Triage Research Articles

Perspectives: just triage.

Perspectives: just triage.

Phone triage nurses’ assessment of respiratory tract infections – the tightrope walk between gatekeeping and service providing. A qualitative study

Background Phone nurses triage callers to Norwegian out-of-hours cooperatives to estimate the appropriate urgency and level of care for the caller. Many callers with mild symptoms of respiratory tract infections receive a doctor’s consultation, which may lead to busy sessions and in turn impair clinical decisions. Objective This study explores how phone triage nurses assess callers with mild-to-moderate symptoms of respiratory tract infections and their views and experiences on triaging and counselling these callers. Methods We conducted four focus groups with 22 nurses (five men and 17 women aged 24–66 years) in three different locations in Norway. The interviews were transcribed verbatim and analysed by systematic text condensation. Results The informants were reluctant to call themselves gatekeepers. However, their description of their work indicates that they practice such a role. When nurses and callers disagreed about the right level of care, the informants sought consensus through strategies and negotiations. The informants described external factors such as organisational or financial issues as decisive for the population’s use of out-of-hours services. They also described callers’ characteristics, such as language deficiency and poor ability to describe symptoms, as determining their own clinical assessments. Conclusions Nurses perceive assessments of callers with respiratory tract infections as challenging. They need skills and time to reach a consensus with the callers and guide them to the right level of health care. This should be considered when planning nurse training and staffing of out-of-hours cooperatives. KEY-POINTS Phone triage nurses assess callers to the out-of-hours service and estimate the level of urgency This study explores how phone triage nurses assess callers with respiratory tract infections and their views and experiences on this task The nurses describe their professional role as a tightrope walk between gatekeeping and service providing The nurses seek consensus with callers through strategies and negotiations

Triage

Triage

A Comparison Between Computer-Assisted Self-Triage by Patients and Triage Performed by Nurses in the Emergency Department.

Background and objectiveEmergency departments (EDs) often find the number of arriving patients exceeding their capacity and find it difficult to triage them in a timely manner. The potential risk to the safety of patients awaiting assessment by a triage professional has led some hospitals to consider implementing patient self-triage, such as using kiosks. Published studies about patient self-triage are scarce and information about patients’ ability to accurately assess the acuity of their condition or predict their need to be hospitalized is limited. In this study, we aimed to compare computer-assisted patient self-triage scores versus the scores assigned by the dedicated ED triage nurse (TN).MethodsThis pilot study enrolled patients presenting to a tertiary care hospital ED without ambulance transport. They were asked a short series of simple questions based on an algorithm, which then generated a triage score. Patients were asked whether they were likely to be admitted to the hospital. Patients then entered the usual ED system of triage. The algorithm-generated triage score was then compared with the Canadian Triage and Acuity Scale (CTAS) score assigned by the TN. Whether the patients actually required hospital admission was determined by checking their medical records.ResultsAmong the 492 patients enrolled, agreement of triage scores was observed in 27%. Acuity was overestimated by 65% of patients. Underestimation of acuity occurred in 8%. Among patients predicting hospitalization, 17% were admitted, but the odds ratio (OR) for admission was 3.4. Half of the patients with cardiorespiratory complaints were correct in predicting the need for hospitalization.Conclusion The use of a short questionnaire by patients to self-triage showed limited accuracy, but sensitivity was high for some serious medical conditions. The prediction of hospitalization was more accurate with regard to cardiorespiratory complaints.

