Emergency Department Triage Nurses Research Articles

Factors Influencing Nurses' Decisions in Using a Mental Health Triage Scale: A Review

The aim of this systematic review was to synthesise evidence regarding ED nurses’ decision-making when applying a mental health triage scale. The review sought to answer the question: What factors influence ED nurses’ decisions and decision-making process in applying a mental health triage scale?
 
 The views, attitudes and experiences of mental health triage nurses performing triages for patients with mental health presentations in emergency department settings were examined in a systematic review of published and peer-reviewed qualitative research articles. CINAHL, PsycINFO, PubMed, and EMBASE were used to find published works from 2013 to 2022. After reading the title and abstract, the whole text of relevant research was obtained. The results of the included papers were analysed using the thematic content and narrative analysis approach, and critical appraisal of the quality of included articles was carried out using CASP. Sub-themes and themes were created by collapsing emerging patterns and codes.
 
 A total of eight full-text studies were included in the review. All the eight articles were qualitative studies conducted in six different countries and published in peer-reviewed journals. The total sample in the included articles consisted of 135 emergency department triage nurses with semi-structured and focus groups used in data collection. The methodological quality of the articles varied, with scores ranging from 16 to 18 out of 20. Three main themes emerged from the systematic review. From the ED triage nurses’ points of view, factors affecting triage decision making for patients with mental health presentations were “nurse-related”, “workplace-related”, and “patient-related”.
 
 This is the first systematic review summarising the evidence of the factors affecting ED triage nurses’ decision-making involving patients with mental health presentations. The findings suggest that the nurse as an individual (personally and professional), the workplace (social, structural and architectural environment), and the patient as an individual (safety, risk, acuity and behaviour) affect the quality of nursing decision-making in applying mental health triage scales. Ongoing review of the literature in this area is important to provide further evidence to inform nursing policy, practice, education and further research.

A comparison between the impacts of lecturing and flipped classrooms in virtual learning on triage nurses’ knowledge and professional capability: an experimental study

BackgroundThe quality of triage in emergency department depends on regular evaluation of triage nurses’ professional capabilities and development of programs to improve them. Flipped classrooms are a new approach to learning which can be employed to improve professional capabilities. The present study aims to compare the impact of lecturing to flipped classrooms in virtual learning on the knowledge and professional capabilities of triage nurses in the emergency departments of the state hospitals of Yazd province in south-western Iran in 2022.MethodsThe present study is an experimental work of research. Seventy-four triage nurses participated in the study. Seventy-four triage nurses were randomly allocated to the two groups, including flipped classrooms (group B) and lecturing (group A). The data collection instruments were an emergency department triage nurses’ professional capability questionnaire and a triage knowledge questionnaire. The collected data were analyzed in SPSS v.22 using independent t-test, chi-squared test, and repeated measures analysis of variance. Level of significance was set at p ≥ 0.05.ResultsThe participants’ mean age was 33.1 ± 4.3 years. As measured one month after the education, the triage knowledge mean score of the nurses who were educated using the flipped classroom method (9.29 ± 1.73) was higher than that of the nurses who were educated via lecturing (8.45 ± 1.788), and the difference was statistically significant (p = 0.001). Also, measured one month after the education, the professional capability mean score of the nurses who were educated using the flipped classroom method (140.27 ± 11.744) was higher than that of the nurses who were educated via lecturing (132.84 ± 10.817), and the difference was statistically significant (p = 0.006).ConclusionThere was a significant difference between the pretest and posttest knowledge and professional capability mean scores of both groups immediately after the education. However, measured one month after the education, the mean and standard deviation of the knowledge and professional capability scores of the triage nurses who had been educated via flipped classrooms were higher than those of the nurses in the lecturing group. Thus, virtual learning using flipped classrooms is more effective than lecturing in improving triage nurses’ knowledge and professional capability in the long run.

Effects of the COVID-19 Pandemic on Emergency Department Triage Nurses' Response to Patients With Potential Acute Coronary Syndrome.

