Piloting an evaluation of triage SUSAN

R.G.N., R.H.V.* Research Associate lk?rrse M.B., B.S., M.Sc., M.F.P.H.M.

READ,

STEVE GEORGE,

Ph.D.,

Lecturer

in Epidemiology

LINDA WESTLAKE,

B.Sc. Stalistician

BRIAN

WILLIAMS,

M.D.,

F.R.C.P.,

F.F.P.H.M.

Director, Medical Care Research Unit, Department of Public Health Medicine. University of Sheffield Medical School, Beech Hill Road, Sheffield SIO 2RX. U.K.

JANICE GLASGOW, TONY POTTER,

R.G.N. A & E Cert. (E.N.B.) R.G.N. A & E Cert. (E.N.B.) Accident

and Emergency Department. Derbyshire Royal Infirmary. London Road, Derby DE1 2QY. U.K.

Abstract-This paper takes a broad view of the work involved in pilot studies of evaluation research. Drawing on their experience of preparation for a field experiment in a British Accident and Emergency department, which was to evaluate the effectiveness of a nurse triage system, the authors stress the importance of careful observation of the system to be studied, in the environment in which it is to be studied. In addition, the usual evaluations of research instruments which comprise formal pilot studies are included.

The problem

facing Accident

and Emergency

departments

One of the most striking characteristics of the work of an Accident and Emergency (A & E) department is its variability. Both the number of patients arriving and the nature of their complaints fluctuate greatly. In any one day, A & E staff may have to cope with violent death, severe trauma, sports injuries, industrial or domestic accidents, psychiatric, ‘Author

to whom

correspondence

should

be addressed.

‘76

S. READ

et al

medical or surgical emergencies. All of these are seen in close pro.ximity to seeming trivialities that should ostensibly have been treated by self-medication or sensible advice. In an attempt to dissuade casual attenders with minor health problems from distracting medical attention away from those with serious injuries, casualty departments in the U.K. were re-named “Accident and Emergency” departments following the publication of the Platt Report in 1962 (Platt, 1962). Despite the change of name, attendance figures have risen inexorably (Milner et al., 1988). and some years after the Platt Report, Gunawardena and Lee (1977) suggested that “A & E” stood appropriately for “anything and everything”. Over the past decade a number of studies have estimated the proportion of A & E attenders who might more appropriately have been treated by their general practitioner (GP) variously as 14% (Worth and Hurst, 1989). 39% (Davison et al., 1983), about 50% (Milner et al., 1988; Warren, 1989; Hobday, 1988), 54% (Myers, 1982) and 68% (Cliff and Wood, 1986). These authors, in concert with others (Holohan, 1976; Lewis and Bradbury, 1981; Calnan, 1984, 1983; Dennis, 1984; Singh, 1988) writing more from the patients’ own perspective, or from a sociological standpoint, suggested that lay perceptions of the need for urgent medical treatment are often very different from professional opinion. In addition, there is widespread ignorance that many general medical practices offer facilities for treatment of minor injury, and that appointment systems can still allow for urgent consultations (Davies, 1986; Farquhar, 1990). Although all residents of the U.K. are encouraged to register with a General Medical Practitioner (GP), some fail to do so. This group tend to use A & E departments as a substitute for seeing a GP. In addition, some attend A & E deliberately seeking a second opinion because they are not satisfied with their GP’s treatment (Jones and McGowan, 1989). Despite some recent attempts to educate the public about use of A & E departments and thus reduce attendance figures (Carew-McCall and Buckles, 1990), the workload of departments remains unpredictable to some extent, and variable in both number and content (Williams and Pottle, 1989; Mitchell, 1987; Wright, 1985). Inevitably there are times when patients have to wait for a number of hours to see a doctor, in overcrowded and uncomfortable conditions, leading to displays of aggression, complaints and stress to both patients and staff (Thayre, 1985; Wright, 1985; Slack, 1985). In such conditions it is even possible that staff may fail to recognize, in their haste and harassment, that a patient is seriously injured or ill, and such a patient may die or suffer serious harm whilst in the waiting room. The risk of this happening is said to be particularly great where the initial responsibility falls to medically untrained reception staff who would normally only divide patients into two categories-urgent and non-urgent (Hughes, 1988, 1989; Jones, 1986a). Reception staff might, out of necessity, make this judgement very rapidly and on the basis of very incomplete information. Thus, in the field of A & E care, persistently rising attendances, problems of inappropriate use, long waiting times, overcrowding and aggression are all familiar stories that have invited solutions. One strategy that has gained wide acceptance, first in the U.S.A. and then in the U.K., is the introduction of triage; patients on arrival at A & E are briefly assessed by a nurse who assigns them a category of priority for treatment. The development of nurse triage has been the subject of research investigation in a number of centres in the U.S.A., but in the U.K. there have only been small-scale “in house” inquiries. For this reason, the Department of Health commissioned the Medical Care Research Unit (IMCRU) at Sheffield University to study the issue in more depth. We began by conducting a literature review.

