site MGE settings considered. Further, as real-world testing of MGE triage tools by non-healthcare professionals has not previously been published [12], it would be a necessary step in further development to ensure testing included non-health care professionals. It is well-
Please cite this article in press as: Ranse J, et al. Using clinical based vignettes to further develop a mass gathering event triage tool. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.12.010
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established that different MGEs have different characteristics that may contribute to variation in in-event patient presentation rates and transport to hospital rates [2]. This may imply that the patients presenting at in-event health services do so with differing severity of injury and illness, therefore requiring different aspects of triage. As such, real-world testing should occur across different types of MGEs. Including multiple organizations would be important in future testing of a MGE triage tool. Such an approach would provide insight into the efficacy of the tool within different organizational governance frameworks. Including nations, beyond Australia, would provide insight into the versatility of the triage tool beyond the Australian content. How the tool is integrated into other countries would be valuable. At present MGE triage tool development has focused on Australia and Canada [11,12]. Study limitations This study was conducted with a small sample, of both vignettes and participants. As such the ability to generalise the findings from this research to other participant and organisations may be limited. Given that there are concerns that vignettes do not accurately reflect real-world phenomena [13], the results from this research can be considered a step towards the real-world application of a triage tool for MGEs. Conclusion This paper has examined the use of real-world clinically based vignettes to further develop a MGE triage tool. This research has demonstrated that the findings from this research are similar to that of the in-hospital, ED, triage tool development. This research provides insight into the decision-making and usage of a MGE triage tool. However, real-world, multi-site, multi-type evaluation is required to further progress the development of this MGE triage tool. Provenance and conflict of interest This paper was not commissioned. This journal, Australasian Emergency Care is the association journal for the College of Emergency Nursing Australasia [CENA]. One author (JM) is the Executive Director of CENA. This author was not involved in the review process of this paper.
Funding This research was partially funded through a competitive research grant from St John Ambulance Australia. References [1] World Health Organization. Public health for mass gatherings: key considerations. Geneva, Switzerland: World Health Organization; 2015. [2] Ranse J, Hutton A, Keene T, et al. Health service impact from mass gatherings: a systematic literature review. Prehosp Disaster Med 2017;32(1):71–7. [3] Hutton A, Ranse J, Verdonk N, et al. Understanding the characteristics of patient presentations of young people at outdoor music festivals. Prehosp Disaster Med 2014;29(2):160–6. [4] Johnston A, Wadham J, Polong-Brown J, et al. Health care during a sporting mass gathering: a structure and process description of on-site care delivery. Prehosp Disaster Med 2019;34(1):62–71. [5] Moutia D, Ranse J, Banu-Lawrence H. Operational aspects of health care delivery at World Youth Day 2008: lessons learnt by an emergency management organisation. Austral J Paramed 2014;11(3):1–9. [6] Zeitz KM, Schneider DP, Jarrett D, Zeitz CJ. Mass gathering events: retrospective analysis of patient presentations over seven years. Prehosp Disaster Med 2002;17(3):147–50. [7] Baker MS. Creating order from chaos: part 1: triage, initial care, and tactical considerations in mass casualty and disaster response. Mil Med 2007;172(3):232–5. [8] Garner A, Lee A, Harrison K, Schultz CH. Comparative analysis of multiple-casualty incident triage algorithms. Ann Emerg Med 2001;38(5):541–8. [9] Christ M, Grossmann F, Winter D, et al. Modern triage in the emergency department. Dtsch Arztebl Int 2010;107(50):892–8. [10] Salhanick SD, Sheahan W, Bazarian JJ. Use and analysis of field triage criteria for mass gatherings. Prehosp Disaster Med 2003;18(4):347–52. [11] Turris SA, Lund A. Triage during mass gatherings. Prehosp Disaster Med 2012;7(6):531–5. [12] Cannon M, Roitman R, Ranse J, Morphet J. Development of a mass-gathering triage tool: an Australian perspective. Prehosp Disaster Med 2017;32(1):101–5. [13] Evans SC, Roberts MC, Keeley JW, et al. Vignette methodologies for studying clinicians’ decision-making: validity, utility, and application in ICD-11 field studies. Int J Clin Health Psychol 2015;15(2):160–70. [14] Varndell W, Hodge A, Fry M. Triage in Australian emergency departments: results of a New South Wales survey. Australas Emergency Care 2019;22:81–6. [15] Ekin, K., Morphet, J. The accuracy and consistency of rural, remote and outpost triage nurse decision making in one Western Australia Country Health Service Region. Australas Emergency Nur J, 18, 227-233. [16] Hinson J, Martinez D, Cabrak S, George K, Whalen M, Hansoti B, et al. Triage performance in emergency medicine: a systematic review. Ann Emergency Med 2019;74(1):140–52.
