Educational preparedness and perceived importance on confidence in new graduate registered nurses' medication administration.

BACKGROUND: Medication errors are the most common type of error affecting patient safety and the most preventable cause of adverse medical events globally. Medication errors occur most frequently (33.3 %) during the administration phase. New nurses felt their education left them vulnerable to errors, suggesting that current curricula may be insufficient. PURPOSE: The purpose of this study was to determine the relationship between new nurses' educational preparedness and perceived importance with confidence in medication administration. A secondary aim was to determine the difference in the variables based on demographic information. METHODS: A descriptive, correlational design was employed using the Theory of Human Error. Ohio newly licensed nurses were surveyed for their educational preparedness, perceived importance, and confidence in nine medication competencies. Descriptive and inferential statistics were used. RESULTS: N = 201. A significant, positive relationship was found between both educational preparedness and confidence, and perceived importance and confidence. Nurses reported high levels of educational preparedness, perceived importance, and confidence. All correlations and regressions were significant, indicating that as nurse educational preparedness and/or perceived importance increases, the odds of confidence increases. Demographic analysis demonstrated that practice area and years of experience significantly contributed to differences in the variables. CONCLUSIONS: Understanding the educational preparedness and perceived importance of the medication competencies can help guide future research into creating educational and clinical interventions to ultimately decrease medication errors.

The contributors to dosage calculation ability and its applicability to nursing education: An integrative review.

Medication errors are a major patient safety issue and account for 1-2 million hospitalizations and between 100,000 and 200,000 deaths annually. Approximately 41 % of all medication errors are due to improper dose calculations. Studies have shown mean scores on the medication dosage calculation test for nursing students range from 35 to 71 %. Despite new technology created to aid in dosage calculations, the issue is still prevalent among nurses. It is critical that the elements contributing to the nurses' ability to complete dosage calculations be determined so that calculation curriculum in nursing schools can be updated to better prepare students for practice. An integrative review was completed using the databases of PubMed, CINAHL, and Embase to answer the research question: What contributors impact nurses' and nursing students' ability to complete dosage calculations? Four articles met the specified inclusion criteria and were used for this review. The three most common contributing themes among the review sample included mathematical medication calculation ability, medication calculation frequencies, and dosage calculation education. Results from this review can inform the issue of dosage calculations and highlight the need for further research regarding the medication administration competencies taught in undergraduate nursing studies.

The emergency nurse responses to triage interruptions and how these responses are perceived by patients: An observational, prospective study.

BACKGROUND: Healthcare providers' responses to triage interruptions in the emergency department affect quality of care. The purposes for this study were to (1) Examine the relationship between nurses' response to triage interruption and each of, patients' perceived confidence in nurses' technical skills, perceived competence of triage nurse, and satisfaction with the triage experience, (2) Examine the relationship between nurses' response to triage interruption and nurse demographics. METHODS: Using an observational, prospective design, this study was conducted in an adult academic level 1 trauma center. Data collection tools were: The Triage Interruptions Assessment Tool, Triage and Provider Satisfaction and Confidence Survey, and Demographic Questionnaire. RESULTS: The number of observed triage interviews is 93. Of them, 66 interviews were interrupted. No significant relationships were found between nurses' response to the interruption and patients' perceived confidence in nurses' technical skills, competence of triage nurse, or satisfaction with triage experience. There were no significant relationships between nurses' response to triage interruptions and nurses' demographics. CONCLUSIONS: Triage interruptions in the emergency environment are common and most often result in delays in care. In the current study, this has not been shown to affect patients' satisfaction. Nurses' individual characteristics did not affect their responses to triage interruptions.

Systematic review of interruptions in the emergency department work environment.

