RESEARCH
AN EXAMINATION OF ESI TRIAGE SCORING ACCURACY IN RELATIONSHIP TO ED NURSING ATTITUDES AND EXPERIENCE Authors: Andrew Martin, MSN, RN, PHRN, CEN, Carolyn L. Davidson, PhD, RN, CCRN, FNP-BC, CPHQ, Anne Panik, MS, BSN, RN, NEA-BC, Charlotte Buckenmyer, MS, RN, CEN, Paul Delpais, MSN, RN, CEN, and Michele Ortiz, BSN, RN, CEN, Allentown, PA Introduction: This research was designed to examine if there is a difference in nurse attitudes and experience for those who assign Emergency Severity Index (ESI) scores accurately and those who do not assign ESI scores accurately. Studies that have used ESI scoring discussed the role of experience, but have not specifically addressed how the amount of experience and attitude towards patients in triage affect the triage nurse's decision-making capabilities. Methods: A descriptive, exploratory study design was used.
Data from 64 nurses and 1,644 triage events at 3 emergency departments was collected. Participants completed demographic data, attitude (Caring Nurse Patient Interaction, CNPI-23) survey, and triage data collection tools during the continuous 8hour triage shift. Clinical nurse expert raters retrospectively reviewed the charts and assigned an ESI score to be compared with the nurse. Descriptive statistics were used to describe the nurse and Pearson's correlation was used to examine the relationship between experience and attitude.
ranged from a high of 0.63 in the nurse participant with 1.00 to 1.99 years of experience to a low of 0.51 in the nurse participant with 15 to 19 years of experience. The nurse participants with an overall mean CNPI-23 score of 106 to 115 achieved the highest agreement compared with a single participant with a CNPI-23 overall mean score of less than 77 who had a Kappa agreement of 0.50. The nurse participants with a CNPI-23 overall mean score between 81 and 92 demonstrated agreement of 0.54 to 0.60. Discussion: Based on the high level of liability the triage area
presents, special consideration needs to be made when deciding which nurse should be assigned to that area. The evidence produced from this study should provide some reassurance to ED managers and nurses alike that nurses with minimal ED experience and a working understanding of the ESI 5-level triage algorithm possess the knowledge and the capacity to safely and appropriately triage patients in the emergency department.
Results: In this study of 64 nurse participants, the ESI score
assigned by nurse participants did not differ significantly based on years of experience or CNPI mean score. The Kappa statistic
Key words: Emergency department; Triage nurse; Nurse
he triage area of the emergency department has been identified by many professional organizations as a location that leaves the hospital vulnerable to liability. Further compounding the vulnerability of the triage area is ED crowding, a problem projected as only worsening by the American College of Emergency
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Physicians. 1 Further, in the landmark report, “The Future of Emergency Care in the United States,” the Institute of Medicine described the worsening crisis of crowding that occurs daily in most emergency departments. 2 Predictions like this highlight the importance of taking all available precautions to manage triage area liability.
Andrew Martin, Member, Berks County Chapter, is Director, Emergency Services, Lehigh Valley Health Network, Allentown, PA.
Michele Ortiz is Emergency Department Patient Care Coordinator, Lehigh Valley Health Network, Allentown, PA. For correspondence, write: Andrew Martin, MSN, RN, PHRN, CEN, Lehigh Valley Health Network, 1637 Chew St, Allentown, PA 18102; E-mail: [email protected]. J Emerg Nurs ■.
Carolyn L. Davidson is Administrator, Quality and Evidence-Based Practice, Lehigh Valley Health Network, Allentown, PA. Anne Panik is Sr. VP, Patient Care Services and Clinical Excellence, Lehigh Valley Health Network, Allentown, PA. Charlotte Buckenmyer is former Director, Emergency Services, Lehigh Valley Health Network, Allentown, PA. Paul Delpais is Director, Emergency Services, Lehigh Valley Health Network, Allentown, PA.
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attitude; Nurse experience; ESI
0099-1767/$36.00 Copyright © 2013 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2013.09.009
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Given the described crowding crisis, the role of the ED triage nurse in the initial assessment may be the most crucial to ensure that the “right patient is in the right place at the right time and that no one is overlooked.” 3 These initial decisions made by the triage nurse affect the entire department. In spite of the current nationwide nursing shortages, it is important to ensure that emergency departments are staffed not only with adequate nursing support but with high-quality, well-trained nurses capable of accurately triaging ED patients. 4 The characteristics of the triage nurse that exemplify proficiency have not been well elucidated in the literature. Reports conflict regarding the adequate amount of experience and the attitude a nurse requires to be considered competent in the skill of triaging. 5–8 The inability to formulate consistent conclusions is further compounded by the study methods chosen to evaluate nurses in triage, because all the studies used simulation scenarios. The accurate triage of patients is leveraged by the Emergency Severity Index (ESI). The ESI is a 5-level triage system guided by algorithms for clinical decision making and is a tool that allows the nurse to rapidly assess the patient, initiate decision making for resources, and assign a score that is familiar to the health care team. The algorithm is simple to use, reduces the subjectivity of the triage decision, and is more accurate than other triage systems, therefore contributing to a common language among ED caregivers. 9 Although the validity and reliability of the ESI have been established, questions remain about the characteristics that contribute to a proficient ED triage nurse. To better evaluate attitude, the definition “a mental position with regard to a fact or state, or a feeling or emotion toward a fact or state” was used for the purposes of this study. 10 The lack of available literature conclusively addressing (1) the effect of attitude toward patients and (2) the amount of experience on the proficiency of the ED triage nurse supports this descriptive, exploratory study. The following research questions were examined: 1. Does the number of years of experience differ between ED nurses who do and do not accurately assign (ESI) triage scores? 2. Does the attitude toward patients in triage differ between ED nurses who do and do not accurately assign ESI triage scores? Setting
The study was conducted in a 988-bed tertiary Magnet™ health network with emergency departments at 3 sites in
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northeast Pennsylvania. The 3 distinct sites—a level I trauma center in a suburban location, a center city location, and a community campus—collectively exceed 130,000 ED patient visits on an annual basis. Sample
A convenience sample was recruited from registered nurses in the 3 emergency departments. Inclusion criteria for the nurse participants were:
• A current full-time, part-time, or ED specialty float pool employee in any one of the 3 emergency departments
• Possession of a current nursing license in the commonwealth of Pennsylvania
• Completion of the Lehigh Valley Health Network (LVHN) required critical care course, or equivalent
• Completion of the ESI training course within the 2 months preceding study enrollment
• Completion of an 8-hour triage shift
All patients who entered the emergency department via the designated triage area and were assigned an ESI score by enrolled nurse participants during the 8-hour shift were identified as eligible for the study. Triaged patients with one of the criteria deemed a protected/vulnerable population (ie, domestic violence, sexual assault, behavioral health, and pediatric patients) defined by LVHN organization policy were excluded from the study. Patients arriving by ambulance were excluded because they bypass the nurse triage area. Study variables
Accuracy of ESI scoring by nurses was the outcome variable in this study. The ESI score was obtained by nurse participants who triaged patients in live situations and assigned a score based on the established valid and reliable ESI algorithm. 11 Secondarily, an ESI score was assigned by ESI-validated clinical nurse expert raters who retrospectively reviewed the presenting information on the ED patient’s chart. The two predictor variables in the study were ED triage experience and attitude toward patients in triage as measured by the Caring Nursing Patient Interactions Scale (CNPI-23), a psychometrically valid tool with 4 subscales (clinical care, relational care, humanistic care, and comfort care) designed to assess nurse attitudes and behaviors based on “Watson’s 10 carative factors.” 12 The interaction at point of triage is linked to many of the caring factors, such as trust, altruism, humanism, sensitivity, supportive, problem-solving, and protective.
