O ne of t he major d e p a r t m e n t a l goals for our e m e r g e n c y d e p a r t m e n t is to d e c r e a s e l eng th of

s t ay (LOS). In add i t i on to mon th ly overall LOS, w e also r ev i ew LOS as i t re la tes to acu i ty and d i spos i - t ion. After w e h a d s t u d i e d the LOS repor t for more t han a year, q u e s t i o n i n g the va l id i ty of t he repor t and b e m o a n i n g the long LOS for s o m e of our p a t i e n t pop- ulat ions, w e no t i c ed tha t t he re was a c o n s i s t e n t n u m b e r of p a t i e n t s a d m i t t e d w i th a n o n u r g e n t a c u i t y c lass i f icat ion. B e c a u s e our d e p a r t m e n t had e x p e n d - ed cons ide rab l e effort in deve lop ing a t r i age class w i th a p r ecep to r sh ip , w e w o n d e r e d w h e t h e r w e h a d b e e n t e a c h i n g the r igh t t h i n g s or if t he re we re o ther r e a sons t h e s e p a t i e n t s ' cond i t ions were c lass i f ied as n o n u r g e n t a t t r iage.

Triage issues There is e v i d e n c e t ha t p r e d i c t i n g a d m i s s i o n s at t r i age is difficult. Evers e t al. 1 found tha t a seve r i ty score could not b e u s e d as a t r i age tool to p r ed i c t ICU a d m i s s i o n in one hospi ta l . Bri l lman et al. 2 found tha t t r i age d e c i s i o n s m a d e by nurses , phys ic ians , or a c o m p u t e r i z e d t r i age p r o g r a m were unab le to p r ed i c t admis s ions . Regard less , w e still a s s u m e d tha t mos t a d m i s s i o n s would be a s s i g n e d an u rgen t or emer - gen t c a t e g o r y at t r iage. However , w h e n w e r e v i e w e d our p rev ious repor ts for 6 months , w e found 26 to 60 p a t i e n t s w h o s e t r i age c lass i f ica t ion was unde re s t i - m a t e d (under t r iaged) each month . With an ave rage of 603 a d m i s s i o n s pe r month , t ha t m e a n t tha t 6.7% of the a d m i t t e d p a t i e n t s h a d lower t r i age ca t ego r i e s t han appropr ia te . A l though the re are p robab ly o ther p a t i e n t s w h o s e t r i age ca t ego r i e s are bo th unde re s t i - m a t e d or ove re s t ima ted , a s s i g n i n g a lower acu i t y

Vicky Bradley is tl~e systems coordinator for Operating Room Services and the Emergency Department. Regina Heiser is the case manager for Operating Room Services and the Emergency Department. Both are employed by the University of Kentucky Hospital, Lexington, Kentucky. Reprints not available from authors. J Emerg Nurs 1996;22:435-8. Copyright �9 1996 by the Emergency Nurses Association. 0099/1767/96 $5.00 + 0 18/62/75803

p r e d i s p o s e s pa t i en t to de lays in t r e a t m e n t b e c a u s e thei r t r i age ca t egory is not "urgent." Whi le w e were r e v i e w i n g this informat ion w e r e c e i v e d an u p g r a d e to the ma in f r ame repor t wr i t ing s y s t e m tha t a l lowed us to d o w n l o a d d a t a from our ED t r a c k i n g s y s t e m

The m o s t c o m m o n m i s s i n g a s s e s s m e n t f indings w e r e related to s y m p t o m frequency (e.g., h o w m u c h rectal b l eed ing , l eve l of pain, type of vag ina l d i scharge , and character i s t ics of sputum) .

into a s p r e a d s h e e t d a t a b a s e . We be l i eved this would be an exce l len t popu la t ion to u se to learn h o w to m a n i p u l a t e d a t a b e t w e e n sys tems . Our p u r p o s e in r e v i e w i n g the u n d e r t r i a g e d c a s e s w a s to d e t e r m i n e w h e t h e r any t r ends e x i s t e d and to iden t i fy s t r a t eg ie s to i n c r e a s e t r iage accuracy .

