Errors in nurse-led triage: An observational study

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Abstract

Background

Nurses play a crucial role in correctly prioritizing patients entering emergency departments. However, little is known of the accuracy of nurse-led triage systems.

Objectives

(1) To determine the frequency of nurse-led triage errors within the Manchester Triage System; (2) to explore patient, work environment and individual nurse factors associated with triage errors; and (3) to explore associations between triage errors and patient outcomes (i.e., length of emergency department stay, hospitalization, and 7- and 30-day mortality).

Setting

This study was conducted in one emergency department in Northern Italy.

Participants

A random sample of 5% (n = 1,929) of all eligible patients accessing the emergency department over an 18-month period.

Methods

For this retrospective observational study, electronic health record data on triage errors (i.e., incorrect presentational flowchart, specific discriminator and/or priority level) and triage nurses were combined with routine data on patient characteristics, outcomes and the work environment. To explore relationships between these variables, we performed univariate and multivariate logistic regression analyses.

Results

We observed triage errors in 16.3% of patients (n = 314). These were significantly associated with patients’ emergency department and hospital stays. Analyses revealed that when > one patient was triaged every 15 min (OR: 2.112;95%CI: 1.331–3.354), older patients (OR: 1.009; 95%CI: 1.003–1.015) with > than two chronic conditions (OR: 1.506; 95%CI: 1.091–2.081) and orange or red priority codes (OR: 1.314; 95%CI: 1.046–1.651,) whose triage nurse had previous experience with another triage system (OR: 3.189; 95%CI: 2.455–4.14) had higher odds of triage errors.

Conclusion

We provided primary evidence on triage errors. Confirming our findings on the prevalence, nature and consequences of such errors will require further prospective multicenter studies. Considering patient factors (e.g., age, polychronicity) as additional discriminators could make the nurse-led triage process using the Manchester Triage System more accurate. Investigating the roles of triage nurses’ training and background and the emergency department work environment on their mental models regarding the triage process will require qualitative research.

Section snippets

Background

Triage is the first assessment and sorting process used to prioritize patients arriving in emergency departments. It is a particularly vulnerable point in patient evaluation, as triage nurses must gauge patients’ acuity levels, the mortality threats their conditions entail, and their anticipated resource needs. However, the need for accurate prioritization is impeded by high demand for emergency care (Rasouli et al., 2019), frequent emergency department overcrowding (Di Somma et al., 2015), and

Study design

We conducted a retrospective observational (chart review) study.

Sample and setting

This study was conducted in the emergency department of Merano Hospital (SABES-ASDAA) in Northern Italy (70,000 emergency department visits per year, 300 acute-care beds). Since 2013, Merano Hospital’s emergency department triage has been standardized according to the Manchester Triage System method. Every shift's (morning/afternoon) triage is performed by two triage nurses; only one is present during night shifts. With certain

Characteristics of the patients, emergency department work environment and triage nurses

The characteristics of the patient sample, the emergency department work environment and the triage nurses are summarized in Table 1. The median patient age was 58, with one-third having at least one chronic condition. Nearly 60% accessed the emergency department during morning shifts; 7% revisited the emergency department < 72 h, 10% of these presenting with high severity (orange or red code). Regarding the emergency department work environment, a median of 20 patients were triaged before the

Discussion

This study provided primary evidence on nurse-led triage errors, their contributing factors and their consequences for patients. In one-sixth of the randomly selected patient files, presentational flow charts and/or specific discriminators were not correctly selected, and/or priority levels not correctly assigned by triage nurses. Factors contributing to triage errors related to patient, emergency department work environment and individual nurse characteristics. Patients with triage errors

Conclusions

With this retrospective study we provided primary evidence on the frequency, contributing factors and outcomes of triage errors. In one-sixth of the randomly selected patients’ files, presentational flow charts and/or specific discriminators were not correctly selected, and/or priority levels not correctly assigned by triage nurses. Factors contributing to triage errors related to patient, emergency department work environment and individual nurse characteristics. Patients with triage errors

CRediT authorship contribution statement

Dietmar Ausserhofer: Methodology, Writing - review & editing, Writing - original draft. Arian Zaboli: Conceptualization, Data curation, Writing - original draft, Writing - review & editing. Norbert Pfeifer: Methodology, Writing - review & editing. Pasquale Solazzo: Conceptualization, Data curation, Writing - review & editing. Gabriele Magnarelli: Conceptualization, Data curation, Writing - review & editing. Tania Marsoner: Conceptualization, Data curation, Writing - review & editing. Marianne

Conflict of Interest

None.

Acknowledgments

We sincerely thank the nursing management and the triage nurses at the emergency department of [BLINDED] for their support and participation in this study.

Funding

None Declared.

Ethical Approval

None Declared.

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