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Nursing and Health Sciences (2015), 17, 148–158
Review Article
Current status of emergency department triage in mainland China: A narrative review of the literature Lingli Peng, RN1 and Karen Hammad, RN, BN (Hons)2 1 Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, Hunan province, China and 2School of Nursing and Midwifery, Flinders University, Adelaide, South Australia, Australia
Abstract
In this review, the current status of emergency department triage in mainland China is explored, with the purpose of generating a deeper understanding of the topic. Literature was identified through electronic databases, and was included for review if published between 2002 and 2012, included significant discussion of daily emergency department triage in mainland China, was peer reviewed, and published in English or Chinese. Thematic analysis was used to identify themes which emerged from the reviewed literature. This resulted in 21 articles included for review. Four themes emerged from the review: triage process, triage training, qualification of triage nurses, and quality of triage.The review demonstrates that there is currently not a unified approach to emergency department triage in mainland China. Additionally, there are limitations in triage training for nurses and confusion around the role of triage nurses. This review highlights that emergency department triage in mainland China is still in its infancy and that more research is needed to further develop the role of triage.
Key words
accident and emergency, emergency department, China, triage, triage process, triage training.
INTRODUCTION In medical terms, “triage” is broadly defined as the sorting or prioritizing of patients based on acuity (McCann & Ames, 2011; McHugh et al., 2012). Triage is a term that is frequently associated with the emergency department (ED). Patient presentations to the ED are unscheduled and unpredictable (Ng et al., 2010), meaning that patients with varying care needs might present simultaneously or within a short period. This makes it necessary to prioritize the care of patients. When performed in the ED, the aim of triage is to ensure that patients are treated in order of their clinical urgency (Australasian College for Emergency Medicine, 2000). This brief clinical assessment determines the priority by which they will be seen and receive treatment (Murray, 2003; Goransson et al., 2005). In many countries, as in China, this initial assessment is considered to be a nursing role (Emergency Nurse Association, 2010; Qureshi, 2010). Performing triage and deciding on an acuity rating is an advanced and challenging task that is foundational to a person’s visit to the ED (Goransson et al., 2005). Decisions are made within a time-sensitive environment – with limited information – for people who generally do not have a medical diagnosis (Ganley & Gloster, 2011). Failure to triage
Correspondence address: Lingli Peng, Orthopedics Department, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan province 410008, China. Email:
[email protected] Received 25 January 2014; revision received 4 June 2014; accepted 8 June 2014
© 2014 Wiley Publishing Asia Pty Ltd.
appropriately could lead to the deterioration of very sick patients while they are waiting (Murray, 2003; Ganley & Gloster, 2011; McHugh et al., 2012). Triage is an important step affecting not only the patient journey but also ED operations, such as the movement of patients through the department and the effective use of resources (Murray, 2003; Ganley & Gloster, 2011; McHugh et al., 2012). There is a large and growing body of literature which informs the current status and development of ED triage in many developed countries, such as Australia, UK, Sweden, USA, and Canada (Murray, 2003; Goransson et al., 2005; Pardey, 2006; Fitzgerald et al., 2010; Ganley & Gloster, 2011; McHugh et al., 2012). Other countries, particularly in the developed world, have adopted national triage systems. Taiwan, which is considered part of China, has been using a unified approach to triage across the island for several years. The Taiwan triage system (TTS) is a four-tier triage scale that was adopted by the Department of Health and National Health Insurance system in 1998 (Chi & Huang, 2006). ED triage categories in this guideline include life threatening, emergent, urgent (prompt care, but can wait), and non-urgent (attention required, but not time critical) (Chi & Huang, 2006). Additionally, in Hong Kong, the Hospital Authority Triage guideline was implemented in all accident and emergency departments in 2001(Han et al., 2005). This five-tier system includes categories for critical, emergency, urgent, semi-urgent, and non-urgent (Fan & Leung, 2013). In the early 1990s, Australia implemented the National Triage Scale, which was later renamed Australasian Triage doi: 10.1111/nhs.12159
Emergency triage status in China
Scale (ATS) (Pardey, 2006; FitzGerald et al., 2010). This system is reportedly the most commonly-used triage system in the world (Qureshi, 2010; Sands et al., 2013). The ATS is a five-tier scale that has formed the basis for other triage scales, such as the Canadian Emergency Department Triage and Acuity Scale, Manchester Triage Scale, and systems in other countries, such as Hong Kong, New Zealand, and Belgium (Pardey, 2006; Christ et al., 2010; Fitzgerald et al., 2010).These scales and the Emergency Severity Index (ESI), which is commonly used in the USA, are all five-tier scales, and considered the international standard for ED triage (Pardey, 2006; Christ et al., 2010). However, there is a paucity of literature which discusses the triage status of mainland China. To our knowledge, there has been no literature review about emergency triage in mainland China. In recent years, rapid economic and technological advances in mainland China have seen an increased incidence of injuries sustained in road traffic accidents, as well as chronic conditions, such as coronary artery disease, stroke, cancer, and diabetes (Wang et al., 2008; Pei & Xiao, 2011). Annual ED presentations in mainland China increased from 79 million in 2010 to 89.3 million of an overall total population of 1.3 billion in 2011. These factors highlight the need for the development of a well-designed and responsive medical system (Ministry of Health of the People’s Republic of China, 2012a). This has seen a heightened demand for improvements in acute and emergency health care (Wang et al., 2008; Pei & Xiao, 2011), and highlights the need for streamlined emergency care to manage patient flow and timely treatment. In this review, the current status of ED triage in mainland China is explored, with the purpose of generating a deeper understanding of the topic.