OBJECTIVE: The purpose of this systematic review is to describe the operationalization of interruptions measurement and to synthesize the evidence on the causes and consequences of interruptions in the emergency department (ED) work environment. METHODS: This systematic review of studies explores the causes and consequences of interruptions in the ED. Of 2836 abstract/titles screened, 137 full-text articles were reviewed, and 44 articles met inclusion criteria of measuring ED interruptions. RESULTS: All articles reported primary data collection, and most were cohort studies (n = 30, 68%). Conceptual or operational definitions of interruptions were included in 27 articles. Direct observation was the most common approach. In half of the studies, quantitative measures of interruptions in the ED were descriptive only, without measurements of interruptions' consequences. Twenty-two studies evaluated consequences, including workload, delays, satisfaction, and errors. Overall, relationships between ED interruptions and their causes and consequences are primarily derived from direct observation within large academic hospitals using heterogeneous definitions. Collective strengths of interruptions research in the ED include structured methods of naturalistic observation and definitions of interruptions derived from concept analysis. Limitations are conflicting and complex evaluations of consequences attributed to interruptions, including the predominance of descriptive reports characterizing interruptions without direct measurements of consequences. CONCLUSIONS: The use of standardized definitions and measurements in interruptions research could contribute to measuring the impact and influence of interruptions on clinicians' productivity and efficiency as well as patients' outcomes, and thus provide a basis for intervention research.

Patient Pain Experiences and the Emergency Department Encounter: A Qualitative Analysis.

BACKGROUND: Legislation, practice recommendations, and the likely link between therapeutic opioid exposure and iatrogenic opioid use disorder (OUD) have led to reduced opioid prescribing. The effects of this change on unrelieved pain and the overdose crisis are not well-characterized. AIM: We explored emergency department (ED) patients' beliefs and experiences involving pain and emergency care to inform the development of future psychosocial interventions that balance the need for acute pain management with risks from opioid exposure. METHODS: Qualitative, semi-structured interviews were conducted after discharge from an urban, academic Level 1 trauma center ED from September 2020 to May 2021 with 18 adult patients presenting with acute pain. After transcription of audio recording, common themes were identified using framework analysis. Thematic hierarchy was validated with Pearson correlation coefficients for cluster analysis of word similarity. RESULTS: Of the 18 participants, most were Black (n = 11, 61%) and male (n = 12, 66.7%). Analysis identified one overarching theme: locus of control with an emergency pain encounter. Four themes were identified surrounding internal and external influences on pain management: (1) accessing healthcare for acute pain; (2) managing the pain after discharge; (3) seeking opioids: self-medicating and misuse; and (4) opioid crisis makes people in pain suffer. CONCLUSIONS: Patients discharged from the ED reported unrelieved pain, factors that influence their pain management, and an ability to seek opioids from non-medical sources. There is a significant disconnect between patients and providers in terms of priorities in pain management and the importance of individualized care.

Interruption of initial patient assessment in the emergency department and its effect on patient perception of care quality.

BACKGROUND: Triage is a critical first step in appropriately caring for patients in the emergency department (ED). Patients' assumptions of the care they will receive can be established in triage. Interruptions to this process can disrupt patient flow, cause errors and lead to patient dissatisfaction. OBJECTIVE: The purpose of this study was to determine how the frequency and duration of interruptions during triage are associated with errors, patient satisfaction and patient's perception of the care they received. METHODS: Prospective, observational, cohort study conducted in the ED of a Level 1 trauma center. Interruptions were measured using time-and-motion observations of triage interviews performed by nurses and physicians. Patients were surveyed immediately after triage interviews were complete. RESULTS: Surveys were completed for 178 observations. In total, 62.9% of the observations were interrupted between 1 and 5 times. While interruptions did not significantly influence patient satisfaction directly, interruptions positively influenced triage duration, which was negatively associated with patient satisfaction. Increased errors were associated with increasing frequency of triage interruptions. Triage interruptions were not associated with either patient satisfaction or perceived caregiver competence. Overall, the majority (76.6%) of patients were satisfied with their care; patient satisfaction was associated with the perceived competency of caregivers but was not associated with errors. CONCLUSION: Interruptions are associated with increased errors and delays in patient care. Although increased triage duration adversely affected patient satisfaction, patients' perceptions were not influenced by interruptions. While patient satisfaction is essential, a lack of association between patient satisfaction and errors suggests that using patient satisfaction as a measure of care quality may omit important safety information.

Identifying Strategies for the Management of Interruptions for Novice Triage Nurses Using an Online Modified Delphi Method.

