Development of physiological discriminators for the Australasian Triage Scale

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Abstract

The Consistency of Triage in Victoria’s Emergency Departments Project (2001), funded by the Victorian Department of Human Services, aimed to improve the consistency of application of the Australasian (National) Triage Scale (ATS). One of the major objectives of the project was the development of an education strategy to promote a consistent approach to triage education, leading to the development of the Adult Physiological Discriminators (APDs) for the ATS and Paediatric Physiological Discriminators (PPDs) for the ATS. The guidelines and physiological discriminators were developed in consultation with the Emergency Nurses’ Association of Victoria (ENA Vic.) and clinical nurse educators, lecturers, nurse unit managers and clinicians from a wide variety of Emergency Departments (EDs) across Victoria. Numerous studies have identified varying degrees of inconsistency in the application of the ATS. A number of factors associated with inconsistency in the application of the ATS have also been alluded to in the literature. These range from the wide variation in the experiential and educational requirements of Victorian triage nurses to the specific clinical characteristics of the patient identified by the triage nurse. However, a consistent approach to triage education and uniform triage guidelines has been repeatedly identified as a key factor in improving the consistency of application of the ATS. Physiological data demonstrates the highest degree of objectivity and consistency and research has shown that physiological observations are useful and measurable indicators of clinical urgency and patient safety. This paper will discuss the development of these discriminators as part of the educational strategy including a critique of other approaches to triage decision-making and a review of the consultative processes used to facilitate consensus amongst triage nurses, ED Nurse Managers and ED Nurse Educators. The physiological discriminators developed by this project are also presented.

Introduction

The physiological discriminators for the Australasian (National) Triage Scale presented in this paper were developed as part of the Consistency of Triage in Victoria’s Emergency Departments Project (2001). This project was funded by the Victorian Department of Human Services and was overseen by a steering committee with representatives from the specific organisations such as the Emergency Nurses, Association of Victoria (ENA Vic.), the Australasian College for Emergency Medicine (ACEM), the Victorian Department of Human Services (DHS), the Australian Nursing Federation (ANF) as well as various representatives from emergency nursing, emergency medicine, and university sectors.

The underlying premise of the project was to aim to improve consistency of application of the Australasian Triage Scale (ATS) (formerly the National Triage Scale—NTS). The categories of the ATS are shown in Table 1.

Part of the project brief was to develop an education strategy for use by Victorian triage nurses with the aim of promoting a consistent approach to triage education and this led to the development of the Adult Physiological Discriminators (APDs) for the ATS and Paediatric Physiological Discriminators (PPDs) for the ATS. This paper will discuss the development of these discriminators as part of the educational strategy and present the physiological discriminators developed as part of this process.

Section snippets

Consistency of triage

Many studies have identified varying degrees of inconsistency of the application of the ATS (Doherty 1996; Jelinek & Little 1996; Whitby et al. 1997; Dilley & Standen 1998; Considine et al. 2000). It is also evident in the literature that triage decisions are unaffected by type of hospital (teaching, non-teaching, rural and private) (Jelinek & Little 1996; Dilley & Standen 1998), triage nurse experience (Jelinek & Little 1996; Dilley & Standen 1998; Considine et al. 2001a) and ED activity (

Consistency of educational preparation of triage nurses

ENA Vic. recommends that emergency nurses be prepared for the triage role “via structured unit based education programmes informed by nationally established triage standards.” (Emergency Nurses’ Association of Victoria Inc 2000a, p. 4). They also recommend that triage nurses are “competent and able to function independently in all aspects of emergency nursing prior to undertaking the triage role” (Emergency Nurses’ Association of Victoria Inc 2000a, p. 2).

Whilst these notions are highly

Selection of a triage education strategy

A critique of the literature pertaining to triage education and approaches to triage was performed. Each of the methods was assessed for suitability for use in this project.

Physiological approach to triage

At this point in time, physiological data seems to demonstrate the highest degree of objectivity and consistency in the triage context. Research has shown that observations were found to be useful and measurable indicators of clinical urgency and that indicators of patient safety (normal clinical characteristics) are used frequently by triage nurses (Whitby et al. 1997). The use of physiological criteria as a basis for clinical decisions is also supported by research. Many studies report that

Protocol/algorithm approach to triage

The supporters of protocol or algorithm triage cite improved consistency as the basis for this support. However, research to date does not demonstrate that the use of protocols or algorithms in the triage context increases level of agreement (Salk et al. 1998). One significant disadvantage of protocol driven triage is that protocols do not allow for patients who present with more than one symptom, for example abdominal pain, vomiting, and diarrhoea (Goodacre et al. 1999). One study cites

Other influences on triage decisions

Anecdotally there is concern that factors other than the clinical condition of the patient are impacting on triage decisions and are a source of inconsistency. Whilst the literature states that these factors may be influential in as many as 30% of triage decisions (Whitby et al. 1997), further examination of these factors reveals that many could be argued as relevant to triage decision-making. The most common ‘other’ factors were significance of patient history, potential for treatment,

Development of Physiological Discriminators for the ATS

The project team conducted a review of existing triage education tools, both international and national. At this point in time a validated triage tool does not exist. The project team used a variety of sources to inform development of the physiological discriminators and education strategy. These sources included results of research conducted as part of the Consistency of Triage in Victoria’s Emergency Departments Project (LeVasseur et al. 2001a; LeVasseur et al. 2001b), works published by the

Consultative processes

The project team was cognisant of the fact that for physiological discriminators and education strategy produced by this project to be successful, it had to be supported by clinicians, managers, and educators, all of whom had vested interests in triage education. A series of triage forums were held across the State of Victoria. These forums were held for multiple reasons:

  • to enable the project team to give feedback about the progress of the project and present preliminary results from the

Development of Physiological Discriminators for the ATS

The format of the physiological discriminators for the ATS was based on that of the “Adult Discriminators for National Triage Scale Categories” contained in the ENA Vic. Position Statement: Educational Preparation of Triage Nurses (Emergency Nurses’ Association Victoria (Inc) 2000b pp. 7–8). This format essentially followed the primary survey approach of airway, breathing, circulation, and disability with reference made to specific elements of triage such as mechanism of injury, psychiatric

Summary

Many studies have indicated that a consistent approach to triage education is warranted (Doherty 1996; Jelinek & Little 1996; Dilley & Standen 1998; Considine et al. 2000), however the results of the Consistency of Triage in Victoria’s Emergency Departments Project suggested that the development of a generic education package would be beneficial in meeting the needs of different emergency departments and a physiological approach to triage education may be useful in promoting consistency of

Acknowledgements

The authors wish to acknowledge the many people and organisations that assisted with this project. A comprehensive list can be found in the Consistency of Triage in Victoria’s Emergency Departments: Guidelines for Triage Education and Practice (Considine et al. 2001b). For the purposes of this paper, the authors wish to acknowledge, Victorian Department of Human Services, Monash Institute of Health Services Research; Deb Berry, Toni Orchard, and Moira Woiwod, Project Nurses, Consistency of

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