The COVID-19 pandemic added challenges to patient assessment and triage in the emergency department (ED). The aim of this study was to describe the effects of the COVID-19 pandemic on ED triage nurse decisions for patients with potential acute coronary syndrome (ACS). This was a secondary analysis of data from a descriptive, electronic, survey-based study. Participants were asked 2 questions: whether the COVID-19 pandemic had affected their triage and/or assessment practices for patients with potential ACS and, if so, how. Descriptive statistics were used to compare the characteristics of participants. A qualitative descriptive approach was used to analyze responses to the open-ended questions about the pandemic's effect on the triage process. Participants from across the United States had a mean age of 41.7 (12.3) years; 358 (80.6%) were women. The participants had a median of 10.0 (interquartile range, 16.0) years of experience as a registered nurse, with a median of 7.0 (interquartile range, 11.0) years of ED experience. A total of 180 of 444 participants (40.5%) indicated that the COVID-19 pandemic affected their triage processes and assessment of potential ACS patients; 156 (86.7%) provided a response to the open-ended question. Responses revealed 4 themes: (1) delays in triage and treatment, (2) ambiguous patient presentation, (3) heightened awareness of COVID-19 complications and sequelae, and (4) process changes. Forty percent of ED triage nurses participating reported that triage processes for patients with potential ACS were affected by the COVID-19 pandemic. Most expressed barriers that resulted in delayed assessment and treatment of patients and often resulted from overlapping cardiac symptoms and COVID-19.

The Impact of Cultural Embeddedness on the Implementation of an Artificial Intelligence Program at Triage: A Qualitative Study.

Triage requires rapid determination of acuity and resources. Current modalities allow for individual judgment, with varied application of algorithmic rules. Although artificial intelligence can improve triage accuracy, gaps remain in understanding implementation facilitators and barriers, especially those related to the cultural understandings by nurses of emergency department presentations. The purpose of this study was to explore the cultural and technological elements of the implementation of an artificial intelligence clinical decision support aid (i.e., KATE) in an emergency nursing triage process in an urban community hospital on the West Coast of the United States. An exploratory qualitative study using semi-structured small group and individual interviews and constant comparison analysis strategies. The sample comprised 13 emergency department triage nurses at one site. Campinha-Bacote's theory of cultural competence framed the study. Responses yielded the overall theme of We know these people and we know these things. Supporting categories included the problem of aire; just another checkbox; gut trumps data; higher acuity with no resources; and technology as a safety net. Participants reported reliance on clinical experience and cultural knowledge to assign acuity. The implementation of an artificial intelligence program was initially received skeptically due to the acontextual nature of AI, but grew to be perceived as a safety net for triage decision making among emergency nurses.

Utilization of Pediatric Standing Orders by Triage Nurses in a Free-Standing Emergency Department.

Pediatric pain-related complaints continue to be a common presenting factor of most emergency departments (EDs). Studies have shown that several barriers in assessing and treating pediatric pain exist, including nursing knowledge regarding appropriate pain level assessment. This quality improvement study aimed to provide and evaluate specific education regarding pediatric pain management for free-standing ED triage nurses to expedite medication administration during the triage phase of an ED visit. This pre/post-test intervention study was used to measure whether the education provided to nurses working in a primarily adult patient free-standing ED increased the utilization of triage standing orders related to pediatric pain management. Paired sample t-tests results indicated a statistically significant increase (p = .000) in the percentage of patients that received pain medication during the triage phase of an ED visit after specific education was provided to triage nurses. Free-standing ED triage nurses are more likely to follow and implement triage standing orders if education explicitly related to pain management in pediatric patients has been provided. Pediatric pain management education should be revisited annually to re-educate nurses on the importance of early interventions.

Improving the accuracy of Nurse Initiated X-ray Orders (NIXO) in the Emergency Department

