Emergency department triage: Is there a link between nurses’ personal characteristics and accuracy in triage decisions?
Introduction
In many countries emergency department (ED) triage is a task that registered nurses (RNs) frequently perform (Purnell, 1991, Considine et al., 2004). However, the requirements differ and there is limited information on suitable educational standards and prerequisites of clinical competence (Gerdtz and Bucknall, 2000, Fry and Burr, 2001). In Sweden, educational requirements and clinical experience vary greatly, where also less qualified personnel perform triage (Palmquist and Lindell, 2000, Göransson et al., 2005). Further, there is limited information on the association between the personal characteristics (e.g. clinical experience, triage education) of RNs and accuracy of triage decisions.
The Canadian Triage and Acuity Scale (CTAS) is one of several internationally accepted triage scales. Originating from the Australian National Triage Scale (NTS), the CTAS has shown good to very good inter-rater reliability (Beveridge et al., 1999, Manos et al., 2002). When employing a triage scale, the triage outcome of an acuity rating may fall into one of three categories: accurate triage assessment, overtriaged or undertriaged (Fernandes et al., 2005).
This study aims at identifying relationships between RNs’ accuracy in triage decisions of patient scenarios and personal characteristics of the RNs.
Section snippets
Sampling process
The ED medical directors at all Swedish hospitals (N = 78) with an ED for somatically ill and injured patients received a letter of information about the study and were asked for permission. In all, 48 of the 78 (62%) EDs agreed to participate. The reasons the other 30 (38%) EDs declined participation were staffing or organisational turbulence and lack of time to conduct data collection. Convenience sampling was used to recruit 423 (29% of the total population of 1447 eligible emergency nurses)
Results
The RNs’ percentage in triage decisions that was in agreement with the expected acuity rating was 58% (SD 12.8). The range of 22–89% acuity ratings in concordance with the expected rating per RN is depicted in Fig. 1. Totally, 18.7% (n = 79) of the RNs accurately triaged more than 70% of the scenarios and 60.3% of the RNs triaged in concordance with expected acuity rating in 50–69% of the scenarios. Further, 21% (n = 89) of the RNs triaged less than 49% of the scenarios accurately. Overtriage (a
Discussion
This study contributes knowledge concerning a relatively unexplored area of ED triage, the relationship between personal characteristics of RNs and their ability to triage. The fact that the RNs could only triage 58% of the scenarios in concordance with the expected acuity rating and the wide range (22–89%) of accurate triage decisions per RN clearly need to be studied further. Even though the group with low accuracy of acuity ratings was only 21% of the RNs, the majority of the RNs (60.3%)
Limitations
Because the CTAS was not used in daily practice by the participants, it might have affected the results. Because the RNs more frequently triaged level 1 and 5 scenarios in concordance with expected outcome, the case mix of 56% of the scenarios having an expected acuity rating of either of these extremes might have influenced the results in a positive direction.
In accordance with ethical considerations in using actual triage situations for research, the design of this study was scenario based, a
Conclusion
The agreement of the 7550 acuity ratings of the RNs was only 58% and the amount of accurate acuity ratings per RN varied greatly. Further, the only significant correlation between personal characteristics and the ability to triage was extremely low, and thus it is unlikely that such a difference could be accounted for by clinical experience alone. Future research that focuses on RNs’ decision making during the triage process is needed to provide important information in identifying and
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