ED triage

A considerable effort has been put into researching ED triage, which most probably indicates the clinical importance of the domain. This was also addressed by Bruce and Suserud (2005) in stating that one of the most important tasks of an ED nurse, when receiving a patient, is the handover and triage function. According to their findings, these are regarded as highly symbolic events, especially when a patient is transferred from ambulance stretcher to the hospital stretcher. The communication between ambulance crew and ED nurses was very structured. If the patient was more seriously ill/injured, the likelihood of a non-ideal triage and handover was elevated. This has clinical relevance, because the aim of the triage and handover process is to safeguard that the patient has received the correct care at the appropriate level, and that this information is conveyed further on. The research identified areas where improvements could be made.

The following categorisation under the theme ED triage follows the appearance of issues obtained by subject headings clinical assessment and clinical judgment. According to the literature reviewed triage seemed to be tightly connected to these phenomena. Albeit triage decisions most definitely are manifestations of ED nurses’ clinical judgment as well as clinical decision-making, they will be presented in this literature review as an own entity under the theme ED triage. This, in turn, was a decision based on the crucial role of triage in the clinical ED nursing. On the other hand, this decision can be challenged with good reasons, as clinical assessment and clinical judgment play a most fundamental role in all ED nursing.

Telephone triage

Telephone triage and patient guidance has received growing attention lately. The legal implications of telephone triage are discussed by Coleman (1997), and the use of detailed documentation and communication skills are emphasised when trying to protect the ED nurse legal action and consequences. The Coleman (1997) article strongly points out the importance of seeing telephone triage as part of an ED nurse’s responsibilities and nursing functions. In a simulated telephone triage situation, it has been shown that this can be implemented within a systematic and identifiable framework by ED nurses responsible for the triage dispositions via telephone (Edwards 1994). The final decision concerning the triage disposition was made through balancing the most probable outcome against the worst possible outcome. Whether the systematics identified within the research were a result of formal training or of experience and more inclined towards tacit knowledge (Nurminen 2000, Loveridge 2004), remains

unclear to the researcher. However, these items have relevance in Finnish hospital organisations as written orders or protocols for telephone guidance and triage are not necessarily always to hand for ED nurses.

Paediatric triage

In the USA, paediatric emergencies are a common problem that result in approximately 12.5 million visits to EDs annually (Thomas 2002). It is thus understandable that paediatric triage is widely researched, especially in North-America and Australia. Furthermore, paediatric triage poses a special challenge for any ED nurse, since the needs of children in emergency situations differ from those concerning adults. Developmental and physiologic variations make communication, assessment and identification of a serious illness/injury essentially different than with adults, not even to mention the challenges posed and confusion resulting should a paediatric patient happen to enter an ED not accustomed to receiving paediatric patients. ED nurses should, according to Thomas (2002), be allowed to develop a sixth sense in recognising and treating children, and to become confident in triage decisions. This does not, however, appear to be the case, as the level of agreement between nurses applying the Australasian Triage Scale (ATS) turned out to be no more than moderate, and lower than the consistency when applied to adult patients. As both ED nurses and paediatric emergency physicians have shown only a moderate level of agreement and accuracy of paediatric triage assignment, a conclusion can be drawn as follows: Inconsistent allocation of triage categories may lead to inappropriate waiting times, which in turn may have detrimental effects on certain patients’ clinical condition. Serious attention is justified to improve paediatric triage, the crucial step in emergency care (Bergeron et al. 2002, Crellin and Johnston 2003).

Detecting signs and indicators of possible child abuse among paediatric patients presenting with physical trauma would be of utmost importance in organising appropriate help for the child and the whole family. McKinney et al. (2004) investigated whether cases of possible non-accidental injuries as identified using five risk indicators would arouse suspicion of child abuse. Triage nurses’ performances were studied, and the results indicated that the introduction of a policy of identifying positive indicators from the five risk indicators of child abuse was not sufficient in itself to raise concern. Additional computer support within EDs was suggested.

Triage with coronary heart disease

Coronary heart disease (CHD) is the major cause of mortality for adults in the USA, and in Finland (Ruotsalainen 2006) as well. Even though men are suffering from CHD more often than women, the likelihood of a woman dying after an acute coronary event is greater, and the likelihood of receiving prompt or aggressive treatment is smaller (Arslanian-Engoren 2004).

Triage nurses’ contribution to the detection, allocation of triage categories, and initiation of treatment with CHD has been thoroughly studied. In order to ascertain whether triage nurses’

initial triage decisions could predict admission or discharge for acute coronary syndromes, a total of 108 nurses’ triage decisions were examined. Accuracy for predicting admission, as well as for discharge diagnosis, turned out to be poor (Arslanian-Engoren 2004). When compared by the gender or demographic characteristics of the triage nurse in terms of triaging male and female patients presenting with symptoms suggestive of acute coronary syndrome (ACS), men and women were equally likely to be given an ACS triage decision. However, female patients were more likely to be assigned a suspected cause of cholecystitis for their symptoms. It was also observed that nurses used different cues to triage men and women with equal symptoms suggestive of ACS (Arslanian-Engoren 2005).

Cardiogenic pulmonary oedema (CPO) is an immediately life-threatening complication of left ventricular dysfunction, usually associated with acute myocardial infarction or other severe manifestations of CHD. Intervention of continuous positive airway pressure therapy (CPAP) in CPO by the triage nurse turned out to have a positive contribution to a favourable outcome with these patients. When the triage nurse was more experienced, these patients were more likely to be recognised at triage as requiring CPAP therapy. The early application of CPAP both reduced hospital mortality, length of hospital stay, and the need for intubation and ventilation. An educational issue is to decide how to more effectively educate nurses in identifying CPO in patients presenting with acute respiratory failure (MacGeorge and Nelson 2003 ).

Education for triage

As the ED triage has shown to be a critical phase in the care of an acutely ill/injured patient, the education and preparation of nurses for this specific purpose has also been the object of research. It appeared that a notable proportion part of the nurses working in triaging roles had not had any formal, unit-based, triage education (Gerdtz and Bucknall 2000). The need for more formal education and the importance of emergency nursing experience, as well as

positive reinforcement from management, were important topics (McNally 2001, Cone and Murray 2002). Naturalistic research methods are pointed out to be needed in order to evaluate and improve the triage process, and of the outcomes of these decisions in practice (Gerdtz and Bucknall 1999).

Issues related to triage decisions

Andersson et al. (2006) have found both internal and external factors to be connected to nurses’ triage decisions. The internal factors reflect the nurse skills and personal capacity, while the external factors reflect work environment, including high workload and practical arrangements. These factors in turn serve as a basis for the clinical decision-making, and combined with patients’ clinical condition, clinical history, various examinations and tests, an assessment is formed which subsequently leads to a prioritisation (Andersson et al. 2006).