Accuracy of Emergency Department Nurse Triage Level Designation A

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2-14-2012
Accuracy of Emergency Department Nurse Triage

Level Designation and Delay in Care of Patients
with Symptoms Suggestive of Acute Myocardial
Infarction
Susan S. Sammons
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Sammons, Susan S., "Accuracy of Emergency Department Nurse Triage Level Designation and Delay in Care of Patients with
Symptoms Suggestive of Acute Myocardial Infarction." Dissertation, Georgia State University, 2012.
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ACCEPTANCE
This dissertation, ACCURACY OF EMERGENCY DEPARTMENT NURSE
TRIAGE LEVEL DESIGNATION AND DELAY IN CARE OF PATIENTS WITH
SYMPTOMS SUGGESTIVE OF ACUTE MYOCARDIAL INFARCTION by Susan
Sanders Sammons was prepared under the direction of the candidates dissertation
committee. It is accepted by the committee members in partial fulfillment of the
requirements for the degree of Doctor of Philosophy in Nursing by the Byrdine F. Lewis
School of Nursing and Health Professions, Georgia State University.
____________________________________
Cecelia M. G. Grindel, PhD, RN, FAAN
Committee Chairperson
____________________________________
Ptlene Minick, PhD, RN
Committee Member
____________________________________
Holli DeVon, PhD, RN
Committee Member
____________________________________
Date
This dissertation meets the format and style requirements established by Byrdine
F. Lewis School of Nursing and Health Professions. It is acceptable for binding, for
placement in the University Library and Archives, and for reproduction and distribution
to the scholarly and lay community by University Microfilms International.
_________________________________
Joan Cranford, EdD, RN
Assistant Dean for Nursing
Byrdine F. Lewis School of Nursing and Health Professions
_________________________________
Cecelia M. G. Grindel, PhD, RN, FAAN
Professor & Interim Dean
Byrdine F. Lewis School of Nursing and Health Profession
AUTHORS STATEMENT
In presenting this dissertation as a partial fulfillment of the requirements for an
advanced degree from Georgia State University, I agree that the Library of the University
shall make it available for inspection and circulation in accordance with its regulations
governing materials of this type. I agree that permission to quote from, to copy from, or
to publish this dissertation may be granted by the author or, in his/her absence, by the
professor under whose direction it was written, or in his/her absence, by the Assistant
Dean for Nursing, Byrdine F. Lewis School of Nursing and Health Professions. Such
quoting, copying, or publishing must be solely for scholarly purposes and will not
involve potential financial gain. It is understood that any copying from or publishing of
this dissertation which involves potential financial gain will not be allowed without
written permission from the author.
____________________________________
Susan Sanders Sammons
ii
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accordance with the stipulations prescribed by the author in the preceding statement.
The author of this dissertation is:
Susan Sanders Sammons
The director of this dissertation is:
Dr. Cecelia M. G. Grindel
Professor
Byrdine F. Lewis School of Nursing and Health Profession
P.O. Box 3995
Atlanta, GA 30302-4019
Users of this dissertation not regularly enrolled as students at Georgia State University
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NAME OF USER
ADDRESS
DATE
iii
TYPE OF USE
(EXAMINATION ONLY
OR COPYING)
VITA
Susan S. Sammons
ADDRESS:
EDUCATION:
PhD
1417 Dale Drive

Savannah, GA 31406
2012
MSN
2005
BSN
2005
ADN
1984
PROFESSIONAL EXPERIENCE:
2011 - Present
2007 2011
2001 2011
1996 2001
1994 1996
1989 1994
1986 1989
1985 1986
1984 1985

Atlanta, Georgia
Armstrong Atlantic State University
Savannah, Georgia
Armstrong Atlantic State University
Savannah, Georgia
Florida State College
Jacksonville, Florida
Emergency Services Clinical Nurse Specialist,

St. Josephs Candler Health System
Assistant Professor, Armstrong Atlantic State
University
Staff Nurse, Senior Nurse, Clinical Nurse
Specialist, Emergency Department, Memorial
University Medical Center
Staff Nurse, Compliance Manager, Hospice
Savannah
Staff Nurse, Oncology Unit, Candler General
Hospital
Charge Nurse, Medical/Surgical Unit, Memorial
University Medical Center
Director of Nursing, Helping Hands Home Care
Staff Nurse, Candler Home Health Services
Staff Nurse, Oncology Unit, Memorial University
Medical Center
iv
PROFESSIONAL ORGANIZATIONS AND CERTIFICATIONS:

2007 Present
Certification in Emergency Nursing (CEN)
2002 Present
Emergency Nurses Association (ENA)
2012 Present
President, ENA Coastal Empire Chapter
2001 - Present
Sigma Theta Tau International, Rho Psi Chapter
2005 Present
Georgia Nurses Association (GNA)
HONORS:
2010
2011
Kaiser-Permanente Evidence-Based Practice

Research Award
Armstrong Atlantic State University, Brockmeier
Faculty Award Nominee
ABSTRACT
ACCURACY OF EMERGENCY DEPARTMENT REGISTERED NURSE TRIAGE
LEVEL DESIGNATION AND DELAY IN CARE OF PATIENTS WITH SYMPTOMS
SUGGESTIVE OF ACUTE MYOCARDIAL INFARCTION
by
SUSAN S. SAMMONS
More than 6 million people present to emergency departments (EDs) across the
US annually with chief complaints of chest pain or other symptoms suggestive of acute
myocardial infarction (AMI). Of the million who are diagnosed with AMI, 350,000 die
during the acute phase. Accurate triage in the ED can reduce mortality and morbidity, yet
accuracy rates are low and delays in patient care are high. The purpose of this study was
to explore the relationship between (a) patient characteristics, registered nurse (RN)
characteristics, symptom presentation, and accuracy of ED RN triage level designations
and (b) delay of care of patients with symptoms suggestive of AMI. Constructs from
Donabedians Structure-Process-Outcome model were used to guide this study.
Descriptive correlational analyses were performed using retrospective triage data
from electronic medical records. The sample of 286 patients with symptoms suggestive
of AMI comprised primarily Caucasian, married, non-smokers, of mean age of 61 with
no prior history of heart disease. The sample of triage nurses primarily comprised
Caucasian females of mean age of 45 years with an associates degree in nursing and 11
years experience in the ED.
i
RNs in the study had an accuracy rate of 54% in triage of patients with symptoms
suggestive of AMI. The older RN was more accurate in triage level designation.
Accuracy in triage level designations was significantly related to patient race/ethnicity.
Logistic regression results suggested that accuracy of triage level designation was twice
as likely (OR 2.07) to be accurate when the patient was non-Caucasian. The patient with
chest pain reported at triage was also twice as likely (OR 2.55) to have an accurate triage
than the patient with no chest pain reported at triage. Electrocardiogram (ECG) delay was
significantly greater in the patient without chest pain and when the RN had more
experience in ED nursing. Triage delay was significantly related to patient gender and
race/ethnicity, with female patients and non-Caucasian patients experiencing greater
delay. An increase in RN years of experience predicted greater delay in triage. Further
studies are necessary to understand decisions at triage, expedite care, improve outcomes,
and decrease deaths from AMI.
ii
ACCURACY OF EMERGENCY DEPARTMENT REGISTERED NURSE TRIAGE

LEVEL DESIGNATION AND DELAY IN CARE OF PATIENTS WITH SYMPTOMS
SUGGESTIVE OF ACUTE MYOCARDIAL INFARCTION
by
SUSAN S. SAMMONS
A DISSERTATION
Presented in Partial Fulfillment of Requirements for the

Degree of Doctor of Philosophy in Nursing in the Byrdine F. Lewis
School of Nursing and Health Professions
Atlanta, Georgia
2012
iii
Copyright by
Susan S. Sammons
2012
iv
ACKNOWLEDGMENTS
This dissertation is the culmination of years of hard work and perseverance both
from my family, my committee, and myself. I must thank first Dr. Laura Kimble who
planted the seed of what could be. She gave me direction in the very early stages of my
research in emergency cardiac care and allowed me to pursue my passion. Each of my
committee members, Drs. Grindel, Minick, and DeVon, have given of their time and
expertise to guide me, and for that I am grateful. A sincere thank you to my friends and
colleagues who have watched me each step of the way, class after class after class. You
have asked, and truly seemed to care, about my topics and homework all along the way.
You emergency nurses are my inspirationI watch you work magic daily, and I am
proud to be among you. A cohort of doctoral students traveled this path with me, driving
mile after mile, reading and having philosophical discussions at every turn. The road less
traveled was made less lonely because of them. To Dee Tanner, Jean Pawl, and Janeen
Amason, I am thankful for each of you. My family has been there for me, faithfully
taking whatever I dished out, literally and metaphorically. I love you totally.
TABLE OF CONTENTS
Section
Page
List of Tables...................................................................................................................x
List of Figures ............................................................................................................... xi
List of Abbreviations .................................................................................................... xii
I.
INTRODUCTION ...............................................................................................1
Statement of Problem ......................................................................................................1

Purpose and Aims ............................................................................................................2
Significance .....................................................................................................................2
Standards of Emergency Cardiac Care ............................................................2
Standards of ED RN Triage ............................................................................3
Importance Of Accurate Triage Level Designation .........................................6
Theoretical Framework ....................................................................................................7
Selection of a Theoretical Framework ............................................................7
Overview of Donabedians Model ..................................................................8
Use of Donabedians Model in Studies ......................................................... 10
Strengths of Donabedians Model................................................................. 12
Summary ....................................................................................................................... 14
II.
REVIEW OF LITERATURE ............................................................................. 15
Accuracy Rates in Triage ............................................................................................... 15

Delay in Emergency Care .............................................................................................. 18
Patient Characteristics ................................................................................................... 21
RN Education, Experience, and Triage .......................................................................... 24
vi
Symptom Presentation ................................................................................................... 26

Summary ....................................................................................................................... 28
III.
METHODOLOGY ............................................................................................ 30
Research Design ............................................................................................................ 30

Setting 30
Sample31
Measures and Instruments.............................................................................................. 32
Variables of Interest ..................................................................................... 33
Accuracy ...................................................................................................... 33
Symptoms Suggestive of AMI ...................................................................... 33
Triage Level Designation ............................................................................. 35
Patient Characteristics .................................................................................. 35
RN Characteristics ....................................................................................... 36
Delay ........................................................................................................... 36
Data Collection .............................................................................................................. 36
Data Analysis ................................................................................................................ 38
Protection of Human Subjects ........................................................................................ 38
Summary ....................................................................................................................... 39
IV.
RESULTS .......................................................................................................... 40
Preliminary Screening Procedures ................................................................................. 41

Descriptive Statistics ..................................................................................................... 45
Description of the Sample of Patients ........................................................... 45
Description of the Sample of RNs ................................................................ 47
vii
Statistical Analysis ........................................................................................................ 49

Predictors of Accuracy of Triage Level Designation ..................................... 49
Predictors of Delay of ECG .......................................................................... 50
Predictors of Amount of Delay of Care ......................................................... 52
Summary ....................................................................................................................... 54
V.
DISCUSSION AND CONCLUSION ................................................................. 57
Accuracy ....................................................................................................................... 57
Accuracy and Patient Characteristics ............................................................ 58
Accuracy and RN characteristics .................................................................. 59
Triage Delay .................................................................................................................. 61
Triage Delay and Patient Characteristics ...................................................... 62
Triage Delay and RN Characteristics ............................................................ 63
ECG Delay .................................................................................................................... 63
ECG Delay and Patient Characteristics ......................................................... 64
ECG Delay and RN Characteristics .............................................................. 65
Accuracy and Delay....................................................................................................... 65
Conclusions ................................................................................................................... 67
Limitations .................................................................................................................... 68
Implications for Nursing Practice................................................................................... 69
Future Research ............................................................................................................. 70
REFERENCES .............................................................................................................. 72
APPENDICES ............................................................................................................... 88
Appendix A: Registered Nurse Demographics Tool ....................................................... 88
viii
Appendix B: Selection of Electronic Medical Records ................................................... 90

Appendix C: Informed Consent ..................................................................................... 92
Appendix D: Institutional Review Board Approval ........................................................ 94
ix
LIST OF TABLES
Table
Page
1.
Triage Scale and Maximum Wait Times in Minutes .............................................5
2.
Data List ............................................................................................................ 34
3.
Skewness and Kurtosis Statistics ........................................................................ 43
4.
Patient Demographics ........................................................................................ 46
5.
Patient Medical History...................................................................................... 47
6.
Characteristics of Registered Nurses .................................................................. 48
7.
Electronic Medical Record Matched Registered Nurse Demographics ................ 48
8.
Accuracy of Triage Level Designation Model .................................................... 50
9.
Delay of Electrocardiogram Model .................................................................... 51
10.
Minutes of Delay in Care ................................................................................... 52
11.
Correlation of Registered Nurse Age and Experience ......................................... 53
12.
Amount of Delay of Triage Model ..................................................................... 54
LIST OF FIGURES
Figure
Page
1.
Donabedians model. ...........................................................................................9
2.
Model of emergency department registered nurse triage of patients with

symptoms suggestive of acute myocardial infarction. ...........................................9
3.
Histogram for minutes to triage. ......................................................................... 43
4.
Histogram for minutes to triage (transformed). ................................................... 44
5.
Registered nurse years of experience in emergency department. ......................... 44
6.
Registered nurse years of experience in emergency department (transformed). ... 45
xi
LIST OF ABBREVIATIONS
ACC
American College of Cardiology
ACS
Acute Coronary Syndrome
ADN
Associate Degree in Nursing
AHA
American Heart Association
AMI
Acute Myocardial Infarction
ATS
Australasian Triage Score
BMI
Body Mass Index
BSN
Bachelor of Science in Nursing
CABG
Coronary Artery Bypass Graft
CHD
Coronary Heart Disease
CPR
Cardiopulmonary Resuscitation
CTAS
Canadian Triage and Acuity Scale
DTN
Door-to-Needle
DTB
Door-to-Balloon
ECG
Electrocardiogram
ED
Emergency Department
EMR
Electronic Medical Record
ENA
Emergency Nurses Association
ESI
Emergency Severity index
IHI
Institute for Healthcare Improvement

