Australasian Emergency Nursing Journal (2014) 17, 51—58

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RESEARCH PAPER

The Emergency Triage Education Kit:Improving paediatric triage

Lorelle Malyon, RN, RM, BN, MPhil a,b,c,∗Alison Williams, RN, MPhil, MPH c,d,e

Robert S. Ware, PhD b,e

a Department of Emergency Medicine, Royal Children’s Hospital, Herston Road, Herston, Brisbane,Queensland 4029, Australiab School of Population Health, The University of Queensland, Herston Road, Herston, Brisbane, Queensland4006, Australiac Nursing Research Unit, Royal Children’s Hospital, Herston Road, Herston, Brisbane, Queensland 4029,Australiad Children’s Nutrition Research Centre, The University of Queensland, Herston Road, Herston, Brisbane,Queensland 4006, Australiae Queensland Children’s Medical Research Institute, The University of Queensland, Herston Road, Herston,Brisbane, Queensland 4006, Australia

Received 7 November 2012; received in revised form 23 September 2013; accepted 9 February 2014

KEYWORDSEmergency;Triage;ETEK;Hospital;Paediatric;

SummaryObjectives: The Emergency Triage Education Kit (ETEK) was published in 2007. To date, theimpact of ETEK has not been measured. The purpose of this study was to measure the effec-tiveness of ETEK on paediatric triage.Method: A retrospective chart audit was undertaken in a tertiary paediatric hospital. Its’ aimwas to review the completeness of documentation recorded at the point of triage after a stan-

Audit dardised documentation framework was introduced and to measure inter-rater agreement.Primary assessment and physiological discriminators documented at the point of triage werecompared with those from the paediatric physiological discriminator table (PPDT) within ETEK.

Using an audit tool developed by the researchers, a parallel decision-making pathway was usedto ascertain whether the original ATS score could be substantiated by the PPDT. Improvement indocumentation of the primary assessment and inter-rater agreement was measured over time.

∗ Corresponding author at: Department of Emergency Medicine, Royal Children’s Hospital, Brisbane, Queensland 4029, Australia.Tel.: +61 7 3636 9008.

E-mail addresses: lorelle malyon@health.qld.gov.au, lorelle mal@bigpond.com (L. Malyon).

http://dx.doi.org/10.1016/j.aenj.2014.02.0021574-6267/© 2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.

52 L. Malyon et al.

Results: 600 triage records were selected; 200 each from 2007, 2008 and 2010. Triage documenta-tion that did not support parallel decision-making decreased significantly according to the year ofpresentation (2007; 112 (56%), 2008; 106 (53%), 2010; 13 (7%), P < 0.001). When parallel decision-making was facilitated by an improvement in triage documentation, there was improvement inmatched triage scores (2007; 54%, 2008; 69%, 2010; 72%, P = 0.01).Conclusion: The introduction of ETEK has had a significant impact in this ED, particularly whencombined with education sessions. The use of the PPDT as a framework to guide documentationand triage language facilitated parallel decision-making and auditing, and led to an improvementin inter-rater agreement when applied to children.© 2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rightsreserved.

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uowbthe study hospital; and July 2010, after the ETEK-basededucation sessions had been conducted. This study receivedethical clearance from the appropriate Hospital and Univer-

What is already known?

The ATS is used to assess urgency and prioritise care,however when applied to children, its reliability hasbeen shown to be only fair. The ETEK provides a stan-dardised education plan for triage nurses in an aimto improve consistency in the application of the ATS.Specifically, ETEK contains paediatric tools to assist thetriage nurse’s decision-making when applying the ATSto children.

What this paper adds?

To date, the effectiveness of ETEK to meet its’ aim hasnot been measured. This paper describes the impact ofthe ETEK on paediatric nursing triage.

ntroduction

he Australasian Triage Scale (ATS) is used to assess urgencynd prioritise access to time-critical intervention withinustralian Emergency Departments (ED).1—5 The accuracyith which a triage scale is applied is fundamentally impor-

ant to positive patient outcomes.6—8 The ATS aims tonsure that a patient will receive the same triage cate-ory in any ED to which they present.9,10 However severaltudies have demonstrated that the ATS has only poor toair inter-rater reliability when applied to children anddolescents.11—13 This may be due to the complexity ofaediatric assessment, in particular the developmental con-iderations that mean there is often a reliance on thearer to provide the history.14 Alternatively, when childrenresent to a mixed ED, the triage nurse may have vari-ble knowledge, experience and self-confidence in assessinghildren.12,15 The lack of consistency in applying triagecores to children may also be attributed to the lackf a paediatric framework on which to base decision-aking.8

Endorsed by the Australian Department of Health andgeing and the College of Emergency Nursing Australasia,

he Emergency Triage Education Kit (ETEK) was introducednto Australian EDs in 2007.5,14 Within ETEK, the pae-iatric physiological discriminator table (PPDT) provides

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vidence-based markers for serious illness and injury. Theseeflect the triage nurses primary nursing assessment (air-ay, breathing, circulation and disability: neurological,eurovascular and pain) and arranges them into ATS triageategories.