PURPOSE: To use the Delphi Method to identify strategies used by triage nurses to effectively manage interruptions. DESIGN: This study was based on the concepts of Benner's Novice to Expert Model. An online, modified Delphi approach was used to engage triage, education, and operational management experts in generating consensus recommendations on successful strategies to address triage interruptions in the emergency department. METHODS AND ANALYSIS: A panel of nine triage, education, and operational management experts were selected based on their publication and presentation history. This panel participated in three Delphi rounds, providing individual responses during each round. All responses were entered into a RedCap database, which allowed research team members to synthesize the results and return summaries to the participants. Final consensus was reached among this panel regarding recommendations for successful strategies to address triage interruptions that can be encompassed in a training module. The experts were then asked to identify the best instructional modality for teaching each of the interruption management strategies. FINDINGS: Eight strategies to mitigate the impact of interruptions were identified: (a) ensure nurses understand impact of interruptions; (b) ensure nurses understand consequences of interruptions on cognitive demands of healthcare workers that could influence behavior and lead to errors; (c) apologize to current patient before tending to interruption and give expectation of when you will return; (d) triage the interruption and decide to (i) ignore interruption, (ii) acknowledge, but delay servicing, interruption, or (iii) acknowledge and service interruption, delaying completion of interrupted task; (e) identify urgent communication as anything clinically significant that impacts the patient immediately or requires immediate intervention; (f) use focused questions to clarify whether interruption can wait; (g) redirect nonpriority interruptions; and (h) finish safety-critical task or tasks near completion before tending to an interruption. The Delphi participants recommended the best teaching modality was simulation for six of the strategies. CONCLUSIONS: Participants agreed that there are strategies that can be taught to novice triage nurses to mitigate the impact of interruptions. The experts in operations management, emergency nursing, and education agree that creating simulations to teach each of these strategies is an effective way to educate nurses. CLINICAL RELEVANCE: Interruptions impact the quality of care provided to patients. Training nurses to prevent interruptions and mitigate the impact of interruptions when they occur has the potential to improve patient outcomes.

Understanding Exception from Informed Consent in Planned Emergency Research.

Many of the current accepted treatment practices provided to patients in the first critical hour after a traumatic injury, stroke, or cardiac arrest have not been rigorously tested in clinical research trials. The inability to obtain informed consent is often a barrier to research in emergency, time-sensitive situations in which the patient is not able to provide informed consent nor is their family member immediately available to provide consent on behalf of the patient. Planned emergency research, often with exception from informed consent, is a type of research study that involves a patient with a life-threatening medical condition that requires urgent interventions, wherein the current treatments may be unproven or suboptimal, and who, because of their current condition, is unable to provide informed consent. This article summarizes the necessary components for using exception from informed consent in planned emergency research. Understanding the research design, particularly research processes specific to time-critical emergency situations, will ensure that the care provided by stretcher-side emergency nurses will result in optimal patient outcomes and is an integral aspect of emergency nursing practice.

Perceptions of the Essential Components of Triage: A Qualitative Analysis.

INTRODUCTION: Triage is an important process to determine severity of illness and prioritize patient emergencies while also ensuring patient safety. The emergency nurse must use critical thinking and decision-making to identify life-threatening emergencies and improve patient outcomes. However, the addition of risk screenings and quality improvement initiatives has extended the triage process time, which may increase interruptions and opportunities for errors. The purpose of this descriptive qualitative study was to determine emergency nurse perceptions of current triage processes and categorize essential and nonessential triage components. METHODS: Focus groups of frontline emergency nurses who regularly conduct triage in the emergency department were conducted to discuss perceptions of triage assessments and questions. The 3 focus group discussions were digitally recorded and transcribed. Data analysis consisted of descriptive statistics of the sample and the conventional content analysis of the transcripts. RESULTS: A total of 12 emergency nurses participated in the study. The overall theme that emerged surrounding essential triage components was a perceived conflict between individualized care and maintaining systems and processes. This theme consisted of 4: (a) must ask, (b) actions of triage, (c) relevant but not urgent for triage, and (d) not perceived as relevant. CONCLUSION: This study identified the perceptions of emergency nurses surrounding the urgency of triage components in the emergency department. Emergency nurses perceived some assessments as essential to determining "sick versus not sick," and other triage components were able to be delayed, streamlining the triage process.

Early Therapeutic Mobility and Changes in Scores for Pain and Fatigue.

