ORIGINAL RESEARCH
Triage: an investigation of the process and potential vulnerabilities Maree Hitchcock, Brigid Gillespie, Julia Crilly & Wendy Chaboyer Accepted for publication 12 October 2013
Correspondence to M. Hitchcock: e-mail: [email protected] Maree Hitchcock MN(Hons) RN PhD Candidate Research Centre for Clinical and Community Practice Innovation, Griffith University, Gold Coast, Queensland, Australia Brigid Gillespie PhD RN Senior Research Fellow Research Centre for Clinical and Community Practice Innovation, Griffith University, Gold Coast, Queensland, Australia National Health and Medical Research Council, Centre of Research Excellence in Nursing Interventions for Hospitalised Patients, Griffith University, Gold Coast, Queensland, Australia and Griffith Health Institute, Griffith University, Gold Coast, Queensland, Australia Julia Crilly PhD RN Associate Professor Research Centre for Clinical and Community Practice Innovation, Griffith University, Gold Coast, Queensland, Australia Emergency Department, Gold Coast Hospital, Southport, Queensland, Australia Wendy Chaboyer PhD RN Professor Research Centre for Clinical and Community Practice Innovation, Griffith University, Gold Coast, Queensland, Australia National Health and Medical Research Council, Centre of Research Excellence in Nursing Interventions for Hospitalised Patients, Griffith University, Gold Coast, Queensland, Australia and Griffith Health Institute, Griffith University, Gold Coast, Queensland, Australia
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H I T C H C O C K M . , G I L L E S P I E B . , C R I L L Y J . & C H A B O Y E R W . ( 2 0 1 4 ) Triage: an investigation of the process and potential vulnerabilities. Journal of Advanced Nursing 70(7), 1532–1541. doi: 10.1111/jan.12304
Abstract Aim. To explore and describe the triage process in the Emergency Department to identify problems and potential vulnerabilities that may affect the triage process. Background. Triage is the first step in the patient journey in the Emergency Department and is often the front line in reducing the potential for errors and mistakes. Design. A fieldwork study to provide an in-depth appreciation and understanding of the triage process. Methods. Fieldwork included unstructured observer-only observation, field notes, informal and formal interviews that were conducted over the months of June, July and August 2012. Over 170 hours of observation were performed covering day, evening and night shifts, 7 days of the week. Sixty episodes of triage were observed; 31 informal interviews and 14 formal interviews were completed. Thematic analysis was used. Findings. Three themes were identified from the analysis of the data and included: ‘negotiating patient flow and care delivery through the Emergency Department’; ‘interdisciplinary team communicating and collaborating to provide appropriate and safe care to patients’; and ‘varying levels of competence of the triage nurse’. In these themes, vulnerabilities and problems described included over and under triage, extended time to triage assessment, triage errors, multiple patients arriving simultaneously, emergency department and hospital overcrowding. Conclusion. Findings suggest that vulnerabilities in the triage process may cause disruptions to patient flow and compromise care, thus potentially impacting nurses’ ability to provide safe and effective care. Keywords: emergency, emergency nursing, errors, fieldwork, nurses, patient flow, patient safety, thematic analysis, triage
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Why is this research or review needed? ● This research was necessary to identify vulnerabilities and potential problems in the triage process that may lead to error and risk patient safety. To date, there is little, if any, research that describes vulnerabilities and potential problems in the context of the triage process.
What are the three key findings? ● Hospital overcrowding, access block and emergency department overcrowding all have negative consequences on patient flow, which influence the effectiveness and efficiency of the triage process. ● Ineffective communication, coordination and teamwork can lead to problems and vulnerabilities in the triage process potentially leading to error and adverse events.
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1995). Adverse events are incidents, which cause patient harm that may result in additional treatment, prolonged hospital stay, disability or death (Runciman 2006). The economic toll of adverse events in two states of Australia over 1 year was estimated at $790 million (Jackson et al. 2011). These findings suggest that research and practice change is imperative for healthcare providers to reduce error and risk. Reducing errors and increasing patient safety has become an international focus in health care. This study identifies problems and potential vulnerabilities in the triage process in Emergency Departments (EDs). Knowledge of these risks may potentially reduce errors and prevent patient harm before it occurs, therefore increasing patient safety.
● The level of competence of triage nurses influences the triage process by directly affecting the accuracy of patient assessment, which can affect quality of patient care and place patient safety at risk.
How should the findings be used to influence policy/ practice/research/education? ● Practice change in the process of triaging patients may be required to combat the risks identified in this study as many of the vulnerable areas such as access block and overcrowding are not simple to overcome. ● Problems, potential vulnerabilities and risks found in this study need further investigation to highlight the most ‘high risk’ areas in the triage process, so that solutions may be identified and implemented to increase patient safety and reduce error. ● Continuing education and professional practice updates should be provided to all triage nurses to ensure a level of competence among triage nurses. Education should include content on the potential vulnerabilities that may influence the triage process.
Introduction According to the Institute of Medicine’s report To Err is Human: Building a Safer Health System, between 44,000 and 98,000 people die in USA hospitals each year due to preventable healthcare errors (Kohn et al. 2000). Since this report, patient safety and preventing patient harm has become a major healthcare reform issue (Wakefield et al. 2010). Approximately one in six patients in Australian public hospitals experiences an adverse event, with approximately half of these considered preventable (Wilson et al. © 2013 John Wiley & Sons Ltd
Background EDs have been identified as a site that preventable errors occur (Wilson et al.1995, Johnstone 2007). EDs are the frontline for patients arriving to the hospital setting and are often chaotic in nature due to the urgency of providing lifesaving care to the critically ill. Patient safety research in EDs has focussed on areas such as medication errors (Croskerry et al. 2004, Juarez et al. 2009), medical and diagnostic errors (Flowerdew et al. 2012), and clinical handover (Bost et al. 2010, Wilson 2011). However, there is a lack of research that has focussed on the problems and potential vulnerabilities in the triage process. Triage is the first step in the patient journey in EDs and therefore is the logical step to begin considering patient safety and reducing the potential for errors and mistakes. Triage is a complex and necessary process that is crucial to the safety and effectiveness of serving the community with emergency care. Triage, a process undertaken by a Registered Nurse (RN), involves performing a focused assessment to sort and prioritize patients according to acuity. Table 1 provides a brief description of the Australasian Triage Scale (ATS) and the recommended time frames for treatment. The ATS has been found to be reliable (Considine et al. 2000) and is used to guide triage decisions and treatment time frames (Fry & Burr 2001, FitzGerald et al. 2010).
The study Aim The aim of this study was to explore and describe the triage process in the ED to identify potential problems and vulnerabilities that may impact the triage process. 1533
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Table 1 ATS categories and descriptions. ATS Category
Description
Recommended treatment time
Category Category Category Category Category
Immediately life threatening Imminently life threatening Potentially life threatening Potentially serious Less urgent
Immediate response Within 10 minutes Within 30 minutes Within 60 minutes Within 120 minutes
1 2 3 4 5
Department of Health and Ageing (2007).
Design Fieldwork methods were employed to gain an in-depth appreciation of the process and the experiences and behaviours of those involved in the process (Rice & Ezzy 2001). During fieldwork, the researcher (lead author) spent a specific period in the field focusing on the triage process.
Setting The study was undertaken in an ED at a regional public teaching hospital in Queensland, Australia. The hospital had 450 beds that catered for both medical and surgical needs of adults and children (Queensland Government, Queensland Health 2012). The ED operated on a 24-hour basis and had approximately 67,000 patient presentations per year.
Sample/participants Informants included staff working in the ED setting that were involved in the triage process including triage nurses, emergency nurses, shift leaders, medical officers, ambulance officers and clerical staff. Purposive sampling was used and informants were chosen because of their particular expertise and their willingness to share that information. Informants had special knowledge or experience and were involved in various stages of the triage process. Informants were also selected if they were involved in a particular situation or scenario that unfolded and were therefore able to provide information that related specifically to that event.