Purpose: In Sengkang General Hospital (SKH), Emergency Department (ED) triage nurses are privileged to order x-rays for patients prior to consultation with the ED doctors based on the initial presenting complaints. This workflow was implemented to improve the efficiency of patient management in ED. However, SKH ED radiographers encountered several orders from triage nurses that were deemed inappropriate or inaccurate. Such orders have led to several near-miss cases that could compromise patient safety and potential medico-legal issues. It also subjects patients to unnecessary radiation. This study aims to evaluate if using an educational tool can improve the accuracy of x-ray orders by ED triage nurses.Methods: Inappropriate or inaccurate x-ray orders are defined as x-ray orders that are ordered for incorrect region, incorrect side or inaccurate clinical history. An educational package in the form of presentation slides was created for the nurses by a team of radiographers. This package is called NIXO, an abbreviation of Nurse Initiated X-ray Orders. NIXO was then presented to the ED triage nurses during their monthly Continuing Professional Development (CPD) session in June 2021. With the assistance of the ED nursing education team, data for nurse's x-ray orders were obtained three months before and after the CPD session. The results of this data will determine the effectiveness of the NIXO presentation to the triage nurses.Results: Data was collected between April 2021 to June 2021 (pre-CPD) and August 2021 to October 2021 (post-CPD). It was found in the initial results that there is a drop in the x-ray orders error rates. This showed that there has been an improvement in the accuracy of ED triage nurse's x-ray ordering. In addition, in a post-CPD presentation survey conducted, 99% of the triage nurses found this initiative to be helpful in their clinical work. Collection of data is still ongoing up till February 2022. The results of this study will be evaluated once again in February 2022.Conclusion: Based on the preliminary findings of this study, it suggests that NIXO has helped reduce the number of inappropriate orders made by ED triage nurses. This inter-professional education initiative has provided ED triage nurses with the knowledge required to order X-rays competently whilst ensuring patient safety and providing care. As such, NIXO education package will be integrated into the ED triage course in future. Purpose: In Sengkang General Hospital (SKH), Emergency Department (ED) triage nurses are privileged to order x-rays for patients prior to consultation with the ED doctors based on the initial presenting complaints. This workflow was implemented to improve the efficiency of patient management in ED. However, SKH ED radiographers encountered several orders from triage nurses that were deemed inappropriate or inaccurate. Such orders have led to several near-miss cases that could compromise patient safety and potential medico-legal issues. It also subjects patients to unnecessary radiation. This study aims to evaluate if using an educational tool can improve the accuracy of x-ray orders by ED triage nurses. Methods: Inappropriate or inaccurate x-ray orders are defined as x-ray orders that are ordered for incorrect region, incorrect side or inaccurate clinical history. An educational package in the form of presentation slides was created for the nurses by a team of radiographers. This package is called NIXO, an abbreviation of Nurse Initiated X-ray Orders. NIXO was then presented to the ED triage nurses during their monthly Continuing Professional Development (CPD) session in June 2021. With the assistance of the ED nursing education team, data for nurse's x-ray orders were obtained three months before and after the CPD session. The results of this data will determine the effectiveness of the NIXO presentation to the triage nurses. Results: Data was collected between April 2021 to June 2021 (pre-CPD) and August 2021 to October 2021 (post-CPD). It was found in the initial results that there is a drop in the x-ray orders error rates. This showed that there has been an improvement in the accuracy of ED triage nurse's x-ray ordering. In addition, in a post-CPD presentation survey conducted, 99% of the triage nurses found this initiative to be helpful in their clinical work. Collection of data is still ongoing up till February 2022. The results of this study will be evaluated once again in February 2022. Conclusion: Based on the preliminary findings of this study, it suggests that NIXO has helped reduce the number of inappropriate orders made by ED triage nurses. This inter-professional education initiative has provided ED triage nurses with the knowledge required to order X-rays competently whilst ensuring patient safety and providing care. As such, NIXO education package will be integrated into the ED triage course in future.

Experiences of emergency triage nurses in the police handover of mentally ill patients: A qualitative descriptive study

BackgroundDue to the high prevalence of mental health illnesses, police officers are often the community resource to emergency calls for someone experiencing a mental health crisis. Despite the successful efforts of crisis intervention teams, the police frequently escort and transfer the individual in crisis to the emergency department (ED). To our knowledge, one study has explored the interactions of first responders and ED staff; however, we lack an understanding of ED triage nurse experiences. AimTo explore the experiences of ED triage nurses regarding the handover of a mental health patient by police in a Quebec University Health Center. MethodSemi-structured interviews with seven nurses were thematically analyzed. The COREQ checklist for reporting qualitative research was used. ResultsNurses and police officers are both concern about patient's well-being; yet, their approach, as discussed in the theme “Medical versus Legal Responsibility”, varied based on their differing responsibilities and views of caring versus protecting. Despite a need for ED-triage protocols, as described in the theme “Ambiguities of Existing ED-Triage Protocols”, all nurses saw police officers as fellow colleagues and expressed that a change had taken place in police culture towards mental health. The latter issues are explained in the themes “Interagency Collaboration and Team-Based Approach”, and “Changing Police Culture on Mental Health.” ConclusionThere is a need for inter-professional collaboration and education to better understand the roles and scope of practice of both professions, and ED triage nurses should receive more training in the domain of mental health.