Pre COVID-19 emergency department nurses’ perspectives of the preparedness to safely manage influenza pandemics: A descriptive exploratory qualitative study

BackgroundPandemics pose significant challenges to healthcare systems worldwide and emergency departments are a crucial component in any pandemic response. This study was designed to explore what New Zealand emergency nurses perceive as the major challenges to nursing care and staff safety during a pandemic, and to identify strategies nurses feel are important in mitigating these challenges. MethodsA descriptive exploratory qualitative design using semi-structured interviews was conducted in March 2019. Participants were 16 triage nurses from two New Zealand emergency departments. Qualitative content and thematic data analysis techniques were used. ResultsEmergency nurses highlighted existing safety issues in their practice, and their concerns about how a pandemic might exacerbate these issues. These themes were identified as: safety of self and family, safety of patients, and safety of organisational systems. Nurses also shared their perspectives on how to mitigate these safety issues. ConclusionsThis study provides a detailed understanding of the concerns emergency nurses hold about working during pandemics. Similar fears for staff and patient safety have been voiced globally during the current COVID-19 pandemic, and it is crucial that emergency departments worldwide develop pandemic plans that address the safety concerns to which fear was attributed.

Work experience of triage nurses in emergency departments during the prevalence of COVID-19

ObjectiveIn December 2019, the global outbreak of Corona Virus Disease 2019 (COVID 19) was reported. As of March 8, 2020, more than 90,000 cases were reported worldwide, resulting in a shortage of global medical resources. The purpose of this study was to understand the working experience of triage nurses in the emergency department (ED) of a large teaching general hospital in Shenzhen (Guangdong province, China) during the COVID-19 epidemic. This will provide a basis for improving the emergency nursing strategies and the epidemic response capabilities of triage nurse. MethodsTen triage nurses were selected as subjects by objective sampling for in- depth interviews, and the data were analyzed by the Colaizzi seven-step analysis method. ResultsThere were four themes in the working experience of triage nurses, including fear of infection and transmission, job stress, gratitude, and expectations of managers. ConclusionDuring the COVID-19, the work experience of triage nurses mainly included the fear of infection and transmission, the high work pressure, the sense of team strength and the care of leaders. It was suggested that nursing managers should ensure the human resources of triage nurses, increase training, strengthen emergency drills, improve emergency nursing countermeasures, and improve the response capability of triage nurses during the epidemic.

NATO Science for Peace and Security (SPS) project“BioPhyMeTRE”: “Novel biological and physical methodsfor triage in radiological and nuclear (R/N) emergencies”

NATO Science for Peace and Security (SPS) project“BioPhyMeTRE”: “Novel biological and physical methodsfor triage in radiological and nuclear (R/N) emergencies”

Comparison of self-reported EDACS versus physician-reported EDACS for the triage of chest pain patients in the emergency department.

ObjectivesCurrently, there are no guidelines to help triage nurses identify high‐risk emergency department chest pain patients. Patient self‐reporting of Emergency Department Assessment of Chest Pain Score (EDACS) could facilitate more reliable triage compared to nursing gestalt, but this novel concept is untested. This study hypothesizes that because EDACS requires minimal clinical gestalt to derive, self‐reported EDACS (S‐EDACS) at triage is likely to correlate well with traditional physician‐reported EDACS (P‐EDACS) and have potential application as a triage tool.MethodsThis single‐center pilot prospective cohort study analyzed 60 patients who completed a self‐reported questionnaire upon triage to determine their S‐EDACS. This was matched against P‐EDACS, derived from an identical questionnaire completed by the blinded treating physician. Secondary endpoint of major adverse cardiovascular events (MACE) within 30 days (all‐cause mortality, myocardial infarction, coronary revascularization) was assessed by 2 blinded emergency physicians who independently reviewed the electronic medical records. S/P‐EDACS also were benchmarked against nursing gestalt (based on triage to low/high‐acuity areas) and emergency physician gestalt (disposition and admitting/discharge diagnoses).ResultsThere was perfect agreement between S/P‐EDACS in this study (K = 1.00). Fifteen patients (25.0%) had minor discordances in their absolute S/P‐EDACS that did not affect risk stratification. Of these, 11/15 (73.3%) had higher S‐EDACS, suggesting S‐EDACS is more likely to safely overcall MACE risk. S‐EDACS outperformed nursing gestalt, triaging a greater proportion of patients (71.7% vs 35.0%) as low risk without compromising patient safety, and demonstrated similar accuracy as emergency physician gestalt.ConclusionS‐EDACS strongly correlates with P‐EDACS with perfect agreement and has potential to be used as a triage tool.