Data collection Four data collection strategies were used during fieldwork and included unstructured observer-only observation, field notes, informal and formal interviews. Data collection occurred from June–August, 2012. Observations encompassed day, evening and night shifts spanning 7 days of the week. Observations were conducted in all areas through the 1534
ED. However, the majority of observations were in locations where triage occurred. Observations were recorded through field notes. Informal interviews were driven by the situation and were performed in response to the ‘here and now’ (Streubert & Carpenter 1995). Informal interviews involved asking questions about observed events and behaviours immediately after they occurred, which allowed for the discovery of meanings assigned by the informants to these events (Roper & Shapira 2000). Key informants for formal interviews were triage nurses and medical officers. Informants were selected after preliminary analysis of the previous interview. The formal interviews used a systematic approach and a semi-structured interview guide that ensured a consistent approach (Roper & Shapira 2000) and to reconfirm the data gathered during observations and informal interviews. Questions included: (a) Can you walk me through the steps you use to assign a triage category to patients? (b) What happens when a patient’s condition deteriorates while waiting in the waiting room? (c) How do you manage the competing priorities in the ED? (d) Do you think that there are any problems in the triage process? (e) Is there anything that you think would improve the triage process? Formal interviews were recorded and transcribed immediately after the interview. Data collection continued until data saturation occurred.
Ethical considerations Research Ethics Committee approval was gained from the Human Research Ethics Committee of the university and the hospital. All participants were provided with information sheets and signed consent forms if they were willing to participate. During the fieldwork period, consent was continually renegotiated and reconfirmed with participants. As the researcher was a Registered Nurse, if unsafe practice was observed, she was obliged to intervene to eliminate any risk. However, this did not occur during the project.
Data analysis Thematic analysis was used to analyse the textual data. The data collected appeared in a variety of forms: for instance, interview transcripts, field notes including diagrams, observations, journal entries and direct verbatim from informal interviews. Thematic analysis is a method of identifying, analysing and reporting patterns or themes in the data (Braun & Clarke 2006). The data were compiled and searched to make comparisons among events, interactions and actions, and allowed for conceptualization and informed the coding and categorizing of data. Analysis was © 2013 John Wiley & Sons Ltd
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conducted using an inductive and iterative approach. Data were analysed in three stages: open coding; categorizing of data; and identifying themes (Braun & Clarke 2006, Elo & Kyngas 2007).
Validity and reliability/rigour The techniques of credibility, auditability, transferability and triangulation were used. Credibility was established by taking the findings back to the participants, to assess and explore whether they were a true reflection of participants’ descriptions. A detailed explanation of the development of the research path confirmed auditability (Tobin & Begley 2004). The concept of transferability is concerned with the issues of generalizability. Although the data collected and analysed in this study may not represent all EDs, the triage process and potential vulnerabilities in it may relate to other EDs. Triangulation using multiple sources of data enabled cross-checking of data, therefore achieving confirmation of the data and completeness (Shih 1998). Regular meetings were held with the research team to ensure the rigour of the research plan and to examine emerging categories and themes during analysis. Decisions were made by consensus.
Findings In this study, a ‘problem’ was defined as an impediment, difficulty or error that was noted to occur or observed to occur. A ‘vulnerability’ was an impediment, difficulty or error that had the potential to occur during the triage process. Fieldwork consisted of over 170 hours of observation. Sixty episodes of triage were observed; 31 informal interviews and 14 formal interviews were completed. Table 2 displays a summary of the triage observations. Three themes were identified from the analysis. They were as follows: ‘negotiating patient flow and care delivery through the ED’, ‘interdisciplinary team communicating and collaborating to provide appropriate and safe care to patients’ and ‘varying levels of competence of the triage nurse’. The categories in each theme are italicized and the categories that comprised the themes are presented in Table 3.
Negotiating patient flow and care delivery through the ED The first theme, ‘negotiating patient flow and care delivery through the ED’ was identified as a key component in the © 2013 John Wiley & Sons Ltd
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Table 2 Fieldwork summary: breakdown of observation hours. Shift of observation
Day of observation
Day: 0700–1500 Hours of observation
Evening: 1500–2300 Hours of observation
Night: 2300–0700 Hours of observation
Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Sundays Total
26 105 21 125 7 25 7 865 (48%)
3 13 13 45 7 65 9 56 (31%)
2 2 6 3 9 4 11 37 (21%)
triage process and an area that had potential vulnerabilities. This theme incorporated the movements of patients throughout the ED and how the team directed the most appropriate care, treatment and service area for each patient and included the triage assessment. Triage involved assessing a diverse range of patients who presented with a variety of conditions. Categories subsumed in this theme included: entering the ED; moving the patient through the ED and exiting the ED; triaging of the patient and managing time. ‘Entering the ED’ was the initial step in the triage process. Patients arrived via private means, anecdotally termed ‘walk ins’ and via the ambulance or police service. The method of arrival was relevant as it often led to problems or potential vulnerabilities. Problems identified at the point of ‘entering the ED’ included triage queuing, ambulance ramping and multiple patients arriving simultaneously, which led to triage overload. For instance, a problem involving multiple patients arriving simultaneously was captured in one informant’s comment: When four or five patients arrive at the same time triage gets difficult because you don’t know if the person at the end of the line is more urgent than the one at the beginning as they have not been triaged yet. (Formal interview 10, triage nurse).
This comment described the time pressures and the difficulties that arose when assessing patients who arrived simultaneously. The category, ‘moving the patient through and exiting the ED’ was observed to be imperative to the triage process and was noted by participants to be ‘crucial’ to being able to provide emergency care. In many instances, delays disrupted patient flow through the ED. Hospital overcrowding was observed to lead to access block from the ED. Access block subsequently led to ED overcrowding and the use of 1535
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Table 3 Themes and categories identifying problems and potential vulnerabilities in the triage process. Theme
Categories
Problems/potential vulnerabilities
Patient Flow and Care Delivery through the ED
Entering the ED Moving the patient through the ED and exiting the ED Triaging of the patient Managing Time
Interdisciplinary team Communicating and Collaborating to provide appropriate and safe care to patients
Communicating with others Handing over and Reporting Working as a team Maintaining Safety Varying levels of education Varying levels of experience Varying levels of knowledge Trusting colleagues’ judgements and decisions
Triage queuing Triage overload Multiple patients arriving simultaneously ED overcrowding Access block Hospital overcrowding Extended time to triage Extended time to further assessment Ineffective communication Ineffective teamwork Ineffective collaboration
Varying levels of competence of the triage nurse
overflow areas. Consequently, overcrowding stopped the flow of patients both in and out of the ED and was exemplified in this medical officer’s informal comment: The flow on from hospital overcrowding and access block seems to have negative effects for the whole ED including the triage process.
When the department was overcrowded, it became difficult to have the newly triaged patients seen in their recommended time frames. This was due to a lack of treatment areas being available, as these areas were already full of patients awaiting transfer to inpatient beds. An experienced triage nurse described the impact of this issue on the timeliness of triage: …when the department’s really busy and the hospital is busy and we can’t get beds upstairs [in-patient beds] then we end up with a problem ‘cause we just can’t get the patients in (Formal interview 11, triage nurse).
The problems of hospital overcrowding, access block and having a lack of inpatient beds were observed to disrupt the flow of patients through the ED and regularly halted patient flow. The category, ‘triaging of the patient’ was observed to involve many aspects. The triage assessment usually began with a visual assessment of the patient, listening to the patient and observing the patient. Triage nurses described various aspects of this during interviews. One experienced nurse stated: While I am asking the patient what their presenting complaint is I am also visually assessing the patient. It is just a quick visual 1536
Inexperienced triage nurses Limited triage education Triage errors Overcautious triage Over triage Under triage
assessment but it usually gives you an idea if the patient is really unwell or not (Formal interview 10, triage nurse).
During observations, the visual assessment of the patient and the information that the triage nurse gathered from listening to the patient guided the nurse’s triage decision, i.e. assigning an ATS category and determining the patients’ disposition following triage to either the waiting room, fast track area or onto a bed in the ED. The decision-making process used to assign a triage category was guided by the ATS, which involved assessing and making a decision based on priority and urgency. This decision-making process was described by triage nurses during interviews: I will make a decision based on the ATS guidelines and how long I feel the patient can safely wait for treatment (Formal interview 2, triage nurse).