PILOTI.VG

Definition

‘-1.V El:-lLUATIO.V

and derivation

OF TRI.dGE

27’

of the term “triage”

The Concise Oxford Dictionary defines “triage” as “sorting according to quality”. It also refers specifically to the medical application in time of disaster as “assignment of degrees of urgency to decide order of treatment of wounded”. Collins Gem French/English Dictionary translates the French word “triage” in railway terms, as a shunting or marshalling yard. This is quite a useful analogy when one thinks of a typical A & E department on a Saturday night, with a number of patients on trolleys being shunted around each time a new, more seriously injured patient arrives. Rund and Rausch (1981) explain that the term “triage” grammatically speaking is a noun, but that it is also used in practice as an adjective or even a verb (“to triage”). They also create a neologism and introduce the word “triageur” meaning “one who triages”. Weinerman et al. (1965) described the first civilian hospital triage scheme in the U.S.A., which was staffed by doctors, while Baldridge (1966) and Slater (1970) were the first to record triage as practised by nurses, and this set an example many were to follow.

Triage

theory and research in the U.S.A.

As experience with triage systems grew in the U.S.A., so did the literature. Articles recounting experiences but also giving advice appeared with increasing frequency (Shields, 1976; Estrada, 1979, 1981; Beach, 1981; Turner, 1981; Barbarick, 1985; Foster, 1985; Selvig, 1985; Thomas, 1988; Wilson, 1988); meanwhile two books were published which were dedicated to the topic of triage- Rausch and Rund (198 I) and Thompson and Dains (1982). Between them, these authors suggested that the following functions all formed part of triage activity for nurses: (I) Early assessment of patient condition in order to determine the urgency of the need for care. (2) Control of patient flow through the A & E department. (3) Assignment of the patient to a suitable location for treatment, and to an appropriate care provider. (3) Early initiation of diagnostic measures. (5) Application of initial therapeutic measures (first aid). (6) Control of infection and isolation of patient where necessary. (7) Promotion of good public relations by immediate demonstration of concern, combined with reduction of anxiety of patient and relatives. (8) Provision of opportunity for health promotion. Both pairs of authors suggest that there is not one simple blue-print for introduction of triage, but that varying circumstances and conditions in A & E departments will affect the way triage is implemented (for instance, the number of urgency categories which may apply, the type of documentation, and the level of discretion given to the nurses). Thompson and Dain’s book (1982) is written within the overall framework of systems theory, and so they give special attention to continuing evaluation of the triage system. Of eight research studies of triage conducted in the U.S.A., five related to adult facilities (Albin et al., 1975; Mills ef al., 1976; Willis, 1979; Rausch and Rund, 1981; Zwicke, 1982) and three to paediatric departments (Russo et al., 1975; de Angelis and McHugh, 1977; Rivara ef al., 1986). The number of patients in each study ranged between 100 and 900, except for one large study covering 11,000 patients (Mills et al., 1976). All studied the safety