METHOD The drive behind this review was to better understand the current status of ED triage in mainland China and a search of electronic databases, including China Knowledge Resource Integrated Database, PubMed, CINAHL, and Science Direct, was undertaken by the first author. The following search terms in the Chinese database were used: “emergency triage”, “emergency classification”, “emergency category”, “triage emergency patients”, and “triage nurse”. Search terms used in PubMed, CINAHL, and Science Direct searches were “emergency triage in China” and “emergency classification in China”. This resulted in 206 articles for potential review. Reference lists of all articles were also searched for more literature, which would inform the subject; however, no further articles were found. The abstracts of all articles were then reviewed using the inclusion and exclusion criteria. Inclusion criteria included original articles describing ED triage in mainland China, published in English or Chinese, and published between 2002 and 2012. Articles were excluded if they were not peer reviewed, if there was not substantial discussion of daily ED triage, or if the focus was not on mainland China. Following the application of inclusion and exclusion criteria, 29 articles
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remained, which were then summarized and collated into a table. All publications for potential inclusion were discussed with two professors of nursing, who are experienced in ED triage in China.As a result, five articles were removed. Both authors then discussed the remaining articles (n = 24); three more articles were removed because they did not have enough relevance to the topic. A summary of this process is outlined in Figure 1. A final number of 21 articles was agreed on by both authors and included for review. All articles were summarized in a table, including methods, findings, strengths, and limitations (see Table 1). Thematic analysis was used to identify themes which emerged from the reviewed literature.Thematic analysis seeks to identify and bring together the main, recurrent, or most important issues or themes arising from a body of literature, and is the most common method adopted within narrative reviews (Mays et al., 2005). The approach to this was to read the literature a number of times, and as themes emerged they were coded and put in a table of themes (Table 2).This process was repeated and discussed at length by both authors. Four themes emerged: triage process, triage training and knowledge, qualification of triage nurses, and quality of triage.
RESULTS AND DISCUSSION Because of the intention of the review was to deepen the understanding of the topic, a narrative approach to the review was considered to be most appropriate. Narrative reviews draw on qualitative and quantitative evidence to summarize, explain, and interpret evidence on a particular topic (Mays et al. 2005). The vast majority of the reviewed literature used quantitative methods (n = 20), with only one study applying a qualitative approach (Guo et al., 2011). Of the articles that were included for review, more than half (n = 14) focused on the process of triage (Liu, 2006; Sun et al., 2006a; 2006b; 2007a; 2007b; Jin et al., 2008; Gu et al., 2010; Tong & Zhang, 2010; Guo et al., 2011; Li, 2011; Lin et al., 2011; Niu et al., 2011; Zhao et al., 2011; Lu et al., 2012). Many of these (n = 11) discussed the implementation of a new triage process where one already existed (Sun et al., 2006a; 2006b; 2007a; 2007b; Jin et al., 2008; Gu et al., 2010; Tong & Zhang, 2010; Li, 2011; Lin et al., 2011; Niu et al., 2011; Lu et al., 2012). Other studies explored patient and ED staff satisfaction with existing or newly-implemented triage processes, evaluation of triage processes, accuracy of triage, nursing assessment of patients at triage, triage training for nurses, and nursing standards for those performing the role of triage nurse.