All triage nurses interviewed stated that they use the ATS to guide triage decisions; however, a medical officer’s opinion was that ‘triage is quite subjective’. There were inconsistencies and problems regarding allocation of triage categories, which may have been due to subjectivity. Problems observed that arose during triage included over and under triage. A triage nurse described ‘over triage’ as: …. triaging each patient thinking that the worst possible outcome will occur rather than triaging their presenting condition (Informal interview).
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Over and under triage was observed to result in patients not being seen and treated in the appropriate order, which lengthened time to treatment in some cases. Other problems observed included lengthy triage assessments, which caused delays for incoming patients and extended time to triage, which led to patients not being seen in recommended time frames. An experienced triage nurse explained: …. it probably takes me about 1 minute to triage a patient, sometimes 2 or 3 minutes if it’s complicated. But it takes some of the newer nurses 5–10 minutes. When it takes that long, patients tend to queue up. If one of those patients in the queue is a cat 2, they have already missed their triage time before their triage assessment is even completed which makes it impossible to see the patient in the recommended time frame (Formal interview 11, triage nurse).
Lengthy triage assessments were observed and mainly involved assessment of patients with complicated problems. Extended time to triage usually involved multiple patients arriving simultaneously. Triage occurred on arrival of the patient or in 1 or 2 minutes. However, waiting for triage was observed: in one instance, a patient waited 19 minutes for triage to commence. Extended time to further assessment or re-assessment was observed. A medical officer described examples that he had experienced: ‘I’ve seen myocardial infarctions take 45 minutes to get through triage’. Examples of extended time to further assessment include 23, 19, 28 minutes (Observations 7, 17 and 24). This occasionally resulted in missing important components of the patient’s condition, triage errors or inappropriate triage category allocation. ‘Managing time’ throughout the triage process was instrumental in facilitating flow. However, it was observed to be difficult due to time pressures. The problem of time pressures was described: The triage nurse has to make a quick decision to keep the flow, so sometimes in an effort to get through the patients as quick as possible you fly through the ones at the beginning of the line and this is where you can miss something’ (Formal interview 10, triage nurse).
Many patients missed recommended triage category time frames. Multiple instances of prolonged waiting times for patients were observed, examples include: Triage category 2 should have been seen within 10 minutes. However, this patient waited 1 hour and 5 minutes (Observation 2). Another patient was allocated a triage category 3, which should be seen within 30 minutes; this patient waited 3 hours and 44 minutes. (Observation 4).
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Entering the ED, moving the patient through the ED, exiting the ED, triaging the patient and managing time impacted on patient flow and care delivery in the triage process.
Interdisciplinary team communicating and collaborating to provide appropriate and safe care to patients The second theme ‘interdisciplinary team communicating and collaborating to provide appropriate and safe care to patients’ incorporated the interactions between ED team members, which were seen to be vital for the continuity of care and moving the patient through the triage process and the ED. Categories included: communicating with others; handing over and reporting; working as a team and maintaining safety. The category, ‘communicating with others’ involved using various methods of interaction among the triage nurse, the patient and other members of the interdisciplinary team. Both verbal and non-verbal communication were used. These two forms of communication were observed throughout the triage process when communicating with patients, patient’s relatives and in the emergency team. Asking questions and listening to responses was observed to be a key aspect of verbal communication. Non-verbal communication involved body language such as waving a medical officer over to see a patient and was usually observed to be followed by verbal communication. Interdisciplinary communication enabled the emergency team to share vital information with each other. Communicating with others also included recording patient information using electronic means. The electronic form of communication provided access for all members of the emergency team to follow the physical location, condition and treatment details of each patient while in the ED. This system appeared to keep all team members informed, without having to ask for details or cause interruptions. ‘Handing over and reporting’ was a part of transfer of responsibility from one care giver to another. Handing over was underpinned by team members’ actions and processes. It was centred on the timely and accurate transfer of patient information used to inform subsequent treatment. Verbal handovers and verbal reporting were commonly witnessed. Some examples of this were seen in verbal handovers by ambulance personnel to ED nurses and quick verbal handovers from the triage nurse to the treating nurse. It was common for handovers to be written in the patient record only. For the majority of patients who were triaged from the waiting room, handover was completed by documenting
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all details on a form which was passed from triage to the treating nurse. Sometimes supplementary information was given verbally to the treating nurse along with the documentation. ‘Working as a team’ and collaborating with others was important to the triage process and the ED as a whole. One aspect of team work in the ED was supporting team members. Examples of working as a team included helping a colleague when needed or supporting an entire resuscitation team when the prognosis for a patient was poor. Collaboration in the emergency team involved coordinating care, discussing plans of action and voicing concerns. Effective teamwork was crucial to the triage process; however, there was always the potential for ineffective teamwork to impede the process as described: …Today we had too many chiefs, a triage nurse, a clinical nurse consultant, a nurse practitioner, the educator and two consultants all trying to do the same thing which seemed to make the rest of the department stop (Informal interview, Nurse).
Staff often had competing priorities, which required decisions to be made based on priority and urgency. An example of competing priorities is described below: It’s the fact that I’ve got a chest pain that is severely short of breath and diaphoretic, I want them seen in 10 minutes, I give them a cat 2. And I can’t find anybody to see that patient. I can’t find the Dr ‘cos he’s off seeing the other two or three patients that have just walked in that are also cat 2′s…. (Formal interview 2, triage nurse).
Maintaining safety throughout the triage process was considered a priority for triage nurses and medical officers. A medical officer’s comment emphasized this: ‘And even if they are just concerned that someone may be unwell but are not completely sure, its best if I go and check as its better to be safe than sorry’ (Formal interview 8, medical officer).
Observation and interviews confirmed that safety was often considered by double checking, evaluating situations, events and managing risks. Clearly, both medical officers and nurses were continually assessing patient safety through the triage process. Team work and communication were shown to be crucial to the triage process.
Varying levels of competence of the triage nurse The third theme identified was ‘varying levels of competence of the triage nurse’, which had the potential to influence the triage process. One a medical officer stated: 1538
… sometimes the lack of experience of some triage nurses is obvious by triage mistakes, it doesn’t happen very often but every now and again you see a prize winner…. (Formal interview 8, medical officer).
Education of triage nurses and developing skills that were used in the triage process appeared essential to providing a high level of care. The level of knowledge and experience of the triage nurse had the potential to affect patient assessment, outcomes and also influenced professional relationships among team members. Categories in this theme include: education; experience; knowledge; trusting colleagues’ judgements; and decisions. Triage ‘education’ and preparing a nurse for the role of triage was crucial. Support and assistance from experienced triage nurses was imperative to developing knowledge and skills that were used in triage. This support was typified in a comment by a junior triage nurse: … I have only been triaging for a month or so, so I’m just starting to get the feel for it. I usually only work triage when there is a more senior nurse who works in the CIN [Clinical Initiatives Nurse] role….. if I need help or guidance I have a more experienced team member…. (Informal interview, junior triage nurse).
Increasing triage education, updating and re-educating triage nurses was an area that many participants said could be improved: … like with anything continuing education, having reviews to observe them and see if their triages are adequate and if not re educate. (Formal interview 6, medical officer).
Many nurses and medical officers believed that the triage nurse’s experience influenced patient assessment and treatment, which was observed during field work. Triage nurses lacking experience were sometimes linked to triage errors and mistakes. Medical officers mentioned this: ‘It is recognised that on occasions a triage category may be incorrectly allocated due to inexperience of the triage nurse’. Many participants thought that triage nurses should have many years of emergency experience before they were considered for the triage role: I would like to see more experienced nurses doing triage at least three or four years post nursing degree (Formal interview 3, medical officer).
Previous experience, exposure or knowledge of an earlier incident involving a triage error or mistake was observed to influence future decisions in relation to triage. An example was given by an experienced triage nurse: You only have to give 1 patient a triage category of 4 who supposedly has a migraine and then you see them having a seizure and a © 2013 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH brain bleed for you to never give anyone presenting with a headache a 4 again, a headache is always a 3, sometimes we learn the hard way (Formal interview 1, triage nurse).