and effectiveness of triage nurses’ decisions, sometimes by comparison with doctors’ assessment of the same patients prospectively (Russo er al., 1975; Zwicke er al., 19S2) or retrospectively (Albin ef al., 1975; Mills et al., 1976; Rivara, 1986). In all studies, there was at least 80% agreement on patient disposition, with nurses tending to vary by assigning greater urgency rather than less-that is, erring on the side of safety. Generally, the studies agreed that nurse triage is safe and effective. One paediatric study (de Angelis and McHugh, 1977) concluded that trained receptionists were more cost effective triage agents than nurses. However, the receptionists’ level of inappropriate referrals was II%, compared with 6% for paediatric nurse practitioners; that was acceptable in that particular department because all patients were seen by a doctor following the triage consultation, thus providing a “safety net”. Willis (1979) concluded that nurses need more training in assessing non-communicative patients, and Albin et al. (1975) stated that continued monitoring of triage schemes was necessary to identify weak spots and staff training needs.

The introduction

of triage in the U.K.

The application of this American innovation to British nursing followed after a time lag of some years. During the 198Os, articles appeared about triage in the U.K. nursing press, for instance by Jones (1983, 1986b), Blythin (1983, 1988a,b), Thayre (1985), Parmar and Hewitt (1985), Wright (1985), Slack (1985), Harris and Fox (1986), Nuttall (1986), Yates (1987), Bailey el al. (1987) and Grose (1988). The A & E Forum of the Royal College of Nursing encouraged the introduction of triage schemes through their conferences and newsletters, and all seemed to agree that the benefits of triage include: (1) The giving of rapid attention to seriously ill or injured patients. (2) The reassurance of professional assessment on arrival for all patients, with the giving of information on likely waiting times to both patients and relatives. (3) The saving of time by early retrieval of old notes and X-rays where appropriate and possibly by referral for X-rays and other diagnostic procedures, where this is permitted. (4) The reduction of waiting times in many cases. Ail these benefits are claimed to reduce anxiety levels, and also risk of aggression and hostility. However, a survey by Pledge and Rock (1988) revealed great variety in departments’ implementation of triage, especially in training and record keeping. The legal aspects of triage need consideration, particularly where nurses are authorized to advise patients either to attend their own doctor, or to treat themselves, without waiting to see an A & E doctor. The boundaries between medical and nursing roles are constantly moving. Kloss maintains that the law does not clearly define the respective roles of doctors and nurses except in the area of drug prescription: “Demarcation between the medical and nursing professions are always changing” [Kloss (1989). p. 401.

rests on custom and practice,

which

Hadfield (1989) advises particular care over documentation, including noting telephone advice given by A & E nurses, and procedures for obtaining consent for investigations and treatment. She also warns that “regular attenders” and intoxicated persons need careful screening in case familiarity masks a serious illness.

PILOTI.VG

Considering

Ah’ E~‘ALUATIO!V

OF TRI.-IGE

the issues involved in evaluation

279

of nurse triage

According to Bulmer (1982) evaluation research typically has five stages: (1) To identify the goals of the policy being evaluated. (2) To translate the goals into measurable indicators of goal achievement. (3) To collect data on these indicators for study participants exposed to the programme. (4) To collect similar data on an equivalent group not exposed to the programme. (5) To compare the results for experimental and control groups in relation to the goals set. All five stages raised problems and questions for the research team. First, the literature review had illuminated at least eight goals for the triage process, as indicated above. Only some of these goals could be translated into measurable indicators; the two upon which finally we concentrated were: (1) To assign a degree of clinical priority to each patient on arrival, so that the most seriously injured or ill received treatment more quickly than those with lesser injuries. (2) To reduce the anxiety of patients and relatives by early assessment, thus offering reassurance where appropriate that delay would not be harmful, and giving information on the probable course of events. In concentrating on these two areas we were implicitly recognizing Bergman’s dictum that “evaluation in nursing is a combination of objective measurement of concrete phenomena, as well as subjective perceptions and opinions on the ‘feeling’ of care as reported by recipients, providers and important others” IBergman (1982). p. 541.

The second stage in evaluation research, translating goals into measurable indicators, is a perennial problem in nursing research; goals are often expressed in global or imprecise terms, and equating them with precisely measurable values may distort their meaning. Clayton and Davies say “There is a real danger that in a desire to be objective, the easily measured aspects come to dominate and the more difficult to identify, but crucially important, issues are played down or ignored” /Clayton

and Davies (1982).

p. 7761.