Please cite this article in press as: Ranse J, et al. Using clinical based vignettes to further develop a mass gathering event triage tool. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.12.010
ARTICLE IN PRESS
AUEC-455; No. of Pages 4
Australasian Emergency Care xxx (2019) xxx–xxx
Contents lists available at ScienceDirect
Australasian Emergency Care journal homepage: www.elsevier.com/locate/auec
Research paper
Using clinical based vignettes to further develop a mass gathering event triage tool Jamie Ranse a,b,∗ , Matt Cannon c,d , Rebecca Roitman d , Julia Morphet e a
Department of Emergency Medicine, Gold Coast Health, Southport, Queensland, Australia Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia St John Ambulance Papua New Guinea, Port Morsbey, Papua New Guinea d St John Ambulance Australia (NSW), Sydney, New South Wales, Australia e Nursing & Midwifery, Monash University, Victoria, Australia b c
a r t i c l e
i n f o
Article history: Received 26 October 2019 Received in revised form 20 December 2019 Accepted 23 December 2019 Keywords: Emergency medical services Health Mass gathering Planned event Triage
a b s t r a c t Background: Previously published triage tools for use at mass gathering events (MGE) lack real-world validation. Non-health care professionals, such as first aiders, first responders, and advanced responders often undertake a triage role at MGEs. This research aimed to determine consistency in the decisionmaking of a MGE triage tool. Method: Volunteer members of St John Ambulance Australia were recruited. Surveys included participant demographics and real-world clinical vignettes. Participants determined a triage category based on the vignettes and supplied triage tool. Demographics were analysed using descriptive statistics and responses to vignettes were analysed using Fleiss Kappa [p-bar]. Results: There were 110 participants, the majority male (60%), having completed a Bachelor or higher degree (53.6%), and were non-health care professionals (70%). Of the vignettes, there was a slightly better than moderate agreement (items: 18, p-bar: 0.55). There was an excellent level of agreeance for the resuscitation category (items: 3, b-par 0.69), and moderate level of agreeance for the urgent (items: 10, b-par 0.52) and minor (items: 5, b-par 0.52) categories. Conclusions: This research demonstrated similar findings to that of emergency department triage tool validation. Multi-country, multi-site, multi-type, real-world testing at MGEs is the next step to progress the development of this tool. © 2019 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
Introduction A mass gathering event (MGE) can be defined as an event where a group of people come together for a common purpose within a particular space or venue [1]. Participants, spectators and/or officials who attend a MGE may become unwell or obtain an injury, requiring health care. This health care may be provided by local ambulance services and/or hospital emergency departments (EDs) [2]. However, patients may require ‘in-event’ healthcare in the first instance. In-event health services are often provided in temporary facilities and are well-established as standard requirements at various types of MGEs, such as outdoor music festivals [3], marathons [4], religious gatherings [5], and agricultural shows [6]. In-event health care delivery models may consist of health care profession-
∗ Corresponding author. E-mail address: [email protected] (J. Ranse).
als, such as medical officers, nurses and/or paramedics. Further, depending on the clinical governance arrangements within individual organizations, non-health care professionals may provide health care at MGEs. Non-health care professional’s level of training may vary and include, first aider, first responder or advanced responder. Both health care professionals and non-health care professionals may be required to triage patients at MGEs and determine appropriate levels of care for patients. Triage is used in a variety of health care contexts with the principle concept being to do the greatest good for the greatest number of people. Doing the greatest good is a concept that relates to the prioritizing of both human and physical resources for patients within the health care context [7]. Triage processes exist, underpinned by triage tools and systems within both the pre-hospital and ED environments. Trained ambulance paramedics use tools and systems in the pre-hospital environment such as ‘triage sieve and sort’ and ‘simple triage and rapid treat’ (START) systems [8]. In the ED environment, nurses commonly use triage tools and systems such as the
https://doi.org/10.1016/j.auec.2019.12.010 2588-994X/© 2019 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Ranse J, et al. Using clinical based vignettes to further develop a mass gathering event triage tool. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.12.010
G Model AUEC-455; No. of Pages 4
ARTICLE IN PRESS J. Ranse et al. / Australasian Emergency Care xxx (2019) xxx–xxx
2
Australasian Triage Scale (ATS) in Australia, the Canadian Triage and Acuity Scale (CTAS) in Canada, the Manchester Triage Scale (MTS) in the United Kingdom, and the Emergency Severity Index (ESI) in the United States [9]. Internationally, triage is becoming gold standard in EDs to assess injury and illness severity to inform patient clinical management priorities [9]. However, how non-health care professionals apply triage tools and systems in unknown. There is limited literature pertaining to triage undertaken relating to MGEs. One study explored ambulance paramedic decision making using a triage criteria to determine which patients required transport from MGEs to hospital and which patients could remain at the MGE [10]. It was demonstrated that this triage criteria had 100% sensitivity and 90% specificity, with appropriate decisions by paramedics on 78% of occasions [10]. A University of British Columbia Mass Gathering Medical (UBC MGM) Triage Acuity Scale/Discharge Acuity Scale (TAS/DAS) has been discussed in the literature [11]. The TAS/DAS is based on the START triage system and incorporates the CTAS [11]. However, the actual TAS/DAS triage tool has not been published. From an Australian perspective, a previously developed and published triage tool for MGEs was developed by Cannon, et al. [12]. This triage tool was “based on: (1) the principles of triage; (2) previous mass-gathering triage tools; (3) existing Australian triage tools, such as SMART Triage and the ATS; (4) Australian contextual considerations, such as ‘between the flags’; and (5) the target population of first responders” (p. 2) [12]. This Australian tool was developed for non-health care professional first responders within MGEs (see Fig. 1).
