Emergency department triage decision-making by registered nurses: An instrument development study.

AIM: To develop and psychometrically test the triage decision-making instrument, a tool to measure Emergency Department Registered Nurses decision-making. DESIGN: Five phases: (1) defining the concept, (2) item generation, (3) face validity, (4) content validity and (5) pilot testing. METHODS: Concept definition informed by a grounded theory study from which four domains emerged. Items relevant to the four domains were generated and revised. Face validity was established using three focus groups. The target population upon which the reliability and validity of the triage decision-making instrument was explored were triage registered nurses in emergency departments. Three expert judges assessed 89 items for content and domain designation using a 4-point scale. Psychometric properties were assessed by exploratory factor analysis, following which the names of the four domains were modified. RESULTS: The triage decision-making instrument is a 22-item tool with four factors: clinical judgement, managing acuity, professional collaboration and creating space. Focus group data indicated support for the domains. Expert review resulted in 46 items with 100% agreement and 13 with 66% agreement. Fifty-nine items were distributed to a convenience sample of 204 triage nurses from six hospitals in 2019. The Kaiser-Meyer-Olkin measures indicated that the data were sufficient for exploratory factor analysis. Bartlett's test indicated patterned relationships among the items (X2 (231) = 1156.69). An eigenvalue of >1.0 was used and four factors explained 48.64% of the variance. All factor loadings were ≥0.40. Internal consistency was demonstrated by Cronbach's alphas of .596 factor 1, .690 factor 2, .749 factor 3 and .822 for factor 4. CONCLUSION: The triage decision-making instrument meets the criteria for face validity, content validity and internal consistency. It is suitable for further testing and refinement. IMPACT: The instrument is a first step in quantifying triage decision-making in real-world clinical environments. The triage decision-making instrument can be used for targeted triage interventions aimed at improving throughput and staff education. STATISTICAL SUPPORT: Dr. Tak Fung who is a member of the research team is a statistician. STATISTICAL METHODS: Development, validation and assessment of instruments/scales. Descriptive statistics. REPORTING METHOD: STROBE cross-sectional checklist. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: The TDI makes the complexity of triage decision-making visible. Identifying the influence of decision-making factors in addition to acuity that affect triage decisions will enable nurse managers and educators to develop targeted interventions and staff development initiatives. By extension, this will enhance patient care and safety.

Clinical Characteristics of Patients Undergoing Needle Thoracostomy in a Canadian Helicopter Emergency Medical Service.

Objective: Needle thoracostomy (NT) can be a life-saving procedure when used to treat tension pneumothorax. However, there is some question regarding the efficacy of NT in the prehospital setting. Failure to treat tension pneumothorax in a helicopter emergency medical service (HEMS) setting may prove especially deleterious to the patient due to gas expansion with increasing altitude. This study's objective was to identify the characteristics of patients treated with NT in a Canadian HEMS setting and the factors that may influence outcomes following NT use.Methods: This was a retrospective chart review of prehospital records from a Canadian HEMS service. Patients aged 18 years and older who underwent at least one NT attempt using a 14-gauge 8.3 cm needle from 2012 to 2018 were identified. Charts were reviewed to collect demographic data, NT procedural characteristics, vital signs, and clinical response metrics. Descriptive statistics were used to characterize the study sample and overall event characteristics. Binary logistic regression was performed to identify variables associated with a clinical response to the initial NT treatment.Results: 163 patients (1.3%) of 12,407 patients attended received NT. A positive clinical response to NT was recorded in 37% (n = 77) of the total events (n = 208), the most common of which was an improvement in blood pressure (BP) (18.8%, n = 39). Initial NT was associated with a low likelihood of clinical improvement in patients presenting with blunt trauma (OR = 0.18; p = .021; 95% CI [.04, .77]), CPR prior to NT (OR = 0.14; p = .02; 95% CI [.03, .73]), or in those who received bilateral NT treatment (OR = 0.13; p < .01; 95% CI [.05, .37]). A pretreatment BP < 90 mmHg was predictive of a positive clinical response to initial NT (OR = 3.33; p = .04; 95% CI [1.09, 10.20]).Conclusions: Only a small portion of patients in the setting of a Canadian HEMS service were treated with NT. Patients most likely to receive NT were males who had suffered blunt trauma. NT may have questionable benefit for patients presenting with blunt trauma, in cardiac arrest, or requiring bilateral NT.