Theme 1: Triage process Triage process was the most common theme to emerge from the reviewed literature, and refers to the ways in which triage is performed (Liu, 2006; Sun et al., 2006a; 2006b; 2007a; 2007b; Jin et al., 2008; Gu et al., 2010; Tong & Zhang, 2010; Guo et al., 2011; Li, 2011; Lin et al., 2011; Niu et al., 2011; Zhao et al., 2011; Lu et al., 2012) and how it is conducted in the ED. © 2014 Wiley Publishing Asia Pty Ltd.
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L. Peng and K. Hammad
Search of electronic databases using search terms: Pub Med n = 15 CINAHL n = 0 Science Direct n = 10 China Knowledge Resource Integrated Database n = 181 Total number of publications = 206
Abstracts reviewed for inclusion and exclusion Articles reviewed again by reading the full text criteria Articles discussed with 2 professors in nursing Publications excluded for the following reasons: (removed n = 5) •
Not related to daily emergency department Articles discussed by both authors (removed triage (n = 14, in English; n = 10, in Chinese )
•
n = 3) Not investigated in mainland China (n = 10, all in English)
•
Not original articles (n = 27, in Chinese)
•
Not peer-reviewed articles (n = 116, all in Chinese)
Articles included in the systematic review (n = 21)
Figure 1.
When a patient presents to the ED, they will, in most cases, be seen and assessed by a nurse who performs triage (Sun et al., 2006a; 2006b; 2007a; 2007b; Jin et al., 2008; Gu et al., 2010; Tong & Zhang, 2010; Li, 2011; Lin et al., 2011; Niu et al., 2011; Lu et al., 2012). In some hospitals in mainland China, tools are used to aid nurses in their initial assessment of the patient who presents to triage. Common approaches use wellknown acronyms, including; SOAP (subjective, objective, assess, plan), SOAPIE (subjective, objective, assess, interventions, evaluation), and PQRST (provokes, quality, radiate, severity, time) (Liu, 2006; Sun et al., 2006a; 2006b; Tong & Zhang, 2010; Lin et al., 2011; Niu et al., 2011).These tools take into account subjective and objective patient data, including the location of pain and acute disease, such as abdominal pain, chest pain, and myocardial infarction (Sun et al., 2006a; 2006b; Tong & Zhang, 2010; Lin et al., 2011; Niu et al., 2011). The tools described in the literature were largely those that were already in use in the ED. Where a publication discussed the implementation of a tool, they did not report on its effectiveness. Once the patient has been assessed by the triage nurse, they will receive a priority status that helps to determine their journey through the ED, including the length of waiting time for treatment, which area of the ED they are sent to, and which doctor they will see (Sun et al., 2006a; 2006b; Tong & Zhang, 2010; Lin et al., 2011; Niu et al., 2011). The approach used to determine the priority of the patient also varies from hospital to hospital. The two most common approaches apparent in the literature were to provide the patient with © 2014 Wiley Publishing Asia Pty Ltd.
Flowchart of the review process.
either a category or a score (Sun et al., 2007a; 2007b; Jin et al., 2008; Gu et al., 2010; Li, 2011; Niu et al., 2011; Lu et al., 2012). Patients are triaged into a category depending on the severity of their illness or injury (Sun et al., 2007a; 2007b; Gu et al., 2010; Lu et al., 2012). The category they receive will dictate their wait to be seen and treated. Patients triaged into category 1, for example, will be seen immediately, whereas patients triaged into other categories will wait longer to be seen, depending on the category they have been assigned. Different hospitals use a different number of categories, ranging from two categories to five (Sun et al., 2007a; 2007b; Gu et al., 2010; Guo et al., 2011; Lu et al., 2012). Where patients receive a score, as opposed to a category, a scoring tool is used to guide the process (Jin et al., 2008; Li, 2011; Niu et al., 2011; Lu et al., 2012). Examples of scoring tools that are used in mainland China include the Modified Early Warning Score; Circulation, Respiration, Abdomen, Motor, Speech (CRAMS); and Rapid Emergency Medicine Score. These tools compare physiological, anatomical, and/or observational data from the patient with normal parameters and provide the patient with a score (Jin et al., 2008; Li, 2011). The score determines the severity of the patient’s illness and the priority in which they will be seen. Many of the studies that discussed this theme reported on newly-implemented triage processes (Liu, 2006; Sun et al., 2006a; 2006b; 2007a; 2007b; Jin et al., 2008; Gu et al., 2010; Tong & Zhang, 2010; Li, 2011; Lin et al., 2011; Niu et al., 2011; Lu et al., 2012). Where a new triage process had been implemented, it was reported that patient satisfaction was
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Table 1. Publications included in the final analysis of the literature Author Ge et al. (2012)
Title Emergency triage nurses’ training demands
Methods Quantitative study: descriptive/exploratory research design survey 122 participants – emergency triage nurses across 3 hospitals
Main findings •
Major demands for triage training are basic life support and abnormal ECG identification. Second most common demands for triage training are triage skills and protection from workplace violence. Demands are different for nurses with different professional titles. Senior nurses require further training in how to deal with sudden events and communication skills. Most accepted training methods are case discussion, lectures, and scenario simulation. Triage was 98.32% more accurate after the training program was implemented. Training programs using scenario simulation and case study are most effective Most of the participants were satisfied with the new triage process. 54.5% of participants are satisfied with the waiting time after the implementation of the new triage guideline. 82.5% of participants considered that the emergency room should triage according to the condition of patients. Significant differences exist between environment, qualifications, triage evaluation, and triage guidelines. Triage accuracy was higher in the experimental group.