Accuracy among nurses in using COVID-19 visual triage in the Emergency Medicine Department of a Tertiary Hospital in the Kingdom of Bahrain

Background: The novel coronavirus 2019 (COVID-19) emerged in December 2019 in Wuhan, China, and rapidly spread worldwide. The Bahrain National COVID Team has released a screening tool called Visual Triage to alert healthcare workers in the Kingdom of Bahrain about the possibility of occurrence of COVID-19 infections among patients presenting to healthcare facilities. The aim of this research is to identify the accuracy rate of nurses in using Visual Triage and to evaluate points of improvement among nurses using the Visual Triage system. Methods: A cross-sectional study was conducted using a scenario-based questionnaire in the Emergency Department (ED) of Bahrain Defense Force Hospital in the Kingdom of Bahrain. The participants were all Visual Triage nurses and ED triage nurses. The data collected through the self-administered questionnaires were analyzed using Excel and SPSS version 26 programs. Results: The number of nurses who participated was 57. Nurses rated 66.89% of the cases correctly. There was no difference in the rate of accuracy between emergency triage nurses and Visual Triage nurses. Years of experience did not affect the accuracy rate of using Visual Triage. A comparison was made between nurses with different levels of education, and the highest accuracy was obtained by those who held a Bachelor of Science degree in nursing. Nurses who had received education about Visual Triage had a higher rate of accuracy than those who had not. In choosing the appropriate destination, nurses rated 64.02% of the cases correctly. Conclusion: The accuracy of nurses in using Visual Triage can be improved if factors leading to inaccuracy can be adjusted. The findings of this study could be used as a guide for improvement.

Effects of environmental distractors on nurse emergency triage accuracy: a pilot study protocol

BackgroundThe clinical decisions of emergency department triage nurses need to be of the highest accuracy. However, studies have found repeatedly that these nurses over- or underestimate the severity of patient health conditions. This has major consequences for patient safety and patient flow management. Workplace distractors such as noise and task interruptions have been pointed to as factors that might explain this inaccuracy. The use of a serious game reproducing the work environment during triage affords the opportunity to explore the impact of these distractors on nurse emergency triage accuracy, in a safe setting.Methods/designA pilot study with a factorial design will be carried out to test the acceptability and feasibility of a serious game developed specifically to simulate the triage process in emergency departments and to explore the primary effects of distractors on nurse emergency triage accuracy. Eighty emergency nurses will be randomized into four groups: three groups exposed to different distractors (A, noise; B, task interruptions; C, noise and task interruptions) and one control group. All nurses will have to complete 20 clinical vignettes within 2 h. For each vignette, a gold standard assessment will be determined by experts. Pre-tests will be conducted with clinicians and certified emergency nurses to evaluate the appeal of the serious game.DiscussionStudy results will inform the design of large-scale investigations and will help identify teaching, training, and research areas that require further development.

Performance of a three-level triage scale in live triage encounters in an emergency department in Hong Kong

BackgroundDespite its continued use in many low-volume emergency departments (EDs), 3-level triage systems have not been extensively studied, especially on live triage cases. We have modified from the Australasian Triage Scale and developed a 3-level triage scale, and sought to evaluate its validity, reliability, and over- and under-triage rates in real patient encounters in our setting.MethodThis was a cross-sectional study in a single ED with 24,000 attendances per year. At triage, each patient was simultaneously assessed by a triage nurse, an adjudicator (the “criterion standard”), and a study nurse independently. Predictive validity was determined by comparing clinical outcomes, such as hospitalization, across triage levels. The discriminating performance of the triage tool in identifying patients requiring earlier medical attention was determined. Inter-observer reliability between the triage nurse and criterion standard, and across providers were determined using kappa statistics.ResultsIn total, 453 triage ratings of 151 triage cases, involving 17 ED triage nurses and 57 nurse pairs, were analysed. The proportion of hospital admission significantly increased with a higher triage rating. The performance of the scale in identifying patients requiring earlier medical attention was as follows: sensitivity, 68.2% (95% CI 45.1–86.1%); specificity, 99.2% (95% CI 95.8–100%); positive predictive value, 93.8% (95% CI 67.6–99.1%); and negative predictive value, 94.8% (95% CI 90.8–97.1%). The over-triage and under-triage rates were 0.7% and 4.6%, respectively. Agreement between the triage nurse and criterion standard was substantial (quadratic-weighted kappa = 0.76, 95% CI, 0.60–0.92, p < 0.001), so was the agreement across nurses (quadratic-weighted kappa = 0.81, 95% CI 0.65–0.97, p < 0.001).ConclusionsThe 3-level triage system appears to have good validity and reasonable reliability in a low-volume ED setting. Further studies comparing 3-level and prevailing 5-level triage scales in live triage encounters and different ED settings are warranted.

