Triage assessment of registered nurses in the emergency department

https://doi.org/10.1016/j.ienj.2012.06.004Get rights and content

Abstract

Standardised triage systems have been implemented in emergency departments (EDs) to improve the efficacy of assessment strategies as performed by registered nurses (RNs). However, the exact effect the standardised triage systems have on the decision-making process remains unclear.

Aim

To evaluate decision making in the triage setting before and after implementation of the Medical Emergency Triage and Treatment System Adult in one hospital’s ED.

Methods

A descriptive intervention design with a quantitative approach. A total of 655 patients before and 413 patients after the intervention were included. A questionnaire was used to evaluate how the RNs assessed the patients before intervention while the emergency patient records were used for data collection after intervention.

Results

Before the intervention, a majority of the assessments were founded on signs and symptoms and medical diagnoses, whereas vital parameters were rarely used. After the intervention, nearly two thirds of the patients were assessed according to a triage system with vital parameters and standardised algorithm for symptoms and signs included in the assessment procedure.

Conclusion

Implementing a standardised triage system, including vital parameters and standardised algorithms for signs and symptoms, increased the use of vital parameters and signs and symptoms for decision making and acuity assignment.

Introduction

The aim of triage assessment in the initial encounter between the nurse and the patient in emergency departments (EDs) is to quickly determine and classify the patients in the order of urgency based on the need for treatment (Brabrand et al., 2010, Gilboy et al., 1999, Huryk, 2006). Because accuracy in triage is critical, acuity assignment affects the prioritisation of limited medical resources among patients in acute need of medical care. Triage assessment constitutes a challenge and responsibility for nurses in EDs. Because patients have unknown and potentially very serious illnesses, there is a high degree of uncertainty and acuity that complicates the assessment process (Göransson et al., 2008, Hale and Tippett, 2009, Wolf, 2010a, Wolf, 2010b). In developed countries several triage protocols and scoring systems are available to support patient quality and safety (Brabrand et al., 2010, Forsgren et al., 2009, Göransson et al., 2008, Odell et al., 2009). Despite different findings on the validity and reliability of triage protocols and scoring systems, the literature supports the use of standardised methods to identify patients at risk for developing critical illnesses (Considine and McGillivray, 2010, Odell et al., 2009, Twomey et al., 2007).

A national review of Norwegian EDs conducted by the Norwegian Board of Health Supervision (NBHS) in 2007 reported a lack of established guidelines in several EDs to secure the reception and priority of the patients as they arrive. Based on these findings, the NBHS concluded that a standardised method for triage to support patient safety and quality care was recommended in all EDs (Norwegian Board of Health Supervision, 2008). This intervention study was based on the implementation of a triage protocol and scoring system called the Medical Emergency Triage and Treatment System Adult (METTS-A) in an ED in a regional hospital in Southern Norway.

Section snippets

Literature

Validating triage protocols and scoring systems has been an important goal for research (Brabrand et al., 2010, Twomey et al., 2007, van Veen and Moll, 2009), even though uncertainty exists regarding the assessment strategies that registered nurses (RNs) use to assign acuity in EDs (Wolf, 2010a, Wolf, 2010b). RNs use a wide range of thinking strategies in detecting deterioration (Odell et al., 2009) or preforming triage (Göransson et al., 2008). Studies have shown that nursing strategies and

Aim

The study aimed to evaluate decision making in the triage setting before and after implementation of the METTS-A in an ED at a regional hospital.

Study design

This study had a descriptive intervention design with a quantitative approach. Data were collected before and after the implementation of METTS-A in an ED. See Fig. 1 for design and timeline.

Setting and sample

This study was conducted in an ED of a regional hospital in Southern Norway between April 2008 and November 2009. This hospital receives approximately 20,000 patients per year with acute need of medical care. Patients with mental health problems are in addition to these numbers and are assessed in a

Results

The data collected before the intervention were analysed using descriptive and comparative statistics. Frequency tables and cross tables were used to present the distribution of the data. A vertical bar chart presents the variance. The software Statistical Package for the Social Sciences v.15.0 for Windows was used for data management and analyses.

Data collection was conducted on 655 adult patients who arrived at the ED over a period of 6 weeks before the intervention (table 1) and 413 adult

Discussion

Implementing a standardised triage protocol and scoring system, including validated ESS algorithms and vital parameters, increased the use of vital parameters and symptoms and signs for decision making and acuity assignment. Our results from the intervention show that, to a small extent, the RNs’ decision making and acuity assignment were based on the patients’ vital parameters. This result corresponds to those from other studies that describe vital parameters to be ignored or disregarded as

Conclusions

Because patients have unknown and potentially very serious illnesses, there is a high degree of uncertainty and acuity that complicate the triage decision process. Performing triage under these difficult conditions is a demanding process and a challenge for the RNs working in an emergency medical service unit. Implementing a standardised triage system, including vital parameters and standardised algorithms for signs and symptoms, was found to increase the use of vital parameters and symptoms

Acknowledgments

The authors wish to thank all of the RNs and patients who participated in this study. We also express our gratitude to all of the ED staff members who contributed to data collection and who photocopied records. We are grateful for the implementation project members and the management for their support. Finally, we are thankful for the financial support of the hospital.

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