S: identifies training needs of emergency nurses
•
CRAMS in combination with the trauma assessment procedure improves triage accuracy in trauma patients.
•
Senior nurses have a high accuracy rate and low error rate. Triage by senior nurses results in shorter average triage time.
W: 1 hospital. W: Did not discuss previous triage system and did not compare new and previous triage systems S: Used a large sample size W: 1 ED. W: Small sample size
•
•
•
Ge et al. (2009)
Gu et al. (2010)
Application of scenario simulation and case study in emergency care nurses training
Quantitative study: control study using survey 29 doctors, 34 emergency nurses, total 63 participants in 1 hospital
•
Study on optimizing the flow sheet visiting doctor’s office and triage standards in emergency department
Quantitative study: survey 154 patients presenting to an ED of 1 hospital
•
•
•
•
Guo et al. (2011)
He et al. (2004)
The difference of triage process between Guangdong province and Hong Kong Application of weekly target teaching in triage of patients in emergency department
Jin et al. (2008)
Application of trauma assessing method to an emergency triage
Li and Wang (2011)
Role of senior nurses with higher seniority in emergency triage
Strengths and weaknesses
Qualitative study: descriptive report
•
Quantitative study: control study Control group: 100, experimental group: 100, total: 200 participants – nursing students in 1 nursing school Quantitative method: descriptive study Compared CRAMS with trauma assessment procedure Total 4023 participants, trauma patients presenting to the ED of 1 hospital Quantitative study: descriptive study Senior nurse- 5, junior nurse- 5 825 patients triaged in 1 ED
•
•
W: 1 hospital W: Small sample size
W: 1 hospital W: Did not discuss previous triage process and did not compare new and existing triage process in patient perception W: Most of the participants are non-emergent patients S: Uses a qualitative approach
W: Only focused on the nursing students in the ED
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Table 1.
L. Peng and K. Hammad
Continued
Author
Title
Methods
Main findings
Li (2011)
The application of Modified Early Warning Score (MEWS) in the emergency triage
Mixed-method study: retrospective descriptive study 19,810 participants, emergency patients presenting to ED of 1 hospital
•
MEWS is a good tool to detect serious patients earlier
Lin et al. (2011)
Application and effect of SOAP (Subjective, Objective, Assess, Plan) triage model in emergency abdominal myocardial infarction patients The application of PDCA (Plan, Do, Check, Action) cycle in the emergency triage The construction of emergency triage and nursing quality index using Delphi method Establishing and practicing of the triage standard in paediatric emergency
Quantitative study: control study SOAP group: 82, control group: 62 patients presenting to ED of 1 hospital
•
Use of the SOAP was more effective than the previous triage method, improving patient satisfaction and triage accuracy.
Quantitative study: control PDCA group:635, control group: 642 patients presenting to ED of 1 hospital Delphi method – questionnaire development
•
PDCA is 94.8% more accurate than the control group. Using PDCA to underpin triage process is more effective
•
Evaluation system was suitable to use for evaluating the triage and emergency nursing quality.
Quantitative study: descriptive study, survey 34,459 participants, pediatric patients presenting to the ED of 1 hospital
•
New triage guideline reduced medical risk and guarantees patient safety, as well as improves patient satisfaction.
Delphi method
•
Evaluation system was reported to have good validity and reliability.
Quantitative study: control study Control group: 200, new triage process: 200, total 400 patients presenting to ED of 1 hospital with acute non-traumatic abdominal pain Quantitative study Mixed method: descriptive/exploratory research design-survey 100 participants – nurses with triage experience in 1 hospital Quantitative study: control study Control group: 100 patients, new triage process: 100 patients, senior nurses: 10, junior nurses: 10 Total 200 patients presenting to ED of 1 hospital with chest pain and 20 triage nurses
•
Waiting and triage times decreased with the new triage process Triage accuracy rate was 95.2% more accurate with the new system.