Table 1 Example of vignette. Patient 1 Age: 26 Gender: Male Presenting problem: Decreased level of consciousness, history of presenting problem: “Sudden onset of decreased level of consciousness. Friends report patient has taken ‘multiple drugs’ - ETOH (alcohol), MDMA, GHB.” Observations RR: 18 HR: 101 BP: 133/100 GCS: 3/ AVPU: U SpO2: 94% RA Temp: 36.5C
The aim of this research was to determine consistency in decision-making of the previously designed MGE triage tool (Fig. 1) [12] prior to real world testing.
presentation including the patient’s demographics, such as age, gender; presenting problem; and observations, such as respiratory rate, heart rate, blood pressure, neurological status, SpO [2] and temperature. See Table 1 for an example of a vignette triage case scenario. Overall, 48 triage case vignettes were developed. Three of the researchers (JR, MC, RR) independently applied the triage tool to these 48 cases, in a blind manner. A blinded approach ensured that the individual researchers did not know of each other’s responses to the cases, until all had completed the application of the triage tool. On 18 occasions, the three researchers had agreeance on the triage category. These 18 vignettes were then used in the online survey. These scenarios varied in triage categories, such as category one (resuscitation), category two (urgent), or category three (minor). Category four (self-help) scenarios were not included in the survey as category four (self-help) includes requests for minor items, such as ‘Band-Aids’ and sun lotion, rather than a clinical assessment or management.
Methods
Data collection
Design
Volunteer members of St John Ambulance Australia, with different clinical qualifications were recruited via closed social media pages, such as Facebook groups. Interested members were directed to the survey directly from the Facebook groups, as such, completing the survey at the time of accepting the invitation. Members were recruited on the basis that they were either a first responder for at least one year, were an advanced responder, or were a health care professional including nurses, doctors and paramedics. The survey, hosted by Survey MonkeyTM , was open from 10th May 2016 to 14th July 2016.
Aim
This research used clinical case vignettes (Evans, et al., 2015) to further develop an existing MGE triage tool. Population and sample The population of this research were volunteer members of St John Ambulance Australia. These members included health care professionals such as doctors, nurses and paramedics; and nonhealth care professionals, such as first aiders, first responders, and advanced responders. The first aider, first responder and advanced responder volunteers with St John Ambulance are lay people with additional training and have real-world experience of providing patient care at MGEs. The sample was purposive of the above population and included members who responded to an invitation to participate in this research, and voluntarily completed the online survey. Survey development The online survey was developed by the researchers and consisted of two parts. The first part was developed based on face validity between the researchers and consisted of questions relating to participant demographics. The second part consisted of triage case vignettes, of which participants were asked to allocate a triage category. Each triage case vignette was based on real-world scenarios by de-identifying real patient case sheets from MGEs covered by St John Ambulance Australia, New South Wales (NSW) in 201314. Each triage scenario included a short summary of the patient’s
Data analysis Demographic data were analysed using descriptive statistics, such as frequencies and means of central tendency. Fleiss Kappa [p-bar] (an adaption of Cohen’s kappa for 3 or more raters) was used to assess the reliability of agreement of individual responses against the various vignettes, and also measured as a total for the 18 vignettes. Using Fleiss Kappa, a score of 0.80 or more per vignette represents very good agreement between participants, a score of between 0.60 and 0.79 represents good agreement, a score between 0.40 and 0.59 represents a satisfactory agreement, and scores less than 0.40 represent poor agreement [9]. Analysis was undertaken using Microsoft Excel (Version: Microsoft Office 2016. Redmond, Washington, US). Protection of human participants Ethical approval was obtained for this research from the St John Ambulance Australian Human Research Ethics Committee.