Thoracic Endotracheal Tube Insertion During Prehospital Thoracostomy: A Case Report.

This case highlights the novel use of endotracheal tubes to maintain patency of simple thoracostomies (STs) performed to relieve a tension pneumothorax after failed needle thoracostomy (NT). Treatment of a tension pneumothorax in the prehospital setting is typically performed using NT because of the minimal equipment required and rapid application. However, the variable efficacy of NT has led to a rise in the use of ST as an alternative procedure to treat a tension pneumothorax. A potential complication of ST is the occlusion of the thoracostomy site, which, left unresolved, may lead to the reoccurrence of tension physiology. In a resource-rich setting, such as in a hospital, the ST would be followed by tube thoracostomy to ensure patency. Unfortunately, this may not be feasible in prehospital environments where constraints exist because of time, equipment, and personnel. A review of the literature surrounding prehospital ST reveals previous reports of endotracheal tubes being used to maintain patency temporarily. However, no cases documenting the successful use of this novel procedure in an air medical setting were found at the time of writing. This case documents the successful use of this novel procedure during the treatment of a polytraumatized adult female resulting from a motorcycle crash.

Transition in Care from EMS Providers to Emergency Department Nurses: A Systematic Review.

Background: Transitions in care between emergency medical services (EMS) providers and emergency department (ED) nurses are critical to patient care and safety. However, interactions between EMS providers and ED nurses can be problematic with communication gaps and have not been extensively studied. The aim of this review was to examine (1) factors that influence transitions in care from EMS providers to ED nurses and (2) the effectiveness of interventional strategies to improve these transitions. Methods: We conducted a mixed-methods systematic review that included searches of electronic databases (DARE, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, Joanna Briggs Institute EBP), gray literature databases, organization websites, querying experts in emergency medicine, and the reference lists cited in included studies. All English-language studies of any design were eligible for inclusion. Two reviewers independently screened titles/abstracts and full-texts for inclusion and methodological quality, as well as extracted data from included studies. We used narrative and thematic synthesis to integrate and explore relationships within the data. Results: In total, 8,348 studies were screened and 130 selected for full text review. The final synthesis included 20 studies. Across 15 studies of moderate-to-high methodological quality, 6 factors influenced transitions: different professional lenses, operational constraints, professional relationships, information shared between the professions, components of the transition process, and patient presentation and involvement. Three interventions were identified in 6 methodologically weak studies: (1) transition guideline (DeMIST, Identification, Mechanism/Medical complaint, Injuries/Information related to the complaint, Signs, Treatment and Trends - Allergies, Medication, Background history, Other information [IMIST-AMBO]) with training, (2) mobile web-based technology (EMS smartphone and geographic information system location data), and (3) a new clinical role (ED ambulance off-load nurse dedicated to triaging and assessing EMS patients). There were mixed findings for the effectiveness of transition guidelines and the new clinical role. Mobile technology was seen positively by both EMS providers and ED nurses as helpful for better describing the pre-hospital context and for planning flow in the ED. Conclusion: While multimedia applications may potentially improve the handoff process, future intervention studies need to be rigorously designed. We recommend interdisciplinary training of EMS and ED staff in the use of flexible structured protocols, especially given review findings that interdisciplinary communication and relationships can be challenging.

Creative adapting in a fluid environment: an explanatory model of paramedic decision making in the pre-hospital setting.

