Triage nursing assessment supports nursing professionals in delivering safe and effective patient care in emergency departments. This staff education project was driven by an observation of inconsistencies in triage among emergency department (ED) nursing staff. The purpose of the project was to improve the triage assessment knowledge of ED nurses. Specifically, the aim was to determine if educating ED nursing staff about using the Emergency Severity Index (ESI), a 5-level triage algorithm and a previously developed tool, would improve nurse knowledge in the triage process. Following discussion with the ED nursing manager at a hospital, a presentation on the ESI was developed and pre- and posttest questions were used to assess and enhance the nursing staff members triage knowledge. The 16 members of the ED nursing staff attended the ESI education session, which was preceded by a pretest and followed by a posttest. The pretest results ranged from 68% to 96% on the 25 items, and the posttest resulted in an increase in test scores. The p value on the sample t test was 0.000, which demonstrated that the training was effective. The outcomes of this project might promote positive social change by helping to ensure that nurses in the ED can improve triage assessment

Globally, higher healthcare demand strains existing systems, already overburdened by a lack of resources and funding while longer life expectancy and increased disease burden force higher patient loads. A majority of the South African population is medically uninsured and therefore depend on emergency care; consequently, the healthcare service demand easily exceeds available acute care to prevent life threat. When this happens, emergency centres suffer from overcrowding and long patient waiting times, which increases morbidity and mortality, associated patient risk. Moreover, critical resources such as staff and hospital beds are required for an even flow of patients through hospitals, but are distributed inefficiently. The South African healthcare system configuration therefore delays access to and compromises the delivery of equitable, unbiased life-saving healthcare in an environment moreover challenged by economic pressures. This calls for sustainable, cost-effective reform. Therefore, more efficient healthcare can save more lives by improving access to life-saving care. Research on current Healthcare Information Systems (HIS) shows an incoherent knowledge body with conceptual gaps in theories on healthcare, which disengages transformation potential. Comprehensive reform tactics thus require a priori concept discovery and diagnostics to make research practically useful. The systematic use of BPM theories allowed for the qualitative assessment of as-is process activity at patient touch-points at three hospitals – two public and one private – in the Western Cape of South Africa. Because a strategic Information Systems (IS) methodology, Business Process Management (BPM) poses business process activity improvement, this research draws from successful BPM activity as a means to improve patient flow processes in Emergency Centres (ECs). Success is evaluated by drawing from empirically supported enabler categories and prescriptive guidelines because BPM practice is not yet fully understood. The results show a clear correlation between the improvement areas at the three hospitals; improvements on aspects of actions and decisions taken during patient-flow process activity, therefore support a pragmatic approach to reform. The data confirms disparity between public and private healthcare. Healthcare appears to be a “doctor driven” service, which, based on qualitative decision-making, navigates patients along defined flows, enabled by supporting human capital and hospital assets. Optimal patient flow is a product of symbiotic working relationships and depends on efficient integration with wider hospital functions. Shorter waiting times and hospital stays reduce process burden. This leads to more efficient resource usage and regulated access to healthcare. However, integrated healthcare reform must consider the time demands and rigidity of clinical processes. The challenge lies in finding the space to invite parallel business agility to drive the reform of the stricken healthcare industry in South Africa.

ABSTRACT Context: Requirements triage is a crucial activity in requirements engineering process for market-driven products. Triage deals with selection of appropriate requirements from large number of requirements for particular release plan. If triage is not performed initially, selection and management of a large number of requirements would be difficult in requirements engineering process. In market-driven product development triage is followed by estimation and prioritization of requirements to be selected for a particular release plan, also termed as requirements selection. Product development is done based on the set of requirements selected in requirements selection process. Objectives: The objective of the thesis is to find whether there is a need to improve existing requirements triage process or not, identify the challenges and shortcomings of the existing requirements triage and selection solutions and suggest improvements to address identified challenges and shortcomings. Methods: In order to identify existing requirements triage and selection solutions (method, model, tool, technique, process, and others), challenges addressed by existing requirements triage and selection solutions, and the shortcomings faced while implementing them, a systematic literature review has been done. A list of challenges and shortcomings, identified through the analysis of systematic literature review results, was used as an input to industrial survey to confirm most applicable (relevant) challenges and shortcomings and to identify possibilities to address those challenges and shortcomings. Results: A process framework for requirements triage has been proposed to address the challenges faced by practitioners during triage. The steps and solutions proposed within the framework also enable to alleviate the shortcomings of the existing requirements triage solutions. Conclusions: The results of the survey have been analyzed from different perspectives: size of organization, number of requirements handled per month and experience of professional doing triage. Therefore, the proposed process framework is usable and useful for both small-scale and large-scale organizations. The initial effort required to put framework process steps in place would be high, however, later the effort will reduce not only for requirements triage but also for later phases in requirements engineering. As a spin off effect the quality of triage decision is increased.