Pragmatic Strategy Empowering Paramedics to Assess Low-Risk Trauma Patients With the Canadian C-Spine Rule and Selectively Transport Them Without Immobilization: Protocol for a Stepped-Wedge Cluster Randomized Trial.

BackgroundEach year, half a million patients with a potential neck (c-spine) injury are transported to Ontario emergency departments (EDs). Less than 1.0% (1/100) of these patients have a neck bone fracture. Even less (1/200, 0.5%) have a spinal cord injury or nerve damage. Currently, paramedics transport all trauma victims (with or without an injury) by ambulance using a backboard, cervical collar, and head immobilizers. Importantly, prolonged immobilization is often unnecessary; it causes patient discomfort and pain, decreases community access to paramedics, contributes to ED crowding, and is very costly. We therefore developed the Canadian C-Spine Rule (CCR) for alert and stable trauma patients. This decision rule helps ED physicians and triage nurses to safely and selectively remove immobilization, without x-rays and missed injury. We successfully taught Ottawa paramedics to use the CCR in the field in a single-center study.ObjectiveThis study aimed to improve patient care and health system efficiency and outcomes by allowing paramedics to assess eligible low-risk trauma patients with the CCR and selectively transport them without immobilization to the ED.MethodsWe propose a pragmatic stepped-wedge cluster randomized design with health economic evaluation, designed collaboratively with knowledge users. Our 36-month study will consist of a 12-month setup and training period (year 1), followed by the stepped-wedge trial (year 2) and a 12-month period for study completion, analyses, and knowledge translation. A total of 12 Ontario paramedic services of various sizes distributed across the province will be randomly allocated to one of three sequences. Paramedic services in each sequence will cross from the control condition (usual care) to the intervention condition (CCR implementation) at intervals of 3 months until all communities have crossed to the intervention. Data will be collected on all eligible patients in each paramedic service for a total duration of 12 months. A major strength of our design is that each community will have implemented the CCR by the end of the study.ResultsInterim results are expected in December 2019 and final results in 2020. If this multicenter trial is successful, we expect the Ontario Ministry of Health will recommend that paramedics evaluate all eligible patients with the CCR in the Province of Ontario.ConclusionsWe conservatively estimate that in Ontario, more than 60% of all eligible trauma patients (300,000 annually) could be transported safely and comfortably, without c-spine immobilization devices. This will significantly reduce patient pain and discomfort, paramedic intervention times, and ED length of stay, thereby improving access to paramedics and ED care. This could be achieved rapidly and with lower health care costs compared with current practices (possible cost saving of Can $36 [US $25] per immobilization or Can $10,656,000 [US $7,335,231] per year).Trial RegistrationClinicalTrials.gov NCT02786966; https://clinicaltrials.gov/ct2/show/NCT02786966.International Registered Report Identifier (IRRID)DERR1-10.2196/16966

Understanding nurses perspectives of acuity in the process of emergency mental health triage: a qualitative study

