Pain assessment by emergency nurses at triage in the emergency department: A qualitative study.

AIMS AND OBJECTIVES: To investigate the assessment of pain intensity in the specific context of triage. BACKGROUND: Acute pain affects most patients admitted to emergency departments, but pain relief in this setting remains insufficient. Evaluation of pain and its treatment at the time of patient triage expedites the administration of analgesia, but may be awkward at this time-pressured moment. The assessment of pain intensity by a validated pain scale is a critical initial step, and a patient's self-reporting is widely considered as the key to effective pain management. According to good practice guidelines, clinicians must accept a patient's statement, regardless of their own opinions. DESIGN: A qualitative methodology rooted in interactionist sociology and on the Grounded theory was used to provide an opportunity to uncover complex decision-making processes, such as those involved in assessing pain. METHODS: A sociologist conducted semi-structured interviews during the 2013-2014 winter months with twelve nurses and trained in the use of an established protocol, focusing on the assessment of pain intensity. The interviews were recorded, fully transcribed and analysed. RESULTS: The most frequently used pain scale was the Verbal Numerical Rating Scale. Discrepancies between self-assessment and evaluation by a nurse were common. To restore congruence between the two, nurses used various tactics, such as using different definitions of the high-end anchor of the scale, providing additional explanations about the scale, or using abnormal vital signs or the acceptance of morphine as a proof of the validity of severe pain ratings. CONCLUSIONS: Nurses cannot easily suspend their own judgement. Their tactics do not express a lack of professionalism, but are consistent with the logic of professional intervention. RELEVANCE TO CLINICAL PRACTICE: This article presents triage nurses' reality in a time-pressured environment, and understanding this conflict may outline new educational targets to further improve pain management in ED.

Impact of triage nurses' recognition of acute coronary syndrome on patients' clinical outcomes: A retrospective study.

BACKGROUND: Triage nurses' pivotal role in initial assessment makes their competence crucial. However, the specific impact on Acute Coronary Syndrome (ACS) recognition and outcomes remains unclear in Jordanian healthcare. Understanding this relationship could enhance ACS management and patient outcomes in Jordanian Emergency Departments (EDs). OBJECTIVE: To assess how triage nurses' recognition of ACS diagnosis affects patient outcomes in Jordan. METHODS: This retrospective study examined records of 150 ACS patients admitted to the coronary care unit (CCU). Data extraction assessed triage nurses' accuracy in recognizing ACS symptoms and the timelines for diagnosis procedures (e.g., electrocardiogram [ECG]) and treatment provision (e.g., thrombolytic) based on triage decisions. It also evaluated the impact on treatment outcomes, including length of stay in the ED and hospital. Multiple linear regression analyses quantified the influence of under-triage on treatment outcomes. RESULTS: The sample comprised 150 patients. Most were female (78.7%), aged 45-59.9 years (37.3%). ACS classifications: unstable angina (52.0%), STEMI (38.0%), NSTEMI (10.0%). The study included a cohort of ACS patients, with findings indicating varying degrees of under-triage by triage nurses. Analysis of timelines revealed significant delays in diagnosis and treatment initiation for patients subjected to under-triage. Multiple linear regression analyses demonstrated a robust association between under-triage and prolonged time to essential treatment outcomes, including delays in physician assessment, ECG performance, thrombolytic administration, and extended ED length of stay. CONCLUSION: Triage nurses' knowledge and competency are crucial determinants of accurate ACS recognition and subsequent clinical outcomes for patients presenting to the ED in Jordan. Investing in ongoing education and training programs for triage nurses may lead to improved ACS recognition rates and better patient outcomes in Jordanian healthcare settings.

Application of quality improvement analytic methodology in emergency medicine research: A comparative evaluation.