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Instruments
The Nurse Characteristic Collection Tool (NCCT) was developed from the relevant literature to collect demographic data and characteristics about the nurse participant: age, sex, educational level, certifications, employment status, shift status, years of nursing experience, years of ED nursing experience, years of ED triage nursing experience, and triage hours worked per week. Additionally, each nurse was asked to rate their perceived competence of triage ability: novice, beginner, intermediate, advanced, or expert. The CNPI-23, a 23-item instrument used to measure caring attitudes and behaviors, was used in this study to reflect attitudes of nurses. The author’s permission was obtained to use this instrument. The CNPI-23 requires a forced choice response on a 5-point Likert scale (1 = not at all to 5 = extremely). The instrument was scaled down from the original 70-item, 10-subscale instrument and produces subscale scores in 4 distinct caring domains (clinical, relational, humanistic, and comfort care). The total CNPI23 score range is 23–115. The instrument has been factor analyzed and tested and found to be reliable (clinical, r = 0.82 to 0.93; relational, r = 0.89 to 0.91; humanistic, r = 0.64 to 0.73; and comfort care, r = 0.61 to 0.74). Attitude is defined as “a mental position with regard to a fact or state, or a feeling or emotion toward a fact or state,” 10 whereas caring is defined as “to be concerned about, to feel interest or concern.” 13 The CNPI-23 and the subscales address Watson’s original theory of carative factors that embody both attitude and caring. These factors provide clear guidelines for the nurse-patient interaction. The subscales are interdependent and reflect an individual nurse’s value system. Decision making in triage is guided primarily by a categorized patient acuity algorithm but also may be a factor of intrapersonal characteristics. 14 The linkage of patient outcomes with intrapersonal behaviors is reflected in the CNPI-23. Items within the subscale of humanistic care refer to a nurse’s attitude and behaviors as they relate to the patient’s own capacities and abilities. Relational care addresses the nurse’s respect of patient perceptions, and the clinical care subscale addresses the clinical expertise. The comforting care subscale is most representative of the hidden work associated with nursing. The ESI is 5-tier algorithm used to categorize patient acuity based on key patient factors: presence of a condition that is life threatening or high risk; vital signs; and how many resources the patient will need. The utilization of the validated and reliable ESI 5-tier triage scoring tool is best used in combination with patient presentation including age, history, pain, current medications, and patient severity of complaint to support an overall ESI score assignment.
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The ESI has evolved during the past 14 years, and with use of the Kappa statistic it has most recently demonstrated interrater reliability ranging from .70 to .80 when nurses make triage decisions based on case studies and 0.69 to 0.87 when nurses make triage decisions for actual patients. 9
Procedures
The study was approved by the Institutional Review Board. Exemption to full Institutional Review Board review was granted because the study met all criteria for posing a low risk to participants. The study data were collected in 3 phases. In phase I, ED nurses were briefed about the study and invited to participate by the principal investigator (PI) at education days. Nurse participants signed an informed consent at enrollment and were given the NCCT and CNPI-23 to complete. In phase II, enrolled nurse participants worked one continuous 8-hour shift in the triage area. During this time they continued to use standard triage procedures to prioritize patients and documented their triage assessments in the ED electronic medical record. In addition, the participants completed the Triage Case Tracking (TCT) form that contained the patient medical record numbers, nurseassigned ESI scores, and the number of resources the nurse predicted the patient would require. Completed TCT forms were placed in a locked box located in each study site’s triage room. To thank them for their participation, the participants received a $25 gift card after completion of all requirements: NCCT, CNPI-23, and an 8-hour shift in triage. In phase III, the completed TCT forms were collected by 1 of the 6 ESI-validated clinical expert nurse reviewers to obtain patient medical record numbers. Using the emergency department’s electronic medical record, the nurse experts carefully reviewed each patient’s medical record to determine if an accurate ESI score was assigned. The clinical experts reviewed medical records on an ongoing basis throughout the study implementation period and recorded their findings on the triage research retrospective review forms. The ESI-validated clinical expert nurse reviewers were identified by ED clinical leadership as proficient in ESI scoring. The expert reviewers were educated on the procedures for retrieving completed TCT forms, accessing the closed medical record, and completing triage research retrospective review forms and were briefed on the study intent by the PI. Additionally, they completed a refresher ESI training module consisting of video case scenarios and a written test after completion. Using the posttest, the expert triage nurses’ interrater reliability was established by
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Enrollment Assessed for Eligibility (n = 185) ESI Trained within past 2 months LVHN required Critical Care Course Completed 8-hour triage shift
Declined to participate (n = 57)
Completed Initial Tools (n = 125) Informed Consent Nurse Characteristic Collection Tool CNPI (Caring Nurse Patient Interaction Scale-23) (n = 125)
Attrition (n = 48) Inability to complete 8-hour triage assignment Changed intent to participate Voluntary Resignation
Completed 8-hour triage assignment (n = 80)
Analysis
Analyzed (n = 64) Excluded from analysis due to missing > 10% CNPI-23 data No prior ED triage experience
ED Triage Experience
0.20-.99 years
1.00-1.99 years
2.0-4.99 years
5.0-9.99 years
10.0-14.99 years
> 15 years
FIGURE 1 ED triage study participation. CNPI-23, Caring Nursing Patient Interactions-23 item; ED, emergency department; ESI, Emergency Severity Index; LVHN, Lehigh Valley Health Network.
independent scoring on a minimum of 20 case scenarios and achieved 0.80 using Fleiss-Kappa statistics.
Data Analysis
SPSS software (version 17.0; SPSS Inc, Chicago, IL) was used to analyze the data. The data were confirmed to ensure its correctness before data analysis. The researcher did not find any patterns for missing data. Unanswered demographic data questions were left blank in the data file. In the
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CNPI-23 instrument measuring attitude, 16 data points were replaced with the group mean, and 3 participants with more than 10% (2 questions) left unanswered were eliminated from the final data analyses. The data points replaced were varied, and no one subscale had more than one data point missing across a single participant. Simple descriptive statistics were used to analyze the demographic characteristics of the nurse participants. The Kappa statistic was used to determine interobserver agreement between nurse participant ESI score assignment and validated, clinical nurse expert ESI score assignment. The
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TABLE 1
Demographic characteristics of registered nurses Characteristic
No. of RNs at site Site A: 36 Site B: 7 Site C: 21 Gender Male Female Age (y) b 25 26-35 36-45 N 45 No response Years of RN ED triage experience .25-.99 1.00-1.99 2-4.99 5-9.99 10-14.99 N 15 Education ADN Diploma BSN No response Employment status N 36 h/wk 20-35 h/wk b 20 h/wk Weekend No response Triage ability (self-rate) Novice Beginner Intermediate Advanced Expert
Frequency triage cases
%
979 121 544
59.5 7.4 33.1
10 54
15.7 84.3
3 19 13 16 13
4.7 30.0 20.3 .25 20.3
6 5 15 14 11 13
9.4 7.8 23.4 22.0 17.2 20.3
28 12 22 2
44.0 19.0 34.4 3.1
49 4 3 3 5
76.5 6.3 4.7 4.7 7.8
5 5 19 32 3
7.8 7.8 30.0 50.0 4.7
ADN, Associate’s degree in nursing; BSN, bachelor of science in nursing; ED, emergency department; RN, registered nurse.
Kappa statistic was used to examine the interobserver agreement by category of experience and by site of triage. Pearson’s correlation was used to examine the relationship
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between experience and attitude. Additionally, one-way analysis of variance was used to test for differences of attitude across sites, gender, ESI agreement, and triage experience.
Results
The data from this study represent 64 nurse participants and 1644 patients triaged during the study period within the 3 emergency departments. The rate of nurse participation (Figure 1) was 34.5% (64 of 185 eligible). The continuous 8-hour ED triage shift deterred some nurses from initially participating; 48 nurses dropped out after completing the required questionnaires because they were unable to fulfill the triage requirement, and 13 nurses were excluded because they did not have the ESI training course. Demographic data are shown in Table 1. Participants were primarily women (84%) and ranged in age from older than 25 years to 65 years (n = 61, with 3 nonrespondents); the 26 to 35 years and 36 to 45 years age groups together represented 42% of the nurses. A majority of the participants had an associate degree in nursing (44.0%). The ED experience ranged from 3 months to 35 years (M = 6.44, SD = 7.80), with the majority reporting 2 to 10 years experience (51.8%). Nurses who indicated they had not completed the ESI training course were eliminated from the primary study sample. The wide range of experience contributed to the large standard deviations. Nurse participants in the 3 emergency departments selfrated their triage ability on a scale of 1 to 5 (novice, beginner, intermediate, advanced, and expert), with 80% identifying as intermediate or advanced. The attitude scores for the study sample measured by the CNPI-23 indicated an overall mean of 92.88 (SD = 14.17). The CNPI-23 score stratified by experience (Table 2) ranged from a low mean of 93.10 (N 20 years) to a high mean of 97.59 (1 to 2 years). The CNPI-23 overall mean score by site was lowest at site B (Table 3) (M = 91.37, SD = 6.59). In phase II of the study, 1644 ED patients were triaged by nurses and assigned an ESI score. Overall, the agreement between the ESI-validated, clinical expert nurse raters’ and the nurse participants’ ESI score assignment using the weighted Kappa statistic was 0.65 (95% confidence interval [CI], 0.63 to 0.68). Four participants had an interobserver agreement less than 0.20; of these, 2 had more than 15 years of experience, one had 7 to 10 years of experience, and one had less than 2 years of experience. The assignment of ESI scores by experience level of the nurse participants and ESI validated raters is described in Table 4. The Kappa statistic ranged from a high of 0.63
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TABLE 2
Experience (Caring Nursing Patient Interactions-23 item scale and Kappa scores) Years of experience
CNPI-23 total mean (SD) Kappa by experience CI
1-2
2.1-4.99
5-9.99
10-14.99
15-19.99
N20
97.59 (10.5) 0.630 0.60, 0.66
93.37 (10.9) 0.59 0.49, 0.67
93.53 (10.4) 0.632 0.61, 0.66
96.79 (9.3) 0.61 0.47, 0.69
95.06 (10.2) 0.51 0.39, 0.63
93.10 (4.0) 0.631 0.62, 0.64
CI, Confidence interval; CNPI-23, Caring Nursing Patient Interactions-23 item scale; SD, standard deviation.
TABLE 3
Site (Caring Nursing Patient Interactions-23 item scale and Kappa scores) CNPI-23 total mean (SD) Kappa by site CI
Site A
Site B
Site C
94.97 (9.8) 0.56 0.51, 0.67
91.37 (6.6) 0.45 0.42, 0.66
96.95(10.7) 0.60 0.46, 0.75
CI, Confidence interval; CNPI-23, Caring Nursing Patient Interactions-23 item scale; SD, standard deviation.
TABLE 4
Years of ED triage experience and Emergency Severity Index score agreement with expert rater RN ED triage experience (y)
No. total cases
Kappa (mean)
CI
0.25-0.99 1.00-1.99 2-4.99 5-9.99 10-14.99 N 15
224 321 315 261 161 314
0.56 0.63 0.59 0.63 0.61 0.51
0.35, 0.60, 0.49, 0.61, 0.47, 0.39,
0.67 0.66 0.67 0.66 0.69 0.63
CI, Confidence interval; ED, emergency department; RN, registered nurse.
(95% CI 0.58 to 0.64, P b .001) in the nurse participant with 1.00 to 1.99 years of experience to a low of 0.51 (95% CI 0.39 to 0.63, P = .03) in the nurse participant with 15 to 19 years of experience. Substantial agreement (0.61 to 0.80, P b .001) was noted in 705 triaged patients, and 3.4% (n = 56) were noted to have slight agreement (0.01 to 0.20). Overall, 1260 cases (77%) had a range of 0.41 to 0.80, indicating moderate to substantial Kappa agreement between participants and the expert raters. Only 56 cases (3.4%) had slight agreement (less than 0.20). Site B agreement was lowest, with 121 triaged patients (Kappa = 0.45, 95% CI 0.38 to 0.52, P b .001). The nurse participants (n = 9) with an overall mean CNPI-23 score of 106 to 115 achieved the highest
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agreement (Kappa = 0.71, P b .001) compared with a single participant with a CNPI − 23 overall mean score of less than 77 who had a Kappa agreement of 0.50 (P b .001). The nurse participants with a CNPI-23 overall mean score between 81 and 92 (n = 54, 84%) demonstrated agreement of 0.54 to 0.60 (P b .001). CNPI-23 overall mean scores and Kappa agreement by site are displayed in Table 3. A one-way between subjects analysis of variance was conducted to compare the effect of ED triage experience on attitude (CNPI-23) at the P ≤ .05 level (F = 0.897, P = .49), the effect of gender on attitude (F = 0.017, P = .90), or the effect of site of practice on attitude (F = 0.216, P = .81). The years of experience in the emergency department and attitude scores were negatively correlated (r = − 0.78, P = .01).
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Discussion
The findings in this study did not achieve statistical significance to support the notion that attitude or a specified amount of experience contributed to accurate ESI score assignment. The findings did not support the current practice at the study sites, which require at least 1 year of ED experience before being assigned in the triage area. The range of ED nurse experience was wide, although most were clustered in the 2- to 10-year range. The lack of representation from the group with less than 2 years’ experience made it difficult to adequately explore experience as a variable. The comprehensive number of nurses with an overall CNPI-23 score exceeding 81 on a scale of 23 to 115 supports an overall attitude of caring in this sample of nurses. The number of triage events examined in this study contributes to the reliability of the ESI scoring tool with acceptable Kappa scores between nurses with varying levels of experience. The overall agreement between the nurse participants and expert raters did achieve statistical significance. It is important to note that the overall rate of agreement was less than the weighted kappa of 0.76 reported by Eitel et al, 9 whose study did not evaluate experience as a factor, as we did in this study. With the usage and demand for care in the emergency department up 32% in the past 10 years—upward of 124 million visits or 340,000 people every day 15—organizations are challenged to consider efficient, effective, and alternate models for triage. In addition, the Patient Protection and Affordable Care Act promises “to provide affordable, quality healthcare for all Americans.” 16 ED leaders must be confident that the right nurses are placed in the triage area to ensure patient safety and decrease liability. Gilboy et al 3 and Schriver et al 4 both concluded that ED nurses’ skills are crucial to accurately triaging patients, and McNair and Gurney 7 suggested that education, experience, and empathy were important factors in triage. None of these 3 articles provided insight into years of experience that would exemplify triage competence. A greater depth of exploration and discovery through qualitative methods may contribute to an expanded meaning of the selected constructs, especially attitude in a cross-sectional examination of ED nursing staff. Limitations
This study had several limitations. First is the use of a convenience sample of nurses who were self-selected for participation and lacked equal representation in experience and number of patients triaged at each site. The size differences between the 3 departments contributed to the
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uneven distribution of participants from one site to another. Additionally, although 6 ESI-validated clinical expert nurse raters were used, one nurse expert rated a larger number of participants than did other expert reviewers, exposing the study to a possible bias. Further, the use of retrospective chart review is contingent upon the accurate documentation of patient presentation and may underestimate the live patient presentation. The length of the data collection period also must be considered, because the duration was longer than one calendar year, leading to a higher rate of attrition of nurse participants.
Implications for Emergency Nurses
An inexperienced nurse should not be confident that his or her experience level alone warrants competence in the triage area. However, the evidence discovered in this study should provide some reassurance to nurses with minimal ED experience and a working understanding of the ESI 5-level triage algorithm that they possess the knowledge and the capacity to safely and appropriately triage patients in the emergency department. The results of this study should also be considered during policy development for triage practices in the emergency department. Acknowledgments The authors would like to thank the Dorothy Rider Pool Health Care Trust for their monetary donations that enabled the completion of this study. They also would like to extend a special thank you to Courtney Vose, MSN, RN, MBA, APRN, NEA-BC, and Dr. Bryan Kane for lending both their intellectual and clinical knowledge throughout the course of this investigation. Finally they would like to extend their sincere gratitude to the nurses who work in the emergency departments of the Lehigh Valley Health Network for participating and helping to foster nursing research.
REFERENCES 1. American College of Emergency Physicians. The ethics of health care reform: issues in emergency medicine—an information paper. http:// www.acep.org/Content.aspx?id=80871. Accessed October 4, 2013. 2. Institute of Medicine. Hospital-based emergency care: at the breaking point. Washington, DC: The National Academies Press; 2006. http:// www.iom.edu/Reports/2006/Hospital-Based-Emergency-Care-At-theBreaking-Point.aspx. Accessed April 18, 2013. 3. Gilboy N, Travers D, Wuercz R. Emergency nursing at the millennium. Re-evaluating triage in the new millennium: a comprehensive look at the need for standardization and quality. J Emerg Nurs. 1999;25:468-73. 4. Schriver JA, Talmadge R, Chuong R, Hedges JR. Emergency nursing: historical, current, and future roles. J Emerg Nurs. 2003;29:431-9. 5. Tippins E. How emergency department nurses identify and respond to critical illness. Emerg Nurse. 2005;13(3):24-33.
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6. Cone K, Murray R. Characteristics, insights, decision making, and preparation of ED triage nurses. J Emerg Nurs. 2002;28:401-6. 7. McNair R, Gurney D. It takes more than string to fly a kite: 5-level acuity scales are effective, but education, clinical expertise, and compassion are essential. J Emerg Nurs. 2005;31:600-3. 8. Hooper C, Craig J, Janvrin D, Wetsel M, Reimels E. Compassion satisfaction, burnout, and compassion fatigue among emergency nurses compared with nurses in other selected inpatient specialties. J Emerg Nurs. 2010;36:420-7. 9. Eitel D, Travers D, Rosenau A, Gilboy N, Wuerz R. The emergency severity index triage algorithm version 2 is a reliable and valid. Acad Emerg Med. 2003;10:1070-80. 10. Attitude definition. Merriam-Webster's Collegiate Dictionary Web site. http://www.merriam-webster.com/dictionary/attitude. Accessed October 4, 2013. 11. Gilboy N, Tanabe P, Travers D, Rosenau AM. Emergency Severity Index: A Triage Tool for Emergency Department Care; version 4. Implementation Handbook. Rockville, MD: Agency for Healthcare Research and Quality; 2012. http://www.ahrq.gov/research/esi/esi2. htm. Accessed October 4, 2013.
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12. Cossette S, Cote JK, Pepin J, Ricard N, D’Aoust LX. A dimensional structure of nurse-patient interactions from a caring perspective: refinement of the Caring Nurse-Patient Interactions Scale (CNPI-Short Scale). J Adv Nurs. 2006;55:198-214. 13. Caring definition. Merriam-Webster's Collegiate Dictionary Web site. http://www.merriam-webster.com/dictionary/caring. Accessed October 4, 2013. 14. Goransson KE, Ehrenberg A, Marklund B, Ehnfors M. Emergency department triage: is there a link between nurses’ personal characteristics and accuracy in triage decisions? Accid Emerg Nurs. 2006;14(2):83-8. 15. Pennsylvania Patient Safety Authority. Managing patient access and flow in the emergency department to improve patient safety. PA Patient Saf Advis. 2010;4:123-34 http://patientsafetyauthority.org/ADVISORIES/ AdvisoryLibrary/2010/dec7%284%29/Pages/123.aspx. Accessed October 4, 2013. 16. US Government Printing Office. Public Law 111-148/152. http:// origin.www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW111publ148.pdf. Accessed October 4, 2013.
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AN EXAMINATION OF ESI TRIAGE SCORING ACCURACY IN RELATIONSHIP TO ED NURSING ATTITUDES AND EXPERIENCE Authors: Andrew Martin, MSN, RN, PHRN, CEN, Carolyn L. Davidson, PhD, RN, CCRN, FNP-BC, CPHQ, Anne Panik, MS, BSN, RN, NEA-BC, Charlotte Buckenmyer, MS, RN, CEN, Paul Delpais, MSN, RN, CEN, and Michele Ortiz, BSN, RN, CEN, Allentown, PA Introduction: This research was designed to examine if there is a difference in nurse attitudes and experience for those who assign Emergency Severity Index (ESI) scores accurately and those who do not assign ESI scores accurately. Studies that have used ESI scoring discussed the role of experience, but have not specifically addressed how the amount of experience and attitude towards patients in triage affect the triage nurse's decision-making capabilities. Methods: A descriptive, exploratory study design was used.
Data from 64 nurses and 1,644 triage events at 3 emergency departments was collected. Participants completed demographic data, attitude (Caring Nurse Patient Interaction, CNPI-23) survey, and triage data collection tools during the continuous 8hour triage shift. Clinical nurse expert raters retrospectively reviewed the charts and assigned an ESI score to be compared with the nurse. Descriptive statistics were used to describe the nurse and Pearson's correlation was used to examine the relationship between experience and attitude.
ranged from a high of 0.63 in the nurse participant with 1.00 to 1.99 years of experience to a low of 0.51 in the nurse participant with 15 to 19 years of experience. The nurse participants with an overall mean CNPI-23 score of 106 to 115 achieved the highest agreement compared with a single participant with a CNPI-23 overall mean score of less than 77 who had a Kappa agreement of 0.50. The nurse participants with a CNPI-23 overall mean score between 81 and 92 demonstrated agreement of 0.54 to 0.60. Discussion: Based on the high level of liability the triage area
presents, special consideration needs to be made when deciding which nurse should be assigned to that area. The evidence produced from this study should provide some reassurance to ED managers and nurses alike that nurses with minimal ED experience and a working understanding of the ESI 5-level triage algorithm possess the knowledge and the capacity to safely and appropriately triage patients in the emergency department.
Results: In this study of 64 nurse participants, the ESI score
assigned by nurse participants did not differ significantly based on years of experience or CNPI mean score. The Kappa statistic
Key words: Emergency department; Triage nurse; Nurse
he triage area of the emergency department has been identified by many professional organizations as a location that leaves the hospital vulnerable to liability. Further compounding the vulnerability of the triage area is ED crowding, a problem projected as only worsening by the American College of Emergency
T
Physicians. 1 Further, in the landmark report, “The Future of Emergency Care in the United States,” the Institute of Medicine described the worsening crisis of crowding that occurs daily in most emergency departments. 2 Predictions like this highlight the importance of taking all available precautions to manage triage area liability.
Andrew Martin, Member, Berks County Chapter, is Director, Emergency Services, Lehigh Valley Health Network, Allentown, PA.
Michele Ortiz is Emergency Department Patient Care Coordinator, Lehigh Valley Health Network, Allentown, PA. For correspondence, write: Andrew Martin, MSN, RN, PHRN, CEN, Lehigh Valley Health Network, 1637 Chew St, Allentown, PA 18102; E-mail: [email protected]. J Emerg Nurs ■.
Carolyn L. Davidson is Administrator, Quality and Evidence-Based Practice, Lehigh Valley Health Network, Allentown, PA. Anne Panik is Sr. VP, Patient Care Services and Clinical Excellence, Lehigh Valley Health Network, Allentown, PA. Charlotte Buckenmyer is former Director, Emergency Services, Lehigh Valley Health Network, Allentown, PA. Paul Delpais is Director, Emergency Services, Lehigh Valley Health Network, Allentown, PA.
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attitude; Nurse experience; ESI
0099-1767/$36.00 Copyright © 2013 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2013.09.009
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Given the described crowding crisis, the role of the ED triage nurse in the initial assessment may be the most crucial to ensure that the “right patient is in the right place at the right time and that no one is overlooked.” 3 These initial decisions made by the triage nurse affect the entire department. In spite of the current nationwide nursing shortages, it is important to ensure that emergency departments are staffed not only with adequate nursing support but with high-quality, well-trained nurses capable of accurately triaging ED patients. 4 The characteristics of the triage nurse that exemplify proficiency have not been well elucidated in the literature. Reports conflict regarding the adequate amount of experience and the attitude a nurse requires to be considered competent in the skill of triaging. 5–8 The inability to formulate consistent conclusions is further compounded by the study methods chosen to evaluate nurses in triage, because all the studies used simulation scenarios. The accurate triage of patients is leveraged by the Emergency Severity Index (ESI). The ESI is a 5-level triage system guided by algorithms for clinical decision making and is a tool that allows the nurse to rapidly assess the patient, initiate decision making for resources, and assign a score that is familiar to the health care team. The algorithm is simple to use, reduces the subjectivity of the triage decision, and is more accurate than other triage systems, therefore contributing to a common language among ED caregivers. 9 Although the validity and reliability of the ESI have been established, questions remain about the characteristics that contribute to a proficient ED triage nurse. To better evaluate attitude, the definition “a mental position with regard to a fact or state, or a feeling or emotion toward a fact or state” was used for the purposes of this study. 10 The lack of available literature conclusively addressing (1) the effect of attitude toward patients and (2) the amount of experience on the proficiency of the ED triage nurse supports this descriptive, exploratory study. The following research questions were examined: 1. Does the number of years of experience differ between ED nurses who do and do not accurately assign (ESI) triage scores? 2. Does the attitude toward patients in triage differ between ED nurses who do and do not accurately assign ESI triage scores? Setting
The study was conducted in a 988-bed tertiary Magnet™ health network with emergency departments at 3 sites in
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northeast Pennsylvania. The 3 distinct sites—a level I trauma center in a suburban location, a center city location, and a community campus—collectively exceed 130,000 ED patient visits on an annual basis. Sample
A convenience sample was recruited from registered nurses in the 3 emergency departments. Inclusion criteria for the nurse participants were:
• A current full-time, part-time, or ED specialty float pool employee in any one of the 3 emergency departments
• Possession of a current nursing license in the commonwealth of Pennsylvania
• Completion of the Lehigh Valley Health Network (LVHN) required critical care course, or equivalent
• Completion of the ESI training course within the 2 months preceding study enrollment
• Completion of an 8-hour triage shift
All patients who entered the emergency department via the designated triage area and were assigned an ESI score by enrolled nurse participants during the 8-hour shift were identified as eligible for the study. Triaged patients with one of the criteria deemed a protected/vulnerable population (ie, domestic violence, sexual assault, behavioral health, and pediatric patients) defined by LVHN organization policy were excluded from the study. Patients arriving by ambulance were excluded because they bypass the nurse triage area. Study variables
Accuracy of ESI scoring by nurses was the outcome variable in this study. The ESI score was obtained by nurse participants who triaged patients in live situations and assigned a score based on the established valid and reliable ESI algorithm. 11 Secondarily, an ESI score was assigned by ESI-validated clinical nurse expert raters who retrospectively reviewed the presenting information on the ED patient’s chart. The two predictor variables in the study were ED triage experience and attitude toward patients in triage as measured by the Caring Nursing Patient Interactions Scale (CNPI-23), a psychometrically valid tool with 4 subscales (clinical care, relational care, humanistic care, and comfort care) designed to assess nurse attitudes and behaviors based on “Watson’s 10 carative factors.” 12 The interaction at point of triage is linked to many of the caring factors, such as trust, altruism, humanism, sensitivity, supportive, problem-solving, and protective.
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Instruments
The Nurse Characteristic Collection Tool (NCCT) was developed from the relevant literature to collect demographic data and characteristics about the nurse participant: age, sex, educational level, certifications, employment status, shift status, years of nursing experience, years of ED nursing experience, years of ED triage nursing experience, and triage hours worked per week. Additionally, each nurse was asked to rate their perceived competence of triage ability: novice, beginner, intermediate, advanced, or expert. The CNPI-23, a 23-item instrument used to measure caring attitudes and behaviors, was used in this study to reflect attitudes of nurses. The author’s permission was obtained to use this instrument. The CNPI-23 requires a forced choice response on a 5-point Likert scale (1 = not at all to 5 = extremely). The instrument was scaled down from the original 70-item, 10-subscale instrument and produces subscale scores in 4 distinct caring domains (clinical, relational, humanistic, and comfort care). The total CNPI23 score range is 23–115. The instrument has been factor analyzed and tested and found to be reliable (clinical, r = 0.82 to 0.93; relational, r = 0.89 to 0.91; humanistic, r = 0.64 to 0.73; and comfort care, r = 0.61 to 0.74). Attitude is defined as “a mental position with regard to a fact or state, or a feeling or emotion toward a fact or state,” 10 whereas caring is defined as “to be concerned about, to feel interest or concern.” 13 The CNPI-23 and the subscales address Watson’s original theory of carative factors that embody both attitude and caring. These factors provide clear guidelines for the nurse-patient interaction. The subscales are interdependent and reflect an individual nurse’s value system. Decision making in triage is guided primarily by a categorized patient acuity algorithm but also may be a factor of intrapersonal characteristics. 14 The linkage of patient outcomes with intrapersonal behaviors is reflected in the CNPI-23. Items within the subscale of humanistic care refer to a nurse’s attitude and behaviors as they relate to the patient’s own capacities and abilities. Relational care addresses the nurse’s respect of patient perceptions, and the clinical care subscale addresses the clinical expertise. The comforting care subscale is most representative of the hidden work associated with nursing. The ESI is 5-tier algorithm used to categorize patient acuity based on key patient factors: presence of a condition that is life threatening or high risk; vital signs; and how many resources the patient will need. The utilization of the validated and reliable ESI 5-tier triage scoring tool is best used in combination with patient presentation including age, history, pain, current medications, and patient severity of complaint to support an overall ESI score assignment.
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The ESI has evolved during the past 14 years, and with use of the Kappa statistic it has most recently demonstrated interrater reliability ranging from .70 to .80 when nurses make triage decisions based on case studies and 0.69 to 0.87 when nurses make triage decisions for actual patients. 9
Procedures
The study was approved by the Institutional Review Board. Exemption to full Institutional Review Board review was granted because the study met all criteria for posing a low risk to participants. The study data were collected in 3 phases. In phase I, ED nurses were briefed about the study and invited to participate by the principal investigator (PI) at education days. Nurse participants signed an informed consent at enrollment and were given the NCCT and CNPI-23 to complete. In phase II, enrolled nurse participants worked one continuous 8-hour shift in the triage area. During this time they continued to use standard triage procedures to prioritize patients and documented their triage assessments in the ED electronic medical record. In addition, the participants completed the Triage Case Tracking (TCT) form that contained the patient medical record numbers, nurseassigned ESI scores, and the number of resources the nurse predicted the patient would require. Completed TCT forms were placed in a locked box located in each study site’s triage room. To thank them for their participation, the participants received a $25 gift card after completion of all requirements: NCCT, CNPI-23, and an 8-hour shift in triage. In phase III, the completed TCT forms were collected by 1 of the 6 ESI-validated clinical expert nurse reviewers to obtain patient medical record numbers. Using the emergency department’s electronic medical record, the nurse experts carefully reviewed each patient’s medical record to determine if an accurate ESI score was assigned. The clinical experts reviewed medical records on an ongoing basis throughout the study implementation period and recorded their findings on the triage research retrospective review forms. The ESI-validated clinical expert nurse reviewers were identified by ED clinical leadership as proficient in ESI scoring. The expert reviewers were educated on the procedures for retrieving completed TCT forms, accessing the closed medical record, and completing triage research retrospective review forms and were briefed on the study intent by the PI. Additionally, they completed a refresher ESI training module consisting of video case scenarios and a written test after completion. Using the posttest, the expert triage nurses’ interrater reliability was established by
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Enrollment Assessed for Eligibility (n = 185) ESI Trained within past 2 months LVHN required Critical Care Course Completed 8-hour triage shift
Declined to participate (n = 57)
Completed Initial Tools (n = 125) Informed Consent Nurse Characteristic Collection Tool CNPI (Caring Nurse Patient Interaction Scale-23) (n = 125)
Attrition (n = 48) Inability to complete 8-hour triage assignment Changed intent to participate Voluntary Resignation
Completed 8-hour triage assignment (n = 80)
Analysis
Analyzed (n = 64) Excluded from analysis due to missing > 10% CNPI-23 data No prior ED triage experience
ED Triage Experience
0.20-.99 years
1.00-1.99 years
2.0-4.99 years
5.0-9.99 years
10.0-14.99 years
> 15 years
FIGURE 1 ED triage study participation. CNPI-23, Caring Nursing Patient Interactions-23 item; ED, emergency department; ESI, Emergency Severity Index; LVHN, Lehigh Valley Health Network.
independent scoring on a minimum of 20 case scenarios and achieved 0.80 using Fleiss-Kappa statistics.
Data Analysis
SPSS software (version 17.0; SPSS Inc, Chicago, IL) was used to analyze the data. The data were confirmed to ensure its correctness before data analysis. The researcher did not find any patterns for missing data. Unanswered demographic data questions were left blank in the data file. In the
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CNPI-23 instrument measuring attitude, 16 data points were replaced with the group mean, and 3 participants with more than 10% (2 questions) left unanswered were eliminated from the final data analyses. The data points replaced were varied, and no one subscale had more than one data point missing across a single participant. Simple descriptive statistics were used to analyze the demographic characteristics of the nurse participants. The Kappa statistic was used to determine interobserver agreement between nurse participant ESI score assignment and validated, clinical nurse expert ESI score assignment. The
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TABLE 1
Demographic characteristics of registered nurses Characteristic
No. of RNs at site Site A: 36 Site B: 7 Site C: 21 Gender Male Female Age (y) b 25 26-35 36-45 N 45 No response Years of RN ED triage experience .25-.99 1.00-1.99 2-4.99 5-9.99 10-14.99 N 15 Education ADN Diploma BSN No response Employment status N 36 h/wk 20-35 h/wk b 20 h/wk Weekend No response Triage ability (self-rate) Novice Beginner Intermediate Advanced Expert
Frequency triage cases
%
979 121 544
59.5 7.4 33.1
10 54
15.7 84.3
3 19 13 16 13
4.7 30.0 20.3 .25 20.3
6 5 15 14 11 13
9.4 7.8 23.4 22.0 17.2 20.3
28 12 22 2
44.0 19.0 34.4 3.1
49 4 3 3 5
76.5 6.3 4.7 4.7 7.8
5 5 19 32 3
7.8 7.8 30.0 50.0 4.7
ADN, Associate’s degree in nursing; BSN, bachelor of science in nursing; ED, emergency department; RN, registered nurse.
Kappa statistic was used to examine the interobserver agreement by category of experience and by site of triage. Pearson’s correlation was used to examine the relationship
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between experience and attitude. Additionally, one-way analysis of variance was used to test for differences of attitude across sites, gender, ESI agreement, and triage experience.
Results
The data from this study represent 64 nurse participants and 1644 patients triaged during the study period within the 3 emergency departments. The rate of nurse participation (Figure 1) was 34.5% (64 of 185 eligible). The continuous 8-hour ED triage shift deterred some nurses from initially participating; 48 nurses dropped out after completing the required questionnaires because they were unable to fulfill the triage requirement, and 13 nurses were excluded because they did not have the ESI training course. Demographic data are shown in Table 1. Participants were primarily women (84%) and ranged in age from older than 25 years to 65 years (n = 61, with 3 nonrespondents); the 26 to 35 years and 36 to 45 years age groups together represented 42% of the nurses. A majority of the participants had an associate degree in nursing (44.0%). The ED experience ranged from 3 months to 35 years (M = 6.44, SD = 7.80), with the majority reporting 2 to 10 years experience (51.8%). Nurses who indicated they had not completed the ESI training course were eliminated from the primary study sample. The wide range of experience contributed to the large standard deviations. Nurse participants in the 3 emergency departments selfrated their triage ability on a scale of 1 to 5 (novice, beginner, intermediate, advanced, and expert), with 80% identifying as intermediate or advanced. The attitude scores for the study sample measured by the CNPI-23 indicated an overall mean of 92.88 (SD = 14.17). The CNPI-23 score stratified by experience (Table 2) ranged from a low mean of 93.10 (N 20 years) to a high mean of 97.59 (1 to 2 years). The CNPI-23 overall mean score by site was lowest at site B (Table 3) (M = 91.37, SD = 6.59). In phase II of the study, 1644 ED patients were triaged by nurses and assigned an ESI score. Overall, the agreement between the ESI-validated, clinical expert nurse raters’ and the nurse participants’ ESI score assignment using the weighted Kappa statistic was 0.65 (95% confidence interval [CI], 0.63 to 0.68). Four participants had an interobserver agreement less than 0.20; of these, 2 had more than 15 years of experience, one had 7 to 10 years of experience, and one had less than 2 years of experience. The assignment of ESI scores by experience level of the nurse participants and ESI validated raters is described in Table 4. The Kappa statistic ranged from a high of 0.63
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TABLE 2
Experience (Caring Nursing Patient Interactions-23 item scale and Kappa scores) Years of experience
CNPI-23 total mean (SD) Kappa by experience CI
1-2
2.1-4.99
5-9.99
10-14.99
15-19.99
N20
97.59 (10.5) 0.630 0.60, 0.66
93.37 (10.9) 0.59 0.49, 0.67
93.53 (10.4) 0.632 0.61, 0.66
96.79 (9.3) 0.61 0.47, 0.69
95.06 (10.2) 0.51 0.39, 0.63
93.10 (4.0) 0.631 0.62, 0.64
CI, Confidence interval; CNPI-23, Caring Nursing Patient Interactions-23 item scale; SD, standard deviation.
TABLE 3
Site (Caring Nursing Patient Interactions-23 item scale and Kappa scores) CNPI-23 total mean (SD) Kappa by site CI
Site A
Site B
Site C
94.97 (9.8) 0.56 0.51, 0.67
91.37 (6.6) 0.45 0.42, 0.66
96.95(10.7) 0.60 0.46, 0.75
CI, Confidence interval; CNPI-23, Caring Nursing Patient Interactions-23 item scale; SD, standard deviation.
TABLE 4
Years of ED triage experience and Emergency Severity Index score agreement with expert rater RN ED triage experience (y)
No. total cases
Kappa (mean)
CI
0.25-0.99 1.00-1.99 2-4.99 5-9.99 10-14.99 N 15
224 321 315 261 161 314
0.56 0.63 0.59 0.63 0.61 0.51
0.35, 0.60, 0.49, 0.61, 0.47, 0.39,
0.67 0.66 0.67 0.66 0.69 0.63
CI, Confidence interval; ED, emergency department; RN, registered nurse.
(95% CI 0.58 to 0.64, P b .001) in the nurse participant with 1.00 to 1.99 years of experience to a low of 0.51 (95% CI 0.39 to 0.63, P = .03) in the nurse participant with 15 to 19 years of experience. Substantial agreement (0.61 to 0.80, P b .001) was noted in 705 triaged patients, and 3.4% (n = 56) were noted to have slight agreement (0.01 to 0.20). Overall, 1260 cases (77%) had a range of 0.41 to 0.80, indicating moderate to substantial Kappa agreement between participants and the expert raters. Only 56 cases (3.4%) had slight agreement (less than 0.20). Site B agreement was lowest, with 121 triaged patients (Kappa = 0.45, 95% CI 0.38 to 0.52, P b .001). The nurse participants (n = 9) with an overall mean CNPI-23 score of 106 to 115 achieved the highest
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agreement (Kappa = 0.71, P b .001) compared with a single participant with a CNPI − 23 overall mean score of less than 77 who had a Kappa agreement of 0.50 (P b .001). The nurse participants with a CNPI-23 overall mean score between 81 and 92 (n = 54, 84%) demonstrated agreement of 0.54 to 0.60 (P b .001). CNPI-23 overall mean scores and Kappa agreement by site are displayed in Table 3. A one-way between subjects analysis of variance was conducted to compare the effect of ED triage experience on attitude (CNPI-23) at the P ≤ .05 level (F = 0.897, P = .49), the effect of gender on attitude (F = 0.017, P = .90), or the effect of site of practice on attitude (F = 0.216, P = .81). The years of experience in the emergency department and attitude scores were negatively correlated (r = − 0.78, P = .01).