BACKGROUND: Paramedics work in a highly complex and unpredictable environment which is characterized by ongoing decision-making. Decisions made by paramedics in the prehospital setting have implications for patient safety, transport, treatment, and health resource utilization. The objective of this study was; a) to understand how paramedics conduct decision-making in the field, and b) to develop a grounded theory of paramedic decision-making in the prehospital setting. METHOD: This study was conducted using classical grounded theory. Paramedics (n = 13) with five or more years' experience, who worked in a large urban center in Western Canada were interviewed. Field observations were conducted, each lasting 12 h, with five different ambulance crews. The data were analyzed and coded using the constant comparative method. RESULTS: The resultant theory, Creative Adapting in a Fluid Environment, indicates paramedic decision-making is a fluid iterative process. Unpredictable and dynamic features of the prehospital environment require paramedics to use a flexible and creative approach to decision-making. The model consists of the three categories constructing a malleable model, revising the model, and situation-specific action. Two additional components, safety and extrication, are considered at each stage of the call. These two components in conjunction with the three categories influence how decisions are made and enacted. CONCLUSION: Paramedic decision-making is highly contextual and requires accurate interpretation and flexible cognitive constructs that are rapidly adaptable. Evaluation of paramedic decision-making needs to account for the complex and dynamic interaction between the environment, patient characteristics, available resources, and provider experience and knowledge.

Staying theoretically sensitive when conducting grounded theory research.

Background Grounded theory (GT) is founded on the premise that underlying social patterns can be discovered and conceptualised into theories. The method and need for theoretical sensitivity are best understood in the historical context in which GT was developed. Theoretical sensitivity entails entering the field with no preconceptions, so as to remain open to the data and the emerging theory. Investigators also read literature from other fields to understand various ways to construct theories. Aim To explore the concept of theoretical sensitivity from a classical GT perspective, and discuss the ontological and epistemological foundations of GT. Discussion Difficulties in remaining theoretically sensitive throughout research are discussed and illustrated with examples. Emergence - the idea that theory and substance will emerge from the process of comparing data - and staying open to the data are emphasised. Conclusion Understanding theoretical sensitivity as an underlying guiding principle of GT helps the researcher make sense of important concepts, such as delaying the literature review, emergence and the constant comparative method (simultaneous collection, coding and analysis of data). Implications for practice Theoretical sensitivity and adherence to the GT research method allow researchers to discover theories that can bridge the gap between theory and practice.

Mass casualty triage for the Emergency Department using the RATE protocol: Validation and results of a quasi-experiment.

BACKGROUND: Triage practices in the Emergency Department (ED) need to be modified during a mass casualty incident (MCI) to accommodate the influx of patients. A triage protocol known as Rapid Assessment Triage for Emergency Department/Urgent Care (RATE) was developed specifically for use in EDs during MCIs. METHODS: Phase 1: validation of the RATE protocol by triage experts. Phase 2: a pretest/ post-test quasi-experiment comparing a RATE infographic with a RATE e-learning module in a convenience sample of 64 triage Registered Nurses from two EDs. RESULTS: Phase 1: the five experts reached 100% consensus for 20 patient vignettes. Phase 2: there were no statistically significant differences on pre-test and post-test scores within and between RN groups controlling for age, years as an RN, years as an ED RN, and years as a triage RN (all p values > 0.05). There was no group by time interaction (p = 0.49). CONCLUSION: The RATE protocol was validated. As there were no statistically significant differences between the groups using the RATE infographic or the elearning module, either method can be used for training purposes. The infographic is cost effective and may be preferred in resource poor environments or when just-in-time training is required.

Triage emergency nurse decision-making: Incidental findings from a focus group study.

INTRODUCTION: Emergency Department (ED) triage decision-making is a complex process. Triage scales are used to determine patient acuity level, however, they do not provide information on how nurses make triage decisions. This focus group study was part of a larger project to develop a psychometrically sound instrument to measure triage decision-making by nurses; the Triage Decision-Making Instrument. We report important incidental findings that emerged during the study that the participants identified as factors impeding triage decision-making. METHODS: Three focus groups were conducted with 11 triage Registered Nurses. They commented on the instrument items and identified factors that influence triage decision-making. Transcripts were analyzed using thematic analysis. RESULTS: Three powerful inter-related themes emerged central to encumbering triage decision-making: competing systems (pre-hospital versus the ED), fluctuating patient volume resulting in 'intra-Canadian Triage and Acuity Scale' triaging, and personal capacity including experience and 'triage fatigue'. DISCUSSION: The findings demonstrate how interrelated system factors impede nurses triage decision-making. Triage nurses require support in their role and initiatives are needed to reduce the pressure they feel in relation to resolving system issues. Larger system issues and the capacity of the individual decision-makers must be accounted for within the context of increasing effectiveness and safety of ED triage.