This report is a secondary analysis of data from a larger study of a nurse-led early therapeutic mobility intervention among patients receiving mechanical ventilation. This analysis evaluated whether intervention frequency or intensity was associated with pain or fatigue. Frequency was defined as once-daily versus twice-daily interventions. Intensity was defined as low (in-bed activities) or moderate (out-of-bed activities). Thirty-nine patients self-reported pain and fatigue immediately before and after the intervention. Neither pain nor fatigue increased significantly (mean increase, <1 [scale of 0-10] for 95% of interventions). Four patients reported decrements in pain; 1 reported a decrease in fatigue. Less than 5% of enrolled patients indicated a score change of +4 to +6 for pain or fatigue, typically with the first intervention that included sitting at the edge of the bed. Future research could examine the distress associated with these symptoms in critically ill adults receiving early therapeutic mobility interventions.

Patient perspectives of pregnancy loss in the emergency department.

OBJECTIVES: While threats to pregnancy such as vaginal bleeding are common, half will miscarry. The ED environment is not always conducive to the emotional and psychological needs of women grieving the loss of a pregnancy. Healthcare providers have a great impact on the women's experience of pregnancy loss. This study describes the perspectives of women experiencing a pregnancy loss in the ED. METHODS: The study used a qualitative descriptive research design interviewing women diagnosed with a pregnancy loss in the ED. Data analysis consisted of descriptive statistics of the sample and content analysis of interviews. RESULTS: Eight participant interviews generated five themes related to the ED as part of the crossroads of motherhood and pregnancy loss. The themes were (a) Decisions to get help, (b) The environment of emergency care, (c) Not knowing, (d) Finally knowing and moving on, (e) Assisting with the grieving process. CONCLUSIONS FOR PRACTICE: Understanding the needs of women diagnosed with pregnancy loss allows emergency nurses and providers to provide more holistic, compassionate care. Knowledge of pregnancy loss experiences will assist in the improvement of future patient care, and may positively impact recovery and transition to normalcy.

Dose of Early Therapeutic Mobility: Does Frequency or Intensity Matter?

OBJECTIVE: Investigate the feasibility of a nurse-led mobility protocol and compare the effects of once- versus twice-daily episodes of early therapeutic mobility (ETM) and low- versus moderate-intensity ETM on serum biomarkers of inflammation and selected outcomes in critically ill adults. DESIGN: Randomized interventional study with repeated measures and blinded assessment of outcomes. SETTING: Four adult intensive care units (ICUs) in two academic medical centers. SUBJECTS: Fifty-four patients with > 48 hr of mechanical ventilation (MV). INTERVENTION: Patients were assigned to once- or twice-daily ETM via sealed envelope randomization at enrollment. Intensity of (in-bed vs. out-of-bed) ETM was administered according to protocolized patient assessment. MEASUREMENTS: Interleukins 6, 10, 8, 15, and tumor necrosis factor-α were collected from serum before and after ETM; change scores were used in the analyses. Manual muscle and handgrip strength, delirium onset, duration of MV, and ICU length of stay (LOS) were evaluated as patient outcomes. MAIN RESULTS: Hypotheses regarding the inflammatory biomarkers were not supported based on confidence intervals. Twice-daily intervention was associated with reduced ICU LOS. Moderate-intensity (out-of-bed) ETM was associated with greater manual muscle test scores and handgrip strength and reduced occurrence of delirium. CONCLUSION: Findings from this study suggest that nurses can provide twice-daily mobility interventions that include sitting on the edge of the bed once patients have a stable status without altering a pro-inflammatory serum biomarker profile.

Effects of Interruptions on Triage Process in Emergency Department: A Prospective, Observational Study.

For 130 million people seeking emergency treatment in the United States, incomplete or inaccurate triage examination can result in delays, which could compromise patient outcomes. The purpose of this study was to identify triage interruptions and determine how interruptions affect the triage process. A significant difference was seen in triage duration between interrupted and uninterrupted interviews. Understanding the impact of interruptions on patient outcomes will allow nurses and other health care providers to develop interventions to mitigate the impact.

A Review of the Management of Loss of Pregnancy in the Emergency Department.