The PPDT was primarily designed to support the decision-aking of nurses.14 It also provides the potential toositively influence documentation standards, audit triagepisodes and improve the consistency by which the ATS ispplied to children. Australia does not have a robust triageuditing system that is utilised nationally. Instead the accu-acy of triage scores has been based on expert opinion orhe use of paper-based scenarios which lack rigour and haveimited generalisability.2

The aim of this study was to assess the effectiveness ofTEK to meet its’ aims by:

. examining the effectiveness of the PPDT to standardiseand improve documentation at the point of triage

. investigating whether standardised documentationassisted in auditing triage practice and

. analysing whether the ATS was more consistently appliedafter introduction of ETEK.

ethods

ethod and setting

he study hospital is a paediatric tertiary referral cen-re, caring for children and young people from birth to 15ears. The ED provides initial assessment and managementf approximately 30 000 acute presentations annually. Allhildren entering this ED are triaged by an experienced andpecifically trained emergency nurse.

A single retrospective, randomised chart audit wasndertaken to review documentation recorded at the pointf triage. Charts were audited from July 2007, before ETEKas published; July 2008, after the publication of ETEK butefore ETEK-based education sessions were introduced at

ity Ethics Committees.The researchers extracted triage records from Emer-

ency Department Information System (EDIS), the electronic

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documentation system used in the study hospital’s ED.Six hundred charts were audited in total; 200 from eachtime period. Charts were selected from the months underreview by a research assistant who de-identified the records.To ensure representation of all categories, the selec-tion system was designed so approximately 15% of chartsselected were for patients receiving an ATS 1 (immedi-ately life-threatening cases), 15% were ATS 2, 25% wereATS 3, 30% were ATS 4 and 15% were ATS 5 (less urgentcases).

Audit tool/data sources

Using the PPDT as the gold standard, an audit tool was devel-oped and piloted by four experienced triage nurses. Thetool was used to scrutinise triage documentation with theresearchers comparing completeness of the primary assess-ment data and the use of the physiological discriminators, tothe PPDT. If primary assessment documentation was incom-plete, the researcher did not assume that the assessmentwas completed and therefore could not match a triage cat-egory. This may have occurred if an integral part of theassessment was omitted, such as a pain assessment for achild whose primary presentation was pain, or neurovascularobservations for a child who presented with an injured limb.The original and audited ATS categories were compared anda determination was made on whether the original triagescore could be substantiated or whether under or over triagehad occurred. Finally, an analysis for improvement over timewas conducted.

Intervention

Education sessions introducing the ETEK and the PPDT wereconducted for current triage nurses between March and May2010. During each session, participants were familiarisedwith the PPDT’s format. In particular, discussion centred onthe use of the table’s physiological discriminators to facili-tate triage decision-making and standardise documentation.Using the sessions as the impetus for practice change, min-imum standards for documentation were modified so theprimary assessment was documented in its entirety. Thatis, for all presentations it was expected that documen-tation addressing; airway, breathing and circulation wereincluded. In addition, participants were expected to addressdisability, however, a neurovascular assessment was onlyrequired when the child presented with a limb injury. Triagenurses were directed to use the terminology of the PPDT todescribe alterations from normal physiology with ‘‘intact’’being an acceptable term used for a child whose physio-logical parameters were within normal parameters for theirage.14 The triage nurses were instructed to document thepresenting problem succinctly along with any known riskfactors.

