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Abstract
Objectives To gain an understanding of the accuracy of acuity assessment made by emergency department (ED) triage nurses, to compare the differences between the characteristics of triage nurses according to hospital variables and the accuracy of acuity ratings, and to explore the influence of nursing variables on the judgement of triages.
Methods A cross-sectional questionnaire survey was conducted at the EDs of hospitals in northern Taiwan. Ten adult emergency case scenarios and a demographic sheet with high validity were developed to survey 279 triage nurses. Data were collected from April to October 2006. All data were analysed using percentage, mean, SD, independent t test, one-way ANOVA and a stepwise logistic regression analysis.
Results The average score of rating accuracy was 5.62 points (out of a possible total of 10 points), which was considered low. Approximately 24.3% (n=68) of nurses' triage ratings were under-triaged and 19.7% (n=55) were over-triaged. Factors included years of ED experience, hours of triage education, level of hospital and triage mode of delivery. These factors were identified as significantly affecting the accuracy of nurses' judgement (p<0.05; adjusted R2=40.0%).
Conclusion The scores of accuracy ratings for triage nurses can be improved if factors contributing to inaccuracy can be altered. The findings of this study can be used to guide improvements.
- Acuity assessment
- clinical decision-making
- emergency care
- triage accuracy
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Introduction
Triage is the process of sorting or prioritising patients for medical care on arrival at an emergency department (ED). Theoretically, the decision of the triage level is made to determine how long the patient will wait before seeing a physician and to treat patients in a timely and appropriate manner.1 In general, hospitals all over the world use some kind of triage system such as 3-level, 4-level or 5-level scales to prioritise the patients in EDs. However, in Taiwan, a 4-level triage scale was developed and has been used as a reference for triage decisions in the EDs since 1999.2 Furthermore, triage is predominantly performed by registered nurses in the EDs.3 The 4-level triage scale, with each acuity level associated with the waiting time limits, is as follows: level 1 requires immediate medical attention; level 2 requires attention within 10–15 min; level 3 requires attention within 30 min; and level 4 means care is not very urgent and the patient can be seen at the outpatient department. There are 24 criteria for level 1 (life-threatening), 15 for level 2 (emergency) and 9 for level 3 (urgent).4 Before patient acuity can be determined, a nurse needs to collect information such as the patient's chief complaints and some physical examination data such as vital signs, symptoms and signals. ED patients can then be assigned to appropriate triage categories and receive medical intervention promptly.
In spite of uncertain situations and enormous pressure to control costs in today's healthcare system, triage nurses are expected to perform professionally and correctly. Nevertheless, triage is a complex and dynamic process so triage judgements at levels that are too high or too low can occur as a result of the internal and external information presented. If a triage category is selected which is different from the one that a patient actually requires, the patient's waiting time until medical intervention may be affected more than anticipated.5 It is therefore necessary to understand what factors may affect the accuracy of triage nurses' judgement in order to alter the factors in an effective way. However, few studies have been undertaken of the factors influencing triage nurses' acuity judgements in EDs. In addition, factors that might influence nurses' accuracy judgements, particularly those not from Western culture, have been under-investigated. The aims of this study were therefore to gain an understanding of the accuracy of acuity assessment made by ED triage nurses, to compare the differences between the characteristics of triage nurses according to hospital variables and the accuracy of acuity ratings, and to explore the influence of nursing variables on the judgement of triages. The findings of this study can be used to guide improvements and to develop effective triage education training programmes for triage nurses to improve the accuracy of nurse triage categorisation.
Methods
A cross-sectional questionnaire survey study was carried out at the EDs of hospitals in northern Taiwan. The EDs of all 38 hospitals with a monthly patient volume >2000 visits were identified through national hospital accreditation records6 and approached to take part in the survey. However, only 14 hospital EDs, representing 36.8% of the hospitals in northern Taiwan, agreed to release the numbers and names of triage nurses and lists of work settings. All triage nurses currently working at the EDs of these 14 hospitals who were involved in the triage process, had at least 1 year of triage experience and worked as full-time nurses were invited to participate in this study.
The survey questionnaire consisted of a demographic sheet and 10 adult emergency case scenarios (ECSs), which were designed by the research team to be as close to real patients as possible. The 10 ECSs covered four different triage categories: level 1 (n=2), level 2 (n=3), level 3 (n=3) and level 4 (n=2). Because children's presentations are more complex, children were not included in this study. Furthermore, to ensure that all triage nurses' responses were based on the same information, only written ECSs were used in this study. One point was given if the patient category allocation was matched with the expected triage category; otherwise, zero was indicated. The 10 ECSs were examined for content validity by five experts from the EDs. The result of the internal consistency testing (using KR-20) was 0.83. The result of the reliability testing (using test/retest) was >0.7. The ECS can be completed in 5–10 min.
All the surveys were carried out at each hospital at previously arranged times and locations. The questionnaire had a cover letter indicating that all data would be used for research purposes only. Before administering the questionnaire, nurses were informed verbally of the research purposes and assured that all information was confidential. The survey was conducted from April to October 2006 and collected mainly by one of the researchers.
Analysis of data
Descriptive analyses were used to analyse the triage nurses' personal characteristics and triage rating scores. The independent t test and one-way ANOVA were used to compare the differences between the characteristics of the triage nurses according to levels of hospital and the accuracy of the triage rating scores. A stepwise regression analysis was employed to identify factors associated with the accuracy of nurses' judgement of acuity ratings. All data were analysed using SPSS for Windows 13.0 with the level of significance for all statistical analyses being set at p=0.05.
Results
About 334 questionnaires were administered and 279 valid questionnaires were returned after subtracting 16 incomplete questionnaires. Thus, the effective response rate was 83.5%. The majority of triage nurses were female (n=275; 98.6%). The average age was about 29.6 years, with ages ranging from 21 to 49 years. The respondents had worked as registered nurses for an average of 7.48 years, as emergency nurses for an average of 5.46 years and as triage nurses for an average of 4.38 years (table 1).
Characteristics of triage nurses (N=279)
The average score of accurate acuity rating was 5.62 points (total=10 points). Of these, approximately 24.3% (n=68) of the nurses' triage ratings were under-triaged and 19.7% (n=55) were over-triaged. Nurses who worked at medical centres had a higher percentage of over-triaged responses (n=19; 21.6%) than those of triage nurses at district hospitals (n=27; 19.7%) and those of triage nurses at regional hospitals (n=10; 18.5%). In contrast, nurses who worked at district hospitals had a higher percentage of under-triaged responses (n=38; 27.7%) than those of triage nurses at medical centres (n=17; 19.3%) and those of triage nurses at regional hospitals (n=13; 24%). These results indicate that there is a high percentage of inaccurate acuity ratings. When the variables of triage nurse characteristics were separated, age, years of being a registered nurse, years of being an emergency nurse, types of professional certification and levels of clinical ladder were found to significantly affect the nurses' rating accuracy (p<0.01, table 2).
Differences between nurses' characteristics and the scores of acuity ratings (N=279)
As shown in table 3, nurses who worked at medical centres (mean 5.94 points) or regional hospitals (mean 5.93 points) had higher average accurate acuity rating scores than nurses who worked at district hospitals (mean 5.28 points) and showed a significant difference (F=6.41; p=0.002). Analysis using Scheffe post hoc tests showed that the scores of acuity rating were higher at medical centres and regional hospitals than at district hospitals. However, no significant difference was found between the scores of accuracy rating and hospital ownership, patient volume and triage mode of delivery (p>0.05).
Differences between hospital characteristics and acuity ratings score (N=279)
When analysing the effect of triage education on the accuracy of nurses' judgement, we found that whether nurses had had triage education before, the hours, type and content of the triage education they had received and the triage education facility from which they received their education significantly affected their acuity ratings (p<0.05, table 4). The results indicated that current triage education training required for or provided to triage nurses is still inadequate and not a standardised requirement for hospitals in Taiwan.
Differences between education variables and acuity rating scores
A stepwise regression model showed that years of ED experience (p=0.001), hours of triage education (p=0.001), hospital level (p=0.002) and triage mode of delivery (p=0.002) were significantly associated with the scores of accuracy ratings and could explain 40% of the variance (table 5). The regression model was expressed as follows:
Stepwise regression analysis of factors influencing the accuracy of triage nurses' judgement (N=279)
This model indicates that hours of triage education is the highest factor in the accuracy of nurses' judgement (β=0.74; p=0.000). The model also indicates that, if the nurses' years of ED experience increase by 0.22, the scores of acuity ratings can increase by one point; if the nurses' hours of triage education increase by 0.74, the scores of acuity ratings can increase by one point; if regional hospitals are used as the reference, the acuity ratings of nurses who work at district hospitals would be reduced by 0.46 points; and if the computerised mode of delivery is used for acuity assessment, then nurses who use paper and pencil would increase their acuity ratings by 0.47 points.
Discussion
This study represents the first large survey of ED triage nurses from different types of hospitals in Taiwan. The overall response rate for the survey was 83.5% which was satisfactory. The results can therefore be considered to reflect the overall judgement of the ED triage nurses involved in this survey.
The study sought to gain an understanding of how accurately triage is done by triage nurses in the EDs and what factors influence the accuracy of nurses' triage judgement. The results showed that the average acuity rating score was 5.62 points (total=10 points), which was considered low. In addition, about 24.3% of acuity ratings were under-triaged and 19.7% were over-triaged. The findings are consistent with two previous studies. Göransson et al1 found that the percentage of the accuracy ratings among registered nurses was only 58%, and Considine et al7 found that ED nurses were more likely to under-triage (18%) than to over-triage (14.1%). However, this finding contradicted the study by Kilner8 which found that all professional providers tended to over-triage patients. The differences in results may be due to variations in the healthcare delivery system and in the educational level of the triage nurses. In this study, <20% of nurses had obtained an educational level equal to or greater than university degrees. Nevertheless, these results may increase the risks to patients, especially in medical centres which had a higher percentage of over-triaged patients and in district hospitals which had a higher percentage of under-triaged patients. If the triage nurse allocates a triage category of higher urgency than the patient actually requires, then other patients in the ED might be affected and may not receive medical intervention promptly. If a patient is under-triaged, then the patient's waiting time until medical intervention is prolonged and adverse outcomes might happen.
Nevertheless, the low scores of acuity ratings may largely be affected by the National Health Insurance (NHI) payment system in Taiwan and the ECSs used in this study. Chi and Huang4 indicated that the universal coverage and co-payment policy of the NHI in Taiwan could affect triage classification and that triage nurses would not assign patients to a level 4 category because of lower payments. Additionally, since the ECSs used in this study were written in paper-pencil format, no visual cue or additional information was provided during tests. Hence, decisions by triage nurses could be affected because more than 55% of hospitals in this study used a computerised triage assistant system. Although Considine et al7 found that the computer-based scenarios resulted in better inter-rater reliability, triage paper-based scenarios have been widely used and tested in studies. We therefore suggest that further research is needed to focus on the observation of nurses' behaviours during triage to find effective strategies for improvement.
We also found that the scores of accuracy ratings made by triage nurses were influenced by age, years of nursing experience, years of ED experience, types of professional certification and levels of the clinical ladder. Past studies9–12 have found that nurses' age, years of working experience, professional certifications and levels of the clinical ladder were highly correlated with their work performance and patient outcomes, as well as being statistically significant predictors of their competency. Nevertheless, under the currently practised environment in hospitals, triage nurses were asked to make rapid and accurate decisions in order to deal with increased patient volumes. Strategies to develop effective triage education programmes are therefore needed to improve the accuracy of nurses' judgement and the quality of emergency care in the future.
Although the scores of accuracy ratings were similar among the three levels of hospitals in this study, a statistically significant difference was found between medical centres and district hospitals and between regional hospitals and district hospitals. This difference is attributable to the fact that nurses in a medical centre usually have more opportunities to receive education training and engage in challenging work because of more resources and higher patient expectations about ED services. It is therefore not surprising to find that nurses in the medical centres had higher average accurate rating scores. Although there is as yet no general consensus on the volume-outcome relationship to nurses' accuracy ratings in the current literature, high-volume hospitals do influence the skills of medical professionals. Furthermore, Venketasubramanian and Yin13 pointed out that high patient-volume hospitals such as medical centres create more learning opportunities for medical professionals to improve their skills in daily clinical practice. However, Krone et al14 found that low-risk patients were more likely to be treated by low-volume healthcare providers. Therefore, nurses who work at low-volume hospitals might have more time to do triage and make triage judgements in an unhurried manner. Nevertheless, because this study is the first study to use large samples in Taiwan to examine factors that would influence nurses' triage judgements in the ED, it remains unclear as to whether the findings can be generalised to other developed countries where the 5-level triage system is used.
We also found that nurses' triage decisions were affected by whether or not they had received prior training, the hours, type and content of the triage education they had received and the facility where they received the triage education. In addition, more than 52.3% of the triage nurses had received no training before and only 51.9% of the triage nurses in this study had received <8 h of triage education. These results are similar to the findings by Chung15 who noted that some nurses had not received formal training and most of them used their previous clinical experience in the triage decision-making processes. As a result, inaccurate judgements may have occurred. A study by Andersson et al16 also pointed out that effective triage depends on the qualifications and personal qualities of the triage nurses. Nursing educators or hospital leaders therefore need to address this important issue and to provide well-designed triage education for triage nurses to improve their judgement accuracy in the future.
We also discovered that the paper-pencil mode of triage delivery had less influence on the scores of accuracy ratings than the computerised triage mode. This result may be because about 44.4% of hospitals in Taiwan still use the paper-pencil triage mode, so nurses are used to this mode of triage delivery. However, using the computerised mode to make triage decisions is a national trend and is reliable and effective. Also, EDs in Taiwan may adjust the 4-level triage scale to a 5-level system and use an all-computerised triage mode in the near future. Triage nurses therefore need to become familiar with this advanced technology to improve their future triage judgements and minimise human error, regardless of the level of their hospitals.
Limitations
Three important limitations should be mentioned. First, with limited financial support, this study surveyed only 279 triage nurses in 14 hospital EDs in northern Taiwan so, the generalisability of the study results might be affected. Second, only 10 adult ECSs with four triage categories were developed in the paper-pencil mode and no additional information was provided during data collection periods; the results might be different if a paediatric population had been included and a 5-level triage system was applied. Third, since the time allowed for completing the 10 adult ECSs was not limited in this study, the results may be unrealistic in relation to the natural environment and should be interpreted with caution because of the role that time limitation may have as an important factor during the triage decision-making processes.
Conclusion
The results of this study have shown a number of significant factors which influence the accuracy of nurses' triage decisions. These factors should be taken into consideration or changed during triage education training programmes. Since triage nurses in EDs face diverse patients each day and must make acuity judgements under uncertain conditions and in a short time, it is important to improve their competency in making accurate triage ratings in order to allocate patients to appropriate categories and to provide proper care for emergency patients in a timely manner.
References
Footnotes
Funding We would like to acknowledge the financial support provided by the National Science Council in Taiwan (NSC 95-2314-B-038-046), for which we are extremely grateful.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.