Australasian Emergency Nursing Journal (2014) 17, 51—58

Available online at www.sciencedirect.com

ScienceDirect journal homepage: www.elsevier.com/locate/aenj

RESEARCH PAPER

The Emergency Triage Education Kit: Improving paediatric triage Lorelle Malyon, RN, RM, BN, MPhil a,b,c,∗ Alison Williams, RN, MPhil, MPH c,d,e Robert S. Ware, PhD b,e a

Department of Emergency Medicine, Royal Children’s Hospital, Herston Road, Herston, Brisbane, Queensland 4029, Australia b School of Population Health, The University of Queensland, Herston Road, Herston, Brisbane, Queensland 4006, Australia c Nursing Research Unit, Royal Children’s Hospital, Herston Road, Herston, Brisbane, Queensland 4029, Australia d Children’s Nutrition Research Centre, The University of Queensland, Herston Road, Herston, Brisbane, Queensland 4006, Australia e Queensland Children’s Medical Research Institute, The University of Queensland, Herston Road, Herston, Brisbane, Queensland 4006, Australia Received 7 November 2012; received in revised form 23 September 2013; accepted 9 February 2014

KEYWORDS Emergency; Triage; ETEK; Hospital; Paediatric; Audit

Summary Objectives: The Emergency Triage Education Kit (ETEK) was published in 2007. To date, the impact of ETEK has not been measured. The purpose of this study was to measure the effectiveness of ETEK on paediatric triage. Method: A retrospective chart audit was undertaken in a tertiary paediatric hospital. Its’ aim was to review the completeness of documentation recorded at the point of triage after a standardised documentation framework was introduced and to measure inter-rater agreement. Primary assessment and physiological discriminators documented at the point of triage were compared with those from the paediatric physiological discriminator table (PPDT) within ETEK. Using an audit tool developed by the researchers, a parallel decision-making pathway was used to ascertain whether the original ATS score could be substantiated by the PPDT. Improvement in documentation of the primary assessment and inter-rater agreement was measured over time.

∗ Corresponding author at: Department of Emergency Medicine, Royal Children’s Hospital, Brisbane, Queensland 4029, Australia. Tel.: +61 7 3636 9008. E-mail addresses: lorelle [email protected], lorelle [email protected] (L. Malyon).

http://dx.doi.org/10.1016/j.aenj.2014.02.002 1574-6267/© 2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.

52

L. Malyon et al. Results: 600 triage records were selected; 200 each from 2007, 2008 and 2010. Triage documentation that did not support parallel decision-making decreased significantly according to the year of presentation (2007; 112 (56%), 2008; 106 (53%), 2010; 13 (7%), P < 0.001). When parallel decisionmaking was facilitated by an improvement in triage documentation, there was improvement in matched triage scores (2007; 54%, 2008; 69%, 2010; 72%, P = 0.01). Conclusion: The introduction of ETEK has had a significant impact in this ED, particularly when combined with education sessions. The use of the PPDT as a framework to guide documentation and triage language facilitated parallel decision-making and auditing, and led to an improvement in inter-rater agreement when applied to children. © 2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.

What is already known? The ATS is used to assess urgency and prioritise care, however when applied to children, its reliability has been shown to be only fair. The ETEK provides a standardised education plan for triage nurses in an aim to improve consistency in the application of the ATS. Specifically, ETEK contains paediatric tools to assist the triage nurse’s decision-making when applying the ATS to children.

What this paper adds? To date, the effectiveness of ETEK to meet its’ aim has not been measured. This paper describes the impact of the ETEK on paediatric nursing triage.

Introduction The Australasian Triage Scale (ATS) is used to assess urgency and prioritise access to time-critical intervention within Australian Emergency Departments (ED).1—5 The accuracy with which a triage scale is applied is fundamentally important to positive patient outcomes.6—8 The ATS aims to ensure that a patient will receive the same triage category in any ED to which they present.9,10 However several studies have demonstrated that the ATS has only poor to fair inter-rater reliability when applied to children and adolescents.11—13 This may be due to the complexity of paediatric assessment, in particular the developmental considerations that mean there is often a reliance on the carer to provide the history.14 Alternatively, when children present to a mixed ED, the triage nurse may have variable knowledge, experience and self-confidence in assessing children.12,15 The lack of consistency in applying triage scores to children may also be attributed to the lack of a paediatric framework on which to base decisionmaking.8 Endorsed by the Australian Department of Health and Ageing and the College of Emergency Nursing Australasia, the Emergency Triage Education Kit (ETEK) was introduced into Australian EDs in 2007.5,14 Within ETEK, the paediatric physiological discriminator table (PPDT) provides

evidence-based markers for serious illness and injury. These reflect the triage nurses primary nursing assessment (airway, breathing, circulation and disability: neurological, neurovascular and pain) and arranges them into ATS triage categories. The PPDT was primarily designed to support the decisionmaking of nurses.14 It also provides the potential to positively influence documentation standards, audit triage episodes and improve the consistency by which the ATS is applied to children. Australia does not have a robust triage auditing system that is utilised nationally. Instead the accuracy of triage scores has been based on expert opinion or the use of paper-based scenarios which lack rigour and have limited generalisability.2 The aim of this study was to assess the effectiveness of ETEK to meet its’ aims by: 1. examining the effectiveness of the PPDT to standardise and improve documentation at the point of triage 2. investigating whether standardised documentation assisted in auditing triage practice and 3. analysing whether the ATS was more consistently applied after introduction of ETEK.

Methods Method and setting The study hospital is a paediatric tertiary referral centre, caring for children and young people from birth to 15 years. The ED provides initial assessment and management of approximately 30 000 acute presentations annually. All children entering this ED are triaged by an experienced and specifically trained emergency nurse. A single retrospective, randomised chart audit was undertaken to review documentation recorded at the point of triage. Charts were audited from July 2007, before ETEK was published; July 2008, after the publication of ETEK but before ETEK-based education sessions were introduced at the study hospital; and July 2010, after the ETEK-based education sessions had been conducted. This study received ethical clearance from the appropriate Hospital and University Ethics Committees. The researchers extracted triage records from Emergency Department Information System (EDIS), the electronic

ETEK and paediatric triage documentation system used in the study hospital’s ED. Six hundred charts were audited in total; 200 from each time period. Charts were selected from the months under review by a research assistant who de-identified the records. To ensure representation of all categories, the selection system was designed so approximately 15% of charts selected were for patients receiving an ATS 1 (immediately life-threatening cases), 15% were ATS 2, 25% were ATS 3, 30% were ATS 4 and 15% were ATS 5 (less urgent cases).

53 decision making could be employed of 20%, with 80% power and alpha = 0.01. Results are described using descriptive statistics, and data was compared across years using the chi-square test for trend. Data was analysed using Stata statistical software version 11.1 (Stata Corp., College Station, TX, USA).

Results Main results

Audit tool/data sources Using the PPDT as the gold standard, an audit tool was developed and piloted by four experienced triage nurses. The tool was used to scrutinise triage documentation with the researchers comparing completeness of the primary assessment data and the use of the physiological discriminators, to the PPDT. If primary assessment documentation was incomplete, the researcher did not assume that the assessment was completed and therefore could not match a triage category. This may have occurred if an integral part of the assessment was omitted, such as a pain assessment for a child whose primary presentation was pain, or neurovascular observations for a child who presented with an injured limb. The original and audited ATS categories were compared and a determination was made on whether the original triage score could be substantiated or whether under or over triage had occurred. Finally, an analysis for improvement over time was conducted.

Intervention Education sessions introducing the ETEK and the PPDT were conducted for current triage nurses between March and May 2010. During each session, participants were familiarised with the PPDT’s format. In particular, discussion centred on the use of the table’s physiological discriminators to facilitate triage decision-making and standardise documentation. Using the sessions as the impetus for practice change, minimum standards for documentation were modified so the primary assessment was documented in its entirety. That is, for all presentations it was expected that documentation addressing; airway, breathing and circulation were included. In addition, participants were expected to address disability, however, a neurovascular assessment was only required when the child presented with a limb injury. Triage nurses were directed to use the terminology of the PPDT to describe alterations from normal physiology with ‘‘intact’’ being an acceptable term used for a child whose physiological parameters were within normal parameters for their age.14 The triage nurses were instructed to document the presenting problem succinctly along with any known risk factors.

Statistical analysis It was calculated that 200 charts were required to be selected from each year to detect a between-year difference in the percentage of records in which parallel

The researchers extracted 200 triage records from each of the three years under investigation. In 2007, the triage records of 34 triage nurses were audited (median records per nurse = 4, range 1—27). In 2008, the triage records of 35 nurses were audited (median records per nurse = 4, range 1—18) and in 2010, the triage records of 36 triage nurses were audited (median records per nurse = 4, range 1—12). In total, 61 different triage nurses were audited over a threeyear period (n = 78% of triage trained nurses and 64% of total ED nurses employed during the study months). There were 71 different primary complaints, the most common of which were fever (14%), difficulty breathing (9%) and vomiting (8%). The number of triage records in which parallel decisionmaking could not be utilised by the researchers decreased significantly according to the year of presentation. In 2007, 112 (56%) triage records did not have enough assessment data documented for the researcher to allocate a triage score. In 2008, the number decreased slightly to 106 (53%). In 2010 after the education sessions and change of minimum documentation standards, the number of triage records in which parallel decision-making could not be applied was reduced significantly to only 13 (7%); (P < 0.001, chi-squared test for trend). This pattern was similar when presentations were separated into injury (63%, 60%, 15% from 2007 to 2010) and illness (53%, 54%, 4%). When the parallel decision-making process could be facilitated, 54% of the primary triage scores matched in 2007, with 21% over triaged and 24% under triaged. In 2008 there was agreement on 69% of occasions, with over triaging occurring on 15%, and under triaging on 16%, of occasions. In 2010 there was agreement on 72% of occasions with over triaging occurring on 20%, and under triaging on 8%, of occasions. The percentage of scores correctly matched increased significantly over time (P = 0.01, chi-square test for trend). Between 2007 and 2010 children were significantly less likely to be under-triaged (risk ratio = 0.34; 95% confidence interval = 0.18—0.62), while the proportion of children overtriaged remained similar (risk ratio = 0.97; 95% confidence interval = 0.58—1.60). Table 1 demonstrates how, when data were analysed by the characteristics of the primary survey, documentation improved across time. Improvement was most significant for the airway assessment; from 12% in 2007 to 92% in 2010 (P < 0.001, chi-square test for trend). Documentation related to an assessment of breathing also significantly improved from 24% in 2007 to 93% in 2010 (P < 0.001, chisquare test for trend). The circulation and neurological assessments were reasonably well documented prior to the

54

L. Malyon et al.

Table 1 Documentation of physiological discriminators characteristic. Two hundred charts were audited each year. Differences between groups assessed using the Chi-square test for trend.

Airway Breathing Circulation Neurological Neurovasculara Pain

2007 n (%)

2008 n (%)

2010 n (%)

P-value

25 (12.5) 49 (24.5) 162 (81.0) 164 (82.0) 3 (9.6) 33 (16.5)

26 (13.0) 44 (22.0) 182 (91.0) 180 (90.0) 16 (61.5) 22 (11.0)

185 (92.5) 187 (93.5) 193 (96.5) 186 (93.0) 15 (44.1) 44 (22.0)

P < 0.001 P < 0.001 P < 0.001 P < 0.001 P < 0.005 P < 0.14

a Neurovascular outcomes considered only when neurovascular compromise was considered a potential at initial triage (n = 31 in 2007, n = 26 in 2008, n = 34 in 2010).

change of practice so relatively modest, yet still statistically significant improvements were seen in these areas (Table 1). Primary triage category allocation, or the category allocated by the triage nurse, is displayed in Table 2. As shown, the distribution of categories one to five was similar between 2007 and 2008. However, in 2010 there was a significantly higher percentage of category 1 and 2 allocations (P < 0.001, chi-square test for trend). The category most likely to concord between the primary triage score and the PPDT guidelines was category five with 100% concordance, this means that all patients categorised as ATS 5 at presentation, who could be allocated according to the PPDT, were correctly categorised. In categories 1, 2, and 3 concordance between the primary allocation and the PPDT was 68%, 77%,

Table 2

Allocation of triage categories by year.

2007 PPDT

Primary triage category

allocation

ATS 1

ATS 2

ATS 3

ATS 4

ATS 5

Total

3

14

25

58

12

112

3

0

1

1

0

5

0

11

7

3

0

21

0

4

12

9

0

25

0

1

1

10

0

12

0

1

1

11

12

25

6

31

47

92

24

200

No category ATS 1

ATS 2

ATS 3

ATS 4

ATS 5

Total

1 category over-

1 category under-

triaged

triaged

>1 category over-

>1 category under-

triaged

triaged

Correct triage

and 64% agreement respectively. Category 4 was relatively poorly matched at only 48% agreement.

Discussion The introduction of ETEK into this ED improved triage performance in this tertiary paediatric hospital. Most improvement occurred after nurses had received ETEK-based education sessions. The PPDT was included in ETEK so that novice triage nurses’ were able to reflect on their primary triage decisions6 however; this study has shown that the PPDT has a much broader use. In this study it was shown to be effective as a framework to guide triage documentation and this

ETEK and paediatric triage

55

Table 2 (Continued ) 2008 Primary triage category ATS 1

ATS 2

ATS 3

ATS 4

ATS 5

Total

0

13

28

50

15

106

3

0

0

0

0

3

0

9

5

3

0

17

0

1

13

7

0

21

0

0

4

15

0

19

0

1

3

5

25

34

3

24

53

80

40

200

No category

ATS 1

ATS 2

ATS 3

ATS 4

ATS 5

Total

Correct triage

1

category

over-

triaged >1

1

category under-

triaged

category

over-

triaged

>1 category undertriaged

2010 PPDT

Primary triage category

allocation

ATS 1

ATS 2

ATS 3

ATS 4

ATS 5

Total

1

4

3

5

1

13

11

1

0

0

0

12

8

37

6

1

0

52

0

6

44

7

0

57

0

2

9

28

0

39

0

0

1

11

14

27

20

50

63

52

15

200

No category

ATS 1

ATS 2

ATS 3

ATS 4

ATS 5

Total

1 category over-

1 category under-

triaged

triaged

>1 category over-

>1 category under-

triaged

triaged

Correct triage

56 facilitated parallel decision-making for the purpose of audit and quality management.

The physiological assessment Physiological data such as that contained within the PPDT underpin the triage nurse’s primary assessment and has been found to provide a high degree of objectivity.16 Physiological discriminators have been used as valuable indicators of clinical urgency at triage.6,17,18 Prior to the publication of ETEK, triage decisions for children were inconsistent11—13 In an attempt to introduce greater consistency, the PPDT with its’ more prescriptive physiological data, was included. The format of the PPDT facilitates decision-making through graded physiological discriminators ranging from no deviation from normal paediatric parameters (ATS 5) to discriminators indicating the critically ill or injured child (ATS 1). This study has shown that the PPDT and the adoption of its terminology have coincided with a more consistent application of the ATS.

Triage categories A significant increase in ATS 1 and 2 was identified in 2010. Analysis of data obtained from EDIS confirms the upward trend in these two categories.19 Key statistics demonstrate that for the total number of patients presenting to the ED in July, the percentage of children receiving an ATS 2 rose from 6.8% (n = 165) in 2008 to 13.7% (n = 314) in 2010.19 Similarly, for ATS 1 patients, the percentage of presentations rose from 0.2% (n = 4) in 2008 to 0.8% (n = 18) in 2010.19 While the cause is likely to be multifactorial; it is possible that some ATS 1 and 2 patients were previously being under triaged. Over triage is defined as the allocation of an ATS category that is higher than the true measure of urgency.14 In this study, over triage represented any presentation that was rated as more urgent than the PPDT indicated. In 2010, over triage was most common for category five patients with 45% (n = 12) allocated a higher category. This number takes into account the potential for the ATS category to be increased when a co-morbidity or risk factor is present but in this study, neither factor was present in this cohort. While over triage decreases the waiting time of the patient, it may inappropriately direct the ED resources and adversely affect the waiting time of other patients.10 It is for this reason that steps should be taken to explore this finding in more detail. Conversely, under triage is the term used when a triage allocation is lower than the true measure of urgency.14 Under triage can have significant consequences when taking into account the fact that children are waiting for treatment longer than their true urgency indicates. This can lead to poor patient outcomes and potentially adverse events.10 The strategy used to change practice showed the risk of under triage decreased significantly, while the proportion of children over-triaged remained similar.

Documentation Nursing documentation must reflect the physiological assessment that has been completed. The quality of triage

L. Malyon et al. documentation may influence practice and patient outcomes so it is important that it accurately reflects the assigned triage category.3,20,21 Further, it can be used as evidence in a court of law for either clinical or professional accountability. Initially, documentation anomalies in this study included incomplete documentation of significant and relevant primary assessment data and phrasing such as ‘‘no work of breathing’’ when what was meant was ‘‘no increased work of breathing’’. In addition, non-standardised abbreviations or the inclusion of irrelevant information also impeded parallel decision-making. These findings are consistent with those of a cross-sectional audit of general nursing documentation undertaken in 2011.20 The study conducted by Wang et al., 2011 identified that documentation can be improved when there is education and organisational support for the introduction of standardised language; findings that are supported in this study. Documentation of the primary assessment was shown to improve after the PPDT was introduced. This finding is important for a number of reasons. Comprehensive documentation of the initial assessment using a standardised format and physiological descriptors facilitates transparent decision-making. This is helpful for the purpose of audit and quality improvement. For the triage nurse, the identification of strategies to improve performance can be linked to reflective practice and education.8 For children, it is important because it means that the ATS will be more consistently applied and more accurately reflect their clinical urgency.

Audit The accuracy of and consistency in which a triage score is allocated largely underpins the quality management process.8 Auditing clinical decision-making is the ideal measure of accuracy and consistency and is best achieved if parallel decision-making occurs.8 In this study, the use of the PPDT and ATS simultaneously was found to contribute to the consistency of triage nurses decisions. Together with the change in documentation standards to reflect the full primary assessment and terminology of the PPDT, the ability of the researchers to use parallel decision-making as a tool to scrutinise concordance at the point of triage greatly improved. The most significant improvement was evident in the discriminators for airway and breathing. Prior to this study, triage nurses in this ED documented circulation and neurological assessments in some form and therefore there was only a moderate improvement over time. For these characteristics, the greatest change was observed in the improvement in the use of standardised physiological discriminators. Pain is a common reason for accessing emergency care and the amount of pain experienced by a patient directly influences urgency and resource allocation.8 Despite this, it was the discriminator least often reported. Auditing of the Manchester Triage Scale in the United Kingdom has shown similar results with the most common documentation omission being the failure of the triage nurse to record a pain score.8 Studies conducted by Considine et al., 2006 and

ETEK and paediatric triage Wang et al., 2011, concur. These studies described ongoing low levels of reporting pain, even after an intervention such as education.20,22 The assessment of pain ensures appropriate pain relief is provided in reasonable time and while some improvement was seen in this study, further work is required.14

57 Queensland’s Human Research Ethics Committee. Approval HREC/09/QRCH/32.

Provenance and conflict of interest There is no conflict of interest. This paper was not commissioned.

Limitations This research was limited to a single site, tertiary referral hospital. However, the nature of the hospital allowed for specialist paediatric nurses to test the tool. Further study is required to explore whether these results can be generalised to other paediatric and mixed EDs.

Conclusion This study has demonstrated that ETEK has had a significant impact in this ED. Further, the introduction of the PPDT has had a number of positive outcomes. Triage nurses now document the complete primary assessment; Airway, Breathing, Circulation and Disability which is a true reflection of the assessment undertaken at the point of triage. This and the adoption of similar terminology as that used in the PPDT have provided a framework for triage nurses to link physiological descriptors for illness and injury to ATS categories. These steps facilitated parallel decision-making for the purpose of auditing. Auditing led to reflective practice, a more consistent use of the ATS and improved inter-rater agreement. Most importantly, the findings of this study have had a direct benefit for the child. That is, improved performance ensures that children receive an ATS allocation commensurate with their level of clinical urgency.

Funding source This paper is part of a larger study that was funded by the Royal Children’s Hospital Foundation Research Skills Development Scholarship for Nurses. Grant no. 10296.

Author contributions L.M. and A.W. were responsible for the study conception. L.M., A.W. and R.W. were responsible for the study design. L.M. was responsible for data collection. L.M., A.W. and R.W. were responsible for data analysis with R.W. providing statistical expertise. L.M., A.W. and R.W. were responsible for drafting the manuscript and L.M., A.W. and R.W. made critical revisions for important intellectual content. R.W. and A.W. supervised the study.

Ethical approval This paper reports the findings of a research study that adhered to the National Statement on the Conduct of Human Research by the Australian National Health and Medical Research Council, and has been approved by the Royal Children’s Hospital, Brisbane and the University of

Acknowledgements The authors would like to acknowledge Dr. Samantha Keogh, Senior Research Fellow, Griffith University for her contribution to the study’s original conception and design. The authors would also like to thank the following members of the expert panel who piloted the audit tool: Judy Harris, Nurse Unit Manager, Redcliffe Hospital (ED), Therese Oates, Clinical Nurse Consultant, Royal Children’s Hospital (ED) and Leanne Philips, Clinical Nurse, Royal Children’s Hospital (ED).

References 1. Gerdtz MF, Chu M, Collins M, Considine J, Crellin D, Sands N, et al. Factors influencing consistency of triage using the Australasian Triage Scale: implications for guideline development. Emerg Med Australas 2009;21:277—85. 2. FitzGerald G, Jelinek GA, Scott D, Gerdtz MF. Emergency department triage revisited. Emerg Med J 2010;27:86—92. 3. Fry M, Triage. In: Curtis K, Ramsden C, Friendship J, editors. Emergency and trauma nursing Sydney: Mosby Elsevier; 2007. p. 84—91. 4. Australian College for Emergency Medicine. Policy on the Australian Triage Scale; 2006. http://www.acem.org.au/media/ policies and guidelines/P06 Aust Triage Scale - nov 2000.pdf [accessed 25.05.09]. 5. College of Emergency Nursing Australasia. Position Statement. Triage Nurse; 2007 [amended 2009]. http://www.cena.org.au/ [accessed 02.08.10]. 6. Le Vasseur S, Charles A, Considine J, Berry D, Orchard T, Woiwod M, et al. Consistency of triage in Victoria’s emergency departments: literature review. Monash Institute of Health Services Research. Report to the Victorian Department of Human Services; July 2001. p. 2—41. http://www.health.vic.gov.au/ hdms.triage.htm [accessed 22.10.10]. 7. Gerdtz MF, Bucknall TK. Triage nurses’ clinical decision-making. An observational study of urgency assessment. J Adv Nurs 2000;35(4):550—61. 8. Mackway-Jones K. Emergency Triage. 2nd ed. London: Blackwell Publishing; 2006. 9. McCallum Pardey TG. Emergency Triage. Editorial. AENJ 2007;10:43—5. 10. Considine J, Ung L, Thomas S. Triage nurses’ decisions using the National Triage Scale for Australian emergency departments. Accid Emerg Nurs 2000;8:201—9. 11. Crellin DJ, Johnston L. Poor agreement in application of the Australasian Triage Scale to paediatric emergency department presentations. Contemp Nurse 2003;15(August (1—2)): 48—59. 12. Durojaiye L, O’Meara M. A study of triage of paediatric patients in Australia. Emerg Med 2002;14:67—76. 13. Gerdtz MF, Collins M, Chu M, Grant A, Tchernomoroff R, Pollard C, et al. Optimising triage consistency in Australian emergency departments: the Emergency Triage Education Kit. Emerg Med Australas 2008;20:250—9.

58 14. Gerdtz MF, Considine J, Sands N, Stewart CJ, Crellin D, Pollock WE, et al. Emergency Triage Education Kit. Canberra: The Australian Commonwealth Department of Health and Ageing. Commonwealth Government of Australia; 2007. p. 3—15. 15. Crellin DJ, Johnston L. Who is responsible for the paediatric triage decisions in Australian emergency departments: a description of the educational and experimental preparation of general and paediatric emergency nurses’. Paediatr Emerg Care 2002;18(5):382—8. 16. Considine J, Le Vasseur SA, Charles A. Development of physiological discriminators for the Australasian Triage Scale. Accid Emerg Nurs 2002;10:221—34. 17. Talbert S. Changing physiological status predicts severe injury and need for specialized trauma centre resources. J Trauma Nurs 2009;16(1):18—23.

L. Malyon et al. 18. Chapman SM, Grocott MPW, Franck LS. Systemic review of paediatric alert criteria for identifying hospitalised children at risk of critical deterioration. Intensive Care Med 2010;36:600—11. 19. Queensland Health. Emergency Department Information System (EDIS): summary of key statistics monthly report (July 2007, 2008, 2010). Brisbane: Royal Children’s Hospital; 2011. 20. Wang N, Hailey D, Yu P. Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review. J Adv Nurs 2011;67(9):1858—75. 21. Cone KJ, Anderson MA, Johnson JA. The effect of in-service on emergency nurses’ documentation of physical assessment. J Emerg Nurs 1996;22:398—402. 22. Considine J, Potter R, Jenkins J. Can written nursing practice standards improve documentation of initial assessment of ED patients? AENJ 2006;9:11—8.

The Emergency Triage Education Kit: improving paediatric triage.

The Emergency Triage Education Kit (ETEK) was published in 2007. To date, the impact of ETEK has not been measured. The purpose of this study was to m...
369KB Sizes 70 Downloads 3 Views