xii
IRB
Institutional Review Board
LPN
Licensed Practical Nurse
MCAR
Littles Missing Completely at Random
MTS
Manchester Triage Scale
NCHS
National Center for Health Statistics
NHAMES
National Hospital Ambulatory Medical Care Survey
NHLBI
National Heart Lung and Blood Institute
NSTEMI
Non-ST segment Elevation
PAWS
Predictive Analytics Software
PCI
Percutaneous Coronary Intervention
RN
Registered Nurse
RNDT
Registered Nurse Demographic Tool
SES
Socioeconomic Status
STEMI
ST-segment Elevation Myocardial Infarction
UA
Unstable Angina
xiii
CHAPTER I
INTRODUCTION
This chapter provides an overview of the significance of rapid cardiac care in the
emergency department (ED). The standards of emergency cardiac care are identified as
well as the standards of ED triage and the importance of accurate triage and rapid cardiac
care. The aims of this study are identified. Donabedians Structure-Process-Outcome
model (Donebedians model; Donabedian, 1966) is presented as a theoretical framework
to investigate accuracy and delay in triage of patients with symptoms suggestive of acute
myocardial infarction (AMI).
Statement of Problem
Coronary heart disease (CHD) is the leading cause of death in the US (Murphy,
Xu, & Kochanek, 2012). More than 6 million patients present to EDs across the US every
year with a chief complaint of chest pain; 6 million more present with possible symptoms
of CHD such as dizziness, nausea, or shortness of breath (National Center for Health
Statistics [NCHS], 2008). Annually in the US, 1 million patients are diagnosed with
AMI, and 350,000 of those die during the acute phase (Institute for Healthcare
Improvement [IHI], 2009). Accurate and timely triage level designation in the ED can
reduce mortality and morbidity, yet data indicate that accuracy rates are low and delays in
patient care are high. The current economic downturn is associated with more people
seeking primary care from EDs than ever before, leading to overcrowding. ED
overcrowding means that the role of the triage registered nurse (RN) in evaluating those
2
who need urgent care and those who can wait is more pressing than ever before.
Therefore, there is a need to investigate conditions involved in ED RN triage level
designations.
Purpose and Aims
The purpose of this study was to explore the relationship between (a) patient
characteristics (gender, age, race/ethnicity, symptom presentation), (b) RN characteristics
(age, years of experience, years of ED experience, and education), (c) accuracy of ED RN
triage level designations, and (d) delay of care of patients with symptoms suggestive of
AMI. Specifically, the aims of this study were
1. to determine if patient characteristics (gender, age, race/ethnicity) and RN
characteristics (age, years of experience, years of ED experience, and education)
predict accuracy of ED RN triage level designation of patients with symptoms
suggestive of AMI, and
2. to determine if patient characteristics (gender, age, race/ethnicity, symptom
presentation), RN characteristics (age, years of experience, years of ED
experience, and education), and triage level designation predict delay of care of
patients with symptoms suggestive of AMI.
Significance
Standards of Emergency Cardiac Care
AMI is defined as a sudden lack of oxygen to the cardiac muscle due to a clot or
atherosclerotic changes that occlude a coronary artery. Cardiac cell death is not
immediate but can occur within 20 minutes and up to 2 hours after the initial occlusion
(Thygesen, Alpert, & White, 2007). The American College of Cardiology (ACC) and the
3
American Heart Association (AHA) recommend in national guidelines that health care
providers meet certain emergency cardiac care goals: obtain an electrocardiogram (ECG)
within 10 minutes of arrival, have a patient evaluated by a physician within 10 minutes,
and initiate thrombolytic medications within 30 minutes or provide percutaneous
coronary intervention (PCI) within 90 minutes of point of entry into the ED with
symptoms of AMI (Krumholz et al., 2008). The initiation of intravenous thrombolytic
medications is also called door-to-needle (DTN), and the provision of PCI is designated
as door-to-balloon (DTB). Rapid assessment and treatment are crucial to restoring blood
flow to the heart, preserving cardiac function, and saving lives. Because of their ability to
recognize the AMI patient and take quick action, ED triage RNs are in the best position
to directly affect early intervention and care.
Standards of ED RN Triage
ED administrators, RNs, and physicians struggle with how to handle the volume
of patients arriving for healthcare (Derlet & Richards, 2000). Determining the severity of
illness and urgency of care required are the main functions of the triage RN. Triage RNs
in the ED have a responsibility to identify patients with cardiac emergencies who need
prompt care. However, triage is not straightforward and few, if any, diagnostic tests are
conducted in triage to aid in that decision. Triage level designation is a subjective
decision based on input from several directions. Along with observational data collected
during a brief nursing assessment, numerous pieces of information, such as previous
medical history and symptoms, are elicited from the patient, and sometimes family,
before the triage level designation is decided. A decision is made to assign the patient to
one of several categories or levels of priority. Although there are no nationally
4
established time parameters to complete the triage process itself, the goal during triage is
to assess the patient and make a triage level designation indicating urgency of symptoms
within 2 to 5 minutes (Travers, 1999).
In the US, there is no standard set of triage guidelines; however, most hospitals in
the US have adopted a three or five level system for triage. Many hospitals use the
Emergency Severity Index (ESI; Gilboy, Tanabe, Travers, Rosenau, & Eitel, 2005), a five
level system. The Emergency Nurses Association (ENA; 2010) supports the use of this
five level triage system. In the ESI, patients are assigned a triage level based on the
following scale: Level 1-resuscitation needed, Level 2-emergent, Level 3-urgent but
stable and can safely wait in the waiting room, Level 4-nonurgent, and Level 5-referable
to another provider of care such as a clinic setting. The triage RN must first assess
whether the patient has a life-threatening issue, noted as a high triage level designation
(ESI Level 1 or 2). Level 1 asks the question: Is this patient dying (i.e., not breathing and
in need of cardiopulmonary resuscitation [CPR])? Level 2 asks the question: Is this a
patient who should not wait? If the patient can wait without harm, then the triage RN
moves to a decision regarding estimation of number of resources needed for the physician
to determine a diagnosis or disposition (Level 3, 4 or 5). The ESI system does not
mandate specific time frames (i.e., how long a patient can wait to see a physician).
However, symptoms of AMI must always be considered a Level 2-emergent in the ESI
system so that national guidelines for cardiac emergencies can be met and prompt care
can begin.
Hospitals in other countries use five level triage systems, including the Canadian
Triage and Acuity Scale (CTAS; Beveridge et al., 1999), the Australasian Triage Score
5
(ATS; Australasian College for Emergency Medicine [ACEM], 2000), or the Manchester
Triage Scale (MTS; Manchester Triage Group, 1997). All three scales use a numbering
system with Level 1 designating the most critical patient situation. The ATS, the CTAS,
and the MTS set maximum wait times for patients in each level (see Table 1).
Table 1
Triage Scale and Maximum Wait Times in Minutes
Scale
Level 1
Level 2
Level 3
Level 4
Level 5
Australasian Triage Scale
10
30
60
120
Canadian Triage and Acuity Scale
15
30
60
120
Manchester Triage Scale
10
60
120
240
In synthesizing the current research of accuracy in ED RN triage level

designations, an emerging issue is inconsistency in the type of triage scales used. Portions
of the EDs in the US do not use the ESI scale but instead use a three-level system: Level
1-emergent, Level 2-urgent, and Level 3-non-urgent. Both three-level and five-level
systems are in use in the United Kingdom, Canada, Australia, and other countries.
Comparing the accuracy of assessments in triage systems is problematic because of the
inconsistency in the number of triage levels in the differing systems (three versus five).
Travers, Waller, Bowling, Flowers, and Tintinalli (2002) compared the five-level
and the three-level systems. A triage level designation assigned a lesser urgency than
needed was denoted as under-triage in the study and a triage level designation assigned
higher than the necessary urgency was denoted over-triage. The under-triage rate for the
three-level systems was 28% but improved to 12% when the five-level ESI was used. The
6
ability to correctly identify those patients who required urgent care was 23% in the threelevel systems, but 75% in the five-level ESI. Travers et al. (2002) concluded that the fivelevel ESI was superior for triage of patients in the ED.
Importance Of Accurate Triage Level Designation
A growing body of evidence points to the association between early intervention
and decreased mortality in patients with AMI. Studies have demonstrated associations
between time to PCI and mortality risk. In a study reviewing the medical records of
27,080 patients with AMI and PCI at 661 hospitals, Cannon et al. (2000) found a median
DTB time of 116 minutes. An increase in DTB time increased in-hospital mortality by
40-60%, with an increase in mortality higher with DTBs greater than 120 minutes.
In a study of 1,791 patients with ST-segment elevation myocardial infarction
(STEMI) treated with angioplasty, DeLuca, Suryapranata, Ottervanger, and Antman
(2004) found risk of dying within 1 year of AMI increased by 7.5% for every 30 minutes
of delay. More importantly, any increase in DTB time equaled an increase in 1-year
mortality, and the longer the duration of the occlusion, the larger the degree of infarct.
In a retrospective database analysis, McNamara et al. (2006) found increased
DTB times that were associated with increase in hospital mortality in patients (N =
29,222) with STEMI and PCI. As DTB time increased so did in-hospital mortality. In a
study investigating DTB times and mortality in STEMI patients (N = 43,801), 42.1% of
patients were delayed past the 90-minute mark, with 18.8% being delayed greater than 2
hours (Rathore et al., 2009). The overall mortality rate for the study cohort was 4.6%. A
significant trend was noted in mortality in that the longer the DTB time, the higher the
mortality rate.
7
As demonstrated in the literature, time to initiation of PCI or fibrinolytic
medication administration is critical. Any action that increases that time is potentially
harmful. Accurate triage level designation is one tool ED RNs can use to facilitate early
intervention and affect patient outcomes.
Theoretical Framework
The individual ED triage process involves a patient presenting to an ED for
medical care. Thus, the patient presenting already has decided that a healthcare need
exists based on symptoms. Once the patient and the triage RN interact, data gathering by
the RN begins. This may be (a) physical evidence such as pale skin, diaphoresis, active
bleeding, or labored breathing or (b) symptoms the patients report, such as pain,
weakness, or fatigue. In either instance, a degree of uncertainty exists. The unknown in
this situation is the seriousness and urgency of the underlying condition responsible for
causing the signs and symptoms. Obtaining symptom progression information and a
health history are part of the triage process for the purpose of data gathering. Initial
diagnostics, such as obtaining a blood pressure, heart rate, respiratory rate, temperature,
and oxygen saturation level, begin in triage. It is unknown whether the patients gender,
age, and race/ethnicity or RN experience and education affect this process. For this study,
understanding what happens during the process of ED triage required a framework that
speaks to the processes involved. Donabedians model (Donabedian, 1966) was used to
address this process.
Selection of a Theoretical Framework
The Donabedian model is useful in framing studies examining ED RN triage of
AMI patients and factors associated with accuracy of triage level designation and delay
8
of care. The use of this framework in this study was appropriate because the framework
mirrors ED triage in that it has a data input point of multiple factors possibly affecting a
process, which in turn affects the output or outcome.
Overview of Donabedians Model
Donabedians model evolved from Donabedians work in health services quality
and patient outcomes. The primary goal of quality assurance processes is improvement in
outcomes directly related to patient care. The key concepts in the model are structure,
process, and outcome. As demonstrated in Figure 1, Donabedians model proposes that
each component has an effect or direct influence on the next (Donabedian, 1980).
Characteristics of the healthcare setting, the healthcare provider, or the healthcare
encounter have the potential to influence both process and outcome. Donabedians model
provides a way of understanding the ED RN-patient encounter at triage and the effect of
accuracy of triage level designation and delay in treatment of AMI.
Figure 2 demonstrates the application of Donebedians model in this study. The
concept of structure refers to attributes of the healthcare setting, the healthcare provider,
or the healthcare encounter in which care is delivered and may include (a) patient
characteristics and RN characteristics; (b) environmental factors that compose the setting
(e.g., day of the week and time of day), and (c) extrinsic factors (e.g., staffing levels, unit
patient volume, overcrowding, and boarding of admitted patients). Measurement of
extrinsic factors was beyond the scope of this project. Factors that compose the attributes
of the setting in ED RN triage were defined in this study as (a) the patient characteristics
of gender, age, race/ethnicity, and symptom presentation and (b) the RN characteristics of
age, years of experience, years of ED experience, and education.
Structure
Process
Outcomes
Figure 1. Donabedians model.
Structure
Patient characteristics
gender
age
race/ethnicity
symptom presentation
RN characteristics
age
race/ethnicity
symptom presentation
Process
Triage level designation
decisions of patients
presenting with symptoms
suggestive of AMI
Outcomes
Accurate triage level
designation; time to triage
and time to ECG
Figure 2. Model of emergency department registered nurse triage of patients with

