Effect of a triage course on quality of rating triage codes in a group of university nursing students:a before-after observational study

doi:10.5847/wjem.j.issn.1920-8642.2013.01.004

Abstract

Abstract:

BACKGROUND: Most current triage tools have been tested among hospital nurses groups but there are not similar studies in university setting. In this study we analyzed if a course on a new four-level triage model, triage emergency method (TEM), could improve the quality of rating in a group of nursing students.
METHODS: This observational study was conducted with paper scenarios at the University of Parma, Italy. Fifty students were assigned a triage level to 105 paper scenarios before and after a course on triage and TEM. We used weighted kappa statistics to measure the inter-rater reliability of TEM and assessed its validity by comparing the students' predictions with the triage code rating of a reference standard (a panel of five experts in the new triage method).
RESULTS: Inter-rater reliability was K=0.42 (95%CI: 0.37-0.46) before the course on TEM, and K=0.61 (95%CI: 0.56-0.67) after. The accuracy of students' triage rating for the reference standard triage code was good: 81% (95%CI: 71-90). After the TEM course, the proportion of cases assigned to each acuity triage level was similar for the student group and the panel of experts.
CONCLUSION: Among the group of nursing students, a brief course on triage and on a new in-hospital triage method seems to improve the quality of rating codes. The new triage method shows good inter-rater reliability for rating triage acuity and good accuracy in predicting the triage code rating of the reference standard.

Key words: Emergency, Reliability, Triage, Triage system, Validity

Nicola Parenti, Maria Letizia Bacchi Reggiani, Diego Sangiorgi, Vito Serventi, Leopoldo Sarli. Effect of a triage course on quality of rating triage codes in a group of university nursing students:a before-after observational study[J]. World Journal of Emergency Medicine, 2013, 4(1): 20-25.

Figures/Tables 5

Figure 1.

Table 1

Triage emergency method (TEM) patient's chief complaints

Code	Symptom and situation guide
Red (Very high risk situations)
	Severe acute pain (NRS=9-10), shock, A.M.I. arrhythmia: actual chest pain with syncope and/or arrhythmia and/or dyspnea; Aphasia and/or numbness <3 h; Dyspnea with wheeze or laryngospasm; Major trauma: penetrating injury, severe facial trauma or cranial trauma with GCS≤ 14, thoracic traumawith volet or dyspnea, abdominal trauma with SBP≤90 mmHg, rachis trauma with sensitive-motor deficit, amputation of long bones, open fractures of long bones, 2nd or 3rd degree skin burns (>30% adult or >20% babies), eyes or airway burns, RTS≤ 10; Multiple trauma with major mechanisms (fall from 5 meters; ejection outside a vehicle; or pedestrian run down; age < 5 years; Severe intoxication (quantity or kind of substance or substance unknown) with dysphonia, dysphagia, chest or abdominal pain. Status epilepticus; Headache with altered level of consciousness or meningism, seizures or syncope; Hematemesis or other severe haemorrhage in action; Severe allergic reactions with dyspnea, dysphonia or severe hypotension; Emergency delivery; eclampsia, severe vaginal bleeding; Children: severe dehydration, headache with GCS ≤14 or lethargy or hypotonia, abuse.
Yellow (High risk situations)
	Cardiac: chest pain ≤6 h, syncope, arrhythmia, limbs ischemia, hypertension crisis (SBP >200 mmHg), unstable hypotension (SBP<100 mmHg); Pneumology: mild dyspnea (SaO₂ 88%-92%); Abdomen: acute abdominal pain, vomit and diarrhea with dehydration, hypovolemia (hypotension-tachycardia), hematemesis, melena, severe rectal bleeding in action; Neurology: headache or with SBP > 200 mmHg, headache after cranial trauma if anticoagulants. Consciousness alterations (agitation, drowsiness, acute confusion), GCS 8-14, aphasia or sensitive-motor deficit <3 h, convulsions. Alcohol or drug abuse. Severe dizziness/vertigo or with headache or motor deficit. Moderate pain (NRS=7-8); Minor intoxication, severe allergic reactions (extensive nettle rash, dysphonia, angioedema, multiple hymenoptera stings in history of anaphylaxis); Infections: fever with lethargy, severe infection (rash or purpura), temperature >39 °C, fever in immunodeficiency; Trauma: concussive cranial trauma or anticoagulants, long bones, dislocation, bone deformation, open fractures, severe lacerations, crush syndrome, limb trauma without pulse, multiple trauma, major dynamic; Acute lumbar pain (if age > 40 yrs or in case of hypertension); severe glycemic failure in diabetes (40 mg/dL < glycemia >300 mg/dL); sexual assault, severe or painful haemorrhage or mild but persistent in anticoagulants or hypertension crisis; Renal-genitourinary: scrotum pain, anuria or oliguria; Gynaecology and obstetrics: vaginal bleeding in the elderly or pregnancy with pain; delivery with active contractions <5 min; pre-eclampsia; pelvic pain. Eye injury with alkali or acid, visual deficit; psychiatric symptoms in patient suffering from mental illness. Severe or mild haemorrhage (any cause); Child: Newborn < 3 months; moderate dehydration, severe vomiting or diarrhea. Recent trauma <12 h.; neonatal crying, recent convulsion.

Table 1

Figure 2.

Table 2

Table 3

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Variables	Before course (without TEM)	After course (with TEM)	Reference standard (with TEM)
K inter weighted (95%CI)	0, 42 (0, 37-0, 46)	0, 61 (0, 56-0, 67)	0, 75 (0, 71-0, 79)
Complete agreement (n, %)	0	0	35/105 (33)
Complete disagreement (n, %)	103/105 (98)	67/105 (64)	1/105 (2)

Variables	Reference standard	Admission status
Sensitivity (95%CI)	81% (68-95)	86% (60-100)
Specificity (95%CI)	80% (66-94)	87% (78-96)
Accuracy (95%CI)	81% (71-90)	87% (78-95)
Positive predictive value (95%CI)	81% (68-95)	46% (19-73)
Negative predictive value (95%CI)	80% (66-94)	98% (94-100)

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