Liu (2006)
Liu and Zhou (2011) Lu et al. (2012)
Luo et al. (2009)
Niu et al. (2011)
Exploring the quality standard for communication with patients at triage Study on clinical application of single triage assessment sheet in acute non-traumatic abdominal pain
Song and Kong (2004)
A survey on the facts which influence the accuracy of emergency triage
Sun et al. (2006b)
Study on the improvement of triage accuracy of patients presenting to ED with acute chest pain
© 2014 Wiley Publishing Asia Pty Ltd.
•
•
Main factors affecting triage accuracy are limited triage knowledge, of poor communication skills, lack of responsibility and large numbers of non-emergent patients. • •
Triage accuracy is increased with new process Triage accuracy is increased with senior triage nurses
Strengths and weaknesses W: 1 hospital. W: Did not discuss previous triage systems and did not compare new and previous triage systems S: Large sample size W: 1 hospital and 1 disease W: Did not discuss previous triage process
W: 1 hospital W: Did not discuss the difference between the previous and new management methods W: Focused on emergency services more, triage services less W: 1 hospital. W: Just described the data, but did not compare the statistic difference between the new and previous systems S: Large sample size W: Only focused on the communication quality. Did not focus the other indexes W: 1 hospital. W: Only focused on patients > 18 years
W: 1 hospital. W: Some participants not currently working in triage S: Identified the current knowledge of triage nurses W: 1 hospital W: Only focused on patients > 14 years
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Table 1. Continued Author
Title
Methods
Sun et al. (2007a)
Creating and practicing of the emergency triage standard
Sun et al. (2007b)
The perception of emergency patients on emergency triage
Sun et al. (2006a)
Application of PORST (provokes, quality, radiate, severity, time) model in triage of the emergency patients with acute abdominal pain Study on improving the accuracy rate of separating diagnosis of acute abdominal pain
Quantitative study: comparative study, survey Previous triage process group: 200 participants, new triage process group: 200 participants, total: 400 patients presenting to ED of 1 hospital Quantitative study: descriptive/exploratory research design survey 100 patients presenting to the ED of 1 hospital Quantitative study: control study Control group: 100, new triage model: 100, total 200 patients presenting to ED of 1 hospital with acute abdominal pain Quantitative study: control study Control group: 100, new triage process: 100, senior nurses: 10, junior nurses: 10 Total 200 patients presenting to ED of 1 hospital with acute abdominal pain and 18 triage nurses Quantitative study: descriptive/exploratory research design-survey Patients: 289, medical staff (including doctors and nurses): 277, total: 566 participants across 6 hospitals
Tong and Zhang (2010)
Zhao et al. The perception of (2011) patients, medical and nursing staff in emergency departments in Shanghai
Main findings
Strengths and weaknesses
•
Participants were more satisfied with the new triage guidelines
W: 1 hospital W: Only compared the patient satisfaction, but did not compare other data, such as accuracy
•
100% of participants were satisfied with the new triage guideline
W: 1 hospital
•
Triage accuracy rate was 95% more accurate with new process
W: 1 hospital W: Did not discuss previous triage system
•
Triage accuracy was improved with new process Triage accuracy was higher with senior triage nurses
W: 1 hospital
•
•
Participants believed triage should be standardized and accurate • Most of the participants (n = 64.7%) believed the emergency triage should be based on the type of the disease and the severity of illness of the patients • Approximately half (n = 46.6%) of medical staff believed doctors (not nurses) should determine the priority of the patients • Patients lacked understanding of triage • Many participants lacked knowledge of triage. Only 31.0% doctors and nurses believed that triage means determining the priority for the patients. Most doctors and nurses (n = 83.1%) supported that triage should be done by the senior nurse or the nurses who have completed triage training • 96.8% (n = 277) of doctors and nurses believed that training is necessary for all triage staff
S: Successfully identified the perceptions from different participants, including doctors, nurses, and patients
CRAMS, Circulation, Respiration, Abdominal Motor, Speech; ECG, electrocardiogram; ED, emergency department; MEWS, Modified Early Warning Score; S, strength; W, weakness.
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Table 2.
L. Peng and K. Hammad
Themes identified from the findings of the studies
Themes Triage process
No. studies
Publications
14
Gu et al. (2010), Lin et al. (2011), Sun et al. (2007a), Li (2011), Jin et al. (2008), Sun et al. (2006a), Tong and Zhang (2010), Niu et al. (2011), Lu et al. (2012), Sun et al. (2006b), Sun et al. (2007b), Guo et al. (2011), Zhao et al. (2011), Liu (2006) Ge et al. (2009), Ge et al. (2012), Guo et al. (2011), He et al. (2004), Lin et al. (2011) Gu et al. (2010), Guo et al. (2011), Sun et al. (2007a), Zhao et al. (2011), Li and Wang (2011), Sun et al. (2006b), Tong and Zhang (2010). Liu (2006), Liu and Zhou (2011), Luo et al. (2009), Song and Kong (2004), Zhao et al. (2011)
Triage training Triage qualification
5 7
Triage quality improvement
5
increased and subsequent triage waiting time was decreased (Sun et al., 2007a; 2007b; Gu et al., 2010; Lin et al., 2011; Lu et al., 2012). Although the outcomes of the newlyimplemented triage processes were reported to be improved, there was minimal comparison with previous triage processes. Patients who present to ED in mainland China are triaged on arrival; however, there is wide variation across the country as to how they are triaged. The implementation of new approaches to triage, demonstrated in this review, might suggest a desire to change what currently exists. In September 2012, the Chinese government published The Design of Normative Flow of Emergency Department (Ministry of Health of the People’s Republic of China, 2012b). This document provides guidelines for ED triage, as well as standards for the delivery of care. The document proposes implementation of the new guidelines in ED as of February 2013. At this stage, however, it is unclear what the program of implementation and uptake of the guideline has been in the hospitals. The new guidelines advocate for a four-tier approach to triage, with categories including life-threating, emergent, urgent, and non-urgent (Ministry of Health of the People’s Republic of China, 2012b). Patients who receive a level 1 category should be seen and treated immediately. Patients in the level 2 category should be seen within 10 min by a doctor in the resuscitation room or rescue room. The waiting time for patients with a level 3 category must not exceed 30 min. The guideline does not give the details about waiting time for patients in the level 4 category; however, it does suggest that if there are too many patients in this category, an area can be set up to rapidly assess and treat these patients with a view to discharging them, therefore creating more resources and space. The guidelines also mention that the ED should implement partition management. This means that patients in different categories should be sent to a designated waiting area, rather than a communal waiting area (Ministry of Health of the People’s Republic of China, 2012b). This guideline has similarities with the TTS, which also uses a four-level approach with similar waiting times.
Theme 2: Triage training This theme explores how nurses prepare for the role of triage. Preparation for triage appears to be largely driven by the employer through short courses and workshops organ© 2014 Wiley Publishing Asia Pty Ltd.
ized by the employer and/or mentorship by a nurse experienced in triage (He et al., 2004; Ge et al., 2009; 2012; Guo et al., 2011; Lin et al., 2011). The content of triage training currently includes triage assessment, triage process, how to register patient information, and how to deal with sudden events (Lin et al., 2011). A study by Ge et al. (2012), which explored the training needs of triage nurses, found a demand for basic life support, abnormal electrocardiogram identification, triage skills, and protection from workplace violence. Ge et al. (2012) also found that training needs vary between junior and senior nurses, with junior triage nurses emphasizing the need for more basic life support knowledge, and senior nurses requiring further training in how to deal with sudden events, as well as communication skills (Ge et al., 2012). According to the literature, training is offered to and attended not only by nurses working in the ED, but by nursing students as well (He et al., 2004; Ge et al., 2009; 2012; Lin et al., 2011). It is unclear from the literature if the content and level of training is adjusted to meet the varying learning needs of the different nurses attending. Additionally, it is not clear if training is provided as a once off or if it is ongoing for nurses wishing to maintain their triage knowledge. Triage training for nurses appears to be haphazard, with wide variation in content and delivery across the country. A study by Song and Kong (2004) further highlights limitations in the accessibility of triage training, stating that nurses feel that their training needs are not being met. Current limitations in triage training are most likely due to the fact that, until recently, there have been no clear guidelines to teach from. The recently-published triage guidelines (Ministry of Health of the People’s Republic of China, 2012b) provide a platform for the development of an educational program for the training of emergency nurses in triage. Other countries, such as the USA, Canada, and Australia, have comprehensive triage training systems which include triage handbooks and courses (Agency for Healthcare Research and Quality, 2012; Ontario Hospital Association, 2012; Australian Government Department of Health and Ageing, 2013). One example is the Emergency Triage Education Kit, which is widely available and easily accessible to emergency nurses online (Australian Government Department of Health and Ageing, 2013). In Canada and the UK, advanced training delivery, such as online education, triage workshops, and patient simulation, is also readily available to nurses (Wolf, 2008; Rankin et al., 2013).
Emergency triage status in China
Theme 3: Qualification of triage nurses This theme discusses who should be performing triage and what level of experience or training they require. There is a lot of debate in the reviewed literature as to what qualifications, experience, or training someone in the triage role should have. Senior nurses and nurses with significant nursing experience are believed to be more suitable for the role of triage (Sun et al., 2006b; 2007a; Tong & Zhang, 2010; Li & Wang, 2011; Zhao et al., 2011). It is also suggested that nursing experience of 1 year or more is considered to be a sufficient timeframe (Gu et al., 2010; Tong & Zhang, 2010; Guo et al., 2011; Li & Wang, 2011). At a minimum, all triage nurses should be licensed registered nurses (Sun et al., 2007a; Gu et al., 2010; Guo et al., 2011; Zhao et al., 2011). The literature also clearly supports the requirement that all nurses undertake specific triage training and pass an examination before being allowed to undertake the role of triage nurse (Sun et al., 2007a; Guo et al., 2011; Zhao et al., 2011). However, definitions in the literature are lacking, and it is unclear what substantiates significant nursing experience and whether this is general or emergency nursing experience. It is also uncertain in the literature as to what triage training nurses should undertake to become triage ready, and who manages the examination process that will deem them competent to be a triage nurse. Due to the complex nature of triage, those undertaking the role of triage need to possess specialist knowledge, as well as experience in a wide range of illnesses and injuries (FitzGerald et al., 2010; Ganley & Gloster, 2011). There is much debate in the literature on the role of triage nurses and the qualifications and experience required by those in triage. Guidelines published by emergency nursing professional bodies in other countries outline selection criteria for the role of the triage nurse related to clinical practice, education, training, and personal attributes, such as communication and organizational skills (College of Emergency Nursing Australasia, 2009; Canadian Association of Emergency Physicians, 2010; Emergency Nurse Association, 2010). All the professional bodies require triage be performed by specifically-trained and experienced registered nurses, and that every registered nurse should have completed a comprehensive and standardized triage education program prior to commencing a triage role (College of Emergency Nursing Australasia, 2009; Canadian Association of Emergency Physicians, 2010; Emergency Nurse Association, 2010). For example, in the USA, in addition to completing a standardized triage education course that includes a didactic component and a clinical orientation prior to their commencing triage duties, a triage nurse should acquire additional education. Additional education is specified as training on cardiopulmonary resuscitation, a standardized advanced life support, an emergency nurse pediatric course, a trauma nurse core course, and geriatric emergency nurse education (Emergency Nurse Association, 2010). The recentlypublished Chinese guidelines for ED triage have only one specification: a minimum requirement of 5 years of experience (Ministry of Health of the People’s Republic of China, 2012b). It is not clear if this experience is in general nursing
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or emergency nursing. There are no other guidelines outlining the minimum standard education or knowledge requirement for a triage nurse in mainland China.
Theme 4: Triage quality Triage quality relates to the approaches that are used to evaluate the quality of triage, as well as barriers that influence the quality of triage (Song & Kong, 2004; Liu, 2006; Luo et al., 2009; Liu & Zhou, 2011; Zhao et al., 2011). The reviewed articles provide very little discussion on the evaluation of triage or the effectiveness of triage systems once implemented.
Evaluation of triage A small number of articles measure triage quality (n = 3). Triage quality appears to be measured predominately through patient and ED staff satisfaction, waiting time, and triage accuracy. This theme emerged primarily in studies that had discussed new triage processes that had been implemented (Liu, 2006; Luo et al., 2009; Liu & Zhou, 2011). Two articles provided a discussion of tools designed to evaluate aspects of triage, such as the communication skills of triage nurses and the quality of the emergency service (Luo et al., 2009; Liu & Zhou, 2011). However, these tools are still in the development phase, and it is not clear if these tools have been validated or are currently in use. One tool that is currently being used in one hospital is the Plan, Do, Check, Action approach developed by William Deming (Liu, 2006). There is a large amount of literature that discusses the validation and evaluation of triage in developed countries, and multiple scales have been adopted to standardize the assessment of triage, which generally includes triage quality processes, reliability and validity of the triage system, triage decision accuracy, and the quality audit tool used, as well as factors affecting triage decision-making in relation to a specific triage system (Christ et al., 2010; Considine et al., 2004; Creaton et al., 2008; Gerdtz et al., 2008; Hodge et al., 2013; Parenti et al., 2014). Three outcomes, including expected, over-triage, and under-triage, have been largely used in the evaluation of the triage process (Kriengsoontornkij et al., 2010; Australian Government Department of Health and Ageing, 2013; Hodge et al., 2013). Various approaches have been taken to assess triage decision consistency; that is, reliability, and accuracy when categorizing patients (Varndell et al., 2013), and quality of triage has been comparatively studied (Kahveci et al., 2012). The six aims of quality, including improving safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity of the healthcare system, were suggested to be used to evaluate the triage process of the ESI (Gilboy et al., 2012). Triage quality indicators and thresholds were also included to monitor implementation of specific triage system and to evaluate other aspects of the broader triage process (Health Policy Priorities Principal Committee, 2011; Gilboy et al., 2012). However, few articles have reported on quality improvement and evaluation of ED triage in mainland China. This might be in part due to the variety of triage systems that are in use in mainland China. © 2014 Wiley Publishing Asia Pty Ltd.