symptoms suggestive of acute myocardial infarction.
10
Process refers to the interpersonal aspects of activities between service providers
and their clients. In ED triage, process is the action that is occurring on the patients
behalf and involves the interaction between the ED triage RN and the patient presenting
for care. In this study, process was defined as the triage interaction between patient and
RN and the resulting triage level designation.
In Donabedians model, the outcome is the result of the structure and process.
Outcomes in most quality assurance programs are generally described in terms of better
survival rates, lower infection rates, quality of life indicators, or some measure of benefit
to the recipient of care, the patient. In this study, the outcome, or measure of benefit to
the recipient of care, was defined as accuracy of ED RN triage level designation of
patients with symptoms suggestive of AMI and delay or no delay in care as measured by
triage and obtainment of ECG within 10 minutes of arrival.
Use of Donabedians Model in Studies
Donabedians model has been used extensively to frame studies examining (a) the
performance of community organizations (Chen, Hong, & Hsu, 2007), (b) radiation
oncology services (Christian, Adamietz, Willich, Schafer, & Micke, 2008), (c) AMI
treatment in Germany (Wubker, 2007), (d) compliance with infection control strategies
(Chou, Yano, McCoy, Willis, & Doebbeling, 2008), and (e) medical care for depressed
elders (Hong, Morrow-Howell, Proctor, Wentz, & Rubin, 2008). Using a sample of 195
community organizations in Taiwan, Chen et al. (2007) conducted a correlational study
examining relationships between community organization capacity characteristics and
performance scores validating the theoretical relationships among concepts identified in
the Donabedian model. The model focused on the relationships between structure and
11
outcome. The performance outcomes were directly influenced by structure factors such as
funding type, designated department, full-time worker, funding linkage, partnership
score, multiple committee use, attitude toward participation, number of volunteers,
education level of volunteers, and position and age of administrator.
Using the Donabedian model in a study of continuing after-hours emergency
radiation therapy services in Germany, Christian et al. (2008) described outcomes which
were based on the characteristics of each institution providing services (N = 140), reasons
for treatment (structure), day and time treatment occurred, dosage delivered, and
equipment used (process). Outcomes were reported in percentages of improvement in
patient indicators. No relationship was identified between structure variables, process
variables, and outcomes leading the authors to re-evaluate continuation of emergency
radiation services. Donabedians model also helped the researchers identify the need to
begin formation of national benchmarks.
Wubker (2007) used the Donabedian model to assess outcomes associated with
diagnostics and treatment of AMI patients in 16 German federal states. Structure was
defined as the number of cardiologists and the number of catheterization facilities;
process was defined as the number of coronary angiography and coronary artery bypass
grafts (CABG) in a 10 year period and adherence to medical standards of care; and
outcomes were mortality rates and potential years of life lost. The study hypothesis was
based on the premise that the better the structure and process, the better the outcome.
However, data revealed only the structure variable of the number of catheterization
facilities was significantly related to better outcomes. Other factors, mainly
socioeconomic factors and risk factors, were found to have an influence on outcomes.
12
Using Donabedians model as a guide in a study of antimicrobial resistance (Chou
et al., 2008), infection control professionals (N = 448) were surveyed about structural
factors such as hand washing policies, operating room procedures, and administrator
support, along with process factors such as the culture of the hospital and
communication. The outcome was the degree of adherence to national guidelines to
optimize antimicrobial use as well as strategies to detect, report, and prevent
antimicrobial resistance. Researchers found numerous structural and process factors
(administrator support, feedback systems, forms, formal processes, policy distribution,
formularies, and computer support) significantly related to the outcome of adherence to
national guidelines to optimize antimicrobial use.
Hong et al. (2008) used Donabedians model to assess medical care for depressed
elders (N = 110) and found that only about 70% of patients received the minimum needed
medical care for co-morbidities with 22% of depressed elders receiving less than half of
care needed. Significant correlations were noted between insurance coverage, marital
status, income (structure factors) and medical services provided (process factor)
indicating that quality outcomes were related to the functions of structure and process.
In these studies, Donabedians model allowed for evaluation of the effectiveness
of a current process or the consideration of a new process based on expected outcomes.
Donabedians model also allowed for the identification of factors not initially included as
structure or process variables to be considered or reconsidered for further studies.
Strengths of Donabedians Model
Using a systematic approach for assessing the usefulness of a model, as defined
by Chinn and Kramer (1995), familiarity, simplicity, and effectiveness were examined to
13
determine the usefulness of Donabedians model in examining ED triage of the patient
with symptoms suggestive of AMI. First noted is the widespread familiarity with the
Donabedians structure-process-outcome model and its simple structure. The diagram
itself is simplistic. Secondly, diagrams illustrating structure-process-outcome are used
effectively to demonstrate links between concepts. The model allows for the
identification of independent variables that can be included. Possible independent
variables that can be investigated include (a) the patient characteristics of gender, age,
race/ethnicity, socioeconomic status (SES), marital status, symptom presentation, and
medical history, (b) the RN characteristics of knowledge, years of experience, years of
ED experience, gender, age, degree, and clinical experience, and (c) the unit
environmental factors of crowded waiting rooms, staffing pattern, acuity of patients, time
of day, available beds, RN/physician communication patterns, culture of the unit,
autonomy of the RN, and protocol use.
Many identified research studies investigating ED triage accuracy and delay lack
a conceptual or theoretical framework. This theory gives direction to begin to understand
the relationships and connections of concepts vital to understanding triage, such as
decision-making, delay, accuracy, symptom presentation, and patient and RN
demographic factors. Donabedians model focuses on structure and process with an
overall goal of achieving a positive outcome. Donabedians model can be used to identify
possible factors affecting ED RN triage level designation. The model can be linked to
empirical indicators testing theoretical relationships and can be used to identify gaps in
the literature. The model can also be used as an organizing framework for ED RN triage
of patients with possible AMI to inform future recommendations for triage in the ED.
14
According to Donabedian (1980), structural characteristics of the setting in which care
takes place have a propensity to influence the process. Similarly, changes in the process
of care will influence outcome. This sets the stage for correlational studies that examine
the relationship of structure and process factors and the rapid treatment of patients with
possible AMI.
There are limitations to the use of Donabedians framework for the study of ED
RN triage level designations for patients with symptoms suggestive of AMI. While
Donabedians model can identify relationships and associations between structure,
process, and outcomes, it is not helpful in determining causality. However, understanding
how structure and process affect delay in treatment of AMI patients has important
implications that may affect policy, education, and training of staff in the ED.
Summary
In this chapter, the standards of emergency cardiac care were identified, and the
significance of rapid cardiac care was discussed. The aims of the study were identified
and a theoretical model proposed as a framework to study accuracy and delay in the ED.
The Donabedian model has been presented, and its usefulness to examine healthcare
work processes, specifically ED RN triage of the patient with symptoms suggestive of
AMI, has been discussed. Key concepts have been identified and strengths and
limitations analyzed. The theoretical framework of structure-process-outcome
(Donabedian, 1980) was used to investigate ED RN triage accuracy and delay and the
relationship to patient and RN characteristics.
CHAPTER II
REVIEW OF LITERATURE
This review of the literature includes a discussion of previous research
investigating accuracy of ED RN triage level designations and delay in ED care. Patient
characteristics as well as RN characteristics in relation to patient care have been
identified in studies and are discussed in this literature review. A discussion of symptom
presentation differences addressed in nursing research studies is included in this review.
Accuracy Rates in Triage
Kosowsky, Shindel, Liu, Hamilton, and Pancioli (2001) hypothesized that ED
triage RNs would be able to identify patients whose condition was serious enough to
warrant hospital admission. Triage RNs were asked to predict during the triage process
which patients would be admitted. RNs (N = 39) in the study had a 62% accuracy rate in
predicting general hospital admission. The researchers found that RNs were only able to
identify patients who were ill enough to need a critical care bed admission 50% of the
time. Arslanian-Engoran (2004) also examined accuracy of the ED triage RN in a study
predicting hospital admission. Registered Nurses (N = 13) in the study exhibited poor
accuracy with a 58% sensitivity and failed to identify acute coronary syndrome (ACS) in
44% during triage of patients who were admitted with a diagnosis of ACS. Holdgate,
Morris, Fry, and Zecevic (2007) examined accuracy of triage RNs in predicting hospital
admission in 1,342 triages. RNs in the study had a 76% accuracy rate, but in 36% of the
cases, the ED RN did not answer the prediction question, leading one to surmise that the
15
16
RN was unsure. The accuracy rate for patients in the study with cardiovascular disease
was only 59%.
In a study of US trends and predictors of wait times, Wilper et al. (2008) found
that 30% of patients with a diagnosis of AMI had an incorrect triage level designation.
The study retrospectively analyzed National Hospital Ambulatory Medical Care Survey
(NHAMES) data pertaining to 92,173 adult visits to EDs from 1997-2004. Considine,
Ung, and Thomas (2000) in a study of RN (N = 31) consistency in triage level
designation noted a 58% accuracy rate when scoring 10 written vignettes. In a study
comparing paper versus computer vignettes to test ED triage RN performance, Considine,
LeVasseur, and Villanueva (2004) found an overall accuracy rate of 61% when RNs (N =
322) scored written vignettes (N = 4,614) depicting all types of illnesses in adult and
pediatric cases. Atzema, Schull, and Tu (2011) identified an accuracy rate at triage of
67.6% in patients (N = 680) with AMI who also happened to have a charted history of
depression.
In a study of ED RN accuracy in triage level designation, Goransson, Ehrenberg,
Marklund, and Ehnfors (2005) noted a mean accuracy rate of 57.6%, with a range of 2289% accuracy per RN (N = 423) in responding to written vignettes (N = 7,550) using
CTAS. In a retrospective review of electronic medical records (EMRs), Atzema, Austin,
Tu, and Schull (2009) investigated triage accuracy in the care of patients with AMI (N =
3,088) and identified a 50% accuracy rate.
In a study of 55 RNs and emergency medical technicians (EMT), Wuerz,
Fernandes, and Alarcon (1998) found poor interrater agreement (k = 0.347) in deciding
triage levels using a 3-level ESI scale in five written vignettes. In test-retest reliability,
17
participants scored five vignettes initially and the same five vignettes 4 to 6 weeks later
with only 24% of the participants assigning the same triage level at time 2. In studies
testing the reliability, validity, and inter-observer agreement of specific triage scales,
researchers found inaccuracies and inconsistencies. In a study testing agreement using the
CTAS, Manos, Petrie, Beveridge, Walter, and Ducharme (2002) noted a good inter-rater
agreement (k = 0.77). In the study, five RNs, five physicians, five EMTs, and five
paramedics scored 41 vignettes with an accuracy rate of 63.4%.
In a study testing reliability of triage using CTAS (Worster, Sardo, Eva,
Fernandes, & Upadhye, 2007), researchers compared written vignettes versus direct
observation of triage. RNs (N = 9) triaged a total of 90 patients while being observed
(Time 1) and triaged the exact scenario 6 months later (Time 2) by written vignette.
Triage level assignment was found to be significantly different from Time 1 to Time 2
with a higher triage level scored on the written vignette. It is possible that RNs assign a
higher ED triage level score when there is more time to make a decision than during live
triage of actual patients.
Numerous studies have identified inaccuracies in triage level designations and an
inability of the ED triage RN to consistently identify patients with emergent symptoms.
Accurate triage level designations by the ED triage RN determine how rapidly a patient
receives medical care in the ED, that is, whether or not the patient is taken straight to a
treatment area or sent back to the waiting room. However, current nursing research has
continued to identify inaccuracies in triage RN decisions. Urgent cases assigned nonurgent status put patients at risk for delayed treatment and poor outcomes. In the field of
cardiac emergency care, specifically AMI, the consequences can be permanent cardiac
18
muscle damage and even death. Patients are sometimes judged not to have a medical
emergency when one exists. When this occurs, the patient is said to be under-triaged,
meaning the patient was assigned a lower triage level than is actually warranted. Patients
are also over-triaged, assigned a triage level higher than necessary, which may cause a
stable patient to be seen ahead of a patient with a medical emergency and fill treatment
areas needed for those emergent patients.
A large portion of these studies identified a descriptive method of exploration to
identify the degree of accuracy at triage without an attempt to investigate the source of
inaccuracies. Atzema et al. (2009), however, used a correlational design investigating a
possible association between inaccurate triage and delay in care of patients with AMI.
Atzema et al. investigated the accuracy of triage as a possible factor in delay of care for
patients with AMI (N = 3088) in a total of 87 EDs. Of the patients, 50% were assigned a
lower triage score of Level 3, 4 or 5. Median door-to-ECG time was 12 minutes, with
only 45.9% of patients having an ECG within 10 minutes. Time from arrival to
thrombolytic medication administration, also called DTN time, was 40 minutes with only
35.6% of patients care meeting the DTN goal time of 30 minutes. Incorrect triage level
designation was found to be significantly associated with delay in door-to-ECG and DTN
time.
Delay in Emergency Care
Delay in care of patients with cardiac symptoms is determined by assessing the
time of arrival, the time of triage, the time of ECG completion, and the time of
assessment by a physician or other healthcare provider. The standard for emergency
cardiac care, set by ACC/AHA guidelines, is an ECG obtained within 10 minutes of
19
arrival to an ED. In a study of adherence to ACC/AHA guidelines for AMI care, ED RNs
were asked if they initiated specific steps in the rapid care of patients with symptoms
suggestive of AMI (Arslanian-Engoren, Eagle, Hagerty, & Reits, 2011). The participants
(N = 158) were specifically asked about nine steps that together make up the ACC/AHA
AMI guidelines. Questions about the guidelines included items such as rapid ECG,
intravenous (IV) access, lab work, minutes to cardiac catheterization, oxygen and aspirin
administration. Only 27% of the participants stated they initiate all nine steps every time.
ODonnell, Condell, Begley, and Fitzgerald (2005) investigated delays in ED care
of patients with AMI (N = 890). Several points of care were assessed and times
identified: door to triage, 6-7 minutes; triage to first medical assessment, 10-19 minutes;
door to first medical assessment, 20-30 minutes; first medical assessment to thrombolytic
medication administration, 31-45 minutes; and DTB, 103-148 minutes. There are no
specific time frames for the first four steps identified; however, the DTB guideline is < 90
minutes. Delays of even a few minutes at the first points of care will generate an overall
delay in DTN and DTB and must be avoided. Weber, McAlpine, and Grimes (2011)
noted unsafe delays in high-acuity patients (N = 3,932) who were assigned a Level 1 or
Level 2 triage designation. Less than half completed the triage process in an appropriate
time frame of 10 minutes or less and 35% spent >20 minutes in the overall triage process,
both waiting to be triaged and during the triage process itself.
Venkat et al. (2003) investigated delay in handling a patient with a chief
complaint of chest pain when presenting to an ED. A registry of patients (N = 7,935) with
chest pain was used to generate the sample. ECG within 10 minutes of ED presentation
was successfully met in approximately 30-40% for patients with AMI and in
20
approximately 33% of patients with unstable angina or non-STEMI. In a study of 63,478
patients (Diercks, Peacock, et al., 2006) found ECG delay in 65.2% of the sample with a
median delay of 25 minutes. Pearlman, Tanabe, Mycyk, Zull, and Stone (2008)
conducted a study of patients presenting to an ED with a chief complaint of chest pain (N
= 214). Median ECG time was noted to be 29 minutes (intra-quartile range 17-52
minutes). In a secondary analysis of 425 patients (Zegre-Hemsey, Sommargren, & Drew,
2011), researchers reported that only 41% of patients with ischemic symptoms received
an ECG within 10 minutes.
Delays other than the ECG window are important to investigate as the factors
influencing each point of care may differ. These points of time are minutes waiting to be
seen by the triage RN, triage to first physician assessment, and time to aspirin
administration. Few researchers have conducted studies in these areas. Only ODonnell,
et al. (2005) investigated some of these specific times in delay of ED care in the triage of
patents with AMI. In this study, at several points of care, gender-based delays were
identified; however, triage levels were not identified nor were possible inaccuracies
leading to these delays addressed. Atzema et al. (2009) did specifically investigate the
association between inaccuracy and delay at two specific time points in a secondary
analysis. The odds of achieving the goal of less than 10 minutes to ECG and less than 90
minutes to PCI were 0.54 and 0.44, respectively, and were independently associated with
an inaccurate triage level assignment. These odds are troubling in the care of patients
with AMI and require further research into the contributing factors.
Wilper et al. (2008) conducted a secondary analysis of NHAMCS data, which
included 92,173 adult visits to EDs from 1997-2004. Mean wait time to see a physician
21
was 27 minutes for patients with AMI and 23 minutes for overall Level 2 patients. In a
study investigating wait times to see a physician in over 151,000 patients (Horwitz &
Bradley, 2009), the median wait time to see a physician for Level 1 and Level 2 patients
combined was 15 minutes. Only 48% of patients in this combined emergent category
were seen in the appropriate amount of time.
Patient Characteristics
Patients with symptoms suggestive of AMI are experiencing delays in treatment
in EDs (ODonnell et al., 2005). Factors including gender, age, race/ethnicity,
socioeconomic status (SES), and other factors have been reported in the literature. In a
study by Diercks, Peacock, et al. (2006), the sole predictor of delay in obtaining an ECG
in the ED in patients with non-ST-elevation ACS was female gender. African American
patients of both genders and Caucasian women experience greater delays in ECG
obtainment (Blomkalns et al., 2005; Diercks, Kirk, et al., 2006; ODonnell et al., 2005;
Pearlman et al., 2008; Takakuwa, Shofer, & Hollander, 2006; Zegre-Hemsey et al.,