Statistical analysis

It was calculated that 200 charts were required to beselected from each year to detect a between-year dif-ference in the percentage of records in which parallel

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53

ecision making could be employed of 20%, with 80% powernd alpha = 0.01. Results are described using descriptivetatistics, and data was compared across years using thehi-square test for trend. Data was analysed using Statatatistical software version 11.1 (Stata Corp., Collegetation, TX, USA).

esults

ain results

he researchers extracted 200 triage records from eachf the three years under investigation. In 2007, the triageecords of 34 triage nurses were audited (median recordser nurse = 4, range 1—27). In 2008, the triage records of5 nurses were audited (median records per nurse = 4, range—18) and in 2010, the triage records of 36 triage nursesere audited (median records per nurse = 4, range 1—12). In

otal, 61 different triage nurses were audited over a three-ear period (n = 78% of triage trained nurses and 64% of totalD nurses employed during the study months). There were1 different primary complaints, the most common of whichere fever (14%), difficulty breathing (9%) and vomiting

8%).The number of triage records in which parallel decision-

aking could not be utilised by the researchers decreasedignificantly according to the year of presentation. In 2007,12 (56%) triage records did not have enough assess-ent data documented for the researcher to allocatetriage score. In 2008, the number decreased slightly

o 106 (53%). In 2010 after the education sessions andhange of minimum documentation standards, the num-er of triage records in which parallel decision-makingould not be applied was reduced significantly to only 137%); (P < 0.001, chi-squared test for trend). This patternas similar when presentations were separated into injury

63%, 60%, 15% from 2007 to 2010) and illness (53%, 54%,%).

When the parallel decision-making process could be facil-tated, 54% of the primary triage scores matched in 2007,ith 21% over triaged and 24% under triaged. In 2008 thereas agreement on 69% of occasions, with over triaging occur-

ing on 15%, and under triaging on 16%, of occasions. In010 there was agreement on 72% of occasions with overriaging occurring on 20%, and under triaging on 8%, of occa-ions. The percentage of scores correctly matched increasedignificantly over time (P = 0.01, chi-square test for trend).etween 2007 and 2010 children were significantly lessikely to be under-triaged (risk ratio = 0.34; 95% confidencenterval = 0.18—0.62), while the proportion of children over-riaged remained similar (risk ratio = 0.97; 95% confidencenterval = 0.58—1.60).

Table 1 demonstrates how, when data were analysed byhe characteristics of the primary survey, documentationmproved across time. Improvement was most significantor the airway assessment; from 12% in 2007 to 92% in010 (P < 0.001, chi-square test for trend). Documentation

elated to an assessment of breathing also significantlymproved from 24% in 2007 to 93% in 2010 (P < 0.001, chi-quare test for trend). The circulation and neurologicalssessments were reasonably well documented prior to the

54 L. Malyon et al.

Table 1 Documentation of physiological discriminators characteristic. Two hundred charts were audited each year. Differencesbetween groups assessed using the Chi-square test for trend.

2007 2008 2010 P-valuen (%) n (%) n (%)

Airway 25 (12.5) 26 (13.0) 185 (92.5) P < 0.001Breathing 49 (24.5) 44 (22.0) 187 (93.5) P < 0.001Circulation 162 (81.0) 182 (91.0) 193 (96.5) P < 0.001Neurological 164 (82.0) 180 (90.0) 186 (93.0) P < 0.001Neurovasculara 3 (9.6) 16 (61.5) 15 (44.1) P < 0.005Pain 33 (16.5) 22 (11.0) 44 (22.0) P < 0.14

a Neurovascular outcomes considered only when neurovascular compromise was considered a potential at initial triage (n = 31 in 2007,

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hange of practice so relatively modest, yet still statis-ically significant improvements were seen in these areasTable 1).

Primary triage category allocation, or the category allo-ated by the triage nurse, is displayed in Table 2. As shown,he distribution of categories one to five was similar between007 and 2008. However, in 2010 there was a significantlyigher percentage of category 1 and 2 allocations (P < 0.001,hi-square test for trend). The category most likely tooncord between the primary triage score and the PPDTuidelines was category five with 100% concordance, this

eans that all patients categorised as ATS 5 at presenta-

ion, who could be allocated according to the PPDT, wereorrectly categorised. In categories 1, 2, and 3 concordanceetween the primary allocation and the PPDT was 68%, 77%,

tdat

Table 2 Allocation of triage categories by year.

Primary triage category PPDT

allocation ATS 1 ATS 2 ATS 3 ATS 4 ATS 5 Total

No

category 3 14 25 58 12 112

ATS 1 3 0 1 1 0 5

ATS 2 0 11 7 3 0 21

ATS 3 0 4 12 9 0 25

ATS 4 0 1 1 10 0 12

ATS 5 0 1 1 11 12 25

Total 6 31 47 92 24 200

Correct triage 1 category over-

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triaged

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2007

nd 64% agreement respectively. Category 4 was relativelyoorly matched at only 48% agreement.