INTRODUCTION: Women frequently seek ED care for complications in early pregnancy, including loss of pregnancy. This review evaluates the current literature and discusses the care of patients experiencing loss of pregnancy in the emergency department. METHODS: A review of pertinent studies identified through multiple database searches was conducted to determine the existing body of knowledge for the care of ED patients diagnosed with loss of pregnancy. Each of the studies was examined for inclusion criteria and a subsequent analysis of the included studies identified themes related to the care of the women. RESULTS: Thirty-two original research articles and systematic reviews published between 1990 and 2016 were included in the review. Eleven articles addressed recommendations for clinical practice, 5 reported statistics related to pregnancy outcome and clinical presentation, 4 discussed the use of speculum examinations, 4 discussed interventions to decrease ED length of stay, and 3 investigated the use of ultrasound in the emergency department. Only 5 of the articles reviewed discussed emotional support and/or experiences of women with loss of pregnancy in the emergency department. CONCLUSION: Although there are multiple recommendations for the clinical management of loss of pregnancy in the emergency department, the psychological and emotional support of women was addressed infrequently. Additional studies investigating holistic care would be beneficial for ED providers in the management of early loss of pregnancy.

Barriers to Research Recruitment of Women Experiencing a Pregnancy Loss in the Emergency Department.

Women often come to the emergency department (ED) with signs and symptoms suggesting an early pregnancy loss; yet, little is known about their experience and how it relates to future outcomes. To improve patient outcomes and experiences of women seeking care for a pregnancy loss, research is required. However, recruitment of participants experiencing an event such as a pregnancy loss is challenging. The purpose of this article is to discuss the application of an electronic medical record (EMR)-based participant screening tool recruiting women seeking care for a pregnancy loss in the ED. This study implemented an EMR-based prompt to assist participant screening completed by ED nurses: (a) The prompts were based on criteria built into triggers that activated a recruitment screening form to print upon discharge; (b) nurses completed the form with patients, asking for willingness to be contacted at home; and (c) participants were subsequently contacted and enrolled in the study. Our research screening program was implemented continuously in 2 EDs: a large, urban, academic medical center and a community academic hospital. Data were analyzed through descriptive statistics of reports built within the EMR. These reports signaled when the screening tool flagged participants and subsequently tied the corresponding information to the completed forms. The recruitment tool fired 1,169 times, with 61% (n = 714) screened. Fifty percent (n = 37) of women experiencing an early pregnancy loss were willing to be contacted at home for research recruitment. Of those approached after discharge (n = 24), 33% (n = 8) enrolled in the study. Of note, at one site, 14% (81/577) of potential participants with early pregnancy loss symptoms left before seeing a provider, with 26% (150/577) of these encounters were repeat visits. Staff education, nurse reluctance to approach potential participants, and patients who left without being seen led to barriers in participant screening.

Using Simulation to Assess the Impact of Triage Interruptions.

INTRODUCTION: Interruptions are common in the emergency department and contribute to catastrophic errors. Care priorities and acuity levels are assigned during triage, meaning that mistakes and omissions during the triage process could have detrimental effects on patients. The purpose of this project was to assess the feasibility of investigating the impact of interruptions on triage and the decision-making process in a simulated setting. METHODS: A 2-phase, sequential exploratory mixed method design was used. Nine nurses from 3 emergency departments in a Midwest area participated. A short demographic questionnaire was used to collect information about the nurses' education and experience. The Emergency Severity Index (ESI) was used for triage categorization. Each participant completed 2 scenarios (one interrupted and one uninterrupted). After completion of the scenarios, video-simulated recall interviews were used to assess the simulation experience and the impact that interruptions had on the triage decision-making process. RESULTS: Triage time had a mean of 10 minutes and ranged between 4.34 minutes and 13.45 minutes. However, triage was significantly longer during the interrupted scenarios. Seventy-seven percent of the acuity assessments (ESI) were correct. Of the 18 scenarios, 3 uninterrupted scenarios had incorrect ESI scores, and one interrupted scenario had a missing acuity score. DISCUSSION: This study provides the basis for future work that looks at how nurses successfully manage interruptions and tests interventions to assist triage nurses in managing or reducing interruptions during this important patient assessment process.

A realist review of shared medical appointments: How, for whom, and under what circumstances do they work?