2011), aspirin administration (Blomkalns et al., 2005; Enriquez, Pratap, Zbilut, Calvin, &
Volgman, 2008; ODonnell et al., 2005), initiation of PCI (Kaul, Chang, Westerhout,
Graham, & Armstrong, 2007; ODonnell et al., 2005; Roger et al., 2000), thrombolytic
therapy (Blomkalns et al., 2005; Roger et al., 2000), hospital admission (ArslanianEngoran, 2001; Kaul et al., 2007; ODonnell et al., 2005; Pope et al., 2000), and
administration of beta blockers and statin drugs (Blomkalns et al., 2005; Enriquez et al.,
2008). The possibility that RNs include patient characteristics during the assignment of
triage level designations was not examined in these studies for a possible relationship to
accuracy and delay.
22
Investigation of accuracy and delay related specifically to ED RN triage level
designations based on patient characteristics are minimal, with only two studies
addressing these issues. In the first regarding delay in the ED, ODonnell et al. (2005)
reported a significant difference in length of time spent by the RN in triage based on
patient gender with ED RN triage taking twice as long for women. In the second,
Arslanian-Engoran (2001) investigated accuracy using written vignettes and found a
significant difference based on gender and age. The 43 year old female patient vignette
was less likely to be given an urgent triage level designation compared to the 43 year old
male patient vignette or the 66 year old patient vignette of either gender despite evidence
of the same symptoms suggestive of AMI.
Studies were identified that investigated age as a possible factor in ED RN triage
accuracy and delay. Arslanian-Engoren (2000) conducted focus group sessions with ED
RNs and found that RNs held different perceptions based on the age of the patient. Age
biases were identified ranging from considering the patient over 70 years old to be more
believable to being more skeptical of symptoms in a younger patient. RNs in these focus
groups admittedly did not consider AMI as a first diagnosis in middle-aged women
despite presenting symptoms. In a study attempting to identify predictive factors
influencing triage level designation during RN-patient triage interactions (N = 334),
Garbez, Carrieri-Kohlman, Stotts, Chan, and Neighbor (2011) found age of the patient
was a significant factor (p = 0.013) influencing triage level designations. Participants (N
= 18) in that study completed a survey immediately after each triage selecting factors
used in the triage decision. No data is given as to which age group influenced the nurses
decisions in triage level designations. Platts-Mills et al. (2010) identified triage
23
inaccuracies in a study of triage accuracy in the elderly population, defined as the > 65
age group, with only 57.7% of those needing immediate lifesaving measures being
assigned a Level 1. Platts-Mills et al. cited high rates of comorbidities and triage by
proxy, i.e., obtaining information from a family member instead of the patient, as reasons
for possible incorrect triages of the elderly.
Pope et al. (2000) found patients were less likely to be hospitalized if they were
less than 55 years old and nonwhite. In fact, the risk of being sent home despite an AMI
was 4 times higher for nonwhite patients. Pearlman et al. (2008) investigated gender, age,
and race/ethnicity in door-to-ECG times for patients with chest pain and found a median
delay of 29 minutes overall. No significant difference was found in gender and
race/ethnicity, but door-to-ECG time was significantly greater (p = .002) for patients in
age categories of 18-39 and 40-59. This might be expected in the younger age group but
not in the 40-59 age category, as the incidence of AMI is greater in this age group.
In a recent study of cardiac triage decision-making (Arslanian-Engoren, 2009),
RNs were found to hold cultural biases and stereotypes. Specific cues utilized in triage
decision-making included past medical history, patient demographics, attitudes,
perceptions, cultural beliefs, and the specific complaint of chest pain. Using focus group
methodology, the researcher reported that statements elicited from RNs (N = 12) reflected
a lack of believing the patient and doubting what the patient told the triage RN. Also
reported was the notion that females who took time to apply makeup prior to the ED visit
caused the RN not to consider the symptoms as being serious in nature. This suggests that
the RN does not trust the female patient to be truthful in reporting symptoms or that the
symptoms were not sufficiently severe to initiate an immediate patient response.
24
RN Education, Experience, and Triage
Studies investigating the RN role in patient care outcomes identify RN education
level and years of experience as two main variables of interest. Benner and Tanner (1987)
hypothesized that the novice RN is hesitant and slow in assessment of patients in their
care, and the experienced RN is rapid and fluid in problem solving in patient situations.
Although Benners work (Benner, 1984) emphasized stages of knowledge from novice to
expert, it is unclear whether these stages influence ED triage accuracy.
In a study of RN staffing models in Canada, researchers found that the less
experienced the RN, the higher the number of wound infections (McGillis-Hall, Doran, &
Pink, 2004). In examining structures and processes of patient care for 46,993 patients in
Canada, Tourangeau et al. (2007) found a higher percentage of bachelor of science in
nursing (BSN) staff associated with lower 30-day mortality rates. The correlations
between increased RN education and decreased mortality rates were also noted in an
analysis of Canadian hospital outcome data for 18,142 patients (Estabrooks, Midodzi,
Cummings, Ricker, & Giovannetti, 2005). Aiken, Clarke, Cheung, Sloane, and Silber
(2003) investigated the association between RN educational preparation and patient
outcomes in a study of 168 U.S. hospitals. Data indicated that as the percentage of nurses
with BSN degrees increased, patient mortality decreased; however, years of experience in
nursing was not found to be associated with decreased mortality.
In a study of ED RN triage decisions, Arslanian-Engoran (2004) found no
association between years of experience and triage accuracy. Registered Nurses in the
study were said to be at the expert level with a mean 12 years of experience. As this was
a small convenience sample (N = 13), the results must be interpreted with caution.
25
Studies testing experience level and the possible association to accuracy with a larger
participant sample are warranted.
In a national survey of 69 EDs in Sweden, Goransson, Ehrenberg, and Ehnfors
(2005) found that qualifications to perform in the triage role varied greatly from basic
nursing training to special education sessions about triage. In fact, 87.5% of the EDs
surveyed had no special requirement or training when assigning RNs in the triage role for
the shift. These researchers reported that only 3 (4.3%) of the 69 EDs in their study
reported criteria limiting new graduate RNs from being in the triage role. Once the degree
of training was surveyed, the authors attempted to identify a relationship between
accuracy of ED triage and RN characteristics of education, age, and experience.
Goransson, Ehrenberg, Marklund, and Ehnfors (2006) noted an accuracy rate of 57.6%,
with a range of 22-89% accuracy per RN (N = 423) responding to written vignettes using
CTAS. The researchers were unable to identify a relationship between RN age, triage
education, years of experience in general nursing or emergency nursing, and accuracy of
ED triage. A limitation of the study was that CTAS was not part of the daily practice of
the RNs in this Swedish study.
Worster et al. (2004) found experience was not related to consistency in triage
level designations in a study of 10 Canadian RNs who scored 400 scenarios, half using
the ESI scale and half using the CTAS scale. The ESI group had more years of
experience (M = 25.2 v. 14.4) but triaged with the same degree of consistency as the
CTAS group (kappa = .91 and .89 respectively). A limitation of this study was that none
of the RNs were experienced in using the ESI 5-level triage system, as it was not part of
26
their daily practice. Actual accuracy of triage level designation decisions was not
identified, only consistency.
Considine et al. (2000) hypothesized that if a triage scale is valid, a patient should
be triaged to the same level designation regardless of which RN is assigning the triage
level. The researchers found a 58% accuracy rate among 31 RNs in two Australian EDs
using the National Triage Scale. Despite 35.5% of the participants being either an ED
CNS or ED manager, no correlation was identified between accuracy and years of
experience. Educational preparation was also assessed in a secondary analysis
(Considine, Ung, & Thomas, 2001) and the researchers noted a positive correlation
between BSN-degreed RNs and accuracy; however, no significant relationship was found
between accuracy and ED training or critical care training. The sample size was small (N
= 31). Correlations between educational preparation and triage accuracy need to be tested
in larger samples of participants.
Symptom Presentation
The AHA and the National Heart, Lung, and Blood Institute (NHLBI) provide a
description of a classic AMI as central chest discomfort that may be described as
pressure, fullness, squeezing, or pain with radiation to the arms, neck, jaw, back, and
abdomen. These symptoms may be accompanied by shortness of breath, nausea,
lightheadedness, and sweating (AHA, 2010; NHLBI, 2010). The ED triage decision is
made more difficult because patients present with varying symptoms, some considered to
be typical of AMI and some atypical. The patient that presents with a classic set of signs
and symptoms suggestive of a heart attack (i.e., clutching the chest, short of breath, pale,
and diaphoretic), will undoubtedly get the attention of the ED triage RN. This immediate
27
recognition of an AMI will generally result in an accurate triage level assignment and a
rapid ECG, a cardiac monitor, and evaluation by an emergency physician. As previously
noted, not all patients present with easily recognizable symptoms and are seen so rapidly.
Previous studies have found the incidence of a classic set of symptoms during an AMI to
be as low as 67% (Canto et al., 2000; Gupta, Tabas, & Kohn, 2002; Horne, James, Petrie,
Weinman & Vincent, 2000). It is concerning that patients without classic symptoms may
be inaccurately triaged.
A recent study of symptoms of AMI found shortness of breath, weakness, and
fatigue as the most frequently occurring acute symptoms in women (McSweeney et al.,
2010). Also identified were racial differences, with 15 symptoms differing significantly
(p = .001) by race/ethnicity after adjustment for cardiovascular risk factors. The
symptoms were unusual fatigue, dizzy or faint, flushed, indigestion, heart racing,
numbness in hands, vomiting, loss of appetite, new vision problems, headache, coughing,
choking sensation, and pain in 10 specific sites. African American women reported more
flushing and indigestion. Hispanic women had the highest rates of pain in all body
locations.
Studies identifying gender-specific symptoms in ACS are noted in the literature
(DeVon, Ryan, Ochs, & Shapiro, 2008; McSweeney, Cody, & Crane, 2001; McSweeney,
et al. 2003). Further studies included (a) differences in the symptoms between unstable
angina (UA) and AMI (DeVon, & Zerwic, 2004), (b) symptom differences in patients
with and without diabetes in UA and ACS (DeVon, Penckofer & Larimer, 2008; DeVon,
Penckofer, & Zerwic, 2005), and (c) symptom clusters in AMI (Ryan et al., 2007).
DeVon and Zerwic (2003) found females with UA to have significantly higher rates of
28
reported weakness, nausea, shortness of breath, anorexia, and upper back pain. Patients
with UA and diabetes were noted to have less nausea, less squeezing, and less aching
pain (DeVon et al., 2005). Older diabetics reported less pain and more fatigue (DeVon,
Penckofer, et al., 2008).
Atypical (or less typical) symptoms may impact triage decisions (Albarran,
Clarke, & Crawford, 2007; Arslanian-Engoran et al., 2006; Carmin, Ownby, Wiegartz, &
Kondos, 2008; Dorsch et al., 2001) highlighting the complexity of patient assessment and
the variations in individuals. Symptoms are frequently attributed to another less serious
cause such as the presence of neck and back pain as reported by women in a study by
McSweeney et al. (2001). In studies about unstable angina and acute myocardial
infarction, DeVon and Zerwic (2003, 2004) identified symptoms of ACS which were
used in this study: chest pressure, chest discomfort, chest pain, shoulder pain, arm pain,
upper back pain, lightheadedness, shortness of breath, sweating, unusual fatigue, nausea,
palpitations, and indigestion. Patients frequently present with symptoms that are not
classic, potentially making triage level designations more complex and prone to
inaccuracies.
Summary
Disparities in emergency cardiac care and diagnostic treatments related to gender,
age, and race/ethnicity exist but have not been investigated thoroughly in relation to ED
RN triage level designations. Studies identify limited accuracy in triage level
designations and the inability of the ED triage RN to consistently identify the patient with
symptoms of possible AMI. Studies thus far have not examined the relationships between
delay in care and accuracy of triage decisions, coupled with patient characteristics.
29
Further studies investigating RN education, experience, and accuracy of triage level
designations are needed. Numerous studies exist that examine differences in rapid cardiac
care from time to ECG to the administration of aspirin to cardiac interventional
procedures. However, few studies were identified that included inaccurate RN triage
level designations as a contributor to delay. The rapid, accurate triage of patients with
symptoms suggestive of AMI remains a challenge in emergency care. There is a need to
investigate delay and inaccuracy of triage decisions to decrease patient wait time for
urgent symptoms, improve morbidity and mortality of patients with AMI, and possibly
lead to changes in ED triage RN educational preparation and training.
CHAPTER III
METHODOLOGY
This chapter introduces the research design and methodology. The study setting
and sample are described. Measures, instruments, and variables are identified. Procedures
used to collect data and methods used to protect human subjects are addressed.
Research Design
This study of ED RN triage was a correlational study using retrospective data
from EMRs. The relationships between (a) patient characteristics (gender, age,
race/ethnicity, symptom presentation), RN characteristics (age, years of experience, years
of ED experience, and education), and (b) delay in ECG obtainment and accuracy in
triage level designations made by ED triage RNs were examined. The dependent
variables were accuracy of triage level designations, time to triage, and time to
obtainment of ECG. The independent variables were patient characteristics (gender, age,
race/ethnicity, symptom presentation), RN characteristics (age, years of experience in
nursing, years of experience in ED nursing, and education level).
Setting
EMRs from a regional healthcare system in the southeast were used to generate
the data needed for this study. The study was conducted at a 660-bed general acute care
not-for-profit health system operating EDs at two separate geographical locations,
designated Site 1 and Site 2 for purposes of this study. At the time of this study, Site 1
30
31
employed 55 ED RNs and logged approximately 50,000 ED visits a year. Site 1 is only
blocks away from a Level 1 trauma center ED reporting a high volume of uninsured
patients. At the time of this study, Site 2 employed 37 ED RNs and logged about 32,000
ED visits a year. Site 2 advertised heavily as a heart hospital and boasted of delivering
rapid cardiac care. Combined, the two sites averaged approximately 2,200 AMI/ruled out
AMI patients per year. Protocol at the sites dictated that the charge RN at the start of the
shift assigns RNs to the triage role, with both sites generally assigning the same RN each
shift. New RN graduates are not assigned to the triage role until each has gained 1 year of
experience. Before they are assigned triage roles, new graduates receive triage training
from an ED educator as well as hands-on experience with their preceptor. Licensed
practical nurses (LPNs) were not employed in either ED. Paramedics, who were
employed in one of the two EDs, did not perform in the triage role. Both facilities had a
line of patients waiting to be triaged at most times of the day and night.
Sample
Inclusion criteria for the selected medical records included (a) patients with
symptoms suggestive of AMI and (b) patients ages 21 years of age and older. Exclusion
criteria include (a) patients who were in critical condition, required immediate intubation,
or had a severely altered level of consciousness; (b) patient records indicating triage by
an RN orienting in the role; (c) patients arriving via ambulance; and (d) patients with a
documented traumatic event.
Some patients were excluded from this study. Patients in critical condition,
requiring immediate intubation, or those with a severely altered level of consciousness
require immediate assistance and triage is deferred. Patients triaged by a RN orienting
32
with another RN is not the standard triage situation. Having two RNs triaging a patient
may change the outcome. Patients who arrive via ambulance are triaged immediately and
may be assigned an urgent level during the triage assessment solely based on mode of
arrival. Patients with a documented traumatic event also were excluded, as the source of
their symptoms is typically thought to be traumatic in nature rather than cardiac.
Based on calculations for determining sample size suggested by Field (2005),
with nine predictor variables, a minimum sample size of 113 was necessary to test
individual predictors in this study. A medium effect size was chosen for this study based
on the earlier described literature review of studies investigating accuracy in triage and
delay in ED care. Online power analysis calculation (Soper, 2004) using a maximum of
nine predictor variables, a medium effect size, and an alpha of < 0.05, with a power of
0.80, also confirmed a minimum sample size of 113 patient triages were needed for the
study. Retrospective data were collected going back approximately 4 months prior to the
month of data collection. No ED documentation system updates occurred during that time
period.
Measures and Instruments
Abstraction of data from the EMR was chosen as the method to capture data
pertaining to time points of care in ED triage and care of patients with symptoms
suggestive of AMI as well as patient demographics. A convenience sample of patient
EMRs was used to obtain variables related to ED triage taken from a general acute care
health system operating two separate EDs. To pull EMRs, the director of health
information systems provided a query with the following criteria: (a) the date of the ED
patient visit was in the 4-month time period prior to data collection and (b) the presenting
33
complaint was chest pain or discomfort, shortness of breath, weakness, nausea, vomiting,
syncope, palpitations, or diaphoresis.
Variables of Interest
Variables of interest (patients chief complaint, final diagnosis, triage level
assigned, patient gender, patient age, patient race/ethnicity, triage RNs name, and clock
times at specific points of care) were obtained from data abstracted from the EMR (see
Table 2). Information regarding RN characteristics was obtained via the RN
demographics tool (RNDT; see Appendix A), which was completed by participating
RNs. The triage level designation decision was the main unit of measure, not the specific
ED triage RN, so that each triage level designation stood alone. Triage level designations
from EMRs were investigated in this study.
Accuracy
Accuracy was determined based on whether or not a patient with symptoms
suggestive of AMI was assigned a Level 2 triage designation. Delay was identified as
actual clock time in minutes from arrival until triage and ECG obtainment with delay
designated as greater than 10 minutes. The clock time was the time recorded by various
personnel in the EMR. Other possible delay points such as minutes to physician
assessment also were collected. Also collected during the EMR review was day of the
week, time of day, and shift.
Symptoms Suggestive of AMI
Symptoms suggestive of AMI, for purposes of this study, were defined as those
symptoms as defined by Hollander et al. (2004) which included chest discomfort or pain,
shortness of breath, weakness, nausea or vomiting, syncope, palpitations, and diaphoresis.
34
Table 2
Data List
Datum
Measure
Type of measure
Patient
Day of visit to ED
Monday, Tuesday, Wednesday, Thursday,