The ‘knowledge’ level of the triage nurse was important; sometimes these differences were reflected in the decisions made by triage nurses. In some situations, knowledge was attributed to experience and therefore knowledge and experience were often grouped together. Overall comments from interviews and observations eluded to the less knowledge and experience of the triage nurse the greater the chance of error. A junior triage nurse offered her thoughts on knowledge and experience: I guess because I am only new at it yet I don’t seem to have that simple 2 second decision that some of the guys have here, because they have so much experience and previous knowledge to draw on (Formal interview 13, triage nurse).
‘Trusting colleagues’ judgements and decisions’ appeared to be related to both knowledge and experience. The higher the level of knowledge and experience displayed by the triage nurse, the more respect and trust they were given from both nursing and medical colleagues. The respect and trust often led to a higher amount of responsibility being given to the triage nurse.
Discussion This field study has identified that issues of ED overcrowding, access block and hospital overcrowding affect and cause further problems in the triage process, especially effecting patient flow. As a result, triage problems such as triage queuing, extended time to triage and extended time to assessment and treatment were observed to occur and may delay patients care and potentially put patients’ safety at risk. Previous research has also shown that ED overcrowding, access block and hospital overcrowding effect flow (Derlet & Richards 2000, Schaferermeyer & Asplin 2003, Richardson 2006, Sun et al. 2006). ED overcrowding is identified as effecting clinical outcomes, by compromising safety and timeliness of care. Our findings suggest that these previously identified ED and hospital problems also cause problems in the triage process. Our findings have described and identified vulnerabilities in the triage process such as time constraints and pressures. In recent times, there has been increased focus surrounding the implementation of the 4-hour rule known as the National Emergency Access Target (NEAT). The NEAT strategy aims for 90% of all patients presenting to EDs being seen, assessed, treated and admitted or discharged in
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a 4-hour time frame (Department of Health & Aging, Australian Government 2011). NEAT may improve the community’s access to emergency care and increase patient flow through the ED and therefore reduce pressure on the triage process. However, the implementation of NEAT is in its early stages. Further research is needed to identify the impact of the NEAT strategy on the Australian healthcare system, EDs and the triage process. Communication, collaboration and teamwork have been highlighted as key to the triage process in these findings. In many instances, there is a need for quick decision-making with limited information that demands effective communication and coordination of caregivers to initiate rapid care to patients. Safe, efficient and quality care require frequent and effective communication between the emergency team. EDs are chaotic environments, which can result in inaccurate or lost information during communication. Therefore, it is important that clear, concise and consistent communication occurs between healthcare providers to minimize the risk of an adverse event occurring (Bost et al. 2010). Previous researchers have linked teamwork to improved patient outcomes (Wheelan et al. 2003). Effective teamwork, coordination and collaboration have been linked to reduced likelihood of error in the ED (Risser et al. 1999). The varying level of triage expertise was found to influence decision-making. A greater level of responsibility and respect was given to the more knowledgeable and experienced nurses and was evidenced by senior medical officers trusting and respecting the decisions and judgements of these nurses without hesitation or question. Senior nurses were sought out by junior nurses and medical staff for advice and support. Education, knowledge and experience of nurses have been investigated in a variety of specialities. Previous research has identified a link between improved patient outcomes and the availability of qualified specialist nurses to provide care for patients (Clark & Aitken 2003). McKenna (1995) identified an association between nurse’s level of education and expertise and the quality of care the nurses provide. More recently, a study conducted in the perioperative speciality identified that more experienced nurses and nurses with speciality education reported higher levels of competence (Gillespie et al. 2011). Education, knowledge and experience of triage nurses are essential to the triage process. Clearly there is an imperative to provide structured education and mentorship of novice ED nurses to increase patient safety and quality of care. Experienced triage nurses take many years to develop the requisite skills and all triage nurses have to start somewhere at some point with no triage experience.
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Limitations The main limitation of this qualitative study is that this was a single site and thus some of the findings may be idiosyncratic. However, by interviewing and observing a variety of health professionals, the triage process itself and identifying potential vulnerabilities in the triage process, many of the findings may be conceptually transferrable to other EDs. Extended fieldwork was used to minimize any Hawthorn effect.
Recommendations for research Through fieldwork methods, multiple vulnerable areas that have potential for error have been identified. These potential errors that may occur during the triage process may affect the entire patient journey through the ED and potentially throughout their entire hospital stay. Therefore, it is crucial to further investigate these potential vulnerable areas in the triage process to improve patient care and safety. This study has provided the impetus for further research, which will empirically assess the probability and severity of each of these potential risk areas.
Conclusion The rationale for this study was to identify problems and potential vulnerabilities in the triage process in an attempt to understand these issues, so that changes or improvements can be made to reduce risk and possible errors in the triage process. ED and hospital overcrowding, access block, patient flow blockages, ineffective communication, collaboration and teamwork and inexperience or a decreased level of competence of the triage nurse have all been identified as problems or potential vulnerabilities in the triage process. It appears that the problems and potential vulnerabilities identified in the triage process herein are similar to those previously identified by other research to effect the overall functioning of the ED. However, our findings have added to this body of evidence: Now, we know that these problems that affect the ED also impact on the triage process and may lead to error and decreased patient safety during the triage process. It is thus imperative to focus specifically on these identified problems that compromise the triage process as they may have far-reaching adverse consequences for patient care and service delivery.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. 1540
M.H. received a government scholarship (Australian Postgraduate Award).
Conflict of interest No conflict of interest has been declared by the author(s).
Author contributions All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/ethical_1author.html)]:
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substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content.
References Bost N., Crilly J., Patterson E. & Chaboyer W. (2010) Clinical handover of patients arriving by ambulance to a hospital emergency department: a qualitative study. International Emergency Nursing 20, 133–141. Braun V. & Clarke V. (2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3, 77–101. Clark S.P. & Aitken L.H. (2003) Failure to rescue: needless deaths are prime examples of the need for more nurses at the bedside. American Journal of Nursing 103(1), 42–47. Considine J., Ung L. & Thomas S. (2000) Triage nurses’ decisions using the National Triage Scale for Australian emergency departments. Accident and Emergency Nursing 8(4), 201–9. Croskerry P., Shapiro M., Campbell S., LeBlanc C., Sinclair D., Wren P. & Marcoux M. (2004) Profiles in patient safety: medication errors in the emergency department. Academic Emergency Medicine 11, 289–299. Department of Health and Aging (2007) Emergency Triage Education Kit. Commonwealth Government, Canberra. Department of Health and Aging, Australian Government (2011) Expert panel review of elective surgery and emergency access targets under the national partnership agreement of improving public hospital services. Retrieved from http://www.yourhealth. gov.au/internet/yourhealth on 8 December 2011. Derlet R.W. & Richards J.R. (2000) Overcrowding in the nation’s emergency departments: complex causes and disturbing effects. Annals of Emergency Medicine 35(1), 63–68. Elo S. & Kyngas H. (2007) The qualitative analysis process. Journal of Advanced Nursing 62(1), 107–115. FitzGerald G., Jelinek G., Scott D. & Gerdtz M. (2010) Emergency department triage revisited. Postgraduate Medical Journal 86 (1018), 502–508. Flowerdew L., Brown R., Vincent C. & Woloshynowych, (2012) Identifying nontechnical skills associated with safety in the
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JAN: ORIGINAL RESEARCH emergency department: a scoping review of the literature. Annals of Emergency Medicine 59(5), 386–394. Fry M. & Burr G. (2001) Using a survey tool to explore the processes underpinning the triage role: a pilot study. Australasian Emergency Nursing Journal 4(11), 27–31. Gillespie B., Chaboyer W., Wallis M. & Werder H. (2011) Education and experience make a difference: results of a predictor study. Association of Operating Room Nurses Journal 94(1), 78–90. Jackson T., Nghiem H., Rowell D., Jorm C. & Wakefield J. (2011) Marginal costs of hospital aquired conditions: information for priority setting for patient safety programmes and research. Journal of Health Services Research Policy 16(3), 141–146. Johnstone M. (2007) Patient safety ethics and human error management in ED contexts Part 2: accountability and the challenge to change. Australasian Emergency Nursing Journal 10, 80–85. Juarez A., Gracki-Smith J., Bauer M., Jepsen D., Paparella S., VonGoerres B. & MacLean S. (2009) Barriers to emergency departments’ adherence to four medication safety-related Joint Commission National patient safety goals. The Joint Commission Journal on Quality and Patient Safety 35(1), 49–59. Kohn L.T., Carrigan J.M. & Donaldson M.S. (2000) To Err is Human: Building a Safer Health System. Institute of Medicine (IOM), National Academy Press, Washington, DC. McKenna H. (1995) Nursing skill mix substitutions and quality of care: an exploration of assumptions from the research literature. Journal of Advanced Nursing 21(3), 452–459. Queensland Government, Queensland Health (2012) Emergency Departments. Retrieved from http://www.health.qld.gov.au/ emergency/default.asp on 28 September 2012. Rice P. & Ezzy D. (2001) Qualitative Research Methods. Oxford University Press, Melbourne. Richardson D.B. (2006) Increase in patient mortality at 10 days associated with emergency department overcrowding. Medical Journal of Australia 184(5), 213–216.