Does pain severity predict stone characteristics or outcomes in emergency department patients with acute renal colic?

After initial emergency department (ED) management of acute renal colic, recurrent or ongoing severe pain is the usual pathway to ED revisits, hospitalizations and rescue interventions. If index visit pain severity is associated with stone size or with subsequent failure of conservative management, then it might be useful in identifying patients who would benefit from early definitive imaging or intervention. Our objectives were to determine whether pain severity correlates with stone size, and to evaluate its utility in predicting important outcomes. We used administrative data and structured chart review to study all ED patients with CT proven renal colic at six hospitals in two cities over one-year. Triage nurses recorded arrival numeric rating scale (NRS) pain scores. We excluded patients with missing pain assessments and stratified eligible patients into severe (NRS 8-10) and less-severe pain groups. Stone parameters were abstracted from imaging reports, while hospitalizations and interventions were identified in hospital databases. We determined the classification accuracy of pain severity for stones >5mm and used multivariable regression to determine the association of pain severity with 60-day treatment failure, defined by hospitalization or rescue intervention. We studied 2206 patients, 68% male, with a mean age of 49 years. Severe pain was 52.0% sensitive and 45.3% specific for larger stones >5mm. After multivariable adjustment, we found a weak negative association (adjusted OR =0.96) between pain severity and stone width. For each unit of increasing pain, the odds of a larger stone fell by 4%. Index visit pain severity was not associated with the need for hospitalization or rescue intervention within 60-days. Pain severity is not helpful in predicting stone size or renal colic outcomes. More severe pain does not indicate a larger stone or a worse prognosis.

Hospital Emergency Room Savings via Health Line S24 in Portugal

Hospital emergency departments are often overused by patients that do not really need urgent care. These admissions are one of the major factors contributing to hospital costs, which should not be allowed to compromise the response and effectiveness of the National Health Services (SNS). The aim of this study is to perform a detailed spatial health econometrics analysis of the non-urgent emergency situations (classified by Manchester triage) by area, linking them with the efficient use of the national health line, the Saude24 line (S24 line). This is evaluated through the S24 savings calls, using a savings index and its spatial effectiveness in solving the non-urgent emergency situations. A savings call is a call by a user whose initial intention was to go to an urgency department, but who. after calling the S24 line. changed his/her mind. Given the spatial nature of the data, and resorting to INLA in a Bayesian paradigm, the number of non-urgent cases in the Portuguese urgency hospital departments is modeled in an autoregressive way. The spatial structure is accounted for by a set of random effects. The model additionally includes regular covariates and a spatially lagged covariate savings index, related with the S24 savings calls. Therefore, the response in a given area depends not only on the (weighted) values of the response in its neighborhood and of the considered covariates, but also on the (weighted) values of the covariate savings index measured in each neighbor, by means of a Bayesian Poisson spatial Durbin model.

The Value of Triage during Periods of Intense COVID-19 Demand: Simulation Modeling Study.

During the COVID-19 pandemic, many intensive care units have been overwhelmed by unprecedented levels of demand. Notwithstanding ethical considerations, the prioritization of patients with better prognoses may support a more effective use of available capacity in maximizing aggregate outcomes. This has prompted various proposed triage criteria, although in none of these has an objective assessment been made in terms of impact on number of lives and life-years saved. An open-source computer simulation model was constructed for approximating the intensive care admission and discharge dynamics under triage. The model was calibrated from observational data for 9505 patient admissions to UK intensive care units. To explore triage efficacy under various conditions, scenario analysis was performed using a range of demand trajectories corresponding to differing nonpharmaceutical interventions. Triaging patients at the point of expressed demand had negligible effect on deaths but reduces life-years lost by up to 8.4% (95% confidence interval: 2.6% to 18.7%). Greater value may be possible through "reverse triage", that is, promptly discharging any patient not meeting the criteria if admission cannot otherwise be guaranteed for one who does. Under such policy, life-years lost can be reduced by 11.7% (2.8% to 25.8%), which represents 23.0% (5.4% to 50.1%) of what is operationally feasible with no limit on capacity and in the absence of improved clinical treatments. The effect of simple triage is limited by a tradeoff between reduced deaths within intensive care (due to improved outcomes) and increased deaths resulting from declined admission (due to lower throughput given the longer lengths of stay of survivors). Improvements can be found through reverse triage, at the expense of potentially complex ethical considerations.