Patientflöden till Sveriges akutmottagningar ökar varje år. För att ta emot och bedöma pati­en­ter på ett patientsäkert sätt används triage. En välfungerande triageprocess är en förut­sätt­ning för ett patientsäkert arbete på akutmottagning. Syftet med denna studie var att göra en granskning av triageprocessen på akutmottagning, uti­från sjuksköterskors och läkares uppfattningar kring utbildning, förtroende och följsam­het.  Metoden var en deskriptiv tvärsnittsstudie baserad på en webbaserad enkätundersökning ställd till sjuksköterskor och läkare som arbetade inom triageprocessen på två sjukhus i Mel­lansverige. Inkluderade respondenter uppgick till n=191. Data har analyserats med hjälp av kvantitativ- och kvalitativ metod. Enkätfrågor med slutna svarsalternativ har analyserats kvantitativt med Chi-2-test [Χ2] och presenteras med deskriptiv statistik. Fritext­svar i enkä­ten har analyserats kvalitativt med manifest innehållsanalys.  Resultatet visar att det finns brister i triageutbildningen på akutmottagningarna som deltog i studien. Framförallt uppger läkarna att de saknar utbildning i triageverktyg och triagepro­cessens rutiner. Respondenternas svar visar att det finns brister i hur väl innehållet i utbild­ningen stämmer överens med hur arbetssättet tillämpas i den kliniska verksamheten och att respondenterna inte känner sig väl förberedda inför att börja arbeta med triage i klinisk verk­samhet. Patienternas sjukdomstillstånd anses inte identifieras adekvat av triageverktyg eller under triageprocess. Utifrån aspekter kring övertriagering samt identifiering av om­vårdnads­behov och medicinska behov har SATS högre förtroende hos sjuksköterskorna än DPT. Dock uppger respondenterna på båda akutmottagningarna att omvårdnadsbehov och medi­cinska behov inte fullt ut identifieras av triageverktyg eller under triageprocessen. Få respon­denter uppger att informationsöverföring i triageprocessen fungerar väl på deras ar­betsplat­ser. Det förekommer att respondenterna avviker från triageverktyget, triageproces­sens ruti­ner samt prioriteringsordning. Respondenternas uppfattningar är att läkare frångår oftare än sjuksköterskor. Sjuksköterskor som arbetar med sjuksköterskeledd triage anser i högre grad än övriga respondenter att bristande följsamhet till triageprocessens rutiner på­verkar patient­säkerheten på deras arbetsplats.  Slutsatsen är att det finns brister i triageprocessen på akutmottagningarna i studien som skulle kunna inverka negativt på patientsäkerheten. / Inflow of patients to Sweden’s emergency departments are increasing every year. In order to receive and assess patients in a patient-safe manner, triage is used. A well-functioning triage process is a prerequisite for patient-safe work at the emergency department. The aim of this review was to study the triage process in the emergency department based on nurses’ and physicians’ perceptions of education, confidence and compliance.  The method was a descriptive cross-sectional study, based on a web-based survey sent to nurses and physicians active in the triage process in two hospitals in Sweden. Respondents included amounted to n=191. Data have been analyzed using quantitative and qualitative meth­ods. Survey questions with closed answer options have been analyzed quantitatively with Chi-squared test [Χ2] and is presented using descriptive statistics. Free text replies have been analyzed qualitatively with manifest content analysis.  The results show that there are shortcomings concerning the triage education at the emer­gency departments participating in this study. Especially physicians state that they lack ed­ucation regarding the triage tool and in the triage process procedures. Respondents’ an­swers show that there are deficiencies regarding how well education content is consistent with how it is applied in the clini­cal ac­tivity and that respondents do not feel well prepared be­fore start­ing triage in clinical ac­tivities. Patients’ disease states are not regarded to be ad­e­quately identified by the triage tool or during the triage process. Based on aspects of over triage and identification of care and medical needs nurses show higher confidence in SATS than DPT. However, respondents at both emergency departments state that care and medi­cal needs are not fully identified by the triage tool or during the triage process. Few re­spondents state that infor­mation transfer in the triage process works well in their work­places. The re­spondents may deviate from the triage tool, the triage process procedures and priority order. Percep­tions of respondents are that physicians more frequently deviate than nurses. Nurses who work with nursing led triage consider in higher degree, than other re­spondents, that lack of compliance to triage process procedures affects patient safety at their place of work.  The conclusion is that there are shortcomings regarding the triage process in the emer­gency departments included in this study that could adversely affect patient safety.