Pediatric nurse triage. Its efficacy, safety, and implications for care

[Impact of a triage scale in a pediatric emergency department]

The pediatric nursing staff of the emergency unit has established a list of items for the triage of patients which can be used by the registered nurses. This scale defined 3 stages of severity.

OBJECTIVES

1) to estimate the relevance of this list through the appraisal of the total time necessary to take care of the patients according to their severity stage, and the confrontation of the severity stage determined by the registered nurse and the severity stage determined by the paediatrician; 2) to determine a possible correlation between the severity stage and the rate of hospitalization.

METHOD

This prospective study was carried out over a period of 1 month in winter for every child admitted in the pediatric emergency unit for medical reasons (traumatisms excluded).

RESULTS

One thousand six hundred and fifty-six children have been included in the study. Among them, 136 have been classified stage I, 1020 stage II and 500 stage III. The children have been taken care of in an average period of 20 min for stage I, 32 min for stage II, 43 min for stage III. The coherence rate between the severity stage determined by the nurse and the severity rate determined by the paediatrician was good. The rate of sub-estimation was low (4,2%). Nevertheless the reception nurses tend to overestimate the stage of severity in 17,6% of the cases. The prediction rate for hospital admittance was good: 68,7% of children classified in stage 1 were admitted, 23,5% of children in stage 2 and only 1,6% of children in stage 3.

CONCLUSION

Patients suffering from severe illnesses were taken care without injurious delay which was the main purpose of this list.

How to minimize inappropriate utilization of Accident and Emergency Departments: improve the validity of classifying the general practice cases amongst the A&E attendees

Studies have found that one-third to two-thirds of all patients attending Accident and Emergency (A and E) Departments could be managed appropriately by general practitioners (GPs). There is also evidence that referral to GPs can be acceptable to patients. The question of primary concern is screening non-urgent cases with high degrees of sensitivity (S), specificity (SP), and positive predictive value (PPV). This paper reports the findings of the validity (S, SP and PPV) of nurses and patients in triaging A and E visitors. A cross sectional study was conducted over a 1 year period and subjects were randomly selected from four A and E Departments located across the four principle geographic regions of Hong Kong by stratified, two-stage sampling. S, SP and PPVs were computed for both non-weighted and weighted conditions. The gold standard for defining the true urgency status of each selected patient was based on a review of the patient's record 3-21 days (or longer if necessary) following the A and E visit. The record review in each A and E was blinded and done independently by a panel of two (and if disagreement existed, three) senior emergency physicians who did not practice in the same hospital. The greatest weights would be for incorrect decisions with greatest impact on patients' well being. The most accurate unweighted nurses' triage classification had an average sensitivity of 87.8%, specificity of 83.9%, and a PPV of 70.1%. When weighted, the average sensitivity reduced to 75%, specificity to 65.7%, and PPV to 54%. The most accurate unweighted patients' self-triage classification yielded a sensitivity of 62.5%, specificity of 69.2%, and a PPV of 58.1%, and correspondingly reduced to 43.3, 49.2 and 38.6% if weights were applied. Validity of the derived patients' self-classifications was too inaccurate for practical use. Hong Kong's current use of a five-point urgency scale by nurses would be further refined for identifying non-urgent visitors. If a mechanism was put in place for additional screening on visitors with a borderline semi-urgent or non-urgent status, the nurses could safely reassign non-urgent patients to GP care. If implemented, a significant impact on hospital costs could be realized.

Patient decision making: use of and adherence to telephone-based nurse triage recommendations

OBJECTIVE

Health plans, employer groups, and medical providers offer telephone-based nurse triage services to provide ready access to medical advice and information to assist patients in making decisions about their medical needs. The purpose of this study is to assess patient adherence to nurse triage recommendations.

PATIENTS AND METHODS

The study includes data for members of an HMO located in a large metropolitan area who used the triage service during 1997 (n = 22,998). The nurse triage call data are linked with medical claims and encounter data to assess patient medical service utilization following a call to the triage service to assess triage adherence. The authors consider no use of medical services following a triage call with the recommendation to use self-care advice at home an indicator of adherence to this recommendation.