BACKGROUND: Shared medical appointments (SMAs) are doctor-patient visits in which groups of patients are seen by one or more health care providers in a concurrent session. There is a growing interest in understanding the potential benefits of SMAs in various contexts to improve clinical outcomes and reduce healthcare costs. This study builds upon the existing evidence base that suggests SMAs are indeed effective. In this study, we explored how they are effective in terms of the underlying mechanisms of action and under what circumstances. METHODS: Realist review methodology was used to synthesize the literature on SMAs, which included a broad search of 800+ published articles. 71 high quality primary research articles were retained to build a conceptual model of SMAs and 20 of those were selected for an in depth analysis using realist methodology (i.e.,middle-range theories and and context-mechanism-outcome configurations). RESULTS: Nine main mechanisms that serve to explain how SMAs work were theorized from the data immersion process and configured in a series of context-mechanism-outcome configurations (CMOs). These are: (1) Group exposure in SMAs combats isolation, which in turn helps to remove doubts about one's ability to manage illness; (2) Patients learn about disease self-management vicariously by witnessing others' illness experiences; (3) Patients feel inspired by seeing others who are coping well; (4) Group dynamics lead patients and providers to developing more equitable relationships; (5) Providers feel increased appreciation and rapport toward colleagues leading to increased efficiency; (6) Providers learn from the patients how better to meet their patients' needs; (7) Adequate time allotment of the SMA leads patients to feel supported; (8) Patients receive professional expertise from the provider in combination with first-hand information from peers, resulting in more robust health knowledge; and (9) Patients have the opportunity to see how the physicians interact with fellow patients, which allows them to get to know the physician and better determine their level of trust. CONCLUSIONS: Nine overarching mechanisms were configured in CMO configurations and discussed as a set of complementary middle-range programme theories to explain how SMAs work. It is anticipated that this innovative work in theorizing SMAs using realist review methodology will provide policy makers and SMA program planners adequate conceptual grounding to design contextually sensitive SMA programs in a wide variety of settings and advance an SMA research agenda for varied contexts.

The nurse response to abnormal vital sign recording in the emergency department.

AIMS AND OBJECTIVES: To examine what occurs after a recorded observation of at least one abnormal vital sign in the emergency department. The aims were to determine how often abnormal vital signs were recorded, what interventions were documented, and what factors were associated with documented follow-up for abnormal vital signs. BACKGROUND: Monitoring quality of care, and preventing or intervening before harm occurs to patients are central to nurses' roles. Abnormal vital signs have been associated with poor patient outcomes and require follow-up after the observation of abnormal readings to prevent patient harm related to a deteriorating status. This documentation is important to quality and safety of care. DESIGN: Observational, retrospective chart review. METHODS: Modified Early Warning Score was calculated for all recorded vital signs for 195 charts. Comparisons were made between groups: (1) no abnormal vital signs, (2) abnormal vital sign present, but normal Modified Early Warning Score and (3) critically abnormal Modified Early Warning Score. RESULTS: About 62·1% of charts had an abnormal vital sign documented. Critically abnormal values were present in 14·9%. No documentation was present in 44·6% of abnormal cases. When interventions were documented, it was usually to notify the physician. The timing within the emergency department visit when the abnormalities were observed and the degree of abnormality had significant relationships to the presence of documentation. CONCLUSIONS: It is doubtful that nurses do not recognise abnormalities because more severely abnormal vital signs were more likely to have documented follow-up. Perhaps the interruptive nature of the emergency department or the prioritised actions of the nurse impacted documentation within this study. Further research is required to determine why follow-up is not being documented. RELEVANCE TO CLINICAL PRACTICE: To ensure safety and quality of patient care, accurate documentation of responses to abnormal vital signs is required.

The Triage Interruptions Assessment Tool: An Instrument Development.

Interruptions contribute to catastrophic errors in health care. Interruptions are breaks in the performance of a human activity initiated by a source internal or external to the recipient. Errors during the initial triage assessment can lead to errors in estimating the acuity of a patient and resources required for appropriate care. To advance the science, a valid and reliable instrument to measure this phenomenon is required. The purpose of this mixed-methods/exploratory sequential study was to develop an instrument sensitive to the uniqueness of the triage assessment that would categorize and measure the number and causes of triage interruptions. The study included 3 phases. Phase 1: Qualitative focus groups were used to qualitatively explore interruptions in triage. In Phase 2: Content Validity Assessment, an online survey was used and a content validity index was calculated for each item to determine which items should be modified or removed. A descriptive correlational design was used to assess interrater reliability in Phase 3. Many of the items identified during the focus group sessions were already on the study instrument; some new items were added. Content validity for the entire instrument was 0.82 and increased to 0.91 once irrelevant items were removed. Interrater reliability for the entire instrument demonstrated substantial agreement at 0.773. The study instrument was shown to have strong psychometrics and can be used in practice to better understand what interruptions are occurring in triage and how they affect the triage process.