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The recently-published Chinese guidelines for ED triage provide scope for the development or implementation of an evaluation tool based on tools that have already been validated around the world.
Barriers to effective triage Barriers to effective triage are reported in the literature as being due to variations in the approach to triage across mainland China, limitations in triage knowledge among ED staff, and the volume of patients presenting to the ED (Song & Kong, 2004; Zhao et al., 2011). The first two factors have already emerged in other themes as current issues of ED triage in China.Wide variations in the process of triage across the country make it difficult to evaluate and validate current processes. Furthermore, there is not a solid foundation for the provision of training, and therefore, the development of nurses with expertise and knowledge in this area. The third factor identified in the literature as a barrier to effective triage is that of large numbers of non-emergent patients presenting to the ED. On a daily basis, this presents a considerable challenge to effective triage, as it is difficult for triage staff to detect patients requiring more urgent care (Song & Kong, 2004; Zhao et al., 2011). This in turn could affect triage accuracy and patient safety by delaying patient waiting times. In mainland China, the government has implemented an “unlimited emergency policy”. This means that anyone, including emergent and non-emergent patients, can access the ED, and the hospitals are not allowed to refuse any patient (Song & Kong, 2004; Ministry of Health of the People’s Republic of China, 2009). This issue might stem from a general lack of understanding by the public regarding the role of ED and ED triage (Zhao et al., 2011). ED overcrowding is not exclusive to mainland China, and is a welldocumented global issue. Thus, raising public awareness of the role of ED and triage is required by the government and related bodies.
STRENGTHS AND LIMITATIONS A limitation of this review was that all reviewed articles are published in the Chinese language. While every effort was taken to prevent this through numerous discussions between the authors and the use of expert opinion, there is a possibility that the translation from Chinese into English might have affected both expression and understanding.
CONCLUSION To the best of our knowledge, this is the first review of its kind to explore and report on the current status of ED triage in mainland China. Although patients who present to ED in mainland China will be triaged on arrival, there is wide variation across the country with regard to how they are triaged. There is no unified approach to triage in China, and a number of different models of triage currently exist. Additionally, other findings related to triage training, role specification of triage nurses, and quality improvement of triage highlight © 2014 Wiley Publishing Asia Pty Ltd.
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that ED triage in China is still developing. As a priority, further research to develop the role of triage in mainland China is imperative. Based on the findings, it can be concluded that there is an urgent need to establish a systematic, standardized national approach to ED triage. Without standardized guidelines, it is difficult to develop or implement a comprehensive and scientific triage training system or determine the requirements of nurses performing the role of triage. The recentlypublished triage guidelines provide the opportunity to explore this further. The government, in collaboration with hospitals and professional nursing organizations, needs to take action and develop strong guidelines and an approach to their implementation.
RELEVANCE TO CLINICAL PRACTICE ED triage in mainland China is in its infancy. With the increasing population and demand for emergency care, there is an immediate need for further research into the development of ED triage. This should be done as a collaborative effort between the government, hospitals, and key stakeholders, such as emergency nursing professional organizations. The development of an accepted national triage guideline will provide a platform to further develop the role of triage and approaches to training nurses for the triage role.
ACKNOWLEDGMENTS The authors wish to thank Professors Honghong Wang (Nursing School, Central South University, Changsha, Hunan province, China) and Yinglan Li (Nursing Department, Xiangya Hospital, Central South University, Changsha, Hunan province, China) for their expert opinion. Furthermore, LP would like to thank Flinders University, School of Nursing and Midwifery staff (Adelaide, South Australia, Australia) for their support.
CONTRIBUTIONS Study Design: LP, KH. Data Collection and Analysis: LP, KH. Manuscript Writing: LP, KH.
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