The measurable indicators used in our study were time waited between arrival and first seeing the doctor, and measures of clinical urgency assigned both prospectively and retrospectively (see below). In addition, patient perceptions were also obtained retrospectively, by postal questionnaire. These measures, whilst demonstrating whether or not the chosen goals of triage were being achieved, are actually process measures, not outcome measures. Had there been a precise way to evaluate clinical outcome for A & E patients, we would have tried to relate outcome to the length of time waited for treatment, which can be crucial in some conditions. However, the multideterminate nature of clinical outcomes, and the comparative rarity of patients with a condition serious enough to be affected by time waited, compared to all patients seen in an A & E department, made an evaluation of outcomes difficult. It would have been impossible to ascribe any differences in outcome to either the presence or absence of triage, or to any aspect of the prioritization process. The measurement of time waited in relation to the urgency of the clinical situation is therefore a proxy; the assumption is made that time waited affects outcome, and therefore that shorter waiting times produce better outcomes. The need to collect information on both an experimental group and a control group and to be able to compare results raised the question of research design. The research team

280

S. RE.4 D tv al.

considered undertaking either a comparative multi-centre study, or a “before and after” study. We felt it was not valid to compare two or more different A & E departments, with or without triage systems, as there are too many confounding variables affecting waiting times and case-loads in different hospitals. “Before and after” studies also have their drawbacks, because other factors can affect waiting times in the interim period and so distort results. This was demonstrated in a study p@lished after we had carried out our research (Mallet and Woolwich, 1990). The research team decided that pursuing an experimental design within one hospital would give the least opportunity for confounding variables to distort results. The hospital needed to have at least 50,000 new A & E attendances each year in order to provide sufficient case numbers in a reasonable period of time, to be reasonably typical of British A & E departments, to have a well-established triage system and yet be willing to suspend this for periods and to tolerate research activity for many weeks. Eventually we obtained access to a busy A & E department in a British industrial city (over 60,000 new patients a year); the staff were willing to suspend their well-established nurse triage system for short periods to enable us to carry out an experimental study with equal periods when triage was, and was not, functioning. In addition, medical, nursing and clerical staff worked well together as a team, and took a joint decision to accept the disruption likely to arise from a research project expected to last some months, if the pilot stages were included. The remaining question to be answered at the design stage was how to compare clinical urgency for all patients in the study. Patiyts seen by the triage nurse would be assigned a triage rating by the triage nurse-a prosBective degree of clinical urgency. However, it would be ethically unacceptable to apply nurse triage both to experimental and control groups and then disregard the result for those in the control group, so in addition to a nurse triage rating a method of retrospective urgency rating was developed using medical case-notes. Furthemore, it would have been incorrect to use the prospective rating for some patients, and the retrospective rating for others, and so the retrospective rating had to be used for all patients in the study, irrespective of group.

The development

of hypotheses

As described above, our evaluation became focussed on two particular goals of nurse triage systems. The first was the assignment of degrees of priority to patients, so that the most seriously ill or injured receive treatment more quickly than those with lesser injuries. The hypothesis thus derived was that when triage was in operation more serious cases would be seen more quickly than equivalent cases attending when triage was not in operation (the corollary to this was that less serious cases would probably wait longer when triage was in operation than otherwise). The second goal to be evaluated was the reduction in anxiety of patients and relatives by early assessment and the provision of information on expected waiting times and the possible nature of the injury. The hypothesis derived from this was that when triage was operating, patients would express lower levels of anxiety and greater satisfaction with the A & E process, compared with patients attending when triage was not in operation.