Friday, Saturday, Sunday
Nominal
Chief complaint
As defined by Hollander et al. (2004)
Nominal
Co-morbidities
Diabetes, heart disease, obesity, smoking
Nominal
Triage level designation
1, 2, 3, 4, 5
Ordinal
Gender
Male, Female
Nominal
Age
Continuous ages
Interval
Race/ethnicity
1-7
Nominal
Marital status
Single, Married, Widowed, Divorced
Nominal
Payor source
1-5
Nominal
Time of arrival
Clock time as entered in EMR at first point of

contact
Interval
Time of triage
Clock time as entered in EMR
Interval
Busyness of unit
Minutes from arrival time to triage time
Interval
Time of MD assessment
Clock time as entered in EMR
Interval
Time of ECG
Clock time as entered in EMR and ECG
Interval
Name
First and last name
Nominal
Gender
Male, Female
Nominal
Age
Continuous ages
Interval
Race/ethnicity
1-5
Nominal
Education
Diploma, ADN, BSN, MSN
Categorical
Years of experience
Actual years
Interval
Years of ED experience
Actual years
Interval
Registered Nurse
Note. ED = emergency department; MR = electronic medical record; MD = medical

doctor (physician); ECG = electrocardiogram; AND = associate in nursing degree; BSN
= bachelor of science in nursing; MSN = master of science in nursing.
35
EMRs indicating a patient presentation of any of these symptoms, in the absence of
trauma, were considered for this study. It was expected that the patients chief complaint
might be one or more of these symptoms. It was also expected that the vague symptoms
of nausea and vomiting might be, in fact, a gastrointestinal complaint and possibly not a
cardiac event.
Triage Level Designation
The triage level designation was the level assigned by the ED triage RN during
the triage process. Triage levels were coded as Level 1, critical; Level 2, emergent; Level
3, urgent but stable; Level 4, nonurgent; and Level 5, minor (Gilboy et al., 2005). The
triage level designation determines which patient is seen next and whether immediate
treatment will be initiated or if the patient will be asked to wait in the waiting room.
Patients presenting with symptoms suggestive of AMI must have been given a triage
Level 2 designation. If this did not occur, the triage level designation was coded as
inaccurate for the purposes of this study. This dependent variable was dichotomously
coded as yes (accurate) or no (not accurate). Because the ED triage RN is unable to
determine for certain, at the point of first contact and without an ECG, whether a triaged
patient truly has a cardiac diagnosis such as AMI, the end diagnosis was not considered
as a variable in this study. Only presenting symptoms were considered.
Patient Characteristics
Gender was recorded as male or female, and age of the patient was recorded in
years. Race/ethnicity was recorded in one of the following seven categories as designated
by Health Information Systems of the participating site: Caucasian, African American,
American Indian/Alaskan Native, Asian, Hispanic or Latino, multiracial, or unknown.
36
Other demographic information collected during the EMR review included payer source
and marital status. Co-morbidities such as diabetes, obesity, smoking status, and previous
heart disease also were collected.
RN Characteristics
The registered nurse demographics tool (RNDT; Appendix A) created by the
researcher was used to collect RN characteristics: gender, age, race/ethnicity, years of
experience in nursing, years of experience in ED nursing, and education level (assessed
as the highest degree in nursing obtained at the time of participation in the study). The
RNDT included a tear away portion to separate the RN demographic information from
the participants name, providing a sense of privacy and confidentiality.
Delay
Time points of care included time of arrival to the ED, time to triage, time to
ECG, and time to physician assessment. All times were recorded in minutes using
military time notation. The time of arrival in the ED was documented automatically when
the patients name was entered into the computer system at the walk up desk in the ED
lobby. Time to ECG was calculated by subtracting the time of arrival from the time
electronically stamped on the ECG itself. If the electronically stamped ECG time was
different from the time charted in the EMR by the ED staff, the ECG stamp was the
accepted time for this study. Time to physician assessment was obtained from the
physicians handwritten first notation documented during that first patient interaction. If
the physician did not note the time of assessment, then the time documented in the
computer was used.
Data Collection
37
Once institutional review board (IRB) approval was received from both the
healthcare system and Georgia State University, the director of health information
management provided a list of patient records to review for possible study inclusion. An
electronic data file was created to hold all data abstracted from the EMR. A working copy
was made of the database. No identifying information was recorded in this working file.
Data abstracted from the EMR included patient gender, age, race/ethnicity, mode of
arrival, and reason for ED visit as well as times associated with arrival to the ED, triage
by the RN, ECG performed, and physician evaluation. Triage level designation assigned
as well as the name of the triage RN were collected during the EMR review. RN
demographics were linked to the initial data file. Once the list of RN names was
available, consent was obtained from participating RNs. A flyer was posted in both EDs,
and a locked box was placed in the area as a receptacle for the completed surveys and
informed consent documents. The study topic, research aims, and risks and benefits of the
study also were discussed at several staff meetings. Each consenting RN completed the
RNDT, which took approximately 2 minutes per RN.
The researcher was given a separate cubicle in the medical records department as
a private place to access the computer system for the purposes of collecting variables for
this study. Between May 2011 and June 2011, 559 records were reviewed. Dates of ED
visit were from January 1, 2011 thru May 7, 2011. Records indicating that the patient
arrived by ambulance were excluded, which removed 175 records. An additional 98
records were excluded due to the chief complaint being other than cardiac in nature, such
as syncope related to seizure, asthma exacerbation, and chest pain due to trauma. The
remaining 286 records were included in this study, and data were recorded on the RNDT
38
for analysis. The triage level designation decision was the main unit of measure (i.e., not
the specific ED triage RN) so that each triage level designation stood alone. Triage level
designations from 286 EMRs were investigated in this study representing 40 triage RNs.
An even distribution of triage level designations among the RNs was not the goal of this
study.
Data Analysis
After collecting data for this study, the researcher conducted various analyses. In
order to describe the variables, the researcher first conducted descriptive statistics on both
the patients and the nurses. Frequencies and percentages were calculated for the patient
characteristics gender, race/ethnicity, marital status, and medical history (smoker, body
mass index [BMI], diabetes, previous cardiac disease, chest pain triage). Means, standard
deviations, and ranges were calculated for the RN characteristics age, years of
experience, and years of ED experience. The researcher then conducted inferential
statistics. These analyses included Pearsons correlations and logistic regression.
Protection of Human Subjects
Selected data were coded and entered into an electronic data file. Patient and RN
identifiers were kept confidential. Information was kept private to the extent allowed by
law. There was no compensation for RNs participating in this study. All RN and patient
identifier information were removed from the data, and unique case numbers were
assigned to data so that no actual patient or RN names were on study records. The data
were stored in a locked file cabinet in the office of the researcher and on a computer with
password and firewall protection. Only the researcher had access to the uncoded data.
The confidentiality of patients, clinicians, and institutions was maintained.
39
Summary
AMI. Specifically, the aims of this study were to determine the predictive nature of (a)
patient and RN characteristics on the accuracy of ED RN triage level designations of
patients with symptoms suggestive of AMI, and (b) patient and RN characteristics, and
accuracy of ED RN triage level designations on delay of care of patients with symptoms
suggestive of AMI. Exploration of this relationship was conducted via retrospective EMR
review and data abstraction from one hospital system in the Southeastern US operating
two EDs. RN demographic information was collected via survey, the RNDT, after
obtaining written consent and confidentiality was maintained.
CHAPTER IV
RESULTS
AMI. Specifically, the aims of this study were
1. to determine if patient characteristics (gender, age, race/ethnicity) and RN
characteristics (age, years of experience, years of ED experience, and education)
predict accuracy of ED RN triage level designation of patients with symptoms
suggestive of AMI, and
2. to determine if patient characteristics (gender, age, race/ethnicity, symptom
presentation), RN characteristics (age, years of experience, years of ED experience, and
education), and triage level designation predict delay of care of patients with symptoms
suggestive of AMI.
Data were obtained from the EMRs of a health system in a Southeast region of the
US. In this chapter, preliminary screening procedures and results are described.
Following that, a description of the sample and the variables used in the study are
presented. In the last section, results are elucidated.
40
41
Preliminary Screening Procedures
Descriptive statistics, frequencies for the categorical variables, and descriptives
for the continuous variables were calculated to determine (a) whether there were
missingvalues and (b) the distribution of the data. A 2-tailed p value of .05 was
considered significant in all analyses. Predictive Analytics Software (PAWS; Version
18.0) software package for statistical analysis was used for all analyses. There were 92
RNs listed as staff members in the two EDs at the time of the study. However, only 66 of
the RNs in the two EDs were identified in EMRs selected for inclusion in the study. Of
those, 40 RNs consented to participate, giving an overall response rate of 60.6%. The
final sample of 40 RNs consisted of 28 females (70%) and 12 males (30%). The triage
level designation decision was the main unit of measure (i.e., not the specific ED triage
RN), so that each triage level designation stood alone. Triage level designations from 286
EMRs were investigated in this study representing 40 triage RNs. An even distribution of
triage level designations among the RNs was not the goal of this study. Of the nurses who
agreed to participate (N = 40), the range of triages conducted was 1 to 22, with five RNs
in the study triaging 10 or more patients (range 10-22). For a portion of Aim 1,
considering nurse demographics, the total sample was 192 EMRs; for the remainder,
considering accuracy and delay and patient demographics, the total sample of EMRs was
286 (see Appendix B).
There were missing values for the following RN characteristics: ethnicity,
education, age, years of experience, and years of ED experience. Accordingly, Littles
Missing Completely at Random (MCAR) test was conducted to determine whether the
pattern of missing data was random or systematic. Results indicated that the pattern was
42
missing at random (2 (3) = 4.17, p = .243). In addition, cross-tabulation procedures
between cases with and without missing values and the dependent measures were all nonsignificant. Values for the continuously measured variables were thus imputed using the
expectation-maximization method (Tabachnick & Fidell, 2007).
The distributions of the variables measured on either an interval or ratio scale
were assessed for normality by inspecting histograms and skew indices, i.e., skewness
statistic/SE. When the distribution of the variable resembles a normal curve (Tabachnick
& Fidell, 2007) and its skew index is below three (Kline, 2005), then the distribution is
deemed to be normal. As seen in Table 3 and in Figures 3 and 4, the distribution of the
minutes to triage was highly skewed as was years of ED experience (see Table 3, Figures
5 and 6). Accordingly, these two variables were transformed using the natural log
function (Tabachnick & Fidell, 2007). After the variables were transformed, the skew
indices fell below three (see Table 3). The transformed variables were used in subsequent
inferential analysis although descriptive statistics are reported in their original metric to
facilitate interpretation.
All continuously measured variables were standardized. Cases whose
standardized values fell above the absolute value of 3.29 were identified as outliers
(Tabachnick & Fidell, 2007). Three cases had extremely low standardized values for RN
experience in the ED (z-score for each case was -3.40) and thus were deleted from the
data set.
43
Table 3
Skewness and Kurtosis Statistics
Variable
Skew
Kurtosis
Skew indices
Patient
Age
.20
-.32
Minutes to triage
3.41
16.22
Minutes to triage (transformed)
.198
23.68
1.375
Registered nurse
Age
.04
.34
Years of experience
-.03
-1.49
1.28
.48
Years of ED experience (transformed)
-.348
8.89
2.42
Note. N = 286. SE for kurtosis = .29; SE for skew indices = .144; ED = emergency
department.
Figure 3. Histogram for minutes to triage.
44
Figure 4. Histogram for minutes to triage (transformed).
Figure 5. Registered nurse years of experience in emergency department.
45
Figure 6. Registered nurse years of experience in emergency department (transformed).
Descriptive Statistics
Description of the Sample of Patients
Patients (N = 283) were between 26 and 95 years old; the mean age was 61.44
(SD + 13.02). The frequencies and percentages of the variables describing the sample of
patients are displayed in Table 4. Slightly more than half of the patients were female
(51.9%). The majority of patients were Caucasian (67.1%); a minority were African
American (31.1%) or other ethnicity (0.8%). Most were married (59.4%), with the
remaining being single (11%), divorced (14.5%), or widowed (14.1%).
46
Table 4
Patient Demographics
Variable
Frequency
Percentage
Gender
Male
136
48.1
Female
147
51.9
Caucasian
190
67.1
African American
88
31.1
Hispanic or Latino
.4
Multiracial
.4
Missing
1.1
Single
31
11.0
Married
168
59.4
Divorced
41
14.5
Widowed
40
14.1
Missing
1.1
Race/ethnicity
Marital Status
Note. N = 283.
Clinical characteristics of the sample are presented in Table 5. Most of the

