Implementation of triage protocol for nurses - Dissertation Example

? Implementation of Triage Protocol for Nurses Introduction Assigning degree of urgency to patients based on the health conditions and nature of the disease increases the effectiveness of the treatment, and reduces the time lag between the patient’s visit and treatment. Triage protocols useful in this regard are highly specialized and needs thorough training to the professionals especially, the nurses. For example, pediatric triage protocols include pediatric cough, pediatric vomiting and several other types. Triage services need to be reliable and cost effective for their application in hospitals or private nursing homes. The process starts from the visits of the patients or the calls received from the patients (telephone triage). Correct protocol needs to be identified based on the symptoms as explained by the patients. The patients are asked the relevant questions based on the check-list for confirmation to make the preliminary diagnostic procedure effective to provide the appropriate health care required. This will make the process simpler down the line for treatment and nursing. Nursing triage protocol system in an organization enhances the efficiency level and improves patient health care. The implementation of Triage Protocol in an organization involves establishment of infrastructure required for triage practice including the support services and training to the triage nurses in the triage policies of the organization and the triage procedures to be adopted on day-to-day work in triage practice. Initiating treatment in triage room calls for broader understanding and knowledge about the triage practices for efficiency in performance. Search strategy There are several permutations and combinations involved in deciding the appropriate course of treatment based on the analysis of symptoms. Triage protocols makes it easier since the diagnostic procedures are seamlessly integrated into the treatments required and the timeline. Inclusion and exclusion criteria in diagnostic process with reference to a particular treatment proposed are standardized. Search strategy mainly depends upon the Key Words. The search is conducted on the components for its causal link with the formal problem. This is followed by clinical trials. The validation of the proposed solution, the evidence of its usefulness, criteria for inclusion and exclusion are the important aspects of the search strategy development. For example, Stacey et al (2012) have found in a study “Acceptability and usability testing of the symptom populated template with 12 practicing oncology nurses revealed: high readability (n=12), just the right amount of information (n=10), appropriate terms (n=10), fit with clinical work flow (n=8), and self-evident for how to complete (n=5).” The important principles governing the template features in respect of clinical nursing protocol are given in Annexure - I. Review of the evidence based literature on triage protocol This paper seeks to provide evidence based literature review on triage protocol covering various aspects related to it. The guidelines issued by the international bodies, articles published in the medical journals and books have been used for the purpose the study. In the Literature Review Grid given under Appendix –III, the study/research type, method used or information available and the results and comments related to the source materials are given for highlighting the reliability of the materials used and its relevance to the study. There are various types of triage scales used in different countries. “Of note is the Manchester Triage System (MTS) used in the United Kingdom, the Emergency Severity Index (ESI) used in America and the Canadian Emergency Department Triage and Acuity Scale (CTAS).” (Monash Institute of Health Services Research, 2001) Triage decisions in respect of nursing are related to emergency care and normal patient care. In a study to assess the workability of triage system in community palliative care, it was found “Triage is a team initiative which has directly benefited patients and carers…” (Coldicott et al, 2011) Initiating treatment in triage room is closely linked to telephone triage, as the details collected in this process forms the basis for treatment. Telephone Triage results into advices from nurses for symptomatic treatment using protocols and it involves patient education and crisis intervention as well. “Telephone triage is commonly defined as the safe, effective, and appropriate disposition of health-related problems via telephone by experienced, trained RNs using physician-approved guidelines or protocols (Wheeler, 2009). Telephone triage interactions may require assessment, patient education, and crisis intervention” (Wild Iris Medical Education, 2012). The telephone triage may have to be revisited based on the physical examination by the practitioner and the clinical tests, if necessary.   The employment as Triage Nurse requires certain qualification and experience. Stephanie (2010) states “The Triage Nurse shall meet specified qualifications for employment: (in addition to 1.1 above* include) ·         Minimum TWO years recent Emergency Nursing Practice ·         Demonstrated competence in Emergency Nursing Practice ·         Displayed acquisition of Advanced Assessment, Interviewing and Interpersonal skills ·         Trained in current CTAS (Canadian Triage and Aquity Scale).” *Qualification and experience required for employment as the Staff Emergency Nurse in Canada. A thorough knowledge about the warning signs noticed in the patients’ health and systems and methods relating to symptomatic treatment could be gained only over the period of experience. Knowledge in emergency nursing methods is essential for decision making at critical times. “Triage assessment of patients on arrival at emergency departments involves complex decision making, resulting in categories being assigned to prioritize patients' needs for attention” (Clioffi, 1998) for efficiency in treatment in triage room. The implementation of Triage system in an organization has almost become a norm for standard treatment in the hospitals. The clinical records are maintained mostly online in the modern hospitals. Telephone triage calls for proper recording system. Hamm (1997) states “Clinical data from the emergency room evaluation, including the history, results of the physical examination, results of cardiac-enzyme tests, and interpretation of the electrocardiograms, were recorded as part of a detailed protocol by the physicians in the emergency room.” Patient safety and timely and optimum utilization of the facilities available is very important for sustainable development of health management practices. Chang et al (2012) state “The introduction of a more accurate acuity and triage system for use in paediatric emergency care should provide greater patient safety and more timely utilisation of appropriate ED resources.” Triage Nurse plays an important role in evidence based practice in an organizational set-up. Roxanne (2008, p. 93) states “The ability of the triage nurse to order targeted tests and treatments prior to physician evaluation provides additional information to the physician during evaluation, improves overall efficiency of patient care, and could have contributed to the formulation of an “evidence based” medical diagnosis by the triage nurse.” Several diseases are inter-related. Triage protocol and evidence based practice requires comprehensive understanding for a meaningful analysis in such cases. Interactions with the clients is also very important for inference and providing necessary information to the patients enhances their participation in the disease recovery process and ensures quality care to the patients and their satisfaction. Therefore, triage protocol or evidence based practice is a continuous learning process which calls for empathy and tact on the part of the nursing professionals. Sammons (2012) states “RNs in the study had an accuracy rate of 54% in triage of patients with symptoms suggestive of AMI. The older RN was more accurate in triage level designation. Accuracy in triage level designations was significantly related to patient race/ethnicity. Logistic regression results suggested that accuracy of triage level designation was twice as likely (OR 2.07) to be accurate when the patient was non-Caucasian.” Though it is claimed that the triage protocols leads to reduction in time, an analysis of data related to rural hospitals by Zegre-Hemsey et al(2008) reveals “the majority of patients with ischemic symptoms did not receive an ECG within 10 minutes of hospital presentation as recommended in evidence-based guidelines. “ In fact the waiting time is more than one hour to see a physician in many cases. The data as per Appendix – II shows the details of patients waited for one hour or more to see a physician. [Centers for Disease Control and Prevention, (n.d.)]. Oreddson (2011) states “Overcrowding calls for re-engineering of triage models and new patient flow processes…Recent reports also show that more teenagers and young adults are seeking medical care in the emergency department. 1 This phenomenon is characterised by expectations of medical service on a 24/7 basis. Together, these changes contribute to overcrowded emergency departments that put patient safety at risk. 2 Can these changes be reversed or prevented?” The triage reduces the workload of the general practitioners considerably. But, the general public usually prefers visiting the hospitals for primary care on ‘same day appointments’ rather than care over telephone, though for out of hours service telephone triage is preferred. External agencies such as NHS Direct can provide triage services to general practitioners. Richards et al (2004) state “If NHS Direct were to increase the number of patients who receive nurse only care up to the levels achieved by the practice, costs would not be different from practice based triage, despite the longer time taken by nurse advisers to work through clinical algorithms. In contrast, nurse time in NHS Direct would need to be reduced by almost 40% before costs would become barely comparable.” However, seamless integration of external triage services to the internal procedures is very important for initiating treatment in the triage room. Strengths and weaknesses of evidence based literature review Each method of analysis or assessment has inherent advantages as well as disadvantages attributable to the method. Method of collection of evidences varies in each method. Collection of data from the secondary sources involves going through many sources available in various forms. These sources in turn adopt different methods of analysis or collection of evidences. For example, interviews and questionnaires are predominantly used for the purpose of data collection. These data are collected from the medical professionals and in some cases from the patients. The data collected through interviews and questionnaires from the medical professionals including nurses and clinical staff are very reliable. Interviews and questionnaires method of collection of data would be very useful in the case of specific risk factor subjected to analysis or a particular activity with regard to the practice. For example, in the case of allergic effects of a particular drug the data will be highly reliable. However, for a nationwide survey in the case of larger issues, this method is not suitable. The study papers or research reports based on interviews or surveys are considered after eliminating statistical and other errors by applying sophisticated tools of quantitative analysis. Therefore, the analysis based on the secondary sources covering such data will be more reliable. The strengths and weaknesses of the various methods used in the source materials reflect on the evidence based literature review. However, the differences are balanced in comparison and a reasonable view precipitates in the process. This could be considered as the major strength of the evidence based literature. The data are collected through various suitable methods for different purposes generally. However, their utility is not restricted for the specific purpose alone for which the data have been collected. For instance, census data could be used for variety of purposes by different users. Identifying the sources for relevant data for the purpose of study or research is very important. After collecting data from various sources, irrelevant, inconsistent or data with insignificant contribution to the present study and data which are out-dated need to be discarded. This could be considered as a major weakness of the literature review based secondary sources as it involves discretion and judgment on the part of the author which could be construed as bias. The use of secondary sources is cost effective. It is also considered as time saving in some cases where the required data is available readily in one source like census data. The inadequacies, if any in the secondary sources, could be bridged by primary data collection by restricting it to specific area or activity. The analyst in the process of secondary analysis gets wide exposure to the subject which will broaden his/her view. The analysis using secondary sources forms the basis for comparison. However, the accuracy level of the secondary data is subject to the accuracy of the primary data relied on for this purpose. Unless the availability of data is adequate and consistent with the research objective, collection of primary data should be called for. Methods and Methodological issues Methods and methodological issues relating to triage and treatment in triage room varies according to the triage system existing in an organization. According to Manchester Triage Group (2006, p. 20), by following the “systematic process, facilitated by the triage methodology, the patient assessment can be performed rapidly and confidently to reach an appropriate clinical priority in order to guide decision making” and in the case of emergency care the approach to the assessment takes into account the medical history of the patient presenting the complaint, interview with focussed questions, physical examination and assessment of physical parameters, pain assessment, priority plan of care, documentation and reassessment (p.19-20) The triage activities corresponding to the assessment components referred above need to be appropriate and relevant to the case in treatment in the triage room. The interview should be designed to elicit the detailed information from the patient which needs expertise, proficiency and competency and knowledge about the triage protocols on the part of the practicing nurse, as this will facilitate decision making process in the treatment in triage room. Training program should be designed in tune with the treatments offered and the speciality services provided, for initiating treatment in the triage room in a logical manner. Tele Triage Systems (n.d.) states, “Studies have shown that training methods limited to experience and observation are inadequate. Formal training would include different methodologies such as reading, lecture, discussion, workshops and role-play, and standardized examinations followed by close observation and monitoring by a preceptor.” Generally in an emergency care set-up, the goal is prioritizing and it is based on the emergency needs of the patients, the most vulnerable gets priority. Veenema Ed. (2007, p. 162) state “Triage methodologies are focussed on the proper sorting and distribution of patients, either in the prehospital (field or community) or hospital (emergency department) settings.” The different studies have highlighted the issues related to communication failures, failure of timely access to Advice Nurses, negligence in telephone triage, delays in returning calls and providing treatment and failure to comply with the triage protocols. These drawbacks will reflect on the treatment in triage room to a considerable extent. However, there are practical issues involved such as non-availability of description of the methods used to analyze the evidence. “Conclusions were based on prospective randomized clinical trials (RCTs) if available, to the exclusion of other data; if RCTs were not available, observational studies were admitted to consideration. If no such data were available for a given link in the problem formulation, expert opinion was used to estimate effect size.” (National Guidelines Clearinghouse, 2012) Rationale for change to Triage Protocol Evidence based practice could be beneficially carried out under triage protocol. Evidence based practice, “EBP is the integration of clinical expertise, patient values, and the best research evidence into the decision making process for patient care. Clinical expertise refers to the clinician's cumulated experience, education and clinical skills. The patient brings to the encounter his or her own personal and unique concerns, expectations, and values. The best evidence is usually found in clinically relevant research that has been conducted using sound methodology. (Sackett D, 2002)” Reduction in waiting time for health care services, such as request for X-Rays, Scanning or other clinical tests can be achieved in a triage protocol environment. Waiting times in hospitals, especially at the time of emergency care or delay in assessment and commencement of treatment are the causes for concern among the patients and their relatives. Worster et al (2007) states “It is impossible to determine which triage setting provides a more accurate triage score but paper case scenarios generally receive lower triage scores than live cases.” After the patients’ arrival, registration process and waiting for the preliminary check-up, diagnostic procedures before moving to the operation theatre or other places for treatment usually take longer times in the hospital setup. Subash et al (2004) state “Doctor-nurse triage teams are an effective way of shortening waiting times. Patients are treated and assessed by experienced medical and nursing staff, whatever the urgency of the condition. There was a significant increase in the number of patients seen and discharged within 20 minutes.” Triage protocol paves way for the systematic scheduling of the activities at all levels in the organization, as it basically moves forward the organization for efficient allocation of resources and time in providing care to the patients. Budgeting in the organization can be made with reasonable accuracy, which will reduce the cost at all levels. Triage protocol forms the basis for a pre-planned treatment procedure for the patients, which increases the level of customer satisfaction. Application of evidence based findings in an organisation for initiating treatment in triage room Problems faced by a practicing nurse in the assessment process are multifarious. Better management processes if they are properly applied through evidence based practice reduce the risk level in the organization and will be cost effective in the long run. In a study by Wachter et al (1999) it has been concluded “in the case of triage, with current trends toward medical decision making by less skilled providers with diminishing patient contact. Although triage protocols may be useful to guide clinical thinking, their consistency must be validated before they may be safely disseminated for general use.” Application of proper tool in practice depends upon several factors relating to the patient’s care, the patients level of understanding and ability to communicate effectively. Therefore, application of triage protocols cannot be viewed in isolation but all the relevant factors need to be taken into consideration for providing effective medical care. For example The Emergency Severity Index (ESI) is an important tool that could be used in emergency department (ED) triage. “The ESI triage algorithm yields rapid, reproducible, and clinically relevant stratification of patients into five groups, from level 1 (most urgent) to level 5 (least urgent). The ESI provides a method for categorizing ED patients by both acuity and resource needs” (Agency for Healthcare Research and Quality, 2012, p. v). Applying triage protocol is not limited to big hospitals. It could be successfully applied to several other areas which include palliative care, community care, family practice management and hospice care. “As a matter of good risk management, appointment systems would benefit from some method of identifying patients who should be seen urgently or referred to the Emergency Department” (Medical Protection Society, 2012). Following triage policy and triage guidelines necessitates training of the personnel, simulation rehearsal and use of tools such as charts and algorithms. Implementation of triage protocol involves creating the infrastructural facilities which includes, establishment of triage policy and procedure, system or software for triage protocols including telephone triage, training to the triage nurse in triage practices and procedures, making arrangements for out of hours service, availability of resources to meet the patients’ requirements of intervention and ensuring compatibility of the support services. Training to the nurse is an import part of implementation. “The Emergency Severity Index (ESI) is a simple to use, five-level triage algorithm that categorizes emergency department patients by evaluating both patient acuity and resource needs. The ESI is intended for use by nurses with triage experience or those who have attended a separate, comprehensive triage educational program.” (Emergency Severity Index (ESI) Implementation Handbook, 2012 Edition) Initiating treatment in triage room Initiating treatment in triage room involves primarily Identification of the patients who need immediate treatment, Prioritizing the patients’ care, Verifying the predetermined care area for facilities and Initiate clinical and therapeutic activities as required. Triage nurse needs to act with discretion in taking decisions based on the primary complaint recorded and the observations made to provide care on priority basis by moving forward the patient for treatment by skipping the normal procedure of further assessment formalities and other procedural hurdles such as registration. “It may not simply be assumed that the use of protocols will standardize care.” (Wachter et al, 1999) Application of triage criteria under certain circumstances such as age factor where mobility of the patient is restricted or just born child where symptoms are difficult to assess and physically challenged or mentally retarded patients where communication acts as a barrier, may vary and the triage nurse needs to be alert in avoiding the risks associated with delay in treatment in such cases while prioritizing. For example, Categorization of the patients in acuity scale of 5 levels as below can be adopted for prioritizing and treatment. “The Triage personnel must use their experience and instincts to “uptriage” priority, even the patient does not fit exactly with the facts or definitions on the triage scale” (CJEM JCMU, 2010). Level  I -- Resuscitation Level II -- Emergent Level III -- Urgent Level IV -- Less Urgent Level V -- Non Urgent” Triage is useful for recognition of the seriousness in the patient’s health condition in the earlier stages. Therefore initiating treatment in triage should serve this purpose eminently for its success. Findings Treatment in triage room needs analytical ability, judgment and swift decision making. It starts from observing the medical history of a person. Not only the habits of a person, body mass, previous diseases, blood pressure and diabetes but also, the social and family background of the patients may be the important determinants of or causes for the present illness or diseases. Apart from the history of the patients which is available in records the psychological approach of the nurse to the patients is very important for a successful triage practice. Triage protocol for nurses is closely linked to efficiency in the organization and the improvements in patient care. New triage protocols are being continuously developed simultaneously along with the new methods for treatment. Therefore, the nurses need to upgrade their skills on a continuous basis. It is important that the organizational planning for training on the new methods and procedures is necessary. Along with prioritizing in treatment, reduction in time required for waiting by the patients in the hospitals for consultation, clinical tests, X-rays, scanning and treatment needs planning at corporate level. Reduction of crowd in various departments will improve mobility in the workplace and consequently efficiency. The time saved could be gainfully used for treating more patients and this will decrease the cost. Strategic management decisions to improve the telephone triage in the organization could reduce the patients’ direct visits for consultations to the hospital. This will also reduce the burden of the on-site medical professionals including nurses greatly. Also, through the telephone triage, the appointments in connection with the direct visits of the patients to the hospitals for consultations with the specialists or other purposes could be regulated. Search strategy in respect of triage protocol mainly depends upon the Key Words. The nurses need to be trained in understanding these words in the right context for enabling them to interact with the patients effectively. Therefore, training in conversation by external expert consultants in this filed would sharpen the skills of the nurses. It is very important that the newly appointed nurses are properly guided through a well designed orientation program. They should also be continuously monitored in the initial stages to confirm their suitability to the job, especially in respect of telephone triage. Patients’ safety and optimum utilization of the resources need to be ensured in triage practices. The interaction of the nurses with the other support services available in the organization is very important for this purpose. Evidence based practice is greatly supported by Triage protocol, by providing evidences collected for assessment which will improve the quality of the care given. Understanding and skills on the part of triage nurses are very important as they have to exhibit greater degree of discretion and quick judgement. High level of empathy is a prerequisite to understand the patients’ point of view in the process for communicating with them effectively and for upward communication with the medical professionals for effective and timely treatment. It could be observed that triage protocols undergo changes continuously based on the research and development in the profession, technological innovations in the field, new medicines and advanced methods of treatment. Therefore, training in triage protocol for nurses is required to be organized by the hospitals in tune with the environmental changes. If the inflow of the patients is very high say due to epidemic or accidents, additional resources are required to be called for. In the case of disaster, the existing facilities cannot cope up with the demand for care based on the needs of the patients with the available resources. Here the attention should be focussed on people who have chances of survival, before backup facilities arrive which might take some time. Corporate social responsibility (CSR) calls for the hospitals to rise up to the expectations of the society on these occasions and the organization needs to have contingent plans ready for this purpose at all times to face such uncertainties. Methodology The methodology used for the study is analysis of secondary sources. There are several universities, healthcare departments of the various governments and medical journals involved in collection of data, dissemination of information, making surveys related medical and nursing profession and publishing research reports. The data published by the government departments involves collection of data on a larger scale. Organizing surveys by the other agencies have been made easier through internet. Therefore, availability of suitable and reliable data is not a prohibiting factor for making further research by using the available data for a particular study. The rich information provided by these sources are analyzed with particular reference to triage protocol for nurses to cover the important aspects related such as telephone triage, waiting time of the patients in the hospitals, relationship between evidence based practice and triage protocols, determinants of efficiency in implementation of triage protocols for nurses, accuracy of triage level designation and other methods and methodological issues. Since the data collected by various institutions or organizations have been subjected to analysis for different purposes the data used could be considered as reliable. The secondary sources used for the purpose of study include books published, journal articles, websites of the government departments and other agencies and the study papers submitted in the universities. Conclusion Triage protocol for nurses in an organization enhances the efficiency level and improves patient health care. The implementation of the triage protocols increases the confidence level of the nurses while initiating treatment in triage room . The reduction of time involved in treatment improves the level of patient care and increases the satisfaction level of the patients and enhances the level of treatments in triage room as telephone triage also involves patient education and crisis intervention. Patients’ safety and optimum utilization of the resources is ensured in triage protocol for nurses. Though there are contrary claims in respect of time reduction in treatment of the patients due to triage services, triage protocol services aids evidence based practice and efficiency at all levels. Search strategy in respect of triage protocol mainly depends upon the Key Words. Triage models undergo changes over a period of time in tune with the increased demand for medical services and cost reduction as well as the research in the field and technological developments taking place in the hospital environment. Nurses play an important role in treatment of the patients and the triage system in an organization. The implementation triage protocol system in an organization calls for establishment of the infrastructure needed and triage training to the personnel. Constant training programs should be designed by the organization in tune with the developments taking place in the medical profession and methods of treatment given to the patients through proper planning on a regular basis. These training programs will enable the nurses to upgrade their skills to rise up to the standards for providing care to patients efficiently. References Centers for Disease Control and Prevention, (n.d.) Emergency Department (ED) Visits Triaged Immediate/Emergent at which Patient Waited to See a Physician for One Hour or More [by Patient Race and Selected Characteristics], United States, 2007-2008. [online] Available at: [Accessed 17 December 2012]. Chang, Y.C., Ng, C.J., Wu, C.T., Chen, L.C., Chen. J.C. and Hsu, K.H., 2012. Effectiveness of a five-level Paediatric Triage System: an analysis of resource utilisation in the emergency department in Taiwan. Department of Emergency Medicine, Chang Gung Memorial Hospital Linkou and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan. Emerg Med J. 2012 Sep 14. [Epub ahead of print]. CJEM (JCMU), 2010, Triage and Acuity Scale -- Category Definitions - Canadian Paediatric Triage and Acuity Scale: Implementation Guidelines for Emergency Departments. http://www.cjem-online.ca/v3/n4/PaedCTAS/p4 Clioffi, J., 1998. Decision making by emergency nurses in triage assessments. Accident and Emergency Nursing. 11/1998, 6(4):184-91. Coldicott, R., Campbell, M. and Rowlands, S., 2011. Is a triage system of referrals to a community palliative care nurse specialist team workable? BMJ Supportive & Palliative Care Volume 1, Issue 2. pp. 206–273. Hamm, C.W., Goldmann, B.U., Heeschen, C. Kreymann, G., Berger, J. and Meinertz, T., 1997. Emergency Room Triage of Patients with Acute Chest Pain by Means of Rapid Testing for Cardiac Troponin T or Troponin I. The New England Journal of Medicine. N Engl J Med 1997; 337:1648-1653. Healthcare Research and Quality, 2012. Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care – Version 4, Implementation Handbook 2012 Edition. [online] Available at: [Accessed 17 December 2012]. Manchester Triage Group, 2006. Emergency Triage, Second Edition, Blackwell Publishing. Monash Institute of Health Services Research. 2001. Consistency of Triage in Victoria’s Emergency Departments. [online] Available at: [Accessed 17 December 2012]. Medical Protection Society, 2012. Triage protocol for non-clinical staff. [online] Available at: [Accessed 17 December 2012]. National Guidelines Clearinghouse, 2012. Guideline Summary. Agency for Healthcare Research and Quality, U.S. Department of Health and Human Sciences. [0nline] Available at: [Accessed 16 December 2012]. Oreddson, S., 2011. Triage and patient safety in emergency departments. Editorial. BMJ 2011;343:d6652 Richards, D.A., Godfrey, L., Tawfic, J., Ryan, M., Meakings, J., Dutton, E. and Miles, J., 2002. NHS Direct versus general practice based triage for same day appointments in primary care: cluster randomised controlled trial. BMJ 2004;329:774 Roxanne, O.G., 2008. Level 2 and Level 3 Patients in a 5-level Triage System: Factors Related to Acuity Assignment and Trajectory of the Emergency Department Experience. ProQuest LLC. Ann Arbor, MI. Sammons, S.S., 2012. Accuracy of Emergency Department Nurse Triage Level Designation and Delay in Care of Patients with Symptoms Suggestive of Acute Myocardial Infarction. Georgia State University. [online] Available at: [Accessed 17 December 2012]. Stacey, D., Macartney., G., Carley, M. and Harrison, M.B., 2012. Development and evaluation of evidence-informed clinical nursing protocols for remote assessment, triage and support of cancer treatment-induced symptoms. Pan-Canadian Oncology Symptom Triage and Remote Support Group. [online] Available at: [Accessed 17 December 2012]. Stephanie, C., 2010. Professional Practice: Standards of Emergency Nursing Practice. National Emergency Nurses’ Affiliation (NENA). [online] Available at: [Accessed 17 December 2012]. Subash, F., Dunn, F., McNicholl, B. and Marlow, J., 2004. Team triage improves emergency department efficiency. Emerg Med J. 2004,21:542–544. Tele Triage Systems (n.d.) Risk Management in Tele Practice: New Trends, Advances and Risks. [online] Available at: [Accessed 17 December 2012]. UNC-Chapel Hill, 2010. Introduction to Evidence-Based Practice, 5th Edition. Duke University Medical Center Library and Health Sciences Library. [online] Available at: [Accessed 17 December 2012]. Veenema, T.G. Ed., 2007. Disaster Nursing and Emergency Preparedness for Chemical, Biological, and Radiological Terrorism and Other Hazards. Second Edition. Springer Publishing Company. Wachter, D.A., Brillman, J.C., Lewis, J. and Sapien, R.E., 1999.  Pediatric telephone triage protocols: Standardized decision-making or false sense of security? Annals of Emergency Medicine, 33(4), 368–94. Wild Iris Medical Education, Inc. (n.d.) Telephone Triage Nursing: Roles, Tools and Rules. [online] Available at: [Accessed 17 December 2012]. Worster , A., Sardo, A., Eva, K., Fernandes, C.M. and Suneel Upadhye, S., 2007. Triage Tool Inter-rater Reliability: A Comparison of Live Versus Paper Case Scenarios. Journal of Emergency Nursing. Volume 33/ Issue 4. 319-323. Zegre-Hemsey, J., Sommargren, C.E. and Barbara, J.D., 2008. Initial ECG Acquisition Within 10 Minutes of Arrival at the Emergency Department in Persons With Chest Pain: Time and Gender Differences, Journal of Emergency Nursing, Volume 37. Issue 1. 109-112. January 2011. Appendix - I Principles for clinical nursing protocol template features 1. Evidence-based using evidence from appraised clinical practice guidelines 2. Template should meet the criteria for being a guideline (AGREE II-rigour) – systematic methods used to search for evidence – clear criteria for selecting the evidence (e.g. quality appraised guidelines) – methods for formulating the recommendations are described – health-related benefits, side effects and risks have been considered – explicit link between recommendations and the supporting evidence – reviewed by experts prior to publication 3. Usable in practice beyond resource on the shelf 4. Be able to be integrated into the electronic health record and clinical practice (e.g., uses Edmonton Symptom Assessment System question that is frequently used to screen for symptoms) 5. Plain language to enhance patients’ health literacy 6. If assessment criteria and triage for severity is vague or absent from guidelines, use the National Cancer Institute Common Terminology Criteria for Adverse Events. 7. Ensure consistency across guidelines (e.g. if blood in vomit listed as severe in the diarrhea guidelines, then it should also be severe on the bleeding guideline) Source: Table 5. Stacey et al (2012) Appendix – II Emergency Department (ED) Visits Triaged Immediate/Emergent at which Patient Waited to See a Physician for One Hour or More [by Patient Race and Selected Characteristics], United States, 2007-2008 Patient Characteristics Unweighted Number of Standard Percent Standard Visits Error waited one Error of Sample Size (in ‘000) (in ‘000) Hour Percent All Races 9,301 31,808 2,080 15.4 1.2 ....0-17 years 1,414 4,972 452 13.3 1.6 ....18-44 years 3,361 10,858 908 17.6 1.7 ....45-64 years 2,297 7,970 511 16.1 1.7 ....65 years and over 2,229 8,008 509 13.1 1.1 ....Female 4,857 16,329 1,103 15.9 1.3 ....Male 4,444 15,479 1,008 14.9 1.2 ....Private age Read More