Criteria for allocation of life-saving resources during the SARS-COV-2 pandemic: ethical implications and aspects of legal liability.

The issue of political, institutional and professional liability in the context of the SARS-COV-2 pandemic is currently widely debated and involves several levels of investigation. One crucial aspect relates to the allocation of life-saving resources in situations where there is an imbalance between need and availability and the associated questions of ethical and legal liability. This work looks at the implications of the criteria applied to rationing under extraordinary conditions and the issue of their legitimacy. Considering the European scenario, we describe the approach taken by Italy in proposing criteria for pandemic triage of intensive treatment and highlight certain problems and critical issues. We emphasise that the decision, based on a comparative assessment, to deny treatment to a patient in critical condition, compromising that patient's right to care, exceeds the scope of decision-making autonomy of the professional concerned and requires a theoretical and procedural definition shared at multiple levels of society.

Acute Risk in Helicopter EmergencyMedical Service Transport Operations

Objective: The highest safety risk for helicopter emergency medical service (HEMS) operations in the United States is during night-time operations. Although guidelines recommend physicians consider the risk to the patient and flight crew when triaging a patient for flight, no objective measure of risk between day and night-time HEMS flights exist. The purpose of this study was to measure the acute risk of HEMS transport within a spectrum of aviation and medical procedure risk. Methods: The number of fatal HEMS accidents, fatal patient injuries and patients transported by day and night between 1995 to 2015 were classified as events and measure of activities, respectively. Acute risk was measured using the MicroMort (mM) which represents a one in a million chance of dying from an accident. Comparisons with other activities were used to contextualize aviation and medical procedure risk. Results: Each daytime HEMS task (7.55 mM) was similar to one parachute jump (7.96 mM). One night-time HEMS task in hazardous operational conditions (18.75 mM) was over ten-times greater than one scuba dive (1.84 mM). Patient night-time mortality (6.43 mM) was similar to one general anaesthetic (8.2 mM). Conclusion: Daytime HEMS accident risk is of similar risk to one parachute jump, and at night-time in hazardous operational conditions over ten-times greater than one scuba dive. Where a patient’s risk of death from their injury or illness is not greater than that of a general anaesthetic, triage for a night HEMS transport may introduce greater risk than the patient’s medical condition itself.

Análise do desenvolvimento neuropsicomotor de pré-termos em ambulatório multidisciplinar: um olhar da fisioterapia