Background: Post deinstitutionalisation, mental health mainstreaming has led to substantial increases in presentations to Emergency Departments (EDs). The assessment process requires the ED triage nurse to undertake a rapid client assessment, assign a clinically appropriate triage score, and then refer the client to a mental health clinician. The initial assessment is important, and a number of factors influence the process of triage, referral and response including an understanding of mental health presentation acuity. Aim: To understand the factors that influence the ED triage assessment, referral and clinical response of clients with a mental illness. Methods: An ethnographic methodology underpinned the research design. ED triage nurses and mental health triage nurses who worked in a regional hospital provided insights through interviews and observations. The study was also informed by institutional policies and procedures regarding triage. Transcribed in-depth interviews, field notes and memos were analysed using an inductive thematic process. Findings: Mental health triage nurses and ED triage nurses concur that triage is an important part of the assessing process for a person who presents to the ED with a mental health problem. Timely and clinically accurate assessment, followed by referral and response is strongly influenced by the user knowledge of the mental health triage scale, and comprehension of mental health acuity. The conflicting understandings between the two professional nursing groups, called professionally cultured orientations, further impact this process. Conclusion: Professionally cultured orientation to mental health triage and acuity comprehension influence the process of emergency mental health triage and therefore may affect optimal client outcomes. Further research into ED triage design, ED triage education, and a shared understanding of acuity is called for.

Time from triage to initial physician assessment: A 5-year retrospective analysis

The aim of the study is to examine whether physicians adhere to the urgency classification as determined by the Canadian Triage and Acuity Scale. A retrospective-archive study was conducted in a tertiary hospital from January 2011 to December 2015. For each patient, we examined the relation between the urgency rating set by the triage nurse and the waiting time for the physician. Additionally, we explored the relationships between waiting times for physicians and several subgroups: patient arrival time, season of the year, assigned care area, and first consultant to examine the patient, using Analysis of Variance (ANOVA) analysis. There were 392,687 unique visits during the study period. The distribution of the classification was heterogeneous: 7,133 (1.8%) patients were classified as Priority (P) P1; 17,318 as P2 (4.4%); 148,657 as P3 (37.8%); 113,502 as P4 (28.9%); and 106,077 as P5 (27%). Median and interquartile ranges for time from triage until physician assessment, by triage group, were: P1, 0.7 minutes (0.2-24); P2, 35 minutes (13-76); P3, 44 minutes (21-88); P4, 45 minutes (20-87); and P5, 46 minutes (22-88). Percentages of visits that met the evaluation time goals, by triage classification, were: P1, 61%; P2, 27%; P3, 37%; P4, 61%; and P5, 85%. ANOVA test for the four subgroups revealed statistically significant differences (P&lt;.001). In conclusion, the standard goals for time to physician evaluation are not being met, and there is little difference in time to evaluation between the P3, P4, and P5 classifications. Initiation of system-wide changes in physician workflow and awareness may improve physician adherence to triage classification, shorten time lags, and improve patient evaluation. Further research may allow for better understanding of the factors influencing triage adherence and reinforce teamwork among Emergency Department triage nurses and physicians.

A Multicenter Program to Implement the Canadian C-Spine Rule by Emergency Department Triage Nurses

The Canadian C-Spine Rule has been widely applied by emergency physicians to safely reduce use of cervical spine imaging. Our objective is to evaluate the clinical effect and safety of real-time Canadian C-Spine Rule implementation by emergency department (ED) triage nurses to remove cervical spine immobilization. We conducted this multicenter, 2-phase, prospective cohort program at 9 hospital EDs and included alert trauma patients presenting with neck pain or with cervical spine immobilization. During phase 1, ED nurses were trained and then had to demonstrate competence before being certified. During phase 2, certified nurses were empowered by a medical directive to "clear" the cervical spine of patients, allowing them to remove cervical spine immobilization and to triage to a less acute area. The primary outcomes were clinical effect (cervical spine clearance by nurses) and safety (missed clinically important cervical spine injuries). In phase 1, 312 nurses evaluated 3,098 patients. In phase 2, 180 certified nurses enrolled 1,408 patients (mean age 43.1 years, women 52.3%, collision 56.5%, and cervical spine injury 1.1%). In phase 2 and for the 806 immobilized ambulance patients, the primary outcome of immobilization removal by nurses was 41.1% compared with 0% before the program. The primary safety outcome of cervical spine injuries missed by nurses was 0. Time to discharge was reduced by 26.0% (3.4 versus 4.6 hours) for patients who had immobilization removed. In only 1.3% of cases did nurses indicate their discomfort with applying the Canadian C-Spine Rule. We clearly demonstrated that ED triage nurses can successfully implement the Canadian C-Spine Rule, leading to more rapid and comfortable management of patients without any threat to patient safety. Widespread adoption of this approach should improve care and comfort for trauma patients, and could decrease length of stay in our very crowded EDs.