RESULTS

The percentage of callers who adhered to triage recommendations to use hospital emergency services, physician office services, or self-care advice was 79.2%, 57.4%, and 65.8%, respectively. Adherence varies somewhat by age.

CONCLUSION

The reported adherence levels are lower than those obtained from self-reported data reported elsewhere. Given the inherent limitations of both types of data, actual telephone-based nurse triage adherence may lie between the 2 levels.

Quality assurance of nurse triage: consistency of results over three years

The study objective was to evaluate the capability and the consistency of the triage nurse to categorize correctly emergency patients and its impact on the waiting time for physician examination over a period of 3 years. The study was performed at the emergency department of the Barzilai Medical Center, Ashkelon, Israel. A retrospective review of the medical records was performed. All patients who were examined by a triage nurse during 2 randomly chosen consecutive weeks during the years 1995 and 1998 participated. All the medical records were reviewed by the authors and the following information was extracted from the medical records: nurse triage category, time of initial evaluation by a triage nurse, duration of employment of the nurse in the ED, and her experience as a triage nurse, time of initial examination by a physician, the total length of stay in the ED, the history taken by the triage nurse and the physician, and the physician's urgency category. Patient in urgency category 1 is a patient whose condition may deteriorate if not examined within 1 hour; patient in category 2 is a patient whose condition may deteriorate if not examined within 2 hours; category 3 is all the rest. Any deterioration and or delay of treatment of the patients were also recorded. Data concerning patients with an initial complaint of chest pain were extracted separately. The data were analyzed using the SPSS software and the results were tested by the student t test and chi square test. Interobserver agreement was measured using the kappa value. A total of 2,886 completely full medical records were reviewed by the authors: 1,310 records from period I (1995) and 1576 from period II (1998). Of the patients 92% and 88.2% were classified by the triage nurse as category 3 in periods I and II respectively, 7% and 9.8% as category 2, and 1% and 2% as category 1 respectively. Full agreement of triage category between nurse and physician was found in 90.5% of the cases in period I and 93% in period II (kappa = 0.90 and kappa = 0.93 respectively). In period I, 70% of the patients in category 1 were examined by a physician in 1 hour versus 100% in period II. Almost all the patients in category 2 were examined within 2 hours (98%, 97%), and 98% of those in category 3 were examined within 3 hours. The average waiting time for physician examination in category 1 patients dropped from 43.1 minutes in period I to 18.2 minutes in period II. The average waiting time for the triage nurse was 9 minutes in period I, and 7.42 minutes in period II. The average length of stay in the ED in period I was 1 hour and 24 minutes and 1 hour and 30 minutes in period II. Of the anamneses taken by the triage nurse 91.8% were fully identical with the physicians' anamneses, but in period II this percentage jumped to 98%. Patients with chest pain were categorized correctly by the triage nurse in 76.8% of the cases in period I and 72.4% in period II, with an overtriage of 18.6% and 20.7% respectively (kappa = 0.75, kappa = 0.70 respectively). In our study, nurse triage was safe and effective in classifying patients to urgency categories. The results are consistent and even improved over a 3-year period. The rates of incorrect classification, deterioration, and delay of treatment of patients because of incorrect triage are very low. Most of the patients were examined by the physician within the expected time. Triage nurse predicted correctly the urgency category of patients with chest in most of the cases and the rate of missing acute coronary events was very low.

Can primary care and community-based models of emergency care substitute for the hospital accident and emergency (A & E) department?