Audit process Init ially w e g e n e r a t e d a repor t tha t re f lec ted the da t a ava i lab le in the c o m p u t e r i z e d t r ack ing s y s t e m for th is g roup of pa t ien t s . We were able to ob ta in the fol- lowing data : t r i age nurse , t r i age acuity, cha rge level a s s i g n e d , chief s y m p t o m , age, d i spos i t ion , p r e s e n t date , LOS, pa t i en t a c c o u n t number , a n d pa t i en t name . We then i m p o r t e d t h e s e d a t a from the main- f l ame into a s p r e a d s h e e t program. Unfortunately, w e found t ha t the d a t a w e n e e d e d to d e t e r m i n e the a c c u r a c y of the t r i age c lass i f ica t ion (the t r i age note) are not ye t c a p t u r e d on-line, so w e r e v i e w e d the g r o u p of c h a r t s for t h e u n d e r t r i a g e d a d m i t t e d p a t i e n t s to d e t e r m i n e the following: (1) c o m p l e t e n e s s of t he t r i age note, (2) a c c u r a c y of t he a s s i g n e d t r iage

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JOURNAL OF EMERGENCY NURSING/Bradley and Heiser

RN ACUITY CHIEF COMPLAIf AGE LOS

1 2 PAIN/BACK 37 0 10:44

2, 2 LOSS/APPETITE 54 0 06:35

2 2 FEVER 2 0 00:40

2 2 COUGH 2M 0 07:53

3 2 PAIN/ABDOM 19 0 06:13

3 2 PAIN/ABDOM 34 0 10:50

3 2 FEVER 3 0 05:22

3 2 BLEED/RECTUM 44 0 03:11

3 2 BLEED/EAR 3 0 03:35

4 1 PSYCHIATRIC 32 0 04:18

5 1 COMBATIVE 93 0 00:49

6 2 PAIN/BACK 44 0 03:39

6 2 WEAK 66 0 07:46

6 2 RIGHT LEG 4 4 0 15:38

6 2 SEIZURE 1M 0 04:52

Figure 1 Sample of data presentation in spreadsheet.

DIAGNOSIS

$1 REDICULOPATHY

MANIC DEPRESSIVE

SEIZURE DILANTIN ALLERGY

BRONCHIOLITIS

DEPRESSIVE DISORDER

ABSCESS

PYLONEPHRITIS

THROMBOSED HEMMORHOID

FOREIGN BODY REMOVAL

SCHIZOPHRENIA

ALZHEIMER

SUICIDAL

CHART UNAVAILABLE

EWING'S SARCOMA-RECURRENCE

SEIZURE

Additonal Triage LAST MD Triage info acuity VISIT assessment needed? accurate 0=not complete 0=no 0=no,l=y charted,1- 0=no,l=yes 1=yes es charted

1 0 0 1

1 0 0 0

0 1 1 0

0 1 1 0

0 1 1 0

0 1 0 0

0 1 0 0

0 1 0 0

0 0 0 1

1 0 0 1

0 1 O~ 0

o 1! ol o

o 11 o I o

I 0 1 I

acuity, (3) adherence to depar tmenta l policies, and (4) d i s c h a r g e d i agnos i s . Both au thors have b e e n involved in c rea t ing and t each ing the depar tmenta l t r iage class and be l ieved we could identify wha t a reasonably p ruden t nurse would do. ED policies, p rocedures , and gu ide l ines , a long wi th ENA's "Making the Right Decis ion: A Tr iage Cur- riculum, ''3 were used as a bas i s for our analysis. We rev iewed 48 charts in two 2-hour sessions. The ini- tial download of the ED t rack ing da ta into a spread- shee t format saved us about 4 hours of audi t and da ta entry time. Figure 1 is a sample of the da ta ob ta ined from the ED t rack ing sys tem combined with the medica l record audit .

Results Data integrity We discovered that some of the data in the records reviewed were inaccurate. In one case, the pat ient was ass igned an acui ty of 3 ("urgent") but 2 ("nonur- gent") was entered into the computer. On another

record, the pa t ien t was actually discharged, not admitted. On two pediatr ic cases, the computer had inaccurately calculated their age on the basis of their birth date. There were d iscrepancies be tween triage nurse initials captured by the computer that did not match the nursing signature on the pat ient record. And in two cases, the triage nurse signature was illegible on the paper record.

Analysis of the triage note We found the spreadshee t format to be very helpful in data analysis. Sorting data by different variables, such as by pat ient age or by tr iage nurse, showed dif- ferent patterns. We found that the triage assessment was complete in 18 of 48 cases, and we agreed with the ass igned tr iage level in only 8 of these 18 cases (Figure 2). We quest ioned the appropria teness of the admission for two of these patients.

When we sorted cases by complete triage note with an underass igned acuity, 20% of the population (10 cases) met this criterion. The chief symptom,

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Bradley and Heiser/JOURNAL OF EMERGENCY NURSING

Chief complaint

Gallstone Seizure Fever Chest pain Arm pain

Diagnosis

ERCP/cholelithiasis Seizure Pneumonia/dehydration Spontaneous pneumothorax Right upper extremity swelling

ERCP, Endoscopic retrograde cholangiopancreatography.

Figure 2 Examples of chief complete and final diagnosis of patients who had accurate triage categories.

age, and final d iagnos is for these pa t i en t s are pre- s e n t e d in Figure 3.

We found 52% of cases wi th an incomple te tr iage a s sessmen t . The mos t c o m m o n mis s ing a s s e s s m e n t f indings were related to symp tom frequency (e.g.,

how m u c h rectal bleeding, level of pain, type of vagi- nal discharge, and character is t ics of sputum). There was also an a b s e n c e of a c c o m p a n y i n g related symp- toms (e.g., for a chief symp tom of abdomina l pain, there was no nota t ion of p re sence or ab sence of nau- sea, vomit ing, or diarrhea). The last phys ic ian visit

was no t d o c u m e n t e d in 48% of the charts rev iewed and would have p rompted addi t ional ques t ions from the tr iage nurse if this ques t ion had b e e n asked. Occasionally, no link was m a d e b e t w e e n current med ica t ions and p re sen t i ng symptoms. For example, a pa t i en t wi th a low-grade fever who was tak ing immunosuppressive m e d i c a t i o n was a s s i g n e d a n o n u r g e n t t r iage category, and no behavioral infor-

ma t ion was d o c u m e n t e d for pa t i en t s who reported tak ing psychia t r ic drugs.

The availabili ty of these da ta on a sp readshee t allowed us to man ipu l a t e the da ta in m a n y different ways. We uncovered unde r t r i ag ing t rends tha t would not have b e e n not iceable or would have required m u c h longer to uncover wi th m a n u a l methods. Some of the other t rends were:

�9 Acu te episodes in pa t i en t wi th chronic d iseases �9 Very young (<6 months) and old, old (>70 years)

�9 Pa t ien ts s een and referred by outs ide phys ic ian �9 Ineffective ou tpa t i en t t r e a tmen t �9 Severe pa in

What did we learn? 1. Check the accuracy of the data

There were errors in the data ob ta ined from the ED t racking system. Because we have a paper sys tem wi th wh ich to compare the computer ized data, we were able to discover da ta entry errors. Staff m e m -

Chief symptom Age Diagnosis

Back pain 37 S1 radiculopathy Back pain 20 Sickle cell crisis Loss of appetite 54 Manic depressive Nose bleed 55 Coumadin toxicity Foreign body in eye 27 Foreign body removal Abdominal pain 9 Pyelonephritis Abdominal pain 23 Appendicitis Suicidal 28 Psychosis Suicide 24 Depression/suicidal Psychiatric 32 Schizophrenia

Figure 3 Primary symptoms, age, and diagnosis of patients who had complete triage assessments but whose condition was undertriaged.

bers ident if ied that the tr iage nurse initials were inaccura t e be c a use they did not upda te the sys tem

each t ime the tr iage nu r se changed. E igh teen nurses t r iaged these 48 pat ients . F requency r anged from one pa t i en t per nurse to a m a x i m u m of n ine pa t ien ts per nurse. The m e d i a n was two pa t i en t s per nurse (average 2.7 pa t ien ts per nurse). We do not know the

f requency of tr iage performed by these nurses and therefore cannot make any a s sumpt ions about why their init ials were p resen t in this audit. It is possible

tha t they triage more frequent ly than other nurses or they m a y be likely to under t r iage. These data could be ob ta ined by gene ra t ing a report tha t coun ts nurse f r equency at triage. Because we now had reason to ques t ion the reliability of this data element , we chose to focus on ways to increase accuracy of the data ele-

m e n t before gene ra t ing any other reports. We also discovered that age was misca lcula ted

from bir th date by our sys tem ' s software in chi ldren younger than 1 year. This problem was reported to information m a n a g e m e n t and subsequen t ly corrected.

As the d e p a r t m e n t b e c o m e s more computer - ized, e n s u r i n g the accuracy of da ta will b e c o m e a greater challenge. Wri t ten reports are an excel lent m e c h a n i s m for check ing da ta accuracy. As n e w sys-

t ems are installed, reports can be u sed as an evalua- t ion tool.

2. Share information

We used Powerpoint (Microsoft Corporation, Redmond, Wash.) to develop overhead transparencies to share the results wi th the Triage Committee. The commit tee took the following actions:

�9 Ident if ied addi t ional da ta e lements for collection (e.g., the t ime from tr iage to the t ime that the

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JOURNAL OF EMERGENCY NURSING/Bradley and Heiser

pa t i en t is t aken to t r e a tmen t room, and type of

admiss ion [ICU, floor, telemetry]) �9 R e c o m m e n d e d tha t we p u r s u e d o w n l o a d i n g

d i scharge d iagnos i s and hospital LOS from the

hospi ta l dec is ion suppor t sys tem �9 Reques ted a chart rev iew for May 1996 data �9 Sugges ted tha t we p resen t f indings of December

1995 and May 1996 to the m a n a g e m e n t staff wi th a plan for ongo ing follow-up

�9 R e c o m m e n d e d revision of guidel ines for tr iage or ienta t ion class and pos t ing of changes in the

d e p a r t m e n t �9 P lanned p resen ta t ion for ED staff �9 Con t inua t ion of month ly report for the Triage

Committee to evaluate the success of interventions

Our goals are to decrease the pe rcen tage of pa t i en t s wi th incomple te data to less t han 10%, a nd to decrease inaccura t e tr iage in this populat ion to 2% or less.

Future r e p o r t s

Although this s tudy requi red 4 hours of da ta col- lect ion t ime, it would have t aken four to five t imes

longer if done manually. As more data are cap tured in computer ized sys tems, such s tudies will be easier. Fu ture reports tha t can be genera ted from our sys tem to help evaluate tr iage accuracy include the following:

�9 Triage acui ty of pa t i en t s admi t t ed to ICU, gener-

al floor bed, or te lemetry �9 Pa t ien ts wi th e m e r g e n t t r iage classification who

are d i scharged This s tudy had three outcomes. We learned how

to download da ta from the ma in f rame into a spread- shee t program. It provided feedback on the accuracy

of the data en te red into the t racking sys tem, and it helped to identify t r ends in our tr iage process. We were able to identify pa t te rns not previously recog- n ized by use of the report. We c h a n g e d our quali ty i m p r o v e m e n t efforts by a d d i n g the ind ica tor of admi t t ed pa t ien ts wi th an initial low acuity.

Reports are no t necessar i ly an e nd product. It

requires vigi lance on the c l inic ian 's par t to ensure tha t the data are correct. However, the data can pro- vide c l inic ians wi th a n e w way to look at pa t ien ts in groups. They allow oversee ing the "big picture" and s u b s e q u e n t analysis in a variety of ways to identify clusters of information that are not a lways evident. Computer ized reports are a n e w tool for today 's emer-

gency nurse.

References

1. Evers ML, Ufondu EE, Hamid Z, Sheikh SU. Utility of a severity scoring system in patient triage. N Engl J Med 1994;91:611-4. 2. Brillman JC, Doezema D, Tandberg D, Sklar DR Davis KD, Simms S, et aL Triage: limitations in predicting need for emergent care and admission. Ann Emerg Med 1996;27:493-500. 3. Emergency Nurses Association. Making the right deci- sion: a triage curriculum. Park Ridge (IL): The Association, 1995.

Contributions for this column shouM be sent to Vicky Bradley, RN, MS, 4017 Palomar Blvd., Lexington, KY 40513; phone (606) 257-2350 (E-mail address.. mnbradley%taonode.mvs.hosp.uky.edu)

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438 Volume 22, Number 5