Please cite this article in press as: Ranse J, et al. Using clinical based vignettes to further develop a mass gathering event triage tool. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.12.010
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Fig. 1. triage tool.
Table 2 Participant demographics. Number of participants Age, median (IQR) Gender, f (%) Male Female Highest achieved qualification, f (%) High School Certificate Diploma Bachelor Degree Postgraduate Degree Other Years as a St John Ambulance Australia member, median (IQR) Clinical skill level, f (%) First aider First Responder Advanced Responder Paramedic Enrolled Nurse Registered Nurse Medical Officer
110 28 (24–43.5) 66 (60) 44 (40) 19 (17.3) 28 (25.5) 38 (34.5) 21 (19.1) 4 (3.6) 7 (3–15) 3 (2.7) 42 (38.2) 32 (29) 16 (14.5) 2 (1.8) 16 (14.5) 4 (3.6)
f, frequency; IQR, interquartile range.
Findings There were 110 completed responses. From a broad perspective, the majority of participants were male (n = 66, 60%), having completed a Bachelors Degree (n = 38, 34.5%), and were currently holding the clinical skill level of ‘first responder’ with St John Ambulance Australia (n = 42, 38.2%). Additional, more detailed participant demographics are outlined in Table 2. Agreeance Of the 18 vignettes, there was a satisfactory agreement overall (items: 18, p-bar: 0.55). In addition to assessing the overall agreement, agreement was determined for each individual triage category against the participant responses. There was a good
level of agreeance amongst responses for the resuscitation category (items: 3, b-par 0.69), and there was satisfactory agreeance amongst responses for the urgent (items: 10, b-par 0.52) and minor (items: 5, b-par 0.52) categories.
Discussion This research provides insight into the decision-making and usage of a previously developed MGE triage tool. The findings from this research demonstrated an overall satisfactory reliability, which is similar to that of the in-hospital emergency department triage tool development. In a literature review of emergency department triage tools and systems, it was identified that there was good to very good reliability for the CTAS and ESI, whereas the ATS and MTS had satisfactory reliability [9]. When exploring the individual triage categories there is greater consistency in the application of the triage tool for higher priority patients, such as those requiring resuscitation [14,15]. Higher priority patients have less subjective presentations, including clear changes in vital signs or threats to life. In contrast, lower priority patients have fewer concrete variables to discriminate between triage categories. A recent systematic review concluded that triage systems internationally, are more reliable when patients present with higher acuity complaints [16]. When used across the broader population, the authors found that interrater reliability for paper-based vignettes ranged from 0.40 to 0.87 [16]. This was also the case for this research in which the resuscitation category had the highest level of agreement. The development of MGE triage tools have been descriptive to date [11,12], however, this research has added an element of reliability to the development of the presented MGE triage tool. Further development of this MGE triage tool should be undertaken at real-world MGEs, with multi-type and multi-site MGE settings considered. Further, as real-world testing of MGE triage tools by non-healthcare professionals has not previously been published [12], it would be a necessary step in further development to ensure testing included non-health care professionals. It is well-
Please cite this article in press as: Ranse J, et al. Using clinical based vignettes to further develop a mass gathering event triage tool. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.12.010
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established that different MGEs have different characteristics that may contribute to variation in in-event patient presentation rates and transport to hospital rates [2]. This may imply that the patients presenting at in-event health services do so with differing severity of injury and illness, therefore requiring different aspects of triage. As such, real-world testing should occur across different types of MGEs. Including multiple organizations would be important in future testing of a MGE triage tool. Such an approach would provide insight into the efficacy of the tool within different organizational governance frameworks. Including nations, beyond Australia, would provide insight into the versatility of the triage tool beyond the Australian content. How the tool is integrated into other countries would be valuable. At present MGE triage tool development has focused on Australia and Canada [11,12]. Study limitations This study was conducted with a small sample, of both vignettes and participants. As such the ability to generalise the findings from this research to other participant and organisations may be limited. Given that there are concerns that vignettes do not accurately reflect real-world phenomena [13], the results from this research can be considered a step towards the real-world application of a triage tool for MGEs. Conclusion This paper has examined the use of real-world clinically based vignettes to further develop a MGE triage tool. This research has demonstrated that the findings from this research are similar to that of the in-hospital, ED, triage tool development. This research provides insight into the decision-making and usage of a MGE triage tool. However, real-world, multi-site, multi-type evaluation is required to further progress the development of this MGE triage tool. Provenance and conflict of interest This paper was not commissioned. This journal, Australasian Emergency Care is the association journal for the College of Emergency Nursing Australasia [CENA]. One author (JM) is the Executive Director of CENA. This author was not involved in the review process of this paper.
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Please cite this article in press as: Ranse J, et al. Using clinical based vignettes to further develop a mass gathering event triage tool. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.12.010