iscussion

he introduction of ETEK into this ED improved triage perfor-ance in this tertiary paediatric hospital. Most improvement

ccurred after nurses had received ETEK-based educationessions. The PPDT was included in ETEK so that novice

riage nurses’ were able to reflect on their primary triageecisions6 however; this study has shown that the PPDT hasmuch broader use. In this study it was shown to be effec-

ive as a framework to guide triage documentation and this

ETEK and paediatric triage 55

Table 2 (Continued )

Primary triage category

ATS 1 ATS 2 ATS 3 ATS 4 ATS 5 Total

No

category 0 13 28 50 15 106

ATS 1 3 0 0 0 0 3

ATS 2 0 9 5 3 0 17

ATS 3 0 1 13 7 0 21

ATS 4 0 0 4 15 0 19

ATS 5 0 1 3 5 25 34

Total 3 24 53 80 40 200

Correct triage 1 category over-

triaged

1 category under-

triaged

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triaged

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triaged

2008

Primary triage category PPDT

allocation ATS 1 ATS 2 ATS 3 ATS 4 ATS 5 Total

No

category 1 4 3 5 1 13

ATS 1 11 1 0 0 0 12

ATS 2 8 37 6 1 0 52

ATS 3 0 6 44 7 0 57

ATS 4 0 2 9 28 0 39

ATS 5 0 0 1 11 14 27

Total 20 50 63 52 15 200

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triaged

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triaged

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triaged

2010

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acilitated parallel decision-making for the purpose of auditnd quality management.

he physiological assessment

hysiological data such as that contained within the PPDTnderpin the triage nurse’s primary assessment and has beenound to provide a high degree of objectivity.16 Physiologicaliscriminators have been used as valuable indicators of clin-cal urgency at triage.6,17,18 Prior to the publication of ETEK,riage decisions for children were inconsistent11—13 In anttempt to introduce greater consistency, the PPDT with its’ore prescriptive physiological data, was included. The for-at of the PPDT facilitates decision-making through gradedhysiological discriminators ranging from no deviation fromormal paediatric parameters (ATS 5) to discriminators indi-ating the critically ill or injured child (ATS 1). This studyas shown that the PPDT and the adoption of its terminol-gy have coincided with a more consistent application of theTS.

riage categories

significant increase in ATS 1 and 2 was identified in 2010.nalysis of data obtained from EDIS confirms the upwardrend in these two categories.19 Key statistics demonstratehat for the total number of patients presenting to the ED inuly, the percentage of children receiving an ATS 2 rose from.8% (n = 165) in 2008 to 13.7% (n = 314) in 2010.19 Similarly,or ATS 1 patients, the percentage of presentations rose from.2% (n = 4) in 2008 to 0.8% (n = 18) in 2010.19 While the causes likely to be multifactorial; it is possible that some ATS 1nd 2 patients were previously being under triaged.

Over triage is defined as the allocation of an ATS cat-gory that is higher than the true measure of urgency.14 Inhis study, over triage represented any presentation that wasated as more urgent than the PPDT indicated. In 2010, overriage was most common for category five patients with 45%n = 12) allocated a higher category. This number takes intoccount the potential for the ATS category to be increasedhen a co-morbidity or risk factor is present but in this study,either factor was present in this cohort. While over triageecreases the waiting time of the patient, it may inappro-riately direct the ED resources and adversely affect theaiting time of other patients.10 It is for this reason that

teps should be taken to explore this finding in more detail.Conversely, under triage is the term used when a triage

llocation is lower than the true measure of urgency.14 Underriage can have significant consequences when taking intoccount the fact that children are waiting for treatmentonger than their true urgency indicates. This can lead tooor patient outcomes and potentially adverse events.10 Thetrategy used to change practice showed the risk of underriage decreased significantly, while the proportion of chil-ren over-triaged remained similar.

ocumentation

ursing documentation must reflect the physiological assess-ent that has been completed. The quality of triage

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L. Malyon et al.

ocumentation may influence practice and patient out-omes so it is important that it accurately reflects thessigned triage category.3,20,21 Further, it can be used as evi-ence in a court of law for either clinical or professionalccountability.

Initially, documentation anomalies in this study includedncomplete documentation of significant and relevant pri-ary assessment data and phrasing such as ‘‘no work ofreathing’’ when what was meant was ‘‘no increased workf breathing’’. In addition, non-standardised abbreviationsr the inclusion of irrelevant information also impeded par-llel decision-making. These findings are consistent withhose of a cross-sectional audit of general nursing documen-ation undertaken in 2011.20 The study conducted by Wangt al., 2011 identified that documentation can be improvedhen there is education and organisational support for the

ntroduction of standardised language; findings that are sup-orted in this study.

