The Practice of Emergency Medicine
The Australasian Triage Scale: Examining emergency department nurses' performance using computer and paper scenarios

https://doi.org/10.1016/j.annemergmed.2004.04.007Get rights and content

Study objective

The purpose of this study is to examine emergency nurses' performance using triage scenarios characterized by type of patient population (adult versus pediatric) and mode of delivery (paper versus computer).

Methods

A combination of paper-based (script alone) and computer-based (script plus still photographs) triage scenarios were used. Of the 28 scenarios used, half were written and half were computer based. Within each subgroup, there were 7 adult and 7 pediatric scenarios. Participants were asked to allocate an Australasian Triage Scale category for each triage scenario.

Results

One hundred sixty-seven participants completed a total of 2,349 adult scenarios, and 161 participants completed 2,265 pediatric scenarios. Sixty-one percent of the triage decisions made by the nurses were “expected” triage decisions, 18% were “undertriage,” decisions, and 21% were “overtriage” decisions. Nurse triage allocation decisions for the scenarios containing still photographs delivered by computer demonstrated a higher average agreement percentage of 66.2% (κ=0.56; τb=0.77; P<.0001) compared with the average agreement percentage of 55.4% (κ=0.42; τb=0.75; P<.0001) using paper-based (text-only) scenarios.

Conclusion

The mode of delivery appeared to have an effect on the nurses' triage performance. It is unclear whether the use of simple still photographs used in the computer mode of delivery resulted in a higher incidence of expected triage decisions and, thus, improved performance. The use of cues such as photographs and video footage to enhance the fidelity of triage scenarios may be useful not only for the education of triage nurses but also the conduct of research into triage decisionmaking. However, further exploration and research in this area are warranted.

Introduction

Triage is a formal process of immediate assessment of all patients who present seeking emergency care.1., 2. Triage assessment findings are then used to prioritize or classify patients according to illness or injury severity and need for medical and nursing care.3., 4. In Australia, triage is predominantly a nursing assessment that begins when the patient presents to the emergency department (ED).

The National Triage Scale was developed by the Australasian College for Emergency Medicine and implemented across Australia in 1993.5 The National Triage Scale was then revised in 2000 and renamed the Australasian Triage Scale.6 All government-funded EDs (and most private EDs) in Australia have been using the Australasian Triage Scale, a 5-point triage scale whose categories are shown in Table 1, since 1993.5

The allocation of an Australasian Triage Scale category is made in response to the need for time-critical intervention to improve patient outcome, potential threat to life, or need to relieve suffering.1., 7., 8., 9. There are 3 well-recognized outcomes of triage decisions using the Australasian Triage Scale. “Expected triage decisions” are those in which the triage nurse allocates an Australasian Triage Scale category that is appropriate to a patient's presenting problem. “Overtriage” occurs when the triage nurse allocates a triage category of higher urgency than required.10., 11., 12. Although the patient's waiting time until medical intervention is shorter than anticipated, the effect of inappropriate allocation of resources has the potential to adversely affect other patients in the ED. “Undertriage” occurs when an Australasian Triage Scale category of lower urgency is selected. The patient's waiting time until medical intervention is increased, as is the risk of an adverse patient outcome.10., 11., 12.

A number of studies have been conducted on the Australasian Triage Scale. These studies include testing the interrater reliability of the Australasian Triage Scale,8., 13., 14., 15., 16. exploration of the effects of clinical characteristics of patients,8 ED activity,11., 17. and triage nurse characteristics on the application of the Australasian Triage Scale.10., 15. The results of these studies identified variability in interrater reliability of the Australasian Triage Scale8., 13., 14., 15., 16. and clinical characteristics used by nurses to allocate an Australasian Triage Scale category.8 However, application of the Australasian Triage Scale was unaffected by ED activity levels11., 17. and triage nurse characteristics such as age, experience, and educational preparation.10., 15.

Triage scenarios based on patient presentations to the ED have been widely used in studies that have examined triage nurses' decisions.8., 16. Traditionally, paper-based scenarios have been widely used and tested. However, these do not provide either visual or aural stimuli. Current technology provides the opportunity to enhance scenarios with stimuli that may improve accuracy of the decisionmaking process. However, the use of computer technology to deliver triage scenarios is relatively untested.

The aim of this study is to examine the effect of patient population (adult versus pediatric) and mode of delivery (paper versus computer) on triage scenario performance.

Section snippets

Materials and methods

A total of 28 (14 adult and 14 pediatric) case scenarios were developed and validated for use in the study, each reflecting a specific Australasian Triage Scale category. An initial examination of the Victorian Emergency Minimum Dataset informed the development of the case scenarios. The Victorian Emergency Minimum Dataset is data detailing characteristics of presentations to EDs in Victoria, Australia. The data identified that a greater proportion of presentations represented Australasian

Results

There were 178 triage nurse participants in the study. The demographic characteristics of participants in terms of age, experience, level of appointment, educational preparation, and type of hospital in which they were employed are shown in Table 2.

A total of 4,614 triage scenarios were completed. One hundred sixty-eight participants completed 2,349 adult scenarios (1,173 paper based and 1,176 computer based), and 162 participants completed 2,265 pediatric scenarios (1,132 paper based and 1,133

Limitations

Although this study consists of a large heterogeneous sample, a number of limitations were present, which may confound the results. For instance, sources of sample selection bias such as the voluntary nature of participation in the study and the lack of data collected on the demographic characteristics of nurses not participating limits our ability to determine generalizability. The higher level of agreement found using the computer-based mode of delivery is unclear. The addition of visual cues

Discussion

The purpose of this study was to examine emergency nurses' triage performance using case scenarios characterized by patient population (adult versus pediatric) and mode of delivery (paper versus computer). To our knowledge, this is the first time a randomized sample has completed a combination of paper-based and computer-based scenarios to measure triage performance of ED nurses using the Australasian Triage Scale across a variety of hospital groups. Other Australian studies published to date

References (19)

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Author contributions: SAL, JC, and EV conceived the study, designed the trial, and obtained research funding. SAL and JC supervised the conduct of the trial and supervised data collection. JC undertook recruitment of participating centers and participants. SAL managed the data, including quality control. EV provided statistical advice on study design and analyzed the data. JC and SAL wrote the project reports. JC drafted the manuscript, and all authors contributed substantially to its revision. JC takes responsibility for the paper as a whole.

Funded by the Victorian Department of Human Services.

Reprints not available from the authors.

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