patients were non-smokers (74.6%). Just less than half of the patients had a BMI over 29
(48.1%). One third (30.4%) of the patients had diabetes, and 43.1% reported a history of
cardiac disease. A majority of the patients (88.7%) reported experiencing chest pain in
addition to their other symptoms at triage, which was unexpected.
47
Table 5
Patient Medical History
Variable
Frequency
Percentage
No
211
74.6
Yes
72
25.4
No
129
45.6
Yes
136
48.1
Missing
18
6.3
No
197
69.6
Yes
86
30.4
No
161
56.9
Yes
122
43.1
No
32
11.3
Yes
251
88.7
Smoker
Body mass index > 29
Diabetes
Previous cardiac disease
Chest pain triage
Note. N = 283.
Description of the Sample of RNs

The descriptive statistics without the imputed values for the demographic
variables measured are displayed in Table 6. Age of RNs (N = 194) ranged from 26 to 64
years with a mean age of 45.46 (SD + 11.72). Years of nursing experience ranged from 3
to 35 years (M = 17.96; SD + 10.43). Similarly, years of ED nursing experience ranged
from 3 to 35 years (M = 10.98; SD + 8.51). As previously discussed, RN demographic
data were determined to be MCAR and therefore did not affect the results of this study.
48
Table 6
Characteristics of Registered Nurses
Variable
Range
SD
Age
194
26-64
45.46
11.72
Years of experience
193
335
17.96
10.43
194
3-35
10.98
8.51
The frequencies and percentages of the variables describing the sample of RNs
are displayed in Table 7. The majority of the RNs were female (70.3%), and all of those
whose ethnicity were reported were Caucasian. A majority had an ADN (45.6%), while
the remainder had a BSN (19.1%) or were diploma RNs (3.5%). No nurses participating
in the study had an advanced practice nursing education.
Table 7
Electronic Medical Record Matched Registered Nurse Demographics
Variable
Frequency
Percentage
Gender
Male
84
29.7
Female
199
70.3
Caucasian
204
72.1
Missing
79
27.9
Diploma
10
3.5
Associate degree
129
45.6
Bachelor degree
54
19.1
Missing
90
31.8
Race/ethnicity
Level of education
49
Statistical Analysis
Predictors of Accuracy of Triage Level Designation
All patients should have been coded as a triage Level 2 (or Level 1 if truly in need
of immediate resuscitation). If they were coded a Level 3, the triage was considered
inaccurate. The overall accuracy rate was 54%. Aim 1 was to determine if patient
characteristics (gender, age, and race/ethnicity, and symptom presentation) and RN
characteristics (age, years of experience, years of ED experience, and education) predict
accuracy of ED RN triage level designation of patients with symptoms suggestive of
AMI. Two logistic regression procedures were conducted. RN level of education data
was missing in 90 cases; therefore, only 196 cases were included in the regression model.
Accordingly, two logistic regression procedures were conducted, one with level of
education and one without level of education.
Because level of education did not significantly predict accuracy of triage level
designation, only the findings of the second logistic regression procedure (that does not
include the education variable) are presented in Table 8. Patients race/ethnicity and
symptom presentation and RNs age significantly predicted accuracy of triage level
designation. Non-Caucasians were more likely to receive an accurate triage level
designation than Caucasians (OR = 2.07, p = .010). Patients who experienced chest pain
were more likely to receive an accurate triage level designation than patients who did not
experience chest pain (OR = 2.55, p = .022). The older the RN, the greater the likelihood
that the triage level designation was accurate ( = .07, p = .037).
50
Table 8
Accuracy of Triage Level Designation Model
Variable
SE
Wald
OR
-.37
.26
2.07
.69
Caucasian vs. non-Caucasian patient
.73
.28
6.58
2.07
No chest pain vs. chest pain
.94
.41
5.24
2.55
.07
.03
4.34
1.07
Years of experience
-.03
.03
.53
.98
-.05
.27
.04
.95
Patient
Gender
Registered Nurse
Age
Note. N = 283. OR = odds ratio. Overall model 2 (7) = 25.44, * p = .001.
Predictors of Delay of ECG

