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Australasian Emergency Nursing Journal (2014) 17, 5158

Available online at www.sciencedirect.com

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journal homepage: www.elsevier.com/locate/aenj

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 Childrens Hospital, Herston Road, Herston, Brisbane,
Queensland 4029, Australia
b
School of Population Health, The University of Queensland, Herston Road, Herston, Brisbane, Queensland
4006, Australia
c
Nursing Research Unit, Royal Childrens Hospital, Herston Road, Herston, Brisbane, Queensland 4029,
Australia
d
Childrens Nutrition Research Centre, The University of Queensland, Herston Road, Herston, Brisbane,
Queensland 4006, Australia
e
Queensland Childrens 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

KEYWORDS
Emergency;
Triage;
ETEK;
Hospital;
Paediatric;
Audit

Summary
Objectives: The Emergency Triage Education Kit (ETEK) was published in 2007. To date, the
impact of ETEK has not been measured. The purpose of this study was to measure the effectiveness of ETEK on paediatric triage.
Method: A retrospective chart audit was undertaken in a tertiary paediatric hospital. Its aim
was to review the completeness of documentation recorded at the point of triage after a standardised documentation framework was introduced and to measure inter-rater agreement.
Primary assessment and physiological discriminators documented at the point of triage were
compared 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 used
to ascertain whether the original ATS score could be substantiated by the PPDT. Improvement in
documentation of the primary assessment and inter-rater agreement was measured over time.

Corresponding author at: Department of Emergency Medicine, Royal Childrens 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.2014.02.002
1574-6267/ 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 documentation that did not support parallel decision-making decreased signicantly according to the year of
presentation (2007; 112 (56%), 2008; 106 (53%), 2010; 13 (7%), P < 0.001). When parallel decisionmaking was facilitated by an improvement in triage documentation, there was improvement in
matched triage scores (2007; 54%, 2008; 69%, 2010; 72%, P = 0.01).
Conclusion: The introduction of ETEK has had a signicant impact in this ED, particularly when
combined with education sessions. The use of the PPDT as a framework to guide documentation
and triage language facilitated parallel decision-making and auditing, and led to an improvement
in inter-rater agreement when applied to children.
2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights
reserved.

What is already known?


The ATS is used to assess urgency and prioritise care,
however when applied to children, its reliability has
been shown to be only fair. The ETEK provides a standardised education plan for triage nurses in an aim
to improve consistency in the application of the ATS.
Specically, ETEK contains paediatric tools to assist the
triage nurses decision-making when applying the ATS
to children.

What this paper adds?


To date, the effectiveness of ETEK to meet its aim has
not been measured. This paper describes the impact of
the ETEK on paediatric nursing triage.

Introduction
The Australasian Triage Scale (ATS) is used to assess urgency
and prioritise access to time-critical intervention within
Australian Emergency Departments (ED).15 The accuracy
with which a triage scale is applied is fundamentally important to positive patient outcomes.68 The ATS aims to
ensure that a patient will receive the same triage category in any ED to which they present.9,10 However several
studies have demonstrated that the ATS has only poor to
fair inter-rater reliability when applied to children and
adolescents.1113 This may be due to the complexity of
paediatric assessment, in particular the developmental considerations that mean there is often a reliance on the
carer to provide the history.14 Alternatively, when children
present to a mixed ED, the triage nurse may have variable knowledge, experience and self-condence in assessing
children.12,15 The lack of consistency in applying triage
scores to children may also be attributed to the lack
of a paediatric framework on which to base decisionmaking.8
Endorsed by the Australian Department of Health and
Ageing and the College of Emergency Nursing Australasia,
the Emergency Triage Education Kit (ETEK) was introduced
into Australian EDs in 2007.5,14 Within ETEK, the paediatric physiological discriminator table (PPDT) provides

evidence-based markers for serious illness and injury. These


reect the triage nurses primary nursing assessment (airway, breathing, circulation and disability: neurological,
neurovascular and pain) and arranges them into ATS triage
categories.
The PPDT was primarily designed to support the decisionmaking of nurses.14 It also provides the potential to
positively inuence documentation standards, audit triage
episodes and improve the consistency by which the ATS is
applied to children. Australia does not have a robust triage
auditing system that is utilised nationally. Instead the accuracy of triage scores has been based on expert opinion or
the use of paper-based scenarios which lack rigour and have
limited generalisability.2
The aim of this study was to assess the effectiveness of
ETEK to meet its aims by:
1. examining the effectiveness of the PPDT to standardise
and improve documentation at the point of triage
2. investigating whether standardised documentation
assisted in auditing triage practice and
3. analysing whether the ATS was more consistently applied
after introduction of ETEK.

Methods
Method and setting
The study hospital is a paediatric tertiary referral centre, caring for children and young people from birth to 15
years. The ED provides initial assessment and management
of approximately 30 000 acute presentations annually. All
children entering this ED are triaged by an experienced and
specically trained emergency nurse.
A single retrospective, randomised chart audit was
undertaken to review documentation recorded at the point
of triage. Charts were audited from July 2007, before ETEK
was published; July 2008, after the publication of ETEK but
before ETEK-based education sessions were introduced at
the study hospital; and July 2010, after the ETEK-based
education sessions had been conducted. This study received
ethical clearance from the appropriate Hospital and University Ethics Committees.
The researchers extracted triage records from Emergency Department Information System (EDIS), the electronic

ETEK and paediatric triage


documentation system used in the study hospitals ED.
Six hundred charts were audited in total; 200 from each
time period. Charts were selected from the months under
review by a research assistant who de-identied the records.
To ensure representation of all categories, the selection system was designed so approximately 15% of charts
selected were for patients receiving an ATS 1 (immediately life-threatening cases), 15% were ATS 2, 25% were
ATS 3, 30% were ATS 4 and 15% were ATS 5 (less urgent
cases).

53
decision making could be employed of 20%, with 80% power
and alpha = 0.01. Results are described using descriptive
statistics, and data was compared across years using the
chi-square test for trend. Data was analysed using Stata
statistical software version 11.1 (Stata Corp., College
Station, TX, USA).

Results
Main results

Audit tool/data sources


Using the PPDT as the gold standard, an audit tool was developed and piloted by four experienced triage nurses. The
tool was used to scrutinise triage documentation with the
researchers comparing completeness of the primary assessment data and the use of the physiological discriminators, to
the PPDT. If primary assessment documentation was incomplete, the researcher did not assume that the assessment
was completed and therefore could not match a triage category. This may have occurred if an integral part of the
assessment was omitted, such as a pain assessment for a
child whose primary presentation was pain, or neurovascular
observations for a child who presented with an injured limb.
The original and audited ATS categories were compared and
a determination was made on whether the original triage
score could be substantiated or whether under or over triage
had occurred. Finally, an analysis for improvement over time
was conducted.

Intervention
Education sessions introducing the ETEK and the PPDT were
conducted for current triage nurses between March and May
2010. During each session, participants were familiarised
with the PPDTs format. In particular, discussion centred on
the use of the tables physiological discriminators to facilitate triage decision-making and standardise documentation.
Using the sