Triage nurses' clinical decision making : an observational study of urgency assessment

Gerdtz, Marie F. and Bucknall, Tracey 2001, Triage nurses' clinical decision making : an observational study of urgency assessment, Journal of advanced nursing, vol. 35, no. 4, pp. 550-561, doi: 10.1046/j.1365-2648.2001.01871.x.

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Title Triage nurses' clinical decision making : an observational study of urgency assessment
Author(s) Gerdtz, Marie F.
Bucknall, TraceyORCID iD for Bucknall, Tracey
Journal name Journal of advanced nursing
Volume number 35
Issue number 4
Start page 550
End page 561
Publisher Blackwell Publishing Ltd.
Place of publication United Kingdom
Publication date 2001-08
ISSN 0309-2402
Keyword(s) decision making
patient assessment
time and motion
emergency nursing
accident and emergency
Summary Background. 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.

Aims. 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.

Design. 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.

Results. 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.

Conclusion. 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 oftime-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.

Notes Published Online: 20 Dec 2001
Language eng
DOI 10.1046/j.1365-2648.2001.01871.x
Field of Research 111003 Clinical Nursing: Secondary (Acute Care)
HERDC Research category C1.1 Refereed article in a scholarly journal
Copyright notice ©2008, Blackwell Publishing Ltd
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