Triage nurses’ clinical decision making. An observational study of urgency assessment

TLDR

Researchers have described the decision tasks performed by triage nurses and identified time as a factor influencing triage quality, yet little is known about the tasks used for acuity assessment or the factors affecting triage duration in real‑world settings. The study aimed to describe the data triage nurses collect for allocating an Australasian Triage Scale priority, the duration of decision making for categories 2‑5, and how patient and nurse variables influence that duration. Observational data were collected in a metropolitan Melbourne emergency department, where 26 nurses performed 404 triage encounters that were recorded with a 20‑item instrument capturing decision tasks, patient, nurse, and environmental variables, and the time of each nurse‑patient interaction. Findings showed limited use of objective physiological data, large variability in triage duration, and significant differences linked to nurse, patient, and environmental factors, indicating that practice standards should require routine physiological measurements and abandon arbitrary time limits.

Abstract

Researchers have described both the various decision tasks performed by triage nurses using self-report methods and identified time as a factor influencing the quality of triage decisions. However, little is known about the decision tasks performed by triage nurses when making acuity assessments, or the factors influencing triage duration in the real world.The aims of this study were to: describe the data triage nurses collect from patients in order to allocate a triage priority using the Australasian Triage Scale (ATS); describe the duration of nurses' decision making for ATS categories 2-5; and to explore the impact of patient and nurse variables on the duration of the triage nurses' decision making in the clinical setting.A structured observational study was employed to address the research aims. Observational data was collected in one adult emergency department located in metropolitan Melbourne, Australia. A total of 26 triage nurses consented and were observed performing 404 occasions of triage. Data was collected by a single observer using a 20-item instrument that recorded the performance frequencies of a range of decision tasks and a number of observable patient, nurse and environmental variables. Additionally, the nurse-patient interaction was recorded as time in minutes.It was found that there was limited use of objective physiological data collected by the nurses' in order to decide patient acuity, and large variability in the duration of triage decisions observed. In addition, analysis of variance indicated strong evidence of a true difference between triage duration and a range of nurse, patient and environmental variables.These findings have implications for the development of practice standards and triage education. In particular, it is argued that practice standards should include routine measurement of physiological parameters in all but the collapsed or obviously unwell patient, where further delay may impede the delivery of time-critical intervention. Furthermore, the inclusion of arbitrary time frames for triage assessment in practice standards are not an appropriate method of evaluating triage decision making in the real world.