A majority of patients (82.6%) did not receive an ECG within the ACC/AHA
guidelines of 10 minutes. Three logistic regression procedures were conducted to address
Aim 2. Aim 2 was to determine if patient characteristics (gender, age, race/ethnicity, and
symptom presentation), RN characteristics (years of experience, years of ED experience,
and education), and triage level designation predict delay of ECG for patients with
symptoms suggestive of AMI. RNs level of education data were missing in 90 cases.
Only 196 cases were included in the regression model. Thus, a regression procedure with
RNs level of education was conducted and a second procedure was conducted without
the level of education variable. Because the second logistic regression procedure did not
converge, a third procedure was conducted. Because the coefficient and standard error of
51
the main symptom presentation variable (i.e., chest pain or discomfort) were very high
and unlikely, this variable was not included in the third procedure.
Given that level of education did not significantly predict delay of ECG, only the
findings of the third logistic regression procedure are presented in Table 9. The findings
revealed that only the number of years spent working as a RN significantly predicted the
odds of delay of ECG. The more experienced the RN, the greater the probability that
there would be a delay in ECG ( = .10, p = .026).
Table 9
Delay of Electrocardiogram Model
Variable
SE
Wald
OR
-.02
.01
1.65
.98
Gender
.35
.33
1.11
1.42
.75
.40
3.58
2.12
-.05
.04
1.59
.95
.10
.04
4.98
1.10
-.26
.39
.45
.77
Patient
Age
Registered Nurse
Age
Years of experience
Note. N = 283. OR = odds ratio. Overall model 2 (6) = 13.32, *p = .038.
Because chest pain was not included in the final logistic regression model, a
logistic regression procedure with only the chest pain variable was conducted. This
procedure still yielded very unlikely parameters. Thus, a chi-square procedure was
52
conducted to determine whether there would be a significant relationship between
symptom presentation and delay of ECG. The chi-square procedure revealed that there
was a significant relationship between symptom presentation and delay of ECG, 2 (1) =
7.56, p = .006. The difference between delay and no delay for those patients who did not
experience chest pain was significantly higher than the difference for those patients who
experienced chest pain. Accordingly, the probability that there would be a delay in ECG
was higher for those patients who did not experience chest pain than for those who
experienced chest pain.
Predictors of Amount of Delay of Care
Delay of care was defined as the number of minutes a patient waited to be triaged
and the number of minutes a patient waited to have an ECG performed. Those time points
are identified in Table 10. The mean time to triage was 11.78 minutes, with women
waiting a mean of 14.01 minutes and non-Caucasian patients waiting a mean of 12.73
minutes. At a mean of 46.32 minutes, the minutes to ECG time was significantly outside
of the recommended 10 minutes for the patient group in this study.
Table 10
Minutes of Delay in Care
Variable
Minutes to triage
Range
11.78
0-116
Male
9.36
Female
14.01
Caucasian
11.31
Non-Caucasian
12.73
Minutes to electrocardiogram
46.32
1-326
SD
+
14.9
50.7
53
To determine if patient characteristics, RN characteristics, and triage level
designation would predict the amount of delay of care, three linear regression procedures
were conducted. Because RNs level of education could not be imputed, only 196 cases
were included in the regression model. Accordingly, one regression procedure was
conducted with the level of education variable. Another procedure was conducted without
the level of education variable. Bivariate associations among variables were evaluated
using Pearsons product moment correlation (Table 11). Lastly, because RN age,
experience in nursing, and experience in ED nursing were highly correlated with each
other, a third procedure, with only the significant RN characteristic predictor of years of
experience, was conducted.
Table 11
Correlation of Registered Nurse Age and Experience
1. Age
2. Years of experience
3. Years of ED experience
SD
---
.904**
.585**
45.46
11.72
---
.510**
17.96
10.43
---
10.98
8.51
**p < .01
Because level of education did not significantly predict amount of delay of ECG,
only the results of the regression without level of education are presented. The findings in
Table 12 reveal that patients gender significantly predicted the amount of delay of triage,
F (1, 277) = 5.53, p = .019). In particular, female patients waited for triage longer (M =
14.01, SD + 17.39) than male patients (M = 9.36, SD + 11.23). Patients race/ethnicity also
54
significantly predicted amount of delay of triage, F (1, 277) = 4.43, p = .036). NonCaucasians waited for triage longer (M = 12.73, SD + 12.58) than Caucasian patients (M =
11.31, SD + 15.94). Lastly, RN experience in years also predicted the amount of delay of
triage, F (1, 277) = 29.90, p = .001); the more experienced the RN, the longer the delay in
triage ( = .31).
Table 12
Amount of Delay of Triage Model
Variable
SE
TOL
-.00
.00
-.02
.14
.98
Gender
.25
.11
.14
5.53*
.96
.24
.11
.12
4.43*
.93
Level 2 TLD vs. Level 3 TLD
.09
.11
.05
.75
.94
.03
.01
.31
29.90**
.97
Patient
Age
Registered nurse
Years of experience
Note. N = 283. TLD = triage level designation; TOL = Tolerance. Overall model F (5,
277) = 8.08, p = .001.
*
p < .05. ** p < .001.
Summary
EMR review revealed 286 triage level designations conducted by predominantly
white females. Of the potential participants, 40 ED RNs consented to participate in the
study, representing 194 triage decisions. The remaining 89 were MCAR and therefore did
not affect the results of the study. All RNs reporting race/ethnicity were Caucasian, and
70.3% were female. The mean age of the RN participants was 45.46 years. A minority
55
(19.1%) of the RNs held a BSN. The mean number of years experience as an RN was
17.96 years, with 10.98 years working in the ED.
Patients in the sample (N = 286) had a mean age of 61.44, and gender was evenly
distributed (48.1% male; 51.9% female). Of the sample, 67% (n = 190) was Caucasian,
and a majority (59.1%) were married. A majority of the patients did not smoke (74.6%).
About a third (30.4%) of the patients had diabetes, and 43.1% reported a history of
cardiac disease. A majority of the patients (88.7%) reported some type of chest symptom,
described by participants as pain, pressure, discomfort, heaviness, or squeezing.
Accuracy in triage level designations was significantly related to race/ethnicity of
the patient with the non-Caucasian patient twice as likely (OR 2.07) to be triaged
accurately. The patient with chest pain was 2.5 times as likely (OR 2.55) to be accurately
triaged than the patient with no chest pain. Age and gender were not found to be
significant predictors of accuracy of triage level designation. ECG delay was significantly
greater in patients without chest pain. ECG delay was not related to the patient
characteristics of gender, age, or race/ethnicity. Triage delay was significantly related to
the patients gender and race/ethnicity with female and non-Caucasian patients waiting
longer than male and Caucasian patients. Triage delay was not significantly related to the
patients age.
RNs in the study had an overall accuracy rate of 54% in triage level designations
of patients with symptoms suggestive of AMI. Neither RN level of education nor years of
experience predicted accuracy of triage level designation; however, older RN age was
predictive of accuracy. The RN demographic of age was significantly related to accuracy
in triage level designations. However, level of education, experience in nursing, and
56
experience in ED nursing were not significant predictors of accurate triage level
designation. ECG delay times were also significantly greater when the RN had more
experience in nursing. ECG delay was not related to RN age, level of education, or years
of experience in ED nursing. Triage delay was significantly related to the RN years of
experience in nursing.
CHAPTER V
DISCUSSION AND CONCLUSION
In this study, the researcher examined patient and RN characterisitcs that may be
associated with accuracy of ED RN triage level designation and delay in care of patients
with symptoms suggestive of AMI. This chapter includes a discussion of the study results
and conclusions of the study. Implications for future research are explored.
Accuracy
Of the patient records (N = 286) included in the study, only 155 (54.1%) had an
appropriate triage level designation of Level 2 required for a patient with symptoms
suggestive of AMI. This triage level designation is crucial in determining how quickly
the patient receives an ECG and is examined by a healthcare provider. Thus, an accuracy
rate of 54% is concerning. It is possible that RNs had trouble determining if symptoms
represented ACS. Previous studies of triage accuracy have identified accuracy rates of
50% to 76 % (Arslanian-Engoren, 2004; Atzema et al., 2009; Considine et al., 2004;
Considine et al. 2000; Goransson, Ehrenberg, Marklund, et al., 2005; Holdgate et al.,
2007; Kosowsky et al., 2001; Wilper et al., 2008). In this study, variables were identified
that may be predictive of accuracy in triage level designations. Of the eight patient and
RN variables investigated, only patient race/ethnicity and symptom presentation and RN
age were identified as significant in predicting accuracy in triage.
57
58
Accuracy and Patient Characteristics
A significant relationship was found between accuracy and patient race/ethnicity
in that non-Caucasian patients in the study were more likely to be accurately triaged. This
was an unexpected finding based on the literature. Arslanian-Engoran (2004) found no
difference in accuracy in triage based on race/ethnicity. However, in a study of painrelated decision-making, Hirsh, George, and Robinson (2009) found that race/ethnicity
was a significant contributor during assessment of pain, with older African American
females perceived by RNs as having and expressing more pain. Although Hirsh et al. did
not identify accuracy of triage level designation, the visual portrayal of pain by patients
was noted as a significant decision point for the RNs (N = 54) in that study.
Although the accuracy rate was only 54%, a significant relationship was found
between accuracy and patient report of chest pain, in that the patients reporting chest pain
as one of their symptoms were more likely to be accurately triaged. It was expected that
more patients would present with atypical symptoms and not report chest pain; however
only 11.3% reported with no chest pain and other symptoms such as shortness of breath,
weakness, nausea or vomiting, syncope, palpitations, and diaphoresis. Chest pain was
identified in the initial triage documentation for 88.7% of the patients in the study. It
could be that upon questioning by the triage RN about chest pain, patients gave a positive
response hoping that they would be seen sooner or be believed as having a true
emergency. Chest pain is the hallmark symptom of cardiac ischemia; therefore, it is
surprising that these patients were not triaged correctly 46% of the time. Of the patients
triaged correctly, recognizing chest pain as a classic symptom of possible cardiac
59
ischemia most likely led to the Level 2 triage level designation for patients in this study,
resulting in increased triage accuracy for patients with chest pain.
Neither gender nor age of patient was found to be a significant predictor of
accuracy in the study. This is contrary to previous studies by Arslanian-Engoren (2000,
2001) who identified gender as a predictor of accuracy with men more likely than women
to be triaged to an accurate triage level designation despite identical symptoms generated
in a vignette. Arslanian-Engoren (2000) also identified age biases in triage decisions
when considering the AMI diagnosis. Similarly, Garbez et al. (2011) and Hirsh et al.
(2009) found increased patient age a significant factor influencing patient assignment of a
triage Level 2 designation instead of a stable to wait Level 3 designation. Although
older patients may be more likely to have CHD, it is possible that the high number of
patients presenting with chest pain increased the accuracy rate and overrode the possible
predictors of patient gender and age.
Accuracy and RN characteristics
The RN characteristic of age was found to be a significant predictor of accuracy
in triage level designation of patients with symptoms suggestive of AMI. The older the
RN, the greater the likelihood of an accurate triage level designation. This may be
explained by the high correlations between age and experience. Older RNs may have
better assessment skills, better critical thinking skills, and be able to synthesize history
and clinical presentation. It is possible that the older RN may have personal or family
experiences with cardiac related events leading to the more accurate triage level
designation for patients triaged. However, age does not necessarily equate to years of
experience in nursing as more adults enter the field of nursing as a second career.
60
During qualitative focus groups of RNs (N = 12) with a mean age of 42,
Arslanian-Engoren (2000) found that RNs tended not to think of AMI in patients who
matched their own age group using the rationale that if it could happen to the patients, it
could happen to the RNs. Nurses in that study perceived the older patient (70 to 80 years)
to be more believable and the younger patients (30 to 40 years) to be more dramatic. Age
of the nurse performing triage has not been identified as a factor in accurate triage
decisions in nursing research studies. In fact, only one study of triage accuracy identified
nurse age as a study variable. In a study of 423 ED triage RNs in 48 EDs, Goransson et
al. (2006) found no relationship between accuracy and nurse age.
Although studies identify the BSN education level as positively affecting overall
patient outcomes (Aiken et al., 2003; Considine et al., 2001; Estabrooks et al., 2005;
Tourangeau et al., 2007; Tourangeau, Giovannetti, Tu, & Wood, 2002), RN education
was not identified as a predictor of accuracy in triage level designations in this study.
Triage level designation decisions are a nursing function that could lead to poor patient
outcomes. Nearly half of the patients in this study (n = 139) were triaged by an RN with a
level of nursing education at below the BSN level (see Table 7).
Neither RN experience in ED nursing nor nursing experience in general was a
predictor of accuracy in triage of patients with symptoms suggestive of AMI. This is
consistent with findings by Arslanian-Engoren (2004) specifically addressing acute
coronary syndromes. Studies have consistently failed to identify a link between
experience in nursing and accuracy in triage level designations (Considine et al., 2000,
2001; Goransson et al., 2006; McGillis-Hall et al., 2004; Worster et al., 2004).
61
Atzema, Austin, Tu, and Schull (2010) defined RN experience as triaging a high
volume of patients and suggested that high volume EDs were better at recognizing AMI
patients and assigning the appropriate triage level designation. Quite possibly the
opposite may be true. The repetitive nature of triaging the same type patient symptoms
over and over may desensitize the nurse to the urgent need and actually result in
inaccuracy by choosing an incorrect triage level. It is possible that the years of experience
in nursing, and ED nursing especially, may color the judgment of the experienced RN
such that more obvious patient deterioration during presentation at triage is deemed
necessary for an RN to decide a true emergency exists and assign a Level 2 designation.
There may also be other factors involved in the decision to choose a Level 3 designation
instead of a Level 2 designation for a patient presenting with symptoms suggestive of
AMI.
Triage Delay
Many studies identify overall delay in the ED for patients with AMI (Diercks,
Peacock, et al., 2006; ODonnell et al., 2005; Pearlman et al., 2008; Venkat et al., 2003;
Weber et al., 2011; Zegre-Hemsey et al., 2011). However, only a few separate waiting to
be triaged as a specific portion of delay in care when investigating overall delay (Lyons,
Brown, & Wears, 2007; ODonnell et al., 2005; Weber et al., 2011). This study addressed
delay in the waiting room. Although rapid recognition is crucial to the initiation of
interventions to reperfuse cardiac muscle, patients with symptoms suggestive of AMI
waited, prior to being seen by an RN to begin the triage assessment, a mean of 11.78
minutes (range 0-116 minutes).
62
Numerous studies have identified overall ED wait times that are lengthy and fall
outside the ESI level recommendations to ensure proper care and best results. Horwitz
and Bradley (2009) found wait times to be dangerously long for patients categorized as
Level 1 and 2, with only 48% of those patients being seen by a physician within 15
minutes. Wilper et al. (2008) noted mean wait times of 27 minutes for patients with AMI.
ODonnell et al. (2005) specifically identified a time delay of 26 minutes in the triage
process. Lyons et al. (2007) also identified a delay to triage of 14 minutes regardless of
severity of chief complaint.
Triage Delay and Patient Characteristics
Non-Caucasians waited significantly longer for triage (M = 12.73 minutes). This
is consistent with previous literature. Studies have associated race/ethnicity with delay in
care with non-Caucasian patients waiting longer for care in EDs (James, Bourgeois, &
Shannon, 2005; Wilper et al., 2008). In addition, James et al. (2005) suggested that
provider-related variables such as stereotyping, cultural unawareness, and prejudices may
play a role in delay of care. However, Wilper et al. (2008) did not find triage biases as
causative for excessive delay in the non-Caucasian ED patient population. These
variables were not investigated in the current study.
Regression analysis revealed that female patients waited longer (14.01 minutes) to
be triaged (p < .001) than male patients. This is consistent with the literature. Numerous
studies have identified delay in the care of females (Concannon et al. 2009; DeLuca et al.,
2004; Diercks, Peacock, et al., 2006; ODonnell et al., 2005; Wilper et al., 2008) relating
to several points of care, from pre-hospital care to post intervention and critical care
placement, but no studies were identified that specifically quantified triage delay and
63
gender. Researchers have identified that females are more likely to present with atypical
symptoms during ACS (Albarran et al., 2007; DeVon, Ryan, et al., 2008; DeVon &
Zerwic, 2002, 2003), which may affect the recognition of the possible AMI. However, in
this study, 88.4% of females and 89.2% of males reported chest pain.
Patient age was not found to be a significant predictor of delay in triage. It is
possible that the RN identifies additional co-morbidities in the older population, resulting
in more timely care. This is not consistent, however, with a study by DeLuca et al. (2004)
who found delay in ED treatment for AMI patients in the > 70 year old patient
population. Also, Elkum, Fahim, Shoukri, and Al-Madouj (2009) identified patient age as
one predictor of delay in ED care with the > 65 age group waiting longer.
Triage Delay and RN Characteristics
Experience in nursing was a significant predictor of triage delay. The more
experienced the RN, the more delay in triage. Studies investigating delay in care
generally do not include demographics pertaining to the ED triage RN. Like accuracy, the
experienced RN may have a higher threshold as to what constitutes an emergency, which
may unnecessarily cause delay in a patient with symptoms suggestive of AMI.
ECG Delay
Of the patient characteristics of gender, age, race/ethnicity, and symptom
presentation and the RN characteristics of age, years of experience in nursing, years of
ED experience in nursing, and education, only patient symptom presentation and RN
experience in nursing were found to be significant predictors of delay in ECG
obtainment. Of the patient records (N = 286) included in this study, only 51 (17.8%)
patients received an ECG within the recommended 10 minutes of arrival. Mean wait time
64
for an ECG was 46.32 minutes. A small number of patients in the study received an ECG
prior to being seen by a physician, but most waited for an assessment by a physician and
an order to do an ECG leading to a further delay in ECG. As with triage delay, ECG
delay was also significantly predicted by RN general experience in nursing. Delay in
ECG may be related to perceptions of autonomy and the older RN may feel less
autonomous especially if this is a change in performance expectation for that RN. If
autonomy has increased as a unit expectation, it could be that the older RN has not
blended that into clinical practice.
Experience may not be the factor that matters in triage level designation
decisions. In an unpublished qualitative study (Sammons & Minick, 2012) ED RNs were
asked to describe triage. Nurses identified two main processes that they used to work
toward the right decision: a) connecting with the patient, which included caring enough to
ask the right questions and b) reading between the lines to identify the salient features of
a patients history or signs and symptoms.
ECG Delay and Patient Characteristics
Patients not reporting chest pain waited longer for an ECG, which was an
expected finding. Studies link atypical presentations to delay in identification of AMI
including a diagnostic ECG (Atzema et al., 2009; Canto et al., 2000). Atypical symptom
presentation, generally discussed as symptoms other than chest pain, may increase the
difficulty of recognizing an AMI at triage. Although not identified in this study, gender
and race/ethnicity have been previously identified in the literature as predictors of delay
in various points of care including ECG (Diercks, Kirk, et al., 2006; Diercks, Peacock, et
al., 2006; Takakuwa et al., 2006; Zegre-Hemsey et al., 2011). There are few studies
65
evaluating age as a possible factor in ECG delay; however, Pearlman et al. (2008)
identified age differences in ECG times with a median ECG time of 29 minutes and a
significant delay noted in the 18-39 and 40-59 age groups as compared to the > 60 age
group.
ECG Delay and RN Characteristics
Increased RN experience was noted as a significant predictor of ECG delay.
Because triage occurred before ECG in a majority of the cases in the study, this ECG
delay may be, in fact, due to the triage delay that occurred. The experienced RN may
have a higher threshold as to what constitutes an emergency, which may unnecessarily
cause delay in obtaining an ECG for a patient with symptoms suggestive of AMI. In other
words, if the triage RN has seen numerous patients do well who presented with shortness
of breath, diaphoresis, or other symptoms suggestive of AMI, the nurse may decide the
next patient can wait, which delays ECG obtainment. Previous studies investigating delay
in obtaining an ECG did not include RN demographics for comparison and no studies
were identified investigating a specific relationship between ECG delay and RN
experience. The experienced RN may be less likely to participate in ongoing education in
the ED leading to a knowledge deficit regarding atypical symptom presentation. If this
RN then becomes the preceptor for new RNs, this lack of knowledge could be
perpetuated.
Accuracy and Delay
Accuracy was not correlated with decreased delay. Accurately choosing a triage
level designation of Level 2 for the patient with symptoms suggestive of AMI did not
guarantee that the patient would receive an ECG within 10 minutes of arrival. The RN
66
may assign a Level 2 designation but not actively seek an ECG or possibly let the patient
continue to wait in the waiting room. This delay may be due to overcrowding in the ED
or processes in the ED itself such as the physical location of the triage booth or
availability of personnel to perform an ECG. For the triage RN to stop the triage process
for the remaining waiting room patients is not appropriate, yet there may not be
additional personnel available to perform this crucial diagnostic test.
Choosing an inaccurate triage designation of Level 3 for the possible AMI may
result in prolonged delay before treatment, especially when there is a high volume of
patients in the ED. Having a large number of Level 3 patients is not uncommon in any
ED on any given day. To inaccurately include the possible AMI in this group is
dangerous and could be deadly. Studies were identified that did identify an association
between assigning an incorrect triage level designation and delay in care of patients with
AMI. Atzema et al. (2009) found an independent association between incorrect triage
level designations and delay in ECG for patients (N = 3,088) diagnosed with AMI. In a
subsequent study, Atzema et al. (2011) found an association between inaccurate triage
level designations and ECG delay in AMI patients (N = 6,784) with a past medical
history of depression. It is possible in those studies that the Level 2 patient is always
taken straight to a treatment room. It is also possible that the Level 3 patient is also able
to get a room quickly thereby decreasing ECG times.
There are several specifically measured time points of care in the ED: from arrival
by ambulance or by public or private vehicle to triage; from triage to ECG; from triage to
physician assessment; from physician assessment to diagnosis, generally noted as
disposition; and from disposition to initiation of interventions to reestablish cardiac
67
muscle perfusion. The total of these time points equals the DTB and DTN times
frequently discussed in cardiac literature. Delay at any point decreases the chances of
meeting the ACC/AHA goal of < 90 minutes DTB or < 60 minutes DTN for
establishment of cardiac muscle reperfusion.
Conclusions
In this study, the accuracy rate of triage level designations for patients with
symptoms suggestive of AMI was 54%. Triage was delayed a mean of 11.78 minutes and
ECG was delayed a mean of 46.32 minutes. Female gender of patient was predictive of
triage delay but not ECG delay nor accuracy of triage level designations. Patient age was
not predictive of accuracy or delay. Patient race/ethnicity was not predictive of ECG
delay but was a predictor in accuracy of triage level designations and triage delay. A
report of chest pain was predictive of increased accuracy and decreased delay in ECG.
RN age played a role in accuracy but not in delays for triage and ECG. RN
experience played no role in accuracy and was predictive of increased delays in both
triage and obtainment of ECG. Neither RN ED experience nor level of education was
predictive of accuracy and delay.
In patients with symptoms suggestive of AMI, delays in individual segments of
care may result in a significant delay in emergent cardiac care. In this study, 11.78
minutes from door to triage plus 46.32 minutes to obtain an ECG led to a prolonged delay
in emergent cardiac care. This study adds to the body of evidence regarding ED triage of
patients arriving by private vehicle with symptoms suggestive of AMI. However,
inconsistency in nurse triage decisions may be due to other condition not yet explored,
68
such as RN critical thinking skills, intelligence, and executive functions. A further
investigation is warranted to assess factors affecting triage level designations.
Limitations
A limitation of this study is that portions of the data were gathered by
retrospective electronic chart review. Patients may have reported additional symptoms
that were not documented by the nurse at time of triage. Missing information in a medical
record has been previously identified in the literature (DeVon, Ryan & Zerwic, 2004).
This missing information could be the report of symptoms such as dizziness or nausea
reported by the patient or family to the triage RN but not documented in the EMR during
triage. This missing information may also have led to the exclusion of some EMRs in the
study, as data collection was dependent on RN documentation of chief complaint.
A second limitation is related to the nurses participation in the research study. A
portion (n = 26) of the nursing staff in the two EDs did not wish to disclose their
demographic information, citing reasons such as a constant barrage of computerized
surveys required of staff by other departments and upper management. Also noted by the
researcher during conversations with staff was a fear of reprisal, a suspicious approach to
research in general, a mistrust of how data are used, and a general reluctance to
participate. Reluctance to participate was also identified by Arslanian-Engoren (2000) in
a study of ED triage nurse decisions.
Other variables not identified in this study may have an impact on ECG delay
times and triage times such as ED overcrowding, physical limitations of the units, and
resource availability. These structure variables were not addressed in the study and
should be variables of interest for future research.
69
Implications for Nursing Practice
A 54% accuracy rate was identified in this study. A triage delay of 11.78 minutes
was also noted, and a majority of the patients in the study (82.6%) received an ECG
outside of the recommended 10 minute window despite symptoms suggestive of possible
AMI. Strategies must be exploredand implementedthat will improve accuracy and
decrease delay. Targeted educational interventions aimed at increasing awareness of AMI
multi-symptom presentations is an appropriate starting point and should be required
periodically for all ED RNs. In a survey of ED triage nurses, nurses reported provision of
(a) targeted educational information in the form of PowerPoint presentations, (b)
discussions of evidence in nursing literature, and (c) memory aids as useful in increasing
accuracy in cardiac triage decisions (Arslanian-Engoren, Hagerty, Antonakos, & Eagle,
2010). Initial education and ongoing competency assessment regarding the symptoms of
ACS for both the new graduate and the experienced nurse must occur. The ability to
recognize shortness of breath, weakness, nausea, vomiting, syncope, palpitations, or
diaphoresis as indicators of possible AMI is a crucial skill in triage.
Further studies are essential to explore the other features of decision making in
triage that may affect accuracy and delay of care in the ED. An exploration of RN
perceptions of the AMI patient population may give insight into nurse biases related to
triage that could be addressed. Studies exploring the cues nurses use to make decisions in
triage are numerous (Arslanian-Engoran, 2005, 2009; Edwards & Sines, 2007; Lyneham,
Parkinson, & Denholm, 2008; Pugh, 2002), yet no single solution exist.
Providing information to ED RNs regarding the differences in individual patient
outcomes when rapid care occurs could be a catalyst to increasing expediency of care in
70
the ED of patients with symptoms suggestive of AMI. This could take the form of follow
up information or case review of patients cared for in the ED who went on to receive care
in the acute care hospital setting and rehabilitation area.
Patient safety indicators often demand acceleration in care without adequate
resources. As pressures in EDs across the nation increased to care for more and more
patients while improving efficiency, streamlined processes for obtaining rapid ECGs
must be explored and instituted. Processes to improve ED RN triage practice such as
clinical case review and supervision as well as documentation audits may need to be
developed.
Future Research
Further studies investigating the impact of ED overcrowding and resource
availability are warranted. Meeting professional guidelines for patients presenting to an
ED with symptoms suggestive of AMI is imperative; however, the task is difficult due to
the multiple variables inherent in the processes surrounding emergent care. Studies must
focus on the factors surrounding inaccuracy and delay in ED care of patients with AMI.
This study investigated variables associated with triage RN inaccuracy and delay in care.
Further studies are necessary to begin to understand decisions at triage and improve the
expedience of care, which will preserve cardiac muscle, improve outcomes, and decrease
deaths from AMI.
A review of the current literature on the topic of ED cardiac emergency care of
patients with AMI failed to identify studies that examined mode of patient arrival in
relation to accuracy of ED RN triage and delay of treatment in the ED. The processes that
occur in the care of a patient who arrives via ambulance are not the same as that of
71
patients who arrive by public or private vehicles. Further studies specifically identifying
mode of arrival are needed. Secondly, there is little evidence of the role continuing ED
education and ED orientation of the novice RN and the experienced RN plays in accuracy
of triage and delay of care. Studies are needed that examine this possible predictor of
accurate triage decisions in the ED and could be conducted by identifying EMRs per
nurse so that an appropriate sample size could be obtained representing each triage RN
equally. Lastly, studies investigating patient outcomes in those who are inaccurately
triaged are needed. This gap in the current literature provides an opportunity to improve
emergency care of all patients with heart disease.
There are three considerations in the research of triage RN accuracy and delay of
care in the ED for patients with suspected AMI: (a) exploring whether or not inaccuracies
and delays exist, (b) identifying possible contributing conditions, and (c) possible
interventions to improve the accuracy and decrease delay. Numerous studies have
addressed the first phase. This study begins to address the second component of possible
factors contributing to inaccuracy in triage and delay of care. The last phase will need to
take the form of intervention studies to identify what strategies are effective in improving
accuracy of ED RN triage of the AMI patient based on data obtained from the second
component of research.
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APPENDICES
APPENDICES
APPENDIX A
REGISTERED NURSE DEMOGRAPHICS TOOL
88
89
REGISTERED NURSE DEMOGRAPHICS TOOL
Please circle one in each category:
Gender: M
Code _____ (to be assigned by researcher)
Race: Caucasian
African American
Education: diploma
ADN
BSN
Hispanic
MSN
Asian
other
doctoral level
Age: ___________
Month and year of first RN licensure: _________________________
Years of experience as an RN: _______ years _______ months
Years of experience in any Emergency Department: _______ years _______ months
Please print your name on the lower portion of this form.

