Title: Nurses´ Experience of Triage Process in the Psychiatric A & E Department for Adults Author: Miljatovic, Milos Department: School of Life Sciences, University of Skövde Course: Degree of Bachelor of Science in Nursing, Thesis in Nursing Care, 15 ECTS Supervisor: - Examiner: Brovall, Maria Pages: 23 Keywords: Triage, Nurse, Psychiatric A & E Department for Adults, Triage scale Background: In the beginning of 21st century some psychiatric A & E departments in Sweden have introduced triage process and psychiatric triage scales. The aim was to meet the growing numbers of patients with mental health problems attending psychiatric A & E departments, in order to shorten waiting and transit times. Aim: The aim of the study was to illustrate nurses´ experiences of triage process in the psychiatric A & E department. Method: Qualitative empirical study was conducted. Results: Three categories were identified: Triage process creates confidence, Obstacles in triage assessment, Possibilities for improved patient care through triage process; and six subcategories: Aid and support in having an assessment tool, Sense of comradeship, Getting possibility to take answer and show the competence, Deficiencies with assessment tool, Sense of inadequateness due to long waiting times to physician, Sense of ambiguity during the triage process. Discussion: Safe triage process is needed to achieve quality care in the psychiatric A & E department, thus it is important that nurses have adequate triage scale, and the results suggest that it is important for nurses to have an adequate triage scale which makes it easier for nurses in nursing care. / Bakgrund: Vissa svenska vuxenpsykiatriska akutmottagningar har i början av 2000-taletinfört triageprocess och triageskalor för att kunna möta det ökade vårdbehovet blandpatienter med psykiska problem. Syftet med införandet av triageprocessen var att kortaväntetider och genomlöpstider på mottagningar.Syfte: Syftet med studien var att belysa sjuksköterskors upplevelser av triageprocessen påen vuxenpsykiatrisk akutmottagning.Metod: Som metod valdes kvalitativ empirisk studie.Resultat: Tre kategorier identifierades: triageprocess skapar en trygghet, hinder itriageprocessen, möjligheter till förbättrad omvårdnad genom triageprocessen; och sexsubkategorier: hjälp och stöd genom ett bedömningsinstrument, känsla av kollegialitet, fåmöjlighet att ta ansvar och visa sitt kunnande, brister med bedömningsinstrumentet, känslaav otillräcklighet vid långa väntetider till läkaren, känsla av otydlighet iförbättringsprocessen.Diskussion: En trygg triageprocess behövs för att uppnå god omvårdnad på envuxenpsykiatrisk akutmottagning, och resultatet tyder på att det är viktigt attsjuksköterskor har en adekvat triageskala som underlättar i omvårdnadsarbetet.

Emergency medical care (EMC) is proposed by the World Health Organization (WHO) as being one of the core components of a horizontal approach to improving population health in low-resource settings; triage is considered to be a fundamental part of this field. Most studies exploring triage have focused on high-income countries. In 2004, the Cape Triage Group (CTG) developed the South African Triage Scale (SATS) a scale that uses a physiologically based scoring system together with a list of discriminators - designed to triage patients into one of four priority groups for medical attention. The SATS was designed for use in the South African context to mitigate the limited numbers of doctors and professional nurses. The SATS has been implemented and assessed extensively in South Africa, but its performance across a spectrum of different low-resource settings, particularly non-sub-Saharan African and trauma-only settings, has not been adequately assessed. Médecins Sans Frontières (MSF), an international humanitarian organisation, introduced EMC in 2006 into low-resource settings. In 2011, MSF began introducing the SATS in various projects where it was providing EMC. Methodology: This was a multi-site retrospective cohort study which sought to assess the reliability and validity of the SATS in different low-resource settings. Aim 1: To implement and evaluate the SATS in Northern Pakistan by describing the steps of implementation and how accurate nurses were in using the triage scale. After one month of implementation, 370 triage forms from a one-week period were evaluated. Aim 2: To assess the inter- and intra-rater reliability and accuracy of nurse triage ratings when using the SATS in an emergency centre (EC) in Timergara, Pakistan. Fifteen EC nurses assigned triage ratings to a set of 42 reference vignettes (written case reports of EC patients) under classroom conditions. Inter-rater reliability was assessed by comparing these triage ratings; intra-rater reliability was assessed by asking the nurses to re-triage ten 12 random vignettes from the original set of 42 vignettes and comparing the duplicate ratings. Accuracy of the nurse ratings was measured against the reference standard. Aim 3: To improve the ability to measure reliability and validity in paediatric settings by developing a set of paediatric paper-based vignettes using the Delphi methodology. In a two-round consensus building process, a panel of EC experts were asked to independently triage 50 clinical vignettes using one of four acuity