The triage process Risser D.T., Rice M.M., Salisbury M.L., Simon R., Jay G.D. & Berns S.D. (1999) The potential for improved teamwork to reduce medical errors in the emergency department. Annals of Emergency Medicine 34(3), 373–383. Roper J.M. & Shapira J. (2000) Ethnography in Nursing Research. Sage, California. Runciman W.B. (2006) Shared meanings: preferred terms and definitions for safety and quality concepts. Medical Journal of Australia 184(5), 41–43. Schaferermeyer R.W. & Asplin B.R. (2003) Hospital and emergency department crowding in the United States. Emergency Medicine 15(1), 22–27. Shih F.S. (1998) Triangulation in nursing research: Issues of conceptual clarity and purpose. Journal of Advanced Nursing 28 (3), 631–641. Streubert H. & Carpenter D. (1995) Qualitative Research in Nursing. J. B. Lippincott, Philadelphia, PA. Sun B.C., Mohanty S.A., Weiss R., Tadeo R., Hasbrouck M., Koenig W., Meyer C. & Asch S. (2006) Effects of hospital closures and hospital characteristics on emergency department ambulance diversion, Los Angeles County, 1998 to 2004. Annals of Emergency Medicine 47(4), 309–316. Tobin G. & Begley C. (2004) Methodological rigour within a qualitative framework. Journal of Advanced Nursing 48(4), 388– 396. Wakefield J., McLaws M., Whitby M. & Patton L. (2010) Patient safety culture: factors that influence clinician involvement in patient safety behaviours. Quality and Safety in Healthcare 19 (6), 585–591. Wheelan S.A., Burchell C.N. & Tilin F. (2003) The link between teamwork and patients’ outcomes in intensive care units. American Journal of Critical Care 12(6), 527–534. Wilson R. (2011) Improving clinical handover in emergency departments. Emergency Nurse 19, 22–26. Wilson R.M., Runciman W.B., Gibberd S.J., Harrison B.T., Newby L. & Hamilton J.D. (1995) The quality in Australian Health Care Study. Medical Journal of Australia 163(6), 458–471.
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Triage: an investigation of the process and potential vulnerabilities Maree Hitchcock, Brigid Gillespie, Julia Crilly & Wendy Chaboyer Accepted for publication 12 October 2013
Correspondence to M. Hitchcock: e-mail: [email protected] Maree Hitchcock MN(Hons) RN PhD Candidate Research Centre for Clinical and Community Practice Innovation, Griffith University, Gold Coast, Queensland, Australia Brigid Gillespie PhD RN Senior Research Fellow Research Centre for Clinical and Community Practice Innovation, Griffith University, Gold Coast, Queensland, Australia National Health and Medical Research Council, Centre of Research Excellence in Nursing Interventions for Hospitalised Patients, Griffith University, Gold Coast, Queensland, Australia and Griffith Health Institute, Griffith University, Gold Coast, Queensland, Australia Julia Crilly PhD RN Associate Professor Research Centre for Clinical and Community Practice Innovation, Griffith University, Gold Coast, Queensland, Australia Emergency Department, Gold Coast Hospital, Southport, Queensland, Australia Wendy Chaboyer PhD RN Professor Research Centre for Clinical and Community Practice Innovation, Griffith University, Gold Coast, Queensland, Australia National Health and Medical Research Council, Centre of Research Excellence in Nursing Interventions for Hospitalised Patients, Griffith University, Gold Coast, Queensland, Australia and Griffith Health Institute, Griffith University, Gold Coast, Queensland, Australia
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H I T C H C O C K M . , G I L L E S P I E B . , C R I L L Y J . & C H A B O Y E R W . ( 2 0 1 4 ) Triage: an investigation of the process and potential vulnerabilities. Journal of Advanced Nursing 70(7), 1532–1541. doi: 10.1111/jan.12304
Abstract Aim. To explore and describe the triage process in the Emergency Department to identify problems and potential vulnerabilities that may affect the triage process. Background. Triage is the first step in the patient journey in the Emergency Department and is often the front line in reducing the potential for errors and mistakes. Design. A fieldwork study to provide an in-depth appreciation and understanding of the triage process. Methods. Fieldwork included unstructured observer-only observation, field notes, informal and formal interviews that were conducted over the months of June, July and August 2012. Over 170 hours of observation were performed covering day, evening and night shifts, 7 days of the week. Sixty episodes of triage were observed; 31 informal interviews and 14 formal interviews were completed. Thematic analysis was used. Findings. Three themes were identified from the analysis of the data and included: ‘negotiating patient flow and care delivery through the Emergency Department’; ‘interdisciplinary team communicating and collaborating to provide appropriate and safe care to patients’; and ‘varying levels of competence of the triage nurse’. In these themes, vulnerabilities and problems described included over and under triage, extended time to triage assessment, triage errors, multiple patients arriving simultaneously, emergency department and hospital overcrowding. Conclusion. Findings suggest that vulnerabilities in the triage process may cause disruptions to patient flow and compromise care, thus potentially impacting nurses’ ability to provide safe and effective care. Keywords: emergency, emergency nursing, errors, fieldwork, nurses, patient flow, patient safety, thematic analysis, triage
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Why is this research or review needed? ● This research was necessary to identify vulnerabilities and potential problems in the triage process that may lead to error and risk patient safety. To date, there is little, if any, research that describes vulnerabilities and potential problems in the context of the triage process.
What are the three key findings? ● Hospital overcrowding, access block and emergency department overcrowding all have negative consequences on patient flow, which influence the effectiveness and efficiency of the triage process. ● Ineffective communication, coordination and teamwork can lead to problems and vulnerabilities in the triage process potentially leading to error and adverse events.
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1995). Adverse events are incidents, which cause patient harm that may result in additional treatment, prolonged hospital stay, disability or death (Runciman 2006). The economic toll of adverse events in two states of Australia over 1 year was estimated at $790 million (Jackson et al. 2011). These findings suggest that research and practice change is imperative for healthcare providers to reduce error and risk. Reducing errors and increasing patient safety has become an international focus in health care. This study identifies problems and potential vulnerabilities in the triage process in Emergency Departments (EDs). Knowledge of these risks may potentially reduce errors and prevent patient harm before it occurs, therefore increasing patient safety.
● The level of competence of triage nurses influences the triage process by directly affecting the accuracy of patient assessment, which can affect quality of patient care and place patient safety at risk.
How should the findings be used to influence policy/ practice/research/education? ● Practice change in the process of triaging patients may be required to combat the risks identified in this study as many of the vulnerable areas such as access block and overcrowding are not simple to overcome. ● Problems, potential vulnerabilities and risks found in this study need further investigation to highlight the most ‘high risk’ areas in the triage process, so that solutions may be identified and implemented to increase patient safety and reduce error. ● Continuing education and professional practice updates should be provided to all triage nurses to ensure a level of competence among triage nurses. Education should include content on the potential vulnerabilities that may influence the triage process.