PILOTl.VG

A.V EC:-lLUATIO.V

OF TRI.-IGE

2YI

The Pilot Study

Having taken the decisions outlined above on the research design and measures, much detailed work was needed to prepare for the main study. This involved a number of stages, carried out over a period of some 4 months at the research site: (1) Ensuring that periods of time in which it was intended that triage woud be functioning could be adequately distinguished from periods in which it was not, and that these periods would be equally divided between days of the week and times of day. Studying the operation of the triage system prior to the evaluation led us to realize that because of occasional irregularities in staff scheduling or emergencies, such as sickness absence, it would be preferable to schedule half-days as the operational unit of time for the study. Although the intention was to alternate the functioning of triage for a week at a time, in the event, odd half-days had to be substituted to achieve an overall balance between experimental and control periods. It was also recognized during the pilot study that from time to time the triage service would be withdrawn, even when it was supposed to be operating, because of other demands on staff such as “flying squad” calls, or inservice training, or even to cover meal breaks for other staff. The research was to operate on an “intention to treat” principle. Providing triage was open at the beginning of a halfday period, this was treated as a “triage on” session, even though part of that period may have been lacking a triage nurse. This is equivalent to a study testing a new drug, where the administration of the drug causes a certain proportion of patients to experience sideeffects so bad that they stop taking the drug. The group to be tested should be all those who were originally intended to receive the drug, rather than only those who can tolerate its side-effects. In this way results are based upon a more “real life” situation. (2) Studying the functioning of the department when triage was and was not in operation. All first and second level nurses in the department had undergone training in triage, and assessed patients according to the following categories: (i) Severely ill or injured, requiring immediate care to combat danger of life or limb and in whom delay would result in deterioration. (ii) Illness or injury requiring treatment within 60 minutes, but in whom the delay poses no threat to life or limb. Patient not in severe pain, poses no danger to self or others. (iii) Illness or injury requiring treatment within 60 to I20 minutes but in whom the delay pores no threat to life or limb. Patient not in modcratc pain. shows no risk of permanent disability or illness. (iv) Patient in whom delay of 24 hours would make no appreciable difference to clinical condition, and who may subsequently be referred to alternative appropriate specialty.

A special triage form was slipped inside the departmental medical record so that the receiving nurse in the major or minor injury area would know what priority to accord the patient. When triage was not operating formally due to shortage of staff, an informal prioritization was carried out by the receiving nurse, following registration at the reception desk and before being directed to a waiting area. Many hospitals do not operate such a system, although it is unlikely that any A & E department in the country sees patients in strict order of arrival. Rather than comparing triage with no form of prioritization, therefore, this study compared formal and informal methods of prioritization, perhaps analogous to “hierarchical” and “matrix” systems of management within organizations. (3) Devising a prioritization system, to assign a degree of urgency to all patients attending the A & E department. In describing the design stage of this project we have already explained the need to devise

22 s

S. READ

er ul.

a method of rating retrospectively according to urgency, and the reasons why this had to be applied to all patients in the study. We devised this common rating system with the help of the two senior clinicians in the department. They took it in turns retrospectively to assign a degree of urgency, using clinical case notes, for all patients in the study. They did not know which patients had been through the triage process or what their ratings were, but of course they did have the benefit of X-ray reports and other clinical findings and knowledge of treatment, including whether the patient was admitted to hospital. The clinicians’ ratings were recognized as being different in kind from the nurses’ ratings, as they had the advantage of hindsight, and did not have the shocked and anxious patient physically present-but we must repeat that it was a way of applying a constant means of urgency assessment to all patients in the study. inter-observer variability between the two clinicians was measured, before and after the data collection period. Using the Kappa statistic (Fleiss, 198 1) reasonabie agreement was achieved beforehand (Kappa = 0.4 15) and good agreement afterwards (Kappa = 0.624). Values of the Kappa statistic between 0.4 and 0.7 represent fair to good agreement beyond chance. A further reason for applying a common rating system to all patients in the study, irrespective of whether they were in the experimental or the control group, was to be able to make meaningful comparisons between patients with similar urgency ratings in the two groups. We had observed that when the triage system was operating, a number of patients were being redirected away from the A & E department towards more appropriate sources of care. Since such redirected individuals would have been stationed, in all likelihood, at the longer end of a distribution of waiting times had they stayed in the department (i.e. if triage had not been functioning), their removal from the scene would have led to the artificial lowering of the average waiting time in the experimental group, without any change in the actual time waited by those patients remaining to be seen. As an example, suppose that 10 patients wait to be seen in an A & E department. Say nine wait 1 hour, and one waits 11 hours (this is an extreme example, but serves to illustrate the point). Their average time is the sum of the hours waited (= 20) divided by the number of people waiting (= 10) giving an answer of 2 hours. If, however, the patient waiting I I hours is sent away, the average waiting time is now the sum of the hours waited (= 9) divided by the number of people waiting (= 9) giving an answer of 1 hour. The nine people left waiting still wait I hour, yet the average waiting time has decreased from 2 hours to 1 hour. Had we not adopted a common urgency rating system for all patients in the study an apparent advantage in terms of waiting time would have been conferred upon the group undergoing triage without any actual change in waiting times having occurred. Our adoption of such a system, therefore, means that just comparisons can be made safely between experimental and comparison groups in the three most urgent categories in our classification of urgency. However, there is likely still to be a considerable difference in case-mix between groups in the least urgent category, because in the experimental (triage) group some patients with very trivial injuries or longstanding conditions would have been redirected to more appropriate sources of care. (4) Devising a system in order to record accurately the time spent in the A & E department by a patient between his or her arrival and seeing a doctor. We originally intended to use the department’s own computer system to record and compute waiting times, but this proved, after observation, to have two major drawbacks. The first was that when triage was operating, patients saw the triage nurse on arrival. Several