INTRODUÇÃO: Desde a gestação até o nascimento o desenvolvimento neuropsicomotor é influenciado por diversos fatores biopsicossociais. Tal influência pode ser ainda mais acentuada em recém-nascidos pré-termo devido a internação na Unidade de Terapia Intensiva Neonatal, por isto bebês pré-termos estão mais susceptíveis a essas influências. OBJETIVO: Analisar sob a ótica do fisioterapeuta o desenvolvimento neuropsicomotor de pré-termos em ambulatório multidisciplinar de um hospital público. METODOLOGIA: Estudo observacional e longitudinal, ambispectivo, de 19 crianças nascidas prematuras de 0 a 12 meses de idade corrigida, sendo critério de exclusão crianças com alterações cognitivas e/ou genéticas ou não terem assinado o termo de consentimento. Os dados foram coletados por meio da análise de prontuários entre agosto de 2017 e dezembro de 2018, o desenvolvimento avaliado por meio do Teste Triagem Denver II , em dois momentos: A1 e A2, em sua admissão e retorno ao serviço após a alta da Unidade de Terapia Intensiva Neonatal e para análise da relação entre mãe e bebê foi utilizada a Avaliação Vínculo Mãe/filho apenas em A1. As estimulações eram realizadas por meio de orientações e folder educativo para os pais e responsáveis. Os dados foram analisados, por meio de média, desvio-padrão, frequência absoluta e relativa, mediana, minimo e máximo e Teste de Wilcoxon para os domínios do Teste Denver II A1 em comparação a A2, utilizando o programa SPSS versão 20.0. RESULTADOS: Foram acompanhadas 19 crianças, destas 79% foram classificadas com desenvolvimento normal no A1. As crianças que apresentaram déficits no A1 (10,5%), superaram no A2. Porém, no segundo atendimento, algumas passaram a apresentar dificuldade em novas tarefas/domínio (motor, motor fino e pessoal-social), de modo que 31,5% apresentaram desenvolvimento geral anormal em A2. Foi encontrada diferença significativa (p=0,02) ao comparar as classificações gerais de Denver II nos dois momentos de avaliação. O vínculo mãe-filho foi classificado como fraco (média de 5,8 pontos). CONCLUSÃO: Observou-se que os bebês superaram os atrasos identificados na primeira avaliação, embora os resultados no Denver tiveram variações ao longo do tempo. Dessa forma, acredita-se que o perfil familiar identificado nesta pesquisa somada a abordagem multiprofissional possa ter favorecido o desenvolvimento neuropsicomotor dos bebês prematuros com até 12 meses de idade corrigida.

Triage Nurse-Ordered Testing in the Emergency Department Setting: A Review of the Literature for the Clinician.

In an effort to decrease length of stay (LOS) and reduce overcrowding, many emergency departments (ED) have implemented triage nurse-ordered testing. To review the medical literature to determine the utility of triage nurse-ordered testing and to offer evidence-based recommendations to emergency physicians. A systematic search of the PubMed literature was performed for publication in English from inception to November 30, 2019 using a combination of the following keywords: "triage," "nurse," "protocol," and "emergency." The articles were screened for relevance and the selected studies were subjected to detailed review by all of the authors and assigned a grade of evidence based on focus, research design, and methodology. Recommendations were drawn from the findings. The initial search yielded a total of 982 potentially relevant studies; 13 articles were ultimately selected for inclusion. Of these, 10 studies assessed ED LOS, with one study assessing time to diagnosis. The three remaining studies compared triage nurse-ordered testing with physician testing in the ED setting. Triage nurses have reasonably similar accuracy as physicians in ordering limb x-ray studies and moderate accuracy for laboratory testing. However, we did not identify a clinically meaningful decrease in ED LOS from the use of nursing triage orders.

Development and Validation of the Japanese Version of a Job Stressor Scale for Triage Nurses in Emergency Departments

Background: With an increasing number of patients who visit emergency outpatient units, a shortage of physicians and nurses in emergency units has become an issue in Japan. Triage nurses who interview patients and their families before medical examinations feel stressed to determine the triage level in a limited time, necessitating the measures to alleviate stressors. Objective: To develop a triage nurse job stressor scale (TNJSS) for Japanese triage nurses in emergency outpatient units and to verify the reliability and validity of this scale. Methods: Anonymous, self-administered questionnaires were sent to nursing directors of 180 emergency and critical care centers randomly selected from 251 centers throughout Japan, requesting to distribute the questionnaire to nurses. Results: Based on the responses obtained from 363 nurses, the construct validity, internal consistency, and criterion-related validity were verified. A factor analysis of 44 items yielded five factors: “Lack of triage ability”, “Busy triage work”, “Patients without understanding of explanations”, “Complaints from patients waiting for treatment”, and “Lack of support to improve triage ability”. Cronbach’s α was 0.93 for the full scale and significant correlations were observed between the nurses’ stressor scores and scores for the Stress Response Scale-18 (r = 0.409; p < 0.01) and for the Nursing Job Stressor Scale (r = 0.410; p < 0.01). Conclusions: The TNJSS with a five-factor structure containing 44 items was determined to be a reliable and valid tool for evaluating Japanese triage nurse job stressors. The findings suggest the necessity to continuously educate and support triage nurses.