OBJECTIVE: Quality improvement (QI) analytic methodology is rarely encountered in the emergency medicine literature. We sought to comparatively apply QI design and analysis techniques to an existing data set, and discuss these techniques as an alternative to standard research methodology for evaluating a change in a process of care. METHODS: We used data from a previously published randomized controlled trial on triage-nurse initiated radiography using the Ottawa ankle rules (OAR). QI analytic tools were applied to the data set from this study and evaluated comparatively against the original standard research methodology. RESULTS: The original study concluded that triage nurse-initiated radiographs led to a statistically significant decrease in mean emergency department length of stay. Using QI analytic methodology, we applied control charts and interpreted the results using established methods that preserved the time sequence of the data. This analysis found a compelling signal of a positive treatment effect that would have been identified after the enrolment of 58% of the original study sample, and in the 6th month of this 11-month study. CONCLUSIONS: Our comparative analysis demonstrates some of the potential benefits of QI analytic methodology. We found that had this approach been used in the original study, insights regarding the benefits of nurse-initiated radiography using the OAR would have been achieved earlier, and thus potentially at a lower cost. In situations where the overarching aim is to accelerate implementation of practice improvement to benefit future patients, we believe that increased consideration should be given to the use of QI analytic methodology.

Effect of Triage Nurse Initiated Radiography Using the Ottawa Ankle Rules on Emergency Department Length of Stay at a Tertiary Centre.

OBJECTIVE: To determine the effect of triage nurse initiated radiographs using the Ottawa Ankle Rules (OAR) on emergency department (ED) throughput. We hypothesized OAR use would reduce median ED length of stay (LOS) by 25 minutes or more. METHODS: A randomized controlled trial was conducted at a tertiary centre ED with an annual census of over 90,000 patients. Adult patients presenting within 10 days of isolated blunt ankle trauma were eligible. Participants were randomly assigned to standard triage or OAR application by 15 explicitly trained triage nurses. Our primary outcome was ED LOS. Secondary outcomes included triage nurses' and patients' satisfaction. A power calculation indicated 142 patients were required. The Mann-Whitney U test was used to compare the medians between the two groups. RESULTS: Of 176 patients with blunt ankle injury screened, 146 were enrolled (83.0%); baseline characteristics in the two groups were similar. The median/mean ED LOS in the control and OAR groups were 128/143 minutes and 108/115 minutes respectively (median difference 20 minutes; p=0.003). Agreement in OAR use between emergency physicians and nurses was moderate (kappa 0.46/0.77 for foot/ankle rule components), and satisfaction of both nurses and participants was high. CONCLUSION: Triage nurse initiated radiography using OAR leads to a statistically significant decrease of 20 minutes in the median ED LOS at a tertiary care centre. The overall impact of implementing such a process is likely site-specific, and the decision to do so should involve consideration of the local context.

Impacts of the introduction of a triage system in Japan: a time series study.

The aim of the present study was to measure and compare the effectiveness of nursing triage before and after introduction of the Japanese Triage and Acuity Scale (JTAS), the Japanese version of the Canadian Triage and Acuity Scale (CTAS), during emergency treatment. Surveys of triage nurses and emergency physicians were conducted before and after JTAS introduction. Respondents were triage nurses (before 112 cases, after 94 cases), emergency physicians (before 50, after 41), and triaged patients (before 1057, after 1025) from seven separate emergency medical facilities. The results showed that nursing triage using the JTAS shortened "time from registration to triage" by 3.8min, "triage duration" by 1min, "time from registration to physician" by 11.2min, and "waiting time perceived by patients to see a physician" by 18.6min (p<0.001). The difference in assigned level of urgency between triage nurses and emergency physicians decreased from 34.2% to 12.2% (p<0.001), over-triage decreased from 24.7% to 8.6% (p<0.001), and under-triage decreased from 9.5% to 3.6% (p<0.001). Furthermore, assessment agreement between triage nurses and emergency physicians increased significantly, from weighted κ=0.486 to weighted κ=0.820. These findings suggest that the introduction of the JTAS promoted more effective nursing triage and medical care.