A renal colic fast track pathway to improve waiting times and outcomes for patients presenting to the emergency department.

IntroductionRenal colic is commonly encountered in the emergency department (ED). We validated a fast track renal colic (FTRC) initiative to decrease patient waiting times and streamline patient flow.MethodThe FTRC pathway was devised according to the National Institute for Health and Care Excellence clinical summary criteria for the management of patients with suspected renal colic. ED triage nurses use the pathway to identify patients with likely renal colic suitable for fast track to analgesia, investigation and management. Investigations, diagnosis and patient demographics were recorded for 1157 consecutive patients coded as renal colic at a single-center ED over 12 months.ResultsThree hundred and two patients were suitable for the FTRC pathway (26.1%), while 855 were seen by the ED clinicians prior to onward referral. Also, 83.9% of patients underwent computed tomography scan. In the FTRC group, 57.3% of patients had radiologically confirmed calculi versus 53.8% in the non-FTRC group (p=0.31). Alternative diagnoses among FTRC patients (2.6%) included ovarian pathology (n=1), diverticulitis (n=2) and incidental renal cell carcinoma (n=2), while 26.1% had no identifiable pathology. No immediately life-threatening diagnoses were identified on imaging. Computed tomography scans performed in the non-FTRC group identified two ruptured abdominal aortic aneurysms and alternative diagnoses (2.57%) including ovarian pathology (n=7), cholecystitis (n=2), incidental renal cell carcinoma (n=3) and inflammatory bowel disease (n=1); 31.2% identified no pathology. Time in ED and time to radiologist-reported imaging were lower for the FTRC group versus non-FTRC group (p<0.0001).ConclusionThe FTRC pathway is a safe and efficacious method of reducing diagnostic delay and improving patient flow in the ED.

Using the Five-Level Taiwan Triage and Acuity Scale Computerized System: Factors in Decision Making by Emergency Department Triage Nurses.

Triage classifies and prioritizes patients' care based on the acuity of the illness in emergency departments (EDs). In Taiwan, the five-level Taiwan Triage and Acuity Scale (TTAS) computerized system was implemented nationally in 2010. The purpose of this study was to understand which factors affect decision-making practices of triage nurses in the light of the implementation of the new TTAS tool and computerized system. The qualitative data were collected by in-depth interviews. Data saturation was reached with 16 participants. Content analysis was used. The results demonstrated that the factors affecting nurses' decision making in the light of the newly implemented computerized system sit within three main categories: external environmental, patients' health status, and nurses' experiences. This study suggests ensuring the patient's privacy while attending the triage desk, improving the critical thinking of triage nurses, and strengthening the public's understanding of the ED visits. These will make ED triage more efficient.

Facilitators and barriers to application of the Canadian C-spine rule by emergency department triage nurses

ObjectivesWe recently conducted a multicentre implementation study on the use of the Canadian C-Spine Rule (CCR) by emergency department (ED) nurses to clear the c-spine in alert and stable trauma patients (n = 4506). The objective of this study was to conduct a survey of nurses, physicians, and administrators to evaluate their views on the facilitators and barriers to the implementation of the CCR. MethodsWe conducted both a paper-based and an electronic survey of the three different ED hospital staff groups of nine large teaching hospitals in Ontario, including six regional trauma centres. The content of this survey was informed by a qualitative evaluation of the opinions of the study nurses who had participated in the validation study. Results57.5% (281/489) ED triage nurses, 50.2% ED physicians, and 82.8% of administrators responded. Nurse responses most often showed support from manager/educators and teamwork between physicians, nurses, and managers as being important facilitators to the use of the CCR. Physician responses most often identified the importance of a nurse leader/champion/educator, and presence of strong physician leaders. Administrator responses indicated the importance of nurse educators/champions, nurse engagement, and educational support. Barriers indicated by all three groups included busy department, lack of physician support, and lack of nursing support. ConclusionsBringing about change in clinical practice is complex. Strong leadership, effective communication, and senior physician buy-in appear to be very important. Identification of system-specific barriers and facilitators are important components of successful knowledge translation.

Perceptions of Emergency Department Triage Nurses About Prehospital Emergency Rescuers in Italy: A Latent Threat to Clinical Handover.