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Discussion
The findings in this study did not achieve statistical significance to support the notion that attitude or a specified amount of experience contributed to accurate ESI score assignment. The findings did not support the current practice at the study sites, which require at least 1 year of ED experience before being assigned in the triage area. The range of ED nurse experience was wide, although most were clustered in the 2- to 10-year range. The lack of representation from the group with less than 2 years’ experience made it difficult to adequately explore experience as a variable. The comprehensive number of nurses with an overall CNPI-23 score exceeding 81 on a scale of 23 to 115 supports an overall attitude of caring in this sample of nurses. The number of triage events examined in this study contributes to the reliability of the ESI scoring tool with acceptable Kappa scores between nurses with varying levels of experience. The overall agreement between the nurse participants and expert raters did achieve statistical significance. It is important to note that the overall rate of agreement was less than the weighted kappa of 0.76 reported by Eitel et al, 9 whose study did not evaluate experience as a factor, as we did in this study. With the usage and demand for care in the emergency department up 32% in the past 10 years—upward of 124 million visits or 340,000 people every day 15—organizations are challenged to consider efficient, effective, and alternate models for triage. In addition, the Patient Protection and Affordable Care Act promises “to provide affordable, quality healthcare for all Americans.” 16 ED leaders must be confident that the right nurses are placed in the triage area to ensure patient safety and decrease liability. Gilboy et al 3 and Schriver et al 4 both concluded that ED nurses’ skills are crucial to accurately triaging patients, and McNair and Gurney 7 suggested that education, experience, and empathy were important factors in triage. None of these 3 articles provided insight into years of experience that would exemplify triage competence. A greater depth of exploration and discovery through qualitative methods may contribute to an expanded meaning of the selected constructs, especially attitude in a cross-sectional examination of ED nursing staff. Limitations
This study had several limitations. First is the use of a convenience sample of nurses who were self-selected for participation and lacked equal representation in experience and number of patients triaged at each site. The size differences between the 3 departments contributed to the
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uneven distribution of participants from one site to another. Additionally, although 6 ESI-validated clinical expert nurse raters were used, one nurse expert rated a larger number of participants than did other expert reviewers, exposing the study to a possible bias. Further, the use of retrospective chart review is contingent upon the accurate documentation of patient presentation and may underestimate the live patient presentation. The length of the data collection period also must be considered, because the duration was longer than one calendar year, leading to a higher rate of attrition of nurse participants.
Implications for Emergency Nurses
An inexperienced nurse should not be confident that his or her experience level alone warrants competence in the triage area. However, the evidence discovered in this study should provide some reassurance to nurses with minimal ED experience and a working understanding of the ESI 5-level triage algorithm that they possess the knowledge and the capacity to safely and appropriately triage patients in the emergency department. The results of this study should also be considered during policy development for triage practices in the emergency department. Acknowledgments The authors would like to thank the Dorothy Rider Pool Health Care Trust for their monetary donations that enabled the completion of this study. They also would like to extend a special thank you to Courtney Vose, MSN, RN, MBA, APRN, NEA-BC, and Dr. Bryan Kane for lending both their intellectual and clinical knowledge throughout the course of this investigation. Finally they would like to extend their sincere gratitude to the nurses who work in the emergency departments of the Lehigh Valley Health Network for participating and helping to foster nursing research.
REFERENCES 1. American College of Emergency Physicians. The ethics of health care reform: issues in emergency medicine—an information paper. http:// www.acep.org/Content.aspx?id=80871. Accessed October 4, 2013. 2. Institute of Medicine. Hospital-based emergency care: at the breaking point. Washington, DC: The National Academies Press; 2006. http:// www.iom.edu/Reports/2006/Hospital-Based-Emergency-Care-At-theBreaking-Point.aspx. Accessed April 18, 2013. 3. Gilboy N, Travers D, Wuercz R. Emergency nursing at the millennium. Re-evaluating triage in the new millennium: a comprehensive look at the need for standardization and quality. J Emerg Nurs. 1999;25:468-73. 4. Schriver JA, Talmadge R, Chuong R, Hedges JR. Emergency nursing: historical, current, and future roles. J Emerg Nurs. 2003;29:431-9. 5. Tippins E. How emergency department nurses identify and respond to critical illness. Emerg Nurse. 2005;13(3):24-33.
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6. Cone K, Murray R. Characteristics, insights, decision making, and preparation of ED triage nurses. J Emerg Nurs. 2002;28:401-6. 7. McNair R, Gurney D. It takes more than string to fly a kite: 5-level acuity scales are effective, but education, clinical expertise, and compassion are essential. J Emerg Nurs. 2005;31:600-3. 8. Hooper C, Craig J, Janvrin D, Wetsel M, Reimels E. Compassion satisfaction, burnout, and compassion fatigue among emergency nurses compared with nurses in other selected inpatient specialties. J Emerg Nurs. 2010;36:420-7. 9. Eitel D, Travers D, Rosenau A, Gilboy N, Wuerz R. The emergency severity index triage algorithm version 2 is a reliable and valid. Acad Emerg Med. 2003;10:1070-80. 10. Attitude definition. Merriam-Webster's Collegiate Dictionary Web site. http://www.merriam-webster.com/dictionary/attitude. Accessed October 4, 2013. 11. Gilboy N, Tanabe P, Travers D, Rosenau AM. Emergency Severity Index: A Triage Tool for Emergency Department Care; version 4. Implementation Handbook. Rockville, MD: Agency for Healthcare Research and Quality; 2012. http://www.ahrq.gov/research/esi/esi2. htm. Accessed October 4, 2013.
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12. Cossette S, Cote JK, Pepin J, Ricard N, D’Aoust LX. A dimensional structure of nurse-patient interactions from a caring perspective: refinement of the Caring Nurse-Patient Interactions Scale (CNPI-Short Scale). J Adv Nurs. 2006;55:198-214. 13. Caring definition. Merriam-Webster's Collegiate Dictionary Web site. http://www.merriam-webster.com/dictionary/caring. Accessed October 4, 2013. 14. Goransson KE, Ehrenberg A, Marklund B, Ehnfors M. Emergency department triage: is there a link between nurses’ personal characteristics and accuracy in triage decisions? Accid Emerg Nurs. 2006;14(2):83-8. 15. Pennsylvania Patient Safety Authority. Managing patient access and flow in the emergency department to improve patient safety. PA Patient Saf Advis. 2010;4:123-34 http://patientsafetyauthority.org/ADVISORIES/ AdvisoryLibrary/2010/dec7%284%29/Pages/123.aspx. Accessed October 4, 2013. 16. US Government Printing Office. Public Law 111-148/152. http:// origin.www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW111publ148.pdf. Accessed October 4, 2013.
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