________________________________________________
_________
Researcher to tear away here after coding.
NAME OF NURSE: ___________________________________________

(This form will be given a code and your name will be removed from the data)
Created: 02-10-2010
Revised: 05-18-2011
APPENDIX B
SELECTION OF ELECTRONIC MEDICAL RECORDS
90
91
Selection of EMRs
559 EMRs
(list generated by
Medical Records)
Arrival
mode POV?
175
ambulance
(excluded)
384
private vehicle
S/SX of
AMI
98
other obvious source
(excluded)
286
yes, S/SX suggestive of
AMI
RN
consent
92 EMRs,
no RN consent
(26 RNs)
194
EMRs with RN
consent
(40 RNs)
APPENDIX C
INFORMED CONSENT
92
93
APPENDIX D
INSTITUTIONAL REVIEW BOARD APPROVAL
94
95
INSTITUTIONAL REVIEW BOARD

Mail:
P.O. Box 3999

Atlanta, Georgia 30302-3999
Phone: 404/413-3500
Fax:
404/413-3504
In Person:
Alumni Hall
30 Courtland St, Suite 217
May 16, 2011
Principal Investigator: Grindel, Cecelia Marie

Student PI: Susan Sammons
Protocol Department: B.F. Lewis School of Nursing
Protocol Title: Accuracy of Emergency Department Nurse Triage Level Designation and Delay
in Care of Patients with Symptoms Suggestive of Acute Myocardial Infarction
Funding Agency: Kaiser Permanente
Submission Type: Protocol H11455
Review Type: Expedited Review
Approval Date: May 13, 2011
Expiration Date: May 12, 2012
The Georgia State University Institutional Review Board (IRB) reviewed and approved the
above referenced study and enclosed Informed Consent Document(s) in accordance with the
Department of Health and Human Services. The approval period is listed above.
Federal regulations require researchers to follow specific procedures in a timely manner. For the
protection of all concerned, the IRB calls your attention to the following obligations that you
have as Principal Investigator of this study.
1.
When the study is completed, a Study Closure Report must be submitted to the IRB.
2.
For any research that is conducted beyond the one-year approval period, you must
submit a Renewal Application 30 days prior to the approval period expiration. As a
courtesy, an email reminder is sent to the Principal Investigator approximately two
months prior to the expiration of the study. However, failure to receive an email
reminder does not negate your responsibility to submit a Renewal Application. In
96
addition, failure to return the Renewal Application by its due date must result in an
automatic termination of this study. Reinstatement can only be granted following
resubmission of the study to the IRB.
3.
Any adverse event or problem occurring as a result of participation in this study must
be reported immediately to the IRB using the Adverse Event Form.
4.
Principal investigators are responsible for ensuring that informed consent is obtained
and that no human subject will be involved in the research prior to obtaining informed
consent. Ensure that each person giving consent is provided with a copy of the
Informed Consent Form (ICF). The ICF used must be the one reviewed and approved
by the IRB; the approval dates of the IRB review are stamped on each page of the
ICF. Copy and use the stamped ICF for the coming year. Maintain a single copy of
the approved ICF in your files for this study. However, a waiver to obtain informed
consent may be granted by the IRB as outlined in 45CFR46.116(d).
All of the above referenced forms are available online at https://irbwise.gsu.edu. Please do not
hesitate to contact Susan Vogtner in the Office of Research Integrity (404-413-3500) if you have
any questions or concerns.
Sincerely,
Susan Laury, IRB Chair
Federal Wide Assurance Number: 00000129

Accuracy of Emergency Department Nurse Triage Level Designation A

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Accuracy of Emergency Department Nurse Triage Level Designation A

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Georgia State University

ScholarWorks @ Georgia State University

Accuracy of Emergency Department Nurse Triage

Follow this and additional works at: http://scholarworks.gsu.edu/nursing_diss

1417 Dale Drive

Georgia State University

Emergency Services Clinical Nurse Specialist,

PROFESSIONAL ORGANIZATIONS AND CERTIFICATIONS:

Kaiser-Permanente Evidence-Based Practice

ACCURACY OF EMERGENCY DEPARTMENT REGISTERED NURSE TRIAGE

Presented in Partial Fulfillment of Requirements for the

Statement of Problem ......................................................................................................1

REVIEW OF LITERATURE ............................................................................. 15

Accuracy Rates in Triage ............................................................................................... 15

Symptom Presentation ................................................................................................... 26

Research Design ............................................................................................................ 30

Preliminary Screening Procedures ................................................................................. 41

Statistical Analysis ........................................................................................................ 49

DISCUSSION AND CONCLUSION ................................................................. 57

Appendix B: Selection of Electronic Medical Records ................................................... 90

Triage Scale and Maximum Wait Times in Minutes .............................................5

Data List ............................................................................................................ 34

Skewness and Kurtosis Statistics ........................................................................ 43

Patient Demographics ........................................................................................ 46

Patient Medical History...................................................................................... 47

Characteristics of Registered Nurses .................................................................. 48

Electronic Medical Record Matched Registered Nurse Demographics ................ 48

Accuracy of Triage Level Designation Model .................................................... 50

Delay of Electrocardiogram Model .................................................................... 51

Minutes of Delay in Care ................................................................................... 52

Correlation of Registered Nurse Age and Experience ......................................... 53

Amount of Delay of Triage Model ..................................................................... 54

Donabedians model. ...........................................................................................9

Model of emergency department registered nurse triage of patients with

Histogram for minutes to triage. ......................................................................... 43

Histogram for minutes to triage (transformed). ................................................... 44

Registered nurse years of experience in emergency department. ......................... 44

Registered nurse years of experience in emergency department (transformed). ... 45

American College of Cardiology

Acute Coronary Syndrome

Associate Degree in Nursing

American Heart Association

Acute Myocardial Infarction

Australasian Triage Score

Body Mass Index

Bachelor of Science in Nursing

Coronary Artery Bypass Graft

Coronary Heart Disease

Canadian Triage and Acuity Scale

Electronic Medical Record

Emergency Nurses Association

Emergency Severity index

Institute for Healthcare Improvement

Institutional Review Board

Licensed Practical Nurse

Littles Missing Completely at Random

Manchester Triage Scale

National Center for Health Statistics

National Hospital Ambulatory Medical Care Survey

National Heart Lung and Blood Institute

Non-ST segment Elevation

Predictive Analytics Software

Percutaneous Coronary Intervention

Registered Nurse Demographic Tool