This systematic review assesses the extent to which primary-secondary substitution is possible in the field of emergency care where the range of options for the delivery of care is increasing in the UK and elsewhere. Thirty-four studies were located which met the review inclusion criteria, covering a range of interventions. This evidence suggested that broadening access to primary care and introducing user charges or other barriers to the hospital accident and emergency (A & E) department can reduce demand for expensive secondary care, although the relative cost-effectiveness of these interventions remains unclear. On a smaller scale, employing primary care professionals in the hospital A & E department to treat patients attending with minor illness or injury seems to be a cost-effective method of substituting primary for secondary care resources. Interventions that addressed both sides of the primary-secondary interface and recognised the importance of patient preferences in the largely demand-driven emergency service were more likely to succeed in complementing rather than duplicating existing services. The evidence on other interventions such as telephone triage, minor injuries units and general practitioner out of hours co-operatives was sparse despite the fact that these interventions are growing rapidly in the UK. Quantifying the scope for substitution in any one health system is difficult since the evidence comes from international research studies undertaken in a variety of very different health settings. Simply transferring interventions which succeed in one setting without understanding the underlying process of change is likely to result in unexpected consequences locally. Nevertheless, the review findings clearly demonstrate that shifting the balance of care is possible. It also highlights a persistent gap in professional and lay perceptions of appropriate sources of care for minor illness and injury.

Improved pediatric patient flow in a general emergency department by altering triage criteria

OBJECTIVE

To evaluate the effect of altering pediatric triage criteria on ED triage scoring and patient flow.

METHODS

A prospective observational study of a pediatric triage modification was performed. Data for all pediatric patients presenting to an urban general ED during a six-month study period were collected. After the first three months, pediatric triage criteria were altered by elevating the acuity of several historical items and specifically listing abnormal signs and symptoms. Outcome measures included triage score assignment, criteria making the patient emergent, proportion of emergent or urgent triage assignments, and times to examination, disposition, and admission.

RESULTS

Altering pediatric triage criteria resulted in a significant (p < 0.05) increase in the number of patients triaged as emergent (2% vs 15%) or urgent (48% vs 55%). In addition, for emergent and urgent patients there was a significant decrease (p < 0.05) in the mean times to ED examination (50 vs 44 min), floor admission (355 vs 245 min), and intensive care unit admission (221 vs 132 min). The triage changes that had a significant impact on these results were a history of color change, decreased activity, and prematurity with complications.

CONCLUSIONS

A significant improvement in pediatric patient flow occurred after posting age-specific abnormal signs and symptoms as well as elevating triage acuity for specific historical clues.

Medical care at mass gatherings: considerations for physician involvement

Although many authorities define a "mass gathering" as a group exceeding 1,000 persons, several times that number likely are to be present. The event for which the group will gather may be anything from a rock concert to an Olympic competition. Preparations for the event can be minor or major. This article reviews the issues that a physician should consider if he or she chooses to become involved in the delivery of medical care to such populations, as well as the evidence suggesting that a physician should be involved in most such gatherings. Emergency medical care at public gatherings is haphazard at best and dangerous at worst. There are surprisingly few data from which to plan the emergency medical needs for public events and no recognized standards or guidelines for providing emergency medical services at mass public gatherings.

"Triaging out" children with minor illnesses from an emergency department by a triage nurse: where do they go?

OBJECTIVE

To determine whether parents of children with minor illnesses actually seek care after they receive advice and are referred from an emergency department by an ED triage nurse.

DESIGN

Descriptive study of 100 parents with children who were given advice and referred from an urban, pediatric tertiary care center by an ED triage nurse.

METHODS

A 10-item telephone survey was designed to determine whether parents took their children to the primary health care provider to whom they were likely to be referred. Parental perceptions of the severity of the child's medical problem, of the nurse's understanding of the problem, and of the satisfaction with the referral process were analyzed with Fisher's exact test.

RESULTS

Most (79%) of the subjects did not seek care with a primary health care provider per referral. However, 81% of parents believed the triage nurse understood the child's problem (rated 4 or 5 on a 5-point Likert scale in which 5 meant "completely understood" the child's problem) and 79% were satisfied with being referred from the emergency department (rated 4 or 5 on a 5-point Likert scale in which 5 meant "most satisfied" with being "triaged out").

CONCLUSION

Parental perceptions of the ED triage nurse's understanding of the child's complaint has a significant positive relationship on the parent's satisfaction with the advice and referral directives given by the nurse for the health care needs of the child. No children in this study experienced a worsening in their condition. Hence the ED triage nurse can be a valuable resource in educating and fostering primary health care practices within the community.