PILOTI.L%

.-1.v EVALtiATI0.V

OF TRIAGE

283

minutes later they were booked into the computerized system by the receptionist; their arrival was automatically logged by the computer as the time at which the receptionist began entering their personal details. Thus when triage was operating, the computer did not show the patient’s true time of arrival, but only the time of first contact with the computer system. Had we taken the computer-recorded time in all cases, whether triage was functioning or not, the triaged patients would have appeared to have had a time advantage over the others. The second part of the problem of accurate timing involved patients with minor injuries. We found that patients were called in from the waiting room to the minor injury area in batches of three or four, then left to wait on a bench outside the clinical rooms. Nurses entered into the computer the time at which patients were called. In reality, most patients waited another 10 or 15 minutes on the bench before actually seeing the doctor. In order to obtain an accurate time recording, we installed digital clocks in the triage room and at all clinical points where doctors first met patients. All these clocks were synchronized with the departmental computer clock, and we asked nurses to record the time of the patient’s arrival at the triage point, and doctors to record the time of their first contact with the patient. Each patient seeing the triage nurse has, therefore, two “times of arrival’, one recorded by the departmental computer at the time of booking in and one recorded by the triage nurse. The earlier of these two times was taken as the true time of arrival in each case. Frequent reminders to triage nurses and to doctors helped to achieve a good level of cooperation. In the main study, fewer than 10% of cases were excluded because of failure to record time data. (5) Sample size estimation. The main outcome to be considered in this study was the waiting time of patients prior to being seen by a doctor, in particular, the waiting time for the most urgent cases. A study was made of patients over the course of a week, in order to determine the relative numbers of cases assigned to each of the four priority categories. Category (i) (containing the most urgent patients) was found to be the smallest, containing 4% of patients, and thus dictated the size of the study. It was also necessary to obtain an estimate of a clinically significant difference in waiting time between those triaged and those not. A discussion was held with the two consultant A & E clinicians, and a time of 2.5 minutes was determined as being the minimum time difference which it was clinically worth detecting. For the purpose of this calculation it was assumed that waiting times in Category (i) would be normally distributed (although this did not prove to be the case). Based upon information from the study week, using a proposed significance level of 0.05, and a power of 0.90, it was determined that the number of patients required to be able to detect a difference in waiting time of 2.5 minutes was 84 in each of the two groups assigned in Category (i). It was estimated from the week’s observation that this number could be collected over a period of 6 weeks. In the main study, 179 patients were assigned to Category (i) over the six week period-70 in the triage group and 109 in the non-triage group. (6) Feasibility of non-participant

observation

in the waiting area in A & E.

To monitor patients’ mood and reductions, approximately IO hours of observation was undertaken by a research nurse seated unobtrusively in the patient waiting area, at varied times when triage was functioning and when it was not. No obvious signs of aggression were visible in either patients or relatives; indeed, it was noted that the patience of those waiting was remarkable throughout all observation periods. It was concluded that the

practice of observing the waiting area during the main study was unlikely to produce worthwhile data, and the idea was abandoned. (7) Formulating a patient satisfaction questionnaire to test the opinions of patients on the time they had spent waiting and any inconvenience it had caused them, the anxiety they had experienced as a result of pain or anticipation of the effect of their illness or condition, and the quality of the information offered to them by the triage nurse or other staff in the A & E department. A questionnaire, based on a study of literature on measuring patient satisfaction (McMillan et al., 1986; Walker and Restuccia, 1984; Heberlein and Baumgartner, 1978; Locker and Dunt, 1978; Lebow, 1974; Ware, 1978; Buckles, 1990) was developed over a period of many weeks. Open-ended interviews began the process, leading to structured interviews and finally testing through a mailed questionnaire to a random sample of 100 patients drawn from a 2 day period in June 1990. The response rate was 73410,after one reminder, and the questionnaire appeared to be comprehensible to the respondents. It was estimated that 500 questionnaires would need to be sent to each group (experimental and control) in the main study, allowing for a 70% response rate, in order to test with sufficient statistical power the important differences in response between the triage and no-triage groups, and between those in the four clinical categories. Under ideal circumstances, proper recognition of the opinions of those in most urgent need of care, coupled with due representation of those with less serious illnesses or injuries, would have meant that an equal number of patients would have been selected from each of the four categories in each of the two study groups. However, the small number of patients in Category (i), the most urgent treatment category, meant that, for each such patient, two patients needed to be selected from each of the other three categories, in order that 500 questionnaires could be sent to both triage and no-triage groups. It was thought that the target would probably just be reached within the 6 week main study period. This forecast subsequently proved to be fairly accurate. Nine hundred and eighty questionnaires were distributed in this manner. (8) Devising the data collection process. We established that the A & E department’s daily computer print-out would be the basis for our study population, beginning each day at OS:00 hours and continuing till 20:59 hours, as these were the times the triage system was normally in operation. The dividing time between the morning and afternoon sessions was 14:30 hours. Experimenting with different ways of recording the necessary data items (see below) led to a decision to use individual small record cards for each patient containing all the data items, and a computer record based on the EPI-INFO programme (Dean et al., 1990) containing numerical items only. A photo-copy of the A & E medical record for each patient was made, to enable the senior clinicians retrospectively to assign urgency ratings. The actual records could not be removed from the reception area in case they were needed for return visits. Permission to do this was obtained from the hospital ethics committee. In addition, all triage forms were collected by the research staff. We decided to use these routine channels of information rather than stationing a researcher at the door of the triage room as we had done during part of the pilot stage. We felt that the presence of a researcher affected the behaviour of staff and patients and could thus bias results.

The data collected for each patient were: name, address, date of birth, date of attendance, departmental computer number, research record number, triage time, triage category, booking-in time, time of first seeing doctor, retrospective clinical priority category, date questionnaire sent, date reminder sent, date questionnaire received (if applicable). Each card was also marked as whether triage was scheduled to be in operation on that particular half-day, thus differentiating the experimental and control groups. Following completion of the eight stages of the pilot study we were able to proceed with the main study, the results of which have been published elsewhere (George et al., 1992). Discussion

The necessity for exhaustive piloting We have interpreted pilot studies in their broadest sense, referring to all preparatory work necessary for introducing a research study. This goes far beyond the testing of research instruments and must include researchers gaining a thorough knowledge of the working of the system under study. Points of weakness and possible breakdown need to be appreciated, as well as strengths. For this reason it is important that the pilot study is carried out in the same setting as that chosen for the main study, when the subject for evaluation is a system that has many variations in its operation in different settings. The literature review enabled the research team to identify some of the problems of A & E departments, and to recognize that the operation of a triage system by nurses has been accepted as a solution to some of those problems. The review also demonstrated that American research has concentrated on the safety of nurses as triage agents, and that British research has been minimal and very limited in scope; despite these limitations, the concept has been widely applied to A & E departments in the U.K., involving extra expenditure on staffing and provision of facilities, and often ignoring the fact that the role of triage nurses in the U.K. may not be comparable with that of their U.S.A. colleagues. Conclusive evidence that triage produces the benefits claimed for it seemed to be lacking, and further research therefore seemed appropriate and timely. Time spent observing the everyday running of the A & E department in question proved invaluable. Of far greater importance than knowing how to answer a question is knowing ivhich question needs to be answered. Observation led to the realization that informal prioritization was operating when formal triage was not being performed, and to the subsequent revision of the study hypothesis. The question to be answered was not “does nurse triage benefit patients, compared to their being seen in strict order of attendance?“, but rather “does nurse triage benefit patients, compared to an existing scheme of informal prioritization?” It is at the pilot stage of a study that any revision of a hypothesis must take place. A hypothesis is “a supposition, arrived at from observation or reflection, that to data after the end leads to refutable predictions” (Last, 1988). Fitting a “hypothesis” of a study is therefore incorrect, and likely to lead to wrong conclusions. We also observed that, despite the best intentions of the staff, the triage system could not always be maintained throughout the period between OS:00 and 21 :OO. As has already been explained, the study had of necessity to be conducted on the basis of “intention to triage”. Such a study therefore reflects the real-life situation. One important function of piloting is to detect possible sources of bias in a study. We

have referred to the necessity for classification of study participants by degree of urgency. This has seldom been done in past studies of triage, and casts doubt upon the validity of their results. Similarly, the pilot study demonstrated the point, made earlier, that the time of attendance, as recorded on the A & E computer, was not always the time at which the patients had actually first presented. Another aspect of observation during the pilot study involved one member of the research team being present in the triage area continuously, in order to record accurately the time at which patients saw the triage nurse. Whilst ensuring accurate data collection, this method also aroused considerable tension amongst nursing staff, and possibly amongst patients. It also became apparent that if this process were to continue throughout the 6 weeks of the main study, extra staff would have to be employed, both to cover the necessary hours of observation, and to keep pace with the remainder of the data collection process. During the pilot study, it was found that 95% of the triage forms reached the research team safely, and so it was decided to rely upon the time recorded by the triage nurse on the triage documentation during the main study. The remaining aspect of observation during the pilot study involved a member of the research team sitting in the waiting area, watching for stress or anxiety exhibited amongst patients caused by the time they were having to wait. This part of the pilot study proved inconclusive, and could therefore be discontinued, thus saving valuable time. The careful compilation and testing of the patient satisfaction questionnaire led to a good response rate (72% after one reminder) in the main study. The quality of responses was also very satisfactory, few patients having had difficulty completing the questionnaire. Ambiguous questions, often the result of hastily-put-together untested questionnaires, can lead to disappointing results. Conclusions

It is not safe to assume that systems operate as they are intended to; researchers need to spend plenty of time observing unobtrusively, talking to staff of all grades, talking to patients and generally getting “the feel” of a place, as well as practising their research techniques. Researchers are sometimes asked the question “What results do you expect to get?” Their answer should be “I expect nothing”. If one expects a certain result before starting research, there is a high likelihood that that will be the result achieved. A good researcher should be as objective as possible. Lastly, conducting a field experiment is an imposition and an intrusion for the host community, and has to be handled with sensitivity. The MCRU team were very grateful for the cooperation they received in this work. Acknowledgemen&-The

research team are grateful to the nursing, medical and administrative staff of the Accident

and Emergency Department at Derbyshire Royal Infirmary for their patience and tolerance of our presence, and their willing cooperation. They also wish to thank Lesley Thorpe for her painstaking work in data collection, and Jill Willoughby and Joanne Garnham for secretarial assistance. This work was funded by the Department of Health. which, with Trent Regional Health Authority, maintains the Medical Care Research Unit. We are grateful for their support. The views expressed in this paper, however, are those of the authors alone.

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