In Italy, volunteer rescuers respond to most prehospital emergency calls. These rescuers provide the majority of patient information during handover at the emergency department triage. Standardized terminology between rescuers and triage nurses is lacking in Italy, and miscommunication may cause a poor handover. Even though rescuers are professional health providers, their qualification is not legally recognized, and triage nurses have a pervasive sense of inadequacy about the rescuers' competences.This work explored triage nurses' perceptions of rescuers and the causes of these perceptions to verify whether difficult interprofessional relationships negatively influence the clinical handover process. We performed a survey among 402 triage nurses for 3 main areas of rescuers' competency: communication, knowledge, and decision making. For each area, we identified communications, decision making, and knowledge indicators. A scale score of 6 or higher was considered not sufficient. We found that 75.5% (n = 302/400) of triage nurses regard rescuers' ability to recognize life-threatening situations as not sufficient (communication ability indicator). Approximately 66% (n = 264/401) of triage nurses regard rescuers' ability to administer oxygen as not sufficient (decision-making indicator), and approximately 58% (n = 232/402) of nurses regard rescuers' ability to report the reason for the emergency call as not sufficient (knowledge indicator). The results of this survey show that the overall perception of triage nurses about prehospital rescuers is slightly below sufficiency. This perception could cause errors during the prehospital or hospital handover at the triage and could lead to delayed decisions and incorrect treatment.

Reliability of Canadian Emergency Department Triage and Acuity Scale (CTAS) in Saudi Arabia.

BackgroundThe Canadian Emergency Department Triage and Acuity Scale (CTAS) is an integral part of the Canadian emergency medicine triaging system. There is growing interest and implementation of CTAS worldwide. However, little is known about its reliability outside Canada. The aim of this study was to determine the reliability agreement of CTAS in a tertiary care emergency center in Saudi Arabia.MethodsTen triage nurses (five senior and five junior nurses) utilized CTAS guidelines to independently assign a triage level for 160 real case-based scenarios. Quadratic weighted kappa statistics were used to measure raters’ agreements.ResultsRaters provided 1600 triage category assignments to case scenarios for analysis. Intra-rater agreement was similar for both senior and junior nurses; for senior nurses (SN1) kappa 0.871 95 % CI (0.840–0.897), and for junior nurses (SN2) kappa 0.871 95 % CI (0.839–0.898). Inter-rater agreement for the SN1 versus SN2 nurses had statistically meaningful agreement across different triage levels (weighted kappa = 0.770) 95 % CI (0.742–0.797).ConclusionsCTAS has good reliability among emergency department (ED) triage nurses in King Abdulaziz Medical City (KAMC), Saudi Arabia. The findings suggest that CTAS might be a reliable instrument when applied in countries outside Canada.

Electronic alerts for triage protocol compliance among emergency department triage nurses: a randomized controlled trial.

Alerts embedded in electronic health records (EHRs) are designed to improve processes at the point of care. The aim of this study was to determine if an EHR alert-at emergency department (ED) triage-increases the ED triage nurse's utilization of triage protocols. ED triage nurses were randomized to receive either a passive EHR alert or no intervention for patients with the following complaints: minor trauma with extremity injuries or female patients with abdominal pain. The EHR alert notified the nurse that the patient was eligible for diagnostic testing: radiographs for patients with injured extremities or urinalysis for female patients with abdominal pain. Twenty-eight nurses triaged 20,410 patients in the 6 months before the intervention and 19,157 in the 6 months after the intervention. Before the intervention, the urinalysis protocol was implemented in 101/624 (16.2%) patients triaged by the intervention group and 116/711 (16.3%) triaged by the control group. After the intervention, the urinalysis protocol was implemented in 146/530 (27.6%) patients triaged by the intervention group and 174/679 (25.6%) triaged by the control group. Before the intervention, the radiograph protocol was implemented in 58/774 (7.5%) patients triaged by the intervention group and 45/684 (6.6%) triaged by the control group. After the intervention, the radiograph protocol was implemented in 78/614 (12.7%) patients triaged by the intervention group and 79/609 (13.0%) triaged by the control group. The use of a passive EHR alert to promote ED triage protocols showed little benefit. Before the widespread implementation of EHR alerts for patient care, rigorous studies are required to determine the best alert methods and the impacts of such interventions.