Quality improvement study in emergency department waiting room times in a private hospital in Kuwait

Background: The emergency department (ED) waiting room duration has been a challenge in many EDs. This study has implemented a focus plan-do-study-act (PDSA) cycle study on ED waiting room patients in a private hospital in Kuwait. Each PDSA cycle included one of the following interventions: hospitality measures, number of triage nurses, number of ED physicians, and number of receptionists to see their impact on the ED waiting times. Methods: The waiting times were collected per patient coming into the ED and their assigned Canadian Triage Acuity Scale (CTAS) level over a 12-month period, as well as the number of patients left without being seen (LWBS). Each intervention was introduced into the ED and a 2-month period following each was given to see the effect on the waiting time. Results: As divided per CTAS level, there were 38,157 patients included in the analysis. The results showed that for every increase in one triage nurse, there was a reduction of 15.09, 20.7, and 20.8 minutes for CTAS 3, 4, and 5 patients, respectively, and for every increase in one doctor there was a reduction in the total ED waiting room time of 11.4, 10.0, and 8.6 minutes for CTAS 3, 4, and 5 patients, respectively, keeping all other variables constant. These quality parameters reduced the LWBS from 6.1% to 2.5%. Conclusion: This study concluded that increasing triage nurses and ED physicians successfully reduces total ED waiting room times and reduces the number of patients LWBS.

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.

Triage Training in Iran from 2010 to 2020: A Systematic Review on Educational Intervention Studies.

Background: Accurate decision-making in triage requires continuous education, so triage nurses should receive annual refresher courses. Identifying the most effective method can make the provision of practical education to triage staff in hospitals possible. This review was conducted with the aim to determine the effectiveness of triage education methods in Iran.Materials and Methods: In this systematic review on educational intervention studies, international and Iranian medical sciences databases were searched using a defined search strategy compatible with each database. PubMed, Scopus, Web of Science, Google Scholar, SID, Islamic Science Center (ISC), and IranDoc databases were searched for literature published from January 2010 to January 2020. The MeSH terms of “health care staff,” “triage,” “education,” and “Iran” in English and Persian were combined to develop a search strategy. Initially, 768 article titles were retrieved. Finally, 16 articles were selected for the review.Results: All conducted studies were quasi-experimental. Half of the studies had used a face-to-face approach for education (workshop, lecture, and simulation), and four studies had used lectures and pamphlets. All studies (except 1) reported that their educational intervention significantly improved nursing knowledge on triage.Conclusions: Almost all studies had reported the effectiveness of an educational intervention in improving nurses' triage knowledge. However, it seems that the non-face-to-face method is superior to the face-to-face method because of its learner-centeredness and cost-effectiveness. Moreover, providing educational content using a blended learning approach (simulation and games) can enhance the effectiveness of triage education.

Prejudice between triage nurses and emergency medical technicians: is it a big deal?

The transmission of information between registered nurses (RNs) and emergency medical technicians (EMTs) in triage plays a fundamental role in patient care. Despite their common purpose is to assure patients to get the best diagnostic, therapeutic and care pathway, triage RNs and EMTs hold different perspectives during the process. One aspect that has not been investigated in the international literature concerns the possible presence of prejudice, meant as a preconceived opinion capable of causing people to adopt unjust attitudes toward EMTs by triage RNs. To investigate this phenomenon a survey was conducted among 740 healthcare workers (197 triage RNs and 543 EMTs), in 14 hub and spoke hospitals in Lombardia region (Italy) in October 2019. The 21.9% of RNs reported negative prejudice toward EMTs (particularly if they are volunteer), while 71% of EMTs perceived negative prejudice from triage RNs. This survey did not investigate the phenomenon exhaustively but witnessed a slippery scenario that is worth to be further explored, also evaluating whether it can affect outcomes in patients.