Transition in care from paramedics to emergency department nurses: a systematic review protocol.

BACKGROUND: Effective and efficient transitions in care between emergency medical services (EMS) practitioners and emergency department (ED) nurses is vital as poor clinical transitions in care may place patients at increased risk for adverse events such as delay in treatment for time sensitive conditions (e.g., myocardial infarction) or worsening of status (e.g., sepsis). Such transitions in care are complex and prone to communication errors primarily caused by misunderstanding related to divergent professional perspectives leading to misunderstandings that are further susceptible to contextual factors and divergent professional lenses. In this systematic review, we aim to examine (1) factors that mitigate or improve transitions in care specifically from EMS practitioners to ED nurses, and (2) effectiveness of interventional strategies that lead to improvements in communication and fewer adverse events. METHODS: We will search electronic databases (DARE, MEDLINE, EMBASE, Cochrane, CINAHL, Joanna Briggs Institute EBP; Communication Abstracts); gray literature (gray literature databases, organization websites, querying experts in emergency medicine); and reference lists and conduct forward citation searches of included studies. All English-language primary studies will be eligible for inclusion if the study includes (1) EMS practitioners or ED nurses involved in transitions for arriving EMS patients; and (2) an intervention to improve transitions in care or description of factors that influence transitions in care (barriers/facilitators, perceptions, experiences, quality of information exchange). Two reviewers will independently screen titles/abstracts and full texts for inclusion and methodological quality. We will use narrative and thematic synthesis to integrate and explore relationships within the data. Should the data permit, a meta-analysis will be conducted. DISCUSSION: This systematic review will help identify factors that influence communication between EMS and ED nurses during transitions in care, and identify interventional strategies that lead to improved communication and decrease in adverse events. The findings can be used to develop an evidence-informed transitions in care tool that ensures efficient transfer of accurate patient information, continuity of care, enhances patient safety, and avoids duplication of services. This review will also identify gaps in the existing literature to inform future research efforts. TRIAL REGISTRATION: PROSPERO CRD42017068844.

Momentary fitting in a fluid environment: A grounded theory of triage nurse decision making.

BACKGROUND: Triage nurses control access to the Emergency Department (ED) and make decisions about patient acuity, patient priority, and placement of the patient in the ED. Understanding the processes and strategies that triage nurses use to make decisions is therefore vital for patient safety and the operation of the ED. The aim of the current study was to generate a substantive grounded theory (GT) of decision making by emergency triage Registered Nurses (RNs). METHOD: Data collection consisted of seven observations of the triage environment at three tertiary care hospitals where RNs conducted triage and twelve interviews with triage RNs. The data were analyzed by constant comparison in accordance with the classical GT method. RESULTS: In the resultant theory, Momentary Fitting in a Fluid Environment, triage is conceptualized as a process consisting of four categories, determining acuity, anticipating needs, managing space, and creating space. The findings indicate that triage RNs continually strive to achieve fit, while simultaneously considering the individual patient and the ED as a whole entity. CONCLUSION: Triage RNs require appropriately designed triage environments and computer technology that enable them to secure real time knowledge of the ED to maintain situation awareness.

The application of theory to triage decision-making.

Theory in nursing is frequently thought of as being a mainly academic exercise with little relevance to the everyday practice of nursing. In nursing there is disagreement about what theory is and what it is not. Scientific theory is an abstract systematic explanation of how concepts are related to each other. Many nursing theories do not fit this description and should therefore, in the opinion of the authors, be thought of as models. Nursing knowledge has been described as the knowledge that is useful to nurses, whether it is derived from the discipline of nursing or other disciplines. Decision-making (DM) and triage nursing have been investigated by several nurse researchers, however, most have not clearly articulated a theoretical or conceptual framework. The recognition primed decision (RPD) model is based on research about DM under uncertain conditions such as time pressure, limited time available, high stakes, and changing cues. The context of emergency triage nursing DM is congruent with the RPD model. The authors propose that the RPD model can serve as a foundation for research that seeks to understand DM by triage nurses with the aim of yielding new knowledge that is useful for their practice.