The Australasian triage scale: examining emergency department nurses' performance using computer and paper scenarios

Study objective: The purpose of this study is to examine emergency nurses' performance using triage scenarios characterized by type of patient population (adult versus pediatric) and mode of delivery (paper versus computer). Methods:   A combination of paper-based (script alone) and computer-based (script plus still photographs) triage scenarios were used. Of the 28 scenarios used, half were written and half were computer based. Within each subgroup, there were 7 adult and 7 pediatric scenarios. Participants were asked to allocate an Australasian Triage Scale category for each triage scenario. Results: One hundred sixty-seven participants completed a total of 2,349 adult scenarios, and 161 participants completed 2,265 pediatric scenarios. Sixty-one percent of the triage decisions made by the nurses were “expected” triage decisions, 18% were “undertriage,” decisions, and 21% were “overtriage” decisions. Nurse triage allocation decisions for the scenarios containing still photographs delivered by computer demonstrated a higher average agreement percentage of 66.2% (κ=0.56; τb=0.77; P<.0001) compared with the average agreement percentage of 55.4% (κ=0.42; τb=0.75; P<.0001) using paper-based (text-only) scenarios. Conclusion: The mode of delivery appeared to have an effect on the nurses' triage performance. It is unclear whether the use of simple still photographs used in the computer mode of delivery resulted in a higher incidence of expected triage decisions and, thus, improved performance. The use of cues such as photographs and video footage to enhance the fidelity of triage scenarios may be useful not only for the education of triage nurses but also the conduct of research into triage decisionmaking. However, further exploration and research in this area are warranted.

Triage nurses' clinical decision making : an observational study of urgency assessment

Background. Researchers have described both the various decision tasks performed by triage nurses using self-report methods and identified time as a factor influencing the quality of triage decisions. However, little is known about the decision tasks performed by triage nurses when making acuity assessments, or the factors influencing triage duration in the real world.

Aims. The aims of this study were to: describe the data triage nurses collect from patients in order to allocate a triage priority using the Australasian Triage Scale (ATS); describe the duration of nurses' decision making for ATS categories 2–5; and to explore the impact of patient and nurse variables on the duration of the triage nurses' decision making in the clinical setting.

Design. A structured observational study was employed to address the research aims. Observational data was collected in one adult emergency department located in metropolitan Melbourne, Australia. A total of 26 triage nurses consented and were observed performing 404 occasions of triage. Data was collected by a single observer using a 20-item instrument that recorded the performance frequencies of a range of decision tasks and a number of observable patient, nurse and environmental variables. Additionally, the nurse–patient interaction was recorded as time in minutes.

Results. It was found that there was limited use of objective physiological data collected by the nurses' in order to decide patient acuity, and large variability in the duration of triage decisions observed. In addition, analysis of variance indicated strong evidence of a true difference between triage duration and a range of nurse, patient and environmental variables.

Conclusion. These findings have implications for the development of practice standards and triage education. In particular, it is argued that practice standards should include routine measurement of physiological parameters in all but the collapsed or obviously unwell patient, where further delay may impede the delivery oftime-critical intervention. Furthermore, the inclusion of arbitrary time frames for triage assessment in practice standards are not an appropriate method of evaluating triage decision making in the real world.

Influence of task properties and subjectivity on consistency of triage: a simulation study

Aim. This paper reports a study to determine nurses' levels of agreement using a standard 5-point triage scale and to explore the influence of task properties and subjectivity on decision-making consistency.

Background. Triage scales are used to define time-to-treatment in hospital emergency departments. Studies of the inter-rater reliability of these scales using paper-based simulation methods report varying levels of consistency. Understanding how various components of the decision task and individual perceptions of the case influence agreement is critical to the development of strategies to improve consistency of triage.

Method. Simulations were constructed from naturalistic observation, cue types and frequencies were classified. Data collection was conducted in 2002, and the final response rate was 41·3%. Participants were asked to allocate an urgency code for 12 scenarios using the Australasian Triage Scale, and provide estimates of case complexity, levels of certainty and available information. Data were analysed descriptively, agreement between raters was calculated using kappa. The influence of task properties and participants' subjective estimates of case complexity, levels of certainty and available information on agreement were explored using a general linear model.

Findings. Agreement among raters varied from moderate to poor (κ = 0·18–0·64). Participants' subjective estimates of levels of available information were found to influence consistency of triage by statistically significant amounts (F 5·68; ≤0·01).

Conclusions. Strategies employed to optimize consistency of triage should focus on improving the quality of the simulations that are used. In particular, attention should be paid to the development of interactive simulations that will accommodate individual differences in information-seeking behaviour.

Do knowledge and experience have specific roles in triage decision-making?

Accuracy of triage decisions is a major influence on patient outcomes. Triage nurses' knowledge and experience have been cited as influential factors in triage decision-making. The aim of this article is to examine the independent roles of factual knowledge and experience in triage decisions. All of the articles cited in this review were research papers that examined the relationship between triage decisions and knowledge and/or experience of triage nurses. Numerous studies have shown that factual knowledge is an important factor in improving triage decisions. Although a number of studies have examined the role of experience as an independent influence on triage decisions, none have found a significant relationship between experience and triage decision-making. Factual knowledge appears to be more important than years of emergency nursing or triage experience in triage decision accuracy. Many triage education programs are underpinned by the assumption that knowledge acquisition will result in improved triage decisions. A better understanding of the relationships between clinical decisions, knowledge, and experience is pivotal for the rigorous evaluation of education programs.