levels: emergency (patient to be seen immediately), very urgent (patient to be seen within 10 min), urgent (patient to be seen within 60 min), or routine (patient to be seen within four hours). The vignettes were based on real paediatric EC cases in South Africa. Vignettes that reached a minimum of 80% group consensus for acuity ratings on either round one or two were included in the final set of reference vignettes. Aim 4: To further assess the reliability of the SATS across MSF-supported hospitals using paper-based vignettes in Afghanistan, Haiti and Sierra Leone. Applying the same methodology as in Northern Pakistan, we assessed reliability under classroom conditions between December 2013 and February 2014. Aim 5: To assess the validity of the SATS across MSF-supported hospitals between June 2013 and June 2014. Validity was assessed by comparing patients’ SATS ratings with their final EC outcomes (i.e., hospital admission, death or discharge) across four sites in Afghanistan, Haiti and Sierra Leone. Findings The SATS was able to be easily implemented and accurately completed in a low-resource setting of Northern Pakistan. We recommended further implementation and assessment of reliability and validity in low-resource settings. Across six sites with a total of 87 nurses, including two trauma-only hospitals in Afghanistan and Haiti, a paediatric-only hospital in Sierra Leone and three mixed medical settings in Afghanistan, Pakistan and Haiti, the SATS demonstrated moderate to substantial reliability. Across all settings in which we measured validity using outcome markers, SATS predicted an increase in the likelihood of admission/death when moving from low- to high-triage acuity. In trauma-only settings of Afghanistan and Haiti, the SATS showed a 1-9% under-triage and 13 a 2-16% over-triage rate. In mixed medical and paediatric settings, under-triage ranged from 0-76% while over-triage ranged from 2-88%. A more logical standardised approach to assessing validity was put forward when using outcome markers that would allow easier comparisons to be done across validity studies irrespective of the number of levels the triage scale had. We developed a set of paediatric vignettes for use in low-resource settings but cautioned against its use after measuring reliability using adult reference vignettes. We found that generic vignettes were poor substitutes in a variety of settings based on a lack of contextualisation and understanding by local nurses. Conclusion: The SATS has reasonable reliability with good validity across different ECs in various lower-source settings. The SATS is a valid triage tool for prioritisation of patients with trauma in low-resource settings. Its use in mixed EC settings seems justified, but in paediatric settings context-specific adjustments and assessments of its performance would be prudent.

[Truncated abstract] Background : Triage systems have evolved from battlefield casualty prioritisation tools to integral components of civilian emergency care systems over the last 50 years. There is significant variation in prehospital triage practices in Australia and little research has been undertaken to validate the triage systems used. There is considerable evidence to support the use of the Australasian Triage Scale (ATS) for triage in the emergency department setting and the ATS is used ubiquitously for emergency department triage in Australasia ... Conclusions : The findings of this thesis support integrating prehospital ATS allocations with emergency department triage processes. It is concluded that Paramedics apply the ATS similarly to nurses ... Allocations to ATS 1, 2 and 3 and most ATS 4 allocations by paramedics are valid when compared to nurse ATS allocations. Australasian Triage Scale category 5 is used inappropriately by paramedics and should be used rarely, if at all, by paramedics. The reliability of paramedic and nurse ATS allocations is sufficient to warrant a trial of the omission of retriage of ambulance presentations at Perth metropolitan emergency departments. However, early nursing assessment of a small proportion of ATS 3 patients may be required to ensure timely assessment for some mistriaged bone fide ATS 2 patients. Paramedic ATS allocations appear sufficiently reliable and valid to warrant a trial of their use as part of a two-tier trauma team activation system ... The implementation of standardised training between paramedics and nurses based on current Australasian College for Emergency Medicine guidelines is recommended. The implementation of paramedic triage audit, including comparison of paramedic ATS allocations with nurse ATS allocations may improve reliability between paramedics and nurses, and particularly the reliability of ATS 4 and ATS 5 allocations. Prehospital ATS allocations may prove useful in prehospital casemix analysis, the evaluation of prehospital service delivery and for prehospital research. Research opportunities include actual trials of the integration of prehospital use of ATS with emergency department triage and trauma system activation, and the evaluation of the ATS as a prehospital casemix and performance evaluation tool. Research into alternative triage tools to the ATS for use in the prehospital environment and into the impact of standardised triage training is also suggested.