Documentation of the primary assessment was showno improve after the PPDT was introduced. This finding ismportant for a number of reasons. Comprehensive doc-mentation of the initial assessment using a standardisedormat and physiological descriptors facilitates transparentecision-making. This is helpful for the purpose of audit anduality improvement. For the triage nurse, the identifica-ion of strategies to improve performance can be linkedo reflective practice and education.8 For children, it ismportant because it means that the ATS will be more con-istently applied and more accurately reflect their clinicalrgency.

udit

he accuracy of and consistency in which a triage scores allocated largely underpins the quality managementrocess.8 Auditing clinical decision-making is the ideal mea-ure of accuracy and consistency and is best achieved ifarallel decision-making occurs.8 In this study, the use ofhe PPDT and ATS simultaneously was found to contributeo the consistency of triage nurses decisions. Together withhe change in documentation standards to reflect the fullrimary assessment and terminology of the PPDT, the abil-ty of the researchers to use parallel decision-making as aool to scrutinise concordance at the point of triage greatlymproved.

The most significant improvement was evident in the dis-riminators for airway and breathing. Prior to this study,riage nurses in this ED documented circulation and neu-ological assessments in some form and therefore thereas only a moderate improvement over time. For theseharacteristics, the greatest change was observed in themprovement in the use of standardised physiological dis-riminators.

Pain is a common reason for accessing emergency carend the amount of pain experienced by a patient directlynfluences urgency and resource allocation.8 Despite this, itas the discriminator least often reported. Auditing of the

anchester Triage Scale in the United Kingdom has shown

imilar results with the most common documentation omis-ion being the failure of the triage nurse to record a paincore.8 Studies conducted by Considine et al., 2006 and

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ETEK and paediatric triage

Wang et al., 2011, concur. These studies described ongoinglow levels of reporting pain, even after an intervention suchas education.20,22 The assessment of pain ensures appropri-ate pain relief is provided in reasonable time and whilesome improvement was seen in this study, further work isrequired.14

Limitations

This research was limited to a single site, tertiary referralhospital. However, the nature of the hospital allowed forspecialist paediatric nurses to test the tool. Further study isrequired to explore whether these results can be generalisedto other paediatric and mixed EDs.

Conclusion

This study has demonstrated that ETEK has had a significantimpact in this ED. Further, the introduction of the PPDT hashad a number of positive outcomes. Triage nurses now docu-ment the complete primary assessment; Airway, Breathing,Circulation and Disability which is a true reflection of theassessment undertaken at the point of triage. This and theadoption of similar terminology as that used in the PPDThave provided a framework for triage nurses to link physi-ological descriptors for illness and injury to ATS categories.These steps facilitated parallel decision-making for the pur-pose of auditing. Auditing led to reflective practice, a moreconsistent use of the ATS and improved inter-rater agree-ment. Most importantly, the findings of this study have hada direct benefit for the child. That is, improved performanceensures that children receive an ATS allocation commensu-rate with their level of clinical urgency.

Funding source

This paper is part of a larger study that was funded by theRoyal Children’s Hospital Foundation Research Skills Devel-opment Scholarship for Nurses. Grant no. 10296.

Author contributions

L.M. and A.W. were responsible for the study conception.L.M., A.W. and R.W. were responsible for the study design.L.M. was responsible for data collection. L.M., A.W. and R.W.were responsible for data analysis with R.W. providing sta-tistical expertise. L.M., A.W. and R.W. were responsible fordrafting the manuscript and L.M., A.W. and R.W. made crit-ical revisions for important intellectual content. R.W. andA.W. supervised the study.

Ethical approval

This paper reports the findings of a research study that

adhered to the National Statement on the Conduct ofHuman Research by the Australian National Health andMedical Research Council, and has been approved by theRoyal Children’s Hospital, Brisbane and the University of

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ueensland’s Human Research Ethics Committee. ApprovalREC/09/QRCH/32.

rovenance and conflict of interest

here is no conflict of interest. This paper was not commis-ioned.

cknowledgements

he authors would like to acknowledge Dr. Samantha Keogh,enior Research Fellow, Griffith University for her contribu-ion to the study’s original conception and design.

The authors would also like to thank the following mem-ers of the expert panel who piloted the audit tool: Judyarris, Nurse Unit Manager, Redcliffe Hospital (ED), Thereseates, Clinical Nurse Consultant, Royal Children’s Hospital

ED) and Leanne Philips, Clinical Nurse, Royal Children’s Hos-ital (ED).

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