Ambulance call triage outcomes for patients reporting pain : a retrospective cross-sectional analysis of pain score versus traige level

Objective: To identify any association between the response priority code generated during calls to the ambulance communication centre and patient reports of pain severity.

Methods: A retrospective analysis of patient care records was undertaken for all patients transported by paramedics over a 7-day period. The primary research interest was the association between the response code allocated at the time of telephone triage and the initial pain severity score recorded using a numeric rating scale (NRS). Univariate and multivariate logistic regression methods were used to analyse the association between the response priority variable and explanatory variables.

Results: There were 1246 cases in which both an initial pain score using the NRS and a response code were recorded. Of these cases, 716/1246 (57.5%) were associated with a code 1 ("time-critical") response. After adjusting for gender, age, cause of pain and duration of pain, a multivariate logistic regression analysis found no significant change in the odds of a patient in pain receiving a time-critical response compared with patients who had no pain, regardless of their initial pain score (NRS 1–3, odds ratio (OR) 1.11, 95% CI 0.7 to 1.8; NRS 4–7, OR 1.12, 95% CI 0.7 to 1.8; NRS 8–10, OR 0.84, 95% CI 0.5 to 1.4).

Conclusion: The severity of pain experienced by the patient appeared to have no influence on the priority (urgency) of the dispatch response. Triage systems used to prioritise ambulance calls and decide the urgency of response or type of referral options should consider pain severity to facilitate timely and humane care.

Crisis and triage clinicians' attitudes toward working with people with personality disorder

PURPOSE. This study aimed to investigate the attitudes of Australian psychiatric triage and crisis clinicians toward those with a diagnosis of personality disorder.
DESIGN AND METHODS. The design of the study was exploratory descriptive research. The study employed a survey method using Bowers and Allan's (2006) Attitude to Personality Disorder Questionnaire, which was designed to identify global attitudes toward those with a diagnosis of personality disorder.
FINDINGS. The findings of this study indicate that psychiatric crisis and triage clinicians hold negative attitudes toward those with a diagnosis of personality disorder.
PRACTICE IMPLICATIONS. Education and clinical supervision is required to address negative clinician attitudes.

Mental health triage nursing : an Australian perspective

This paper presents the findings of a doctoral research project that involved a state-wide investigation into mental health triage nursing in Victoria, Australia. Mental health triage is a specialized domain of nursing practice that has emerged within the context of wider mental health reform in the State. The overall aim of the study was to produce a comprehensive definition and description of psychiatric triage nursing in Victoria. Methodological triangulation was used in the design of the study to enable the use of both survey (n = 139) and semi-structured interview (n = 21) data collection methods. Mental health triage nursing was found to be a complex, stressful role that involves high levels of responsibility, clinical decision making, and multiple role functions, many of which overlap into areas of practice previously the exclusive domain of medicine, such as assessment, diagnosis, and referral. The paper raises discussion on contemporary professional issues of concern to mental health triage nursing, and concludes with recommendations for the future development of the discipline.

Mental health triage : towards a model for nursing practice

Mental health triage/duty services play a pivotal role in the current framework for mental health service delivery in Victoria and other states of Australia. Australia is not alone in its increasing reliance on mental health triage as a model of psychiatric service provision; at a global level, there appears to be an emerging trend to utilize mental health triage services staffed by nurses as a cost-effective means of providing mental health care to large populations. At present, nurses comprise the greater proportion of the mental health triage workforce in Victoria and, as such, are performing the majority of point-of-entry mental health assessment across the state. Although mental health triage/duty services have been operational for nearly a decade in some regional healthcare sectors of Victoria, there is little local or international research on the topic, and therefore a paucity of established theory to inform and guide mental health triage practice and professional development. The discussion in this paper draws on the findings and recommendations of PhD research into mental health triage nursing in Victoria, to raise discussion on the need to develop theoretical models to inform and guide nursing practice. The paper concludes by presenting a provisional model for mental health triage nursing practice.

Assessing the risk of suicide at triage

Mental health related presentations to Australian emergency departments are steadily increasing. There is a growing incidence of depression, substance abuse, and other mental illnesses in the Australian population. Mental health problems will contribute 15% of the total world disease burden by 2020. Triage nurses are pivotal to the early detection and management of mental health problems.

The rapid assessment of mental health presentations at triage requires skill, knowledge, experience and confidence. One of the more complex aspects of triage is suicide risk assessment.

An ABC approach to assessing the risk of violence at triage

There is evidence to suggest that the incidence of violent behaviour in the emergency department by patients toward staff is on the rise. As part of the process of determining urgency, triage nurses must assess the risk of violence at point of entry. The risk of violence, that is, behaviour that either involves a threat of physical or psychological harm to one's self or to others, is considered a critical predictor of urgency in mental health triage. A rapid violence risk assessment strategy will be described which can be utilised in emergency department triage.