Differences in priorities assigned to patients by triage nurses and by consultant physicians in accident and emergency departments

STUDY OBJECTIVES

To investigate whether the greater urgency assigned to accident and emergency patients by triage nurses than by accident and emergency doctors was uniform across all patient groups.

DESIGN

Patients attending an accident and emergency department between 8.00 am and 9.00 pm over a six week period were assessed prospectively for degree of urgency by triage nurses, and retrospectively for urgency by one of two consultant accident and emergency doctors. Patients were grouped according to their clinical mode of presentation.

SETTING

An accident and emergency department of a district general hospital in the Midlands, UK, in 1990.

PATIENTS

1213 patients who presented over six weeks.

MEASUREMENTS AND MAIN RESULTS

As might be expected, patients' conditions were assessed as being more urgent prospectively than retrospectively. This finding, however, was not uniform across all patient groups. Nurses' assessments of urgency tended to favour children and patients who presented with eye complaints and gave less priority to medical cases, particularly those with cardiorespiratory symptoms.

CONCLUSIONS

These findings have implications for all those involved in the organisation of triage systems and in the training of nurses in accident and emergency departments. It is essential that judgements on how urgently patients need to be seen are made in a completely objective manner.

Piloting an evaluation of triage

This paper takes a broad view of the work involved in pilot studies of evaluation research. Drawing on their experience of preparation for a field experiment in a British Accident and Emergency department, which was to evaluate the effectiveness of a nurse triage system, the authors stress the importance of careful observation of the system to be studied, in the environment in which it is to be studied. In addition, the usual evaluations of research instruments which comprise formal pilot studies are included.

Level of medical care required for mass gatherings: the XV Winter Olympic Games in Calgary, Canada

STUDY OBJECTIVE

To determine the level of medical care required for mass gatherings and describe the types of medical problems encountered in a major winter event.

DESIGN

Standard charts were available for 3,395 encounters. Interviews with medical staff showed that the few unrecorded encounters were for very minor medical problems. A four-tiered triage system (low, moderate, urgent, and emergent) developed before the Games was applied to each chart retrospectively by a single emergency physician. Chi-squared tests were used to test significant differences.

SETTING

This winter sporting and entertainment event had 12 urban and rural venues. Medical staff (98 physicians, 161 nurses, and 337 first-aid attendants) were based in 28 advanced life support (ALS) clinics. The medical service operated for four weeks.

TYPE OF PARTICIPANTS

There were 1.8 million spectator-days. Patients included spectators, athletes, and support staff.

INTERVENTIONS

First-aid attendants referred patients to the clinics, where nurses conducted initial assessments and referred patients to physicians at the venue, or more rarely, to local hospital emergency departments. Paramedic ambulances were stationed at the venues. The triage system was not used for patient management.

MEASUREMENTS AND MAIN RESULTS

Only 40 urgent and one emergent medical problems were encountered. The majority of patients could have been managed by trained nurses working alone under standing orders. Fifty patients were transported to the hospital by ground ambulance and three by helicopter. No significant differences were found in the low acuity levels experienced at indoor urban venues, outdoor urban venues, and the rural cross-country ski venue. The Alpine ski venue was characterized by significantly higher acuity and a long prehospital transfer phase.

CONCLUSION

Owing to the low acuity encountered and the availability of Calgary's ALS ambulance service, we concluded that physician-based ALS teams were not required for patient management at the urban venues. Such teams were found to be required at the rural Alpine ski venue. Other reasons for using physicians are discussed, as is development of a standard triage system for mass gatherings.

Computerized algorithm-directed triage in the emergency department

A retrospective audit was conducted evaluating the effectiveness of the computerized algorithm-directed triage at Brooke Army Medical Center. A total of 98,086 charts were reviewed. From this, 58,282 patients were given dispositions to our acute care clinic and the remainder to the emergency department. Of these, 733 patients (1.2%) were retriaged from the acute care clinic to the ED. Based on these data, we conclude that the computerized algorithm-directed triage, using minimally trained personnel, appears to be an effective system.