Introduction According to the Institute of Medicine’s report To Err is Human: Building a Safer Health System, between 44,000 and 98,000 people die in USA hospitals each year due to preventable healthcare errors (Kohn et al. 2000). Since this report, patient safety and preventing patient harm has become a major healthcare reform issue (Wakefield et al. 2010). Approximately one in six patients in Australian public hospitals experiences an adverse event, with approximately half of these considered preventable (Wilson et al. © 2013 John Wiley & Sons Ltd
Background EDs have been identified as a site that preventable errors occur (Wilson et al.1995, Johnstone 2007). EDs are the frontline for patients arriving to the hospital setting and are often chaotic in nature due to the urgency of providing lifesaving care to the critically ill. Patient safety research in EDs has focussed on areas such as medication errors (Croskerry et al. 2004, Juarez et al. 2009), medical and diagnostic errors (Flowerdew et al. 2012), and clinical handover (Bost et al. 2010, Wilson 2011). However, there is a lack of research that has focussed on the problems and potential vulnerabilities in the triage process. Triage is the first step in the patient journey in EDs and therefore is the logical step to begin considering patient safety and reducing the potential for errors and mistakes. Triage is a complex and necessary process that is crucial to the safety and effectiveness of serving the community with emergency care. Triage, a process undertaken by a Registered Nurse (RN), involves performing a focused assessment to sort and prioritize patients according to acuity. Table 1 provides a brief description of the Australasian Triage Scale (ATS) and the recommended time frames for treatment. The ATS has been found to be reliable (Considine et al. 2000) and is used to guide triage decisions and treatment time frames (Fry & Burr 2001, FitzGerald et al. 2010).
The study Aim The aim of this study was to explore and describe the triage process in the ED to identify potential problems and vulnerabilities that may impact the triage process. 1533
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Table 1 ATS categories and descriptions. ATS Category
Description
Recommended treatment time
Category Category Category Category Category
Immediately life threatening Imminently life threatening Potentially life threatening Potentially serious Less urgent
Immediate response Within 10 minutes Within 30 minutes Within 60 minutes Within 120 minutes
1 2 3 4 5
Department of Health and Ageing (2007).
Design Fieldwork methods were employed to gain an in-depth appreciation of the process and the experiences and behaviours of those involved in the process (Rice & Ezzy 2001). During fieldwork, the researcher (lead author) spent a specific period in the field focusing on the triage process.
Setting The study was undertaken in an ED at a regional public teaching hospital in Queensland, Australia. The hospital had 450 beds that catered for both medical and surgical needs of adults and children (Queensland Government, Queensland Health 2012). The ED operated on a 24-hour basis and had approximately 67,000 patient presentations per year.
Sample/participants Informants included staff working in the ED setting that were involved in the triage process including triage nurses, emergency nurses, shift leaders, medical officers, ambulance officers and clerical staff. Purposive sampling was used and informants were chosen because of their particular expertise and their willingness to share that information. Informants had special knowledge or experience and were involved in various stages of the triage process. Informants were also selected if they were involved in a particular situation or scenario that unfolded and were therefore able to provide information that related specifically to that event.
Data collection Four data collection strategies were used during fieldwork and included unstructured observer-only observation, field notes, informal and formal interviews. Data collection occurred from June–August, 2012. Observations encompassed day, evening and night shifts spanning 7 days of the week. Observations were conducted in all areas through the 1534
ED. However, the majority of observations were in locations where triage occurred. Observations were recorded through field notes. Informal interviews were driven by the situation and were performed in response to the ‘here and now’ (Streubert & Carpenter 1995). Informal interviews involved asking questions about observed events and behaviours immediately after they occurred, which allowed for the discovery of meanings assigned by the informants to these events (Roper & Shapira 2000). Key informants for formal interviews were triage nurses and medical officers. Informants were selected after preliminary analysis of the previous interview. The formal interviews used a systematic approach and a semi-structured interview guide that ensured a consistent approach (Roper & Shapira 2000) and to reconfirm the data gathered during observations and informal interviews. Questions included: (a) Can you walk me through the steps you use to assign a triage category to patients? (b) What happens when a patient’s condition deteriorates while waiting in the waiting room? (c) How do you manage the competing priorities in the ED? (d) Do you think that there are any problems in the triage process? (e) Is there anything that you think would improve the triage process? Formal interviews were recorded and transcribed immediately after the interview. Data collection continued until data saturation occurred.
Ethical considerations Research Ethics Committee approval was gained from the Human Research Ethics Committee of the university and the hospital. All participants were provided with information sheets and signed consent forms if they were willing to participate. During the fieldwork period, consent was continually renegotiated and reconfirmed with participants. As the researcher was a Registered Nurse, if unsafe practice was observed, she was obliged to intervene to eliminate any risk. However, this did not occur during the project.
Data analysis Thematic analysis was used to analyse the textual data. The data collected appeared in a variety of forms: for instance, interview transcripts, field notes including diagrams, observations, journal entries and direct verbatim from informal interviews. Thematic analysis is a method of identifying, analysing and reporting patterns or themes in the data (Braun & Clarke 2006). The data were compiled and searched to make comparisons among events, interactions and actions, and allowed for conceptualization and informed the coding and categorizing of data. Analysis was © 2013 John Wiley & Sons Ltd
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conducted using an inductive and iterative approach. Data were analysed in three stages: open coding; categorizing of data; and identifying themes (Braun & Clarke 2006, Elo & Kyngas 2007).
Validity and reliability/rigour The techniques of credibility, auditability, transferability and triangulation were used. Credibility was established by taking the findings back to the participants, to assess and explore whether they were a true reflection of participants’ descriptions. A detailed explanation of the development of the research path confirmed auditability (Tobin & Begley 2004). The concept of transferability is concerned with the issues of generalizability. Although the data collected and analysed in this study may not represent all EDs, the triage process and potential vulnerabilities in it may relate to other EDs. Triangulation using multiple sources of data enabled cross-checking of data, therefore achieving confirmation of the data and completeness (Shih 1998). Regular meetings were held with the research team to ensure the rigour of the research plan and to examine emerging categories and themes during analysis. Decisions were made by consensus.
Findings In this study, a ‘problem’ was defined as an impediment, difficulty or error that was noted to occur or observed to occur. A ‘vulnerability’ was an impediment, difficulty or error that had the potential to occur during the triage process. Fieldwork consisted of over 170 hours of observation. Sixty episodes of triage were observed; 31 informal interviews and 14 formal interviews were completed. Table 2 displays a summary of the triage observations. Three themes were identified from the analysis. They were as follows: ‘negotiating patient flow and care delivery through the ED’, ‘interdisciplinary team communicating and collaborating to provide appropriate and safe care to patients’ and ‘varying levels of competence of the triage nurse’. The categories in each theme are italicized and the categories that comprised the themes are presented in Table 3.
Negotiating patient flow and care delivery through the ED The first theme, ‘negotiating patient flow and care delivery through the ED’ was identified as a key component in the © 2013 John Wiley & Sons Ltd
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Table 2 Fieldwork summary: breakdown of observation hours. Shift of observation
Day of observation
Day: 0700–1500 Hours of observation
Evening: 1500–2300 Hours of observation
Night: 2300–0700 Hours of observation
Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Sundays Total
26 105 21 125 7 25 7 865 (48%)
3 13 13 45 7 65 9 56 (31%)
2 2 6 3 9 4 11 37 (21%)
triage process and an area that had potential vulnerabilities. This theme incorporated the movements of patients throughout the ED and how the team directed the most appropriate care, treatment and service area for each patient and included the triage assessment. Triage involved assessing a diverse range of patients who presented with a variety of conditions. Categories subsumed in this theme included: entering the ED; moving the patient through the ED and exiting the ED; triaging of the patient and managing time. ‘Entering the ED’ was the initial step in the triage process. Patients arrived via private means, anecdotally termed ‘walk ins’ and via the ambulance or police service. The method of arrival was relevant as it often led to problems or potential vulnerabilities. Problems identified at the point of ‘entering the ED’ included triage queuing, ambulance ramping and multiple patients arriving simultaneously, which led to triage overload. For instance, a problem involving multiple patients arriving simultaneously was captured in one informant’s comment: When four or five patients arrive at the same time triage gets difficult because you don’t know if the person at the end of the line is more urgent than the one at the beginning as they have not been triaged yet. (Formal interview 10, triage nurse).
This comment described the time pressures and the difficulties that arose when assessing patients who arrived simultaneously. The category, ‘moving the patient through and exiting the ED’ was observed to be imperative to the triage process and was noted by participants to be ‘crucial’ to being able to provide emergency care. In many instances, delays disrupted patient flow through the ED. Hospital overcrowding was observed to lead to access block from the ED. Access block subsequently led to ED overcrowding and the use of 1535
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Table 3 Themes and categories identifying problems and potential vulnerabilities in the triage process. Theme
Categories
Problems/potential vulnerabilities
Patient Flow and Care Delivery through the ED
Entering the ED Moving the patient through the ED and exiting the ED Triaging of the patient Managing Time
Interdisciplinary team Communicating and Collaborating to provide appropriate and safe care to patients
Communicating with others Handing over and Reporting Working as a team Maintaining Safety Varying levels of education Varying levels of experience Varying levels of knowledge Trusting colleagues’ judgements and decisions
Triage queuing Triage overload Multiple patients arriving simultaneously ED overcrowding Access block Hospital overcrowding Extended time to triage Extended time to further assessment Ineffective communication Ineffective teamwork Ineffective collaboration
Varying levels of competence of the triage nurse
overflow areas. Consequently, overcrowding stopped the flow of patients both in and out of the ED and was exemplified in this medical officer’s informal comment: The flow on from hospital overcrowding and access block seems to have negative effects for the whole ED including the triage process.
When the department was overcrowded, it became difficult to have the newly triaged patients seen in their recommended time frames. This was due to a lack of treatment areas being available, as these areas were already full of patients awaiting transfer to inpatient beds. An experienced triage nurse described the impact of this issue on the timeliness of triage: …when the department’s really busy and the hospital is busy and we can’t get beds upstairs [in-patient beds] then we end up with a problem ‘cause we just can’t get the patients in (Formal interview 11, triage nurse).
The problems of hospital overcrowding, access block and having a lack of inpatient beds were observed to disrupt the flow of patients through the ED and regularly halted patient flow. The category, ‘triaging of the patient’ was observed to involve many aspects. The triage assessment usually began with a visual assessment of the patient, listening to the patient and observing the patient. Triage nurses described various aspects of this during interviews. One experienced nurse stated: While I am asking the patient what their presenting complaint is I am also visually assessing the patient. It is just a quick visual 1536
Inexperienced triage nurses Limited triage education Triage errors Overcautious triage Over triage Under triage
assessment but it usually gives you an idea if the patient is really unwell or not (Formal interview 10, triage nurse).
During observations, the visual assessment of the patient and the information that the triage nurse gathered from listening to the patient guided the nurse’s triage decision, i.e. assigning an ATS category and determining the patients’ disposition following triage to either the waiting room, fast track area or onto a bed in the ED. The decision-making process used to assign a triage category was guided by the ATS, which involved assessing and making a decision based on priority and urgency. This decision-making process was described by triage nurses during interviews: I will make a decision based on the ATS guidelines and how long I feel the patient can safely wait for treatment (Formal interview 2, triage nurse).
All triage nurses interviewed stated that they use the ATS to guide triage decisions; however, a medical officer’s opinion was that ‘triage is quite subjective’. There were inconsistencies and problems regarding allocation of triage categories, which may have been due to subjectivity. Problems observed that arose during triage included over and under triage. A triage nurse described ‘over triage’ as: …. triaging each patient thinking that the worst possible outcome will occur rather than triaging their presenting condition (Informal interview).
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Over and under triage was observed to result in patients not being seen and treated in the appropriate order, which lengthened time to treatment in some cases. Other problems observed included lengthy triage assessments, which caused delays for incoming patients and extended time to triage, which led to patients not being seen in recommended time frames. An experienced triage nurse explained: …. it probably takes me about 1 minute to triage a patient, sometimes 2 or 3 minutes if it’s complicated. But it takes some of the newer nurses 5–10 minutes. When it takes that long, patients tend to queue up. If one of those patients in the queue is a cat 2, they have already missed their triage time before their triage assessment is even completed which makes it impossible to see the patient in the recommended time frame (Formal interview 11, triage nurse).
Lengthy triage assessments were observed and mainly involved assessment of patients with complicated problems. Extended time to triage usually involved multiple patients arriving simultaneously. Triage occurred on arrival of the patient or in 1 or 2 minutes. However, waiting for triage was observed: in one instance, a patient waited 19 minutes for triage to commence. Extended time to further assessment or re-assessment was observed. A medical officer described examples that he had experienced: ‘I’ve seen myocardial infarctions take 45 minutes to get through triage’. Examples of extended time to further assessment include 23, 19, 28 minutes (Observations 7, 17 and 24). This occasionally resulted in missing important components of the patient’s condition, triage errors or inappropriate triage category allocation. ‘Managing time’ throughout the triage process was instrumental in facilitating flow. However, it was observed to be difficult due to time pressures. The problem of time pressures was described: The triage nurse has to make a quick decision to keep the flow, so sometimes in an effort to get through the patients as quick as possible you fly through the ones at the beginning of the line and this is where you can miss something’ (Formal interview 10, triage nurse).
Many patients missed recommended triage category time frames. Multiple instances of prolonged waiting times for patients were observed, examples include: Triage category 2 should have been seen within 10 minutes. However, this patient waited 1 hour and 5 minutes (Observation 2). Another patient was allocated a triage category 3, which should be seen within 30 minutes; this patient waited 3 hours and 44 minutes. (Observation 4).
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Entering the ED, moving the patient through the ED, exiting the ED, triaging the patient and managing time impacted on patient flow and care delivery in the triage process.
Interdisciplinary team communicating and collaborating to provide appropriate and safe care to patients The second theme ‘interdisciplinary team communicating and collaborating to provide appropriate and safe care to patients’ incorporated the interactions between ED team members, which were seen to be vital for the continuity of care and moving the patient through the triage process and the ED. Categories included: communicating with others; handing over and reporting; working as a team and maintaining safety. The category, ‘communicating with others’ involved using various methods of interaction among the triage nurse, the patient and other members of the interdisciplinary team. Both verbal and non-verbal communication were used. These two forms of communication were observed throughout the triage process when communicating with patients, patient’s relatives and in the emergency team. Asking questions and listening to responses was observed to be a key aspect of verbal communication. Non-verbal communication involved body language such as waving a medical officer over to see a patient and was usually observed to be followed by verbal communication. Interdisciplinary communication enabled the emergency team to share vital information with each other. Communicating with others also included recording patient information using electronic means. The electronic form of communication provided access for all members of the emergency team to follow the physical location, condition and treatment details of each patient while in the ED. This system appeared to keep all team members informed, without having to ask for details or cause interruptions. ‘Handing over and reporting’ was a part of transfer of responsibility from one care giver to another. Handing over was underpinned by team members’ actions and processes. It was centred on the timely and accurate transfer of patient information used to inform subsequent treatment. Verbal handovers and verbal reporting were commonly witnessed. Some examples of this were seen in verbal handovers by ambulance personnel to ED nurses and quick verbal handovers from the triage nurse to the treating nurse. It was common for handovers to be written in the patient record only. For the majority of patients who were triaged from the waiting room, handover was completed by documenting
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all details on a form which was passed from triage to the treating nurse. Sometimes supplementary information was given verbally to the treating nurse along with the documentation. ‘Working as a team’ and collaborating with others was important to the triage process and the ED as a whole. One aspect of team work in the ED was supporting team members. Examples of working as a team included helping a colleague when needed or supporting an entire resuscitation team when the prognosis for a patient was poor. Collaboration in the emergency team involved coordinating care, discussing plans of action and voicing concerns. Effective teamwork was crucial to the triage process; however, there was always the potential for ineffective teamwork to impede the process as described: …Today we had too many chiefs, a triage nurse, a clinical nurse consultant, a nurse practitioner, the educator and two consultants all trying to do the same thing which seemed to make the rest of the department stop (Informal interview, Nurse).
Staff often had competing priorities, which required decisions to be made based on priority and urgency. An example of competing priorities is described below: It’s the fact that I’ve got a chest pain that is severely short of breath and diaphoretic, I want them seen in 10 minutes, I give them a cat 2. And I can’t find anybody to see that patient. I can’t find the Dr ‘cos he’s off seeing the other two or three patients that have just walked in that are also cat 2′s…. (Formal interview 2, triage nurse).
Maintaining safety throughout the triage process was considered a priority for triage nurses and medical officers. A medical officer’s comment emphasized this: ‘And even if they are just concerned that someone may be unwell but are not completely sure, its best if I go and check as its better to be safe than sorry’ (Formal interview 8, medical officer).
Observation and interviews confirmed that safety was often considered by double checking, evaluating situations, events and managing risks. Clearly, both medical officers and nurses were continually assessing patient safety through the triage process. Team work and communication were shown to be crucial to the triage process.
Varying levels of competence of the triage nurse The third theme identified was ‘varying levels of competence of the triage nurse’, which had the potential to influence the triage process. One a medical officer stated: 1538
… sometimes the lack of experience of some triage nurses is obvious by triage mistakes, it doesn’t happen very often but every now and again you see a prize winner…. (Formal interview 8, medical officer).
Education of triage nurses and developing skills that were used in the triage process appeared essential to providing a high level of care. The level of knowledge and experience of the triage nurse had the potential to affect patient assessment, outcomes and also influenced professional relationships among team members. Categories in this theme include: education; experience; knowledge; trusting colleagues’ judgements; and decisions. Triage ‘education’ and preparing a nurse for the role of triage was crucial. Support and assistance from experienced triage nurses was imperative to developing knowledge and skills that were used in triage. This support was typified in a comment by a junior triage nurse: … I have only been triaging for a month or so, so I’m just starting to get the feel for it. I usually only work triage when there is a more senior nurse who works in the CIN [Clinical Initiatives Nurse] role….. if I need help or guidance I have a more experienced team member…. (Informal interview, junior triage nurse).
Increasing triage education, updating and re-educating triage nurses was an area that many participants said could be improved: … like with anything continuing education, having reviews to observe them and see if their triages are adequate and if not re educate. (Formal interview 6, medical officer).
Many nurses and medical officers believed that the triage nurse’s experience influenced patient assessment and treatment, which was observed during field work. Triage nurses lacking experience were sometimes linked to triage errors and mistakes. Medical officers mentioned this: ‘It is recognised that on occasions a triage category may be incorrectly allocated due to inexperience of the triage nurse’. Many participants thought that triage nurses should have many years of emergency experience before they were considered for the triage role: I would like to see more experienced nurses doing triage at least three or four years post nursing degree (Formal interview 3, medical officer).
Previous experience, exposure or knowledge of an earlier incident involving a triage error or mistake was observed to influence future decisions in relation to triage. An example was given by an experienced triage nurse: You only have to give 1 patient a triage category of 4 who supposedly has a migraine and then you see them having a seizure and a © 2013 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH brain bleed for you to never give anyone presenting with a headache a 4 again, a headache is always a 3, sometimes we learn the hard way (Formal interview 1, triage nurse).
The ‘knowledge’ level of the triage nurse was important; sometimes these differences were reflected in the decisions made by triage nurses. In some situations, knowledge was attributed to experience and therefore knowledge and experience were often grouped together. Overall comments from interviews and observations eluded to the less knowledge and experience of the triage nurse the greater the chance of error. A junior triage nurse offered her thoughts on knowledge and experience: I guess because I am only new at it yet I don’t seem to have that simple 2 second decision that some of the guys have here, because they have so much experience and previous knowledge to draw on (Formal interview 13, triage nurse).
‘Trusting colleagues’ judgements and decisions’ appeared to be related to both knowledge and experience. The higher the level of knowledge and experience displayed by the triage nurse, the more respect and trust they were given from both nursing and medical colleagues. The respect and trust often led to a higher amount of responsibility being given to the triage nurse.
Discussion This field study has identified that issues of ED overcrowding, access block and hospital overcrowding affect and cause further problems in the triage process, especially effecting patient flow. As a result, triage problems such as triage queuing, extended time to triage and extended time to assessment and treatment were observed to occur and may delay patients care and potentially put patients’ safety at risk. Previous research has also shown that ED overcrowding, access block and hospital overcrowding effect flow (Derlet & Richards 2000, Schaferermeyer & Asplin 2003, Richardson 2006, Sun et al. 2006). ED overcrowding is identified as effecting clinical outcomes, by compromising safety and timeliness of care. Our findings suggest that these previously identified ED and hospital problems also cause problems in the triage process. Our findings have described and identified vulnerabilities in the triage process such as time constraints and pressures. In recent times, there has been increased focus surrounding the implementation of the 4-hour rule known as the National Emergency Access Target (NEAT). The NEAT strategy aims for 90% of all patients presenting to EDs being seen, assessed, treated and admitted or discharged in
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The triage process
a 4-hour time frame (Department of Health & Aging, Australian Government 2011). NEAT may improve the community’s access to emergency care and increase patient flow through the ED and therefore reduce pressure on the triage process. However, the implementation of NEAT is in its early stages. Further research is needed to identify the impact of the NEAT strategy on the Australian healthcare system, EDs and the triage process. Communication, collaboration and teamwork have been highlighted as key to the triage process in these findings. In many instances, there is a need for quick decision-making with limited information that demands effective communication and coordination of caregivers to initiate rapid care to patients. Safe, efficient and quality care require frequent and effective communication between the emergency team. EDs are chaotic environments, which can result in inaccurate or lost information during communication. Therefore, it is important that clear, concise and consistent communication occurs between healthcare providers to minimize the risk of an adverse event occurring (Bost et al. 2010). Previous researchers have linked teamwork to improved patient outcomes (Wheelan et al. 2003). Effective teamwork, coordination and collaboration have been linked to reduced likelihood of error in the ED (Risser et al. 1999). The varying level of triage expertise was found to influence decision-making. A greater level of responsibility and respect was given to the more knowledgeable and experienced nurses and was evidenced by senior medical officers trusting and respecting the decisions and judgements of these nurses without hesitation or question. Senior nurses were sought out by junior nurses and medical staff for advice and support. Education, knowledge and experience of nurses have been investigated in a variety of specialities. Previous research has identified a link between improved patient outcomes and the availability of qualified specialist nurses to provide care for patients (Clark & Aitken 2003). McKenna (1995) identified an association between nurse’s level of education and expertise and the quality of care the nurses provide. More recently, a study conducted in the perioperative speciality identified that more experienced nurses and nurses with speciality education reported higher levels of competence (Gillespie et al. 2011). Education, knowledge and experience of triage nurses are essential to the triage process. Clearly there is an imperative to provide structured education and mentorship of novice ED nurses to increase patient safety and quality of care. Experienced triage nurses take many years to develop the requisite skills and all triage nurses have to start somewhere at some point with no triage experience.
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Limitations The main limitation of this qualitative study is that this was a single site and thus some of the findings may be idiosyncratic. However, by interviewing and observing a variety of health professionals, the triage process itself and identifying potential vulnerabilities in the triage process, many of the findings may be conceptually transferrable to other EDs. Extended fieldwork was used to minimize any Hawthorn effect.
Recommendations for research Through fieldwork methods, multiple vulnerable areas that have potential for error have been identified. These potential errors that may occur during the triage process may affect the entire patient journey through the ED and potentially throughout their entire hospital stay. Therefore, it is crucial to further investigate these potential vulnerable areas in the triage process to improve patient care and safety. This study has provided the impetus for further research, which will empirically assess the probability and severity of each of these potential risk areas.
Conclusion The rationale for this study was to identify problems and potential vulnerabilities in the triage process in an attempt to understand these issues, so that changes or improvements can be made to reduce risk and possible errors in the triage process. ED and hospital overcrowding, access block, patient flow blockages, ineffective communication, collaboration and teamwork and inexperience or a decreased level of competence of the triage nurse have all been identified as problems or potential vulnerabilities in the triage process. It appears that the problems and potential vulnerabilities identified in the triage process herein are similar to those previously identified by other research to effect the overall functioning of the ED. However, our findings have added to this body of evidence: Now, we know that these problems that affect the ED also impact on the triage process and may lead to error and decreased patient safety during the triage process. It is thus imperative to focus specifically on these identified problems that compromise the triage process as they may have far-reaching adverse consequences for patient care and service delivery.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. 1540
M.H. received a government scholarship (Australian Postgraduate Award).
Conflict of interest No conflict of interest has been declared by the author(s).
Author contributions All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/ethical_1author.html)]:
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substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content.
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