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RESEARCH PAPER
Department of Emergency Medicine, Royal Childrens Hospital, Herston Road, Herston, Brisbane,
Queensland 4029, Australia
b
School of Population Health, The University of Queensland, Herston Road, Herston, Brisbane, Queensland
4006, Australia
c
Nursing Research Unit, Royal Childrens Hospital, Herston Road, Herston, Brisbane, Queensland 4029,
Australia
d
Childrens Nutrition Research Centre, The University of Queensland, Herston Road, Herston, Brisbane,
Queensland 4006, Australia
e
Queensland Childrens Medical Research Institute, The University of Queensland, Herston Road, Herston,
Brisbane, Queensland 4006, Australia
Received 7 November 2012; received in revised form 23 September 2013; accepted 9 February 2014
KEYWORDS
Emergency;
Triage;
ETEK;
Hospital;
Paediatric;
Audit
Summary
Objectives: The Emergency Triage Education Kit (ETEK) was published in 2007. To date, the
impact of ETEK has not been measured. The purpose of this study was to measure the effectiveness of ETEK on paediatric triage.
Method: A retrospective chart audit was undertaken in a tertiary paediatric hospital. Its aim
was to review the completeness of documentation recorded at the point of triage after a standardised documentation framework was introduced and to measure inter-rater agreement.
Primary assessment and physiological discriminators documented at the point of triage were
compared with those from the paediatric physiological discriminator table (PPDT) within ETEK.
Using an audit tool developed by the researchers, a parallel decision-making pathway was used
to ascertain whether the original ATS score could be substantiated by the PPDT. Improvement in
documentation of the primary assessment and inter-rater agreement was measured over time.
Corresponding author at: Department of Emergency Medicine, Royal Childrens Hospital, Brisbane, Queensland 4029, Australia.
Tel.: +61 7 3636 9008.
E-mail addresses: lorelle malyon@health.qld.gov.au, lorelle mal@bigpond.com (L. Malyon).
http://dx.doi.org/10.1016/j.aenj.2014.02.002
1574-6267/ 2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
52
L. Malyon et al.
Results: 600 triage records were selected; 200 each from 2007, 2008 and 2010. Triage documentation that did not support parallel decision-making decreased signicantly according to the year of
presentation (2007; 112 (56%), 2008; 106 (53%), 2010; 13 (7%), P < 0.001). When parallel decisionmaking was facilitated by an improvement in triage documentation, there was improvement in
matched triage scores (2007; 54%, 2008; 69%, 2010; 72%, P = 0.01).
Conclusion: The introduction of ETEK has had a signicant impact in this ED, particularly when
combined with education sessions. The use of the PPDT as a framework to guide documentation
and triage language facilitated parallel decision-making and auditing, and led to an improvement
in inter-rater agreement when applied to children.
2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights
reserved.
Introduction
The Australasian Triage Scale (ATS) is used to assess urgency
and prioritise access to time-critical intervention within
Australian Emergency Departments (ED).15 The accuracy
with which a triage scale is applied is fundamentally important to positive patient outcomes.68 The ATS aims to
ensure that a patient will receive the same triage category in any ED to which they present.9,10 However several
studies have demonstrated that the ATS has only poor to
fair inter-rater reliability when applied to children and
adolescents.1113 This may be due to the complexity of
paediatric assessment, in particular the developmental considerations that mean there is often a reliance on the
carer to provide the history.14 Alternatively, when children
present to a mixed ED, the triage nurse may have variable knowledge, experience and self-condence in assessing
children.12,15 The lack of consistency in applying triage
scores to children may also be attributed to the lack
of a paediatric framework on which to base decisionmaking.8
Endorsed by the Australian Department of Health and
Ageing and the College of Emergency Nursing Australasia,
the Emergency Triage Education Kit (ETEK) was introduced
into Australian EDs in 2007.5,14 Within ETEK, the paediatric physiological discriminator table (PPDT) provides
Methods
Method and setting
The study hospital is a paediatric tertiary referral centre, caring for children and young people from birth to 15
years. The ED provides initial assessment and management
of approximately 30 000 acute presentations annually. All
children entering this ED are triaged by an experienced and
specically trained emergency nurse.
A single retrospective, randomised chart audit was
undertaken to review documentation recorded at the point
of triage. Charts were audited from July 2007, before ETEK
was published; July 2008, after the publication of ETEK but
before ETEK-based education sessions were introduced at
the study hospital; and July 2010, after the ETEK-based
education sessions had been conducted. This study received
ethical clearance from the appropriate Hospital and University Ethics Committees.
The researchers extracted triage records from Emergency Department Information System (EDIS), the electronic
53
decision making could be employed of 20%, with 80% power
and alpha = 0.01. Results are described using descriptive
statistics, and data was compared across years using the
chi-square test for trend. Data was analysed using Stata
statistical software version 11.1 (Stata Corp., College
Station, TX, USA).
Results
Main results
Intervention
Education sessions introducing the ETEK and the PPDT were
conducted for current triage nurses between March and May
2010. During each session, participants were familiarised
with the PPDTs format. In particular, discussion centred on
the use of the tables physiological discriminators to facilitate triage decision-making and standardise documentation.
Using the sessions as the impetus for practice change, minimum standards for documentation were modied so the
primary assessment was documented in its entirety. That
is, for all presentations it was expected that documentation addressing; airway, breathing and circulation were
included. In addition, participants were expected to address
disability, however, a neurovascular assessment was only
required when the child presented with a limb injury. Triage
nurses were directed to use the terminology of the PPDT to
describe alterations from normal physiology with intact
being an acceptable term used for a child whose physiological parameters were within normal parameters for their
age.14 The triage nurses were instructed to document the
presenting problem succinctly along with any known risk
factors.
Statistical analysis
It was calculated that 200 charts were required to be
selected from each year to detect a between-year difference in the percentage of records in which parallel
54
L. Malyon et al.
Table 1 Documentation of physiological discriminators characteristic. Two hundred charts were audited each year. Differences
between groups assessed using the Chi-square test for trend.
Airway
Breathing
Circulation
Neurological
Neurovasculara
Pain
2007
n (%)
2008
n (%)
2010
n (%)
P-value
25 (12.5)
49 (24.5)
162 (81.0)
164 (82.0)
3 (9.6)
33 (16.5)
26 (13.0)
44 (22.0)
182 (91.0)
180 (90.0)
16 (61.5)
22 (11.0)
185 (92.5)
187 (93.5)
193 (96.5)
186 (93.0)
15 (44.1)
44 (22.0)
P < 0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.005
P < 0.14
a Neurovascular outcomes considered only when neurovascular compromise was considered a potential at initial triage (n = 31 in 2007,
n = 26 in 2008, n = 34 in 2010).
change of practice so relatively modest, yet still statistically signicant improvements were seen in these areas
(Table 1).
Primary triage category allocation, or the category allocated by the triage nurse, is displayed in Table 2. As shown,
the distribution of categories one to ve was similar between
2007 and 2008. However, in 2010 there was a signicantly
higher percentage of category 1 and 2 allocations (P < 0.001,
chi-square test for trend). The category most likely to
concord between the primary triage score and the PPDT
guidelines was category ve with 100% concordance, this
means that all patients categorised as ATS 5 at presentation, who could be allocated according to the PPDT, were
correctly categorised. In categories 1, 2, and 3 concordance
between the primary allocation and the PPDT was 68%, 77%,
Table 2
2007
PPDT
allocation
ATS 1
ATS 2
ATS 3
ATS 4
ATS 5
Total
14
25
58
12
112
11
21
12
25
10
12
11
12
25
31
47
92
24
200
No
category
ATS 1
ATS 2
ATS 3
ATS 4
ATS 5
Total
1 category over-
1 category under-
triaged
triaged
triaged
triaged
Correct triage
Discussion
The introduction of ETEK into this ED improved triage performance in this tertiary paediatric hospital. Most improvement
occurred after nurses had received ETEK-based education
sessions. The PPDT was included in ETEK so that novice
triage nurses were able to reect on their primary triage
decisions6 however; this study has shown that the PPDT has
a much broader use. In this study it was shown to be effective as a framework to guide triage documentation and this
55
Table 2 (Continued )
2008
Primary triage category
ATS 1
ATS 2
ATS 3
ATS 4
ATS 5
Total
13
28
50
15
106
17
13
21
15
19
25
34
24
53
80
40
200
No
category
ATS 1
ATS 2
ATS 3
ATS 4
ATS 5
Total
Correct triage
category
over-
triaged
>1
category under-
triaged
category
over-
triaged
2010
PPDT
allocation
ATS 1
ATS 2
ATS 3
ATS 4
ATS 5
Total
13
11
12
37
52
44
57
28
39
11
14
27
20
50
63
52
15
200
No
category
ATS 1
ATS 2
ATS 3
ATS 4
ATS 5
Total
1 category over-
1 category under-
triaged
triaged
triaged
triaged
Correct triage
56
facilitated parallel decision-making for the purpose of audit
and quality management.
Triage categories
A signicant increase in ATS 1 and 2 was identied in 2010.
Analysis of data obtained from EDIS conrms the upward
trend in these two categories.19 Key statistics demonstrate
that for the total number of patients presenting to the ED in
July, the percentage of children receiving an ATS 2 rose from
6.8% (n = 165) in 2008 to 13.7% (n = 314) in 2010.19 Similarly,
for ATS 1 patients, the percentage of presentations rose from
0.2% (n = 4) in 2008 to 0.8% (n = 18) in 2010.19 While the cause
is likely to be multifactorial; it is possible that some ATS 1
and 2 patients were previously being under triaged.
Over triage is dened as the allocation of an ATS category that is higher than the true measure of urgency.14 In
this study, over triage represented any presentation that was
rated as more urgent than the PPDT indicated. In 2010, over
triage was most common for category ve patients with 45%
(n = 12) allocated a higher category. This number takes into
account the potential for the ATS category to be increased
when a co-morbidity or risk factor is present but in this study,
neither factor was present in this cohort. While over triage
decreases the waiting time of the patient, it may inappropriately direct the ED resources and adversely affect the
waiting time of other patients.10 It is for this reason that
steps should be taken to explore this nding in more detail.
Conversely, under triage is the term used when a triage
allocation is lower than the true measure of urgency.14 Under
triage can have signicant consequences when taking into
account the fact that children are waiting for treatment
longer than their true urgency indicates. This can lead to
poor patient outcomes and potentially adverse events.10 The
strategy used to change practice showed the risk of under
triage decreased signicantly, while the proportion of children over-triaged remained similar.
Documentation
Nursing documentation must reect the physiological assessment that has been completed. The quality of triage
L. Malyon et al.
documentation may inuence practice and patient outcomes so it is important that it accurately reects the
assigned triage category.3,20,21 Further, it can be used as evidence in a court of law for either clinical or professional
accountability.
Initially, documentation anomalies in this study included
incomplete documentation of signicant and relevant primary assessment data and phrasing such as no work of
breathing when what was meant was no increased work
of breathing. In addition, non-standardised abbreviations
or the inclusion of irrelevant information also impeded parallel decision-making. These ndings are consistent with
those of a cross-sectional audit of general nursing documentation undertaken in 2011.20 The study conducted by Wang
et al., 2011 identied that documentation can be improved
when there is education and organisational support for the
introduction of standardised language; ndings that are supported in this study.
Documentation of the primary assessment was shown
to improve after the PPDT was introduced. This nding is
important for a number of reasons. Comprehensive documentation of the initial assessment using a standardised
format and physiological descriptors facilitates transparent
decision-making. This is helpful for the purpose of audit and
quality improvement. For the triage nurse, the identication of strategies to improve performance can be linked
to reective practice and education.8 For children, it is
important because it means that the ATS will be more consistently applied and more accurately reect their clinical
urgency.
Audit
The accuracy of and consistency in which a triage score
is allocated largely underpins the quality management
process.8 Auditing clinical decision-making is the ideal measure of accuracy and consistency and is best achieved if
parallel decision-making occurs.8 In this study, the use of
the PPDT and ATS simultaneously was found to contribute
to the consistency of triage nurses decisions. Together with
the change in documentation standards to reect the full
primary assessment and terminology of the PPDT, the ability of the researchers to use parallel decision-making as a
tool to scrutinise concordance at the point of triage greatly
improved.
The most signicant improvement was evident in the discriminators for airway and breathing. Prior to this study,
triage nurses in this ED documented circulation and neurological assessments in some form and therefore there
was only a moderate improvement over time. For these
characteristics, the greatest change was observed in the
improvement in the use of standardised physiological discriminators.
Pain is a common reason for accessing emergency care
and the amount of pain experienced by a patient directly
inuences urgency and resource allocation.8 Despite this, it
was the discriminator least often reported. Auditing of the
Manchester Triage Scale in the United Kingdom has shown
similar results with the most common documentation omission being the failure of the triage nurse to record a pain
score.8 Studies conducted by Considine et al., 2006 and
57
Queenslands Human Research Ethics Committee. Approval
HREC/09/QRCH/32.
Limitations
This research was limited to a single site, tertiary referral
hospital. However, the nature of the hospital allowed for
specialist paediatric nurses to test the tool. Further study is
required to explore whether these results can be generalised
to other paediatric and mixed EDs.
Conclusion
This study has demonstrated that ETEK has had a signicant
impact in this ED. Further, the introduction of the PPDT has
had a number of positive outcomes. Triage nurses now document the complete primary assessment; Airway, Breathing,
Circulation and Disability which is a true reection of the
assessment undertaken at the point of triage. This and the
adoption of similar terminology as that used in the PPDT
have provided a framework for triage nurses to link physiological descriptors for illness and injury to ATS categories.
These steps facilitated parallel decision-making for the purpose of auditing. Auditing led to reective practice, a more
consistent use of the ATS and improved inter-rater agreement. Most importantly, the ndings of this study have had
a direct benet for the child. That is, improved performance
ensures that children receive an ATS allocation commensurate with their level of clinical urgency.
Funding source
This paper is part of a larger study that was funded by the
Royal Childrens Hospital Foundation Research Skills Development Scholarship for Nurses. Grant no. 10296.
Author contributions
L.M. and A.W. were responsible for the study conception.
L.M., A.W. and R.W. were responsible for the study design.
L.M. was responsible for data collection. L.M., A.W. and R.W.
were responsible for data analysis with R.W. providing statistical expertise. L.M., A.W. and R.W. were responsible for
drafting the manuscript and L.M., A.W. and R.W. made critical revisions for important intellectual content. R.W. and
A.W. supervised the study.
Ethical approval
This paper reports the ndings of a research study that
adhered to the National Statement on the Conduct of
Human Research by the Australian National Health and
Medical Research Council, and has been approved by the
Royal Childrens Hospital, Brisbane and the University of
Acknowledgements
The authors would like to acknowledge Dr. Samantha Keogh,
Senior Research Fellow, Grifth University for her contribution to the studys original conception and design.
The authors would also like to thank the following members of the expert panel who piloted the audit tool: Judy
Harris, Nurse Unit Manager, Redcliffe Hospital (ED), Therese
Oates, Clinical Nurse Consultant, Royal Childrens Hospital
(ED) and Leanne Philips, Clinical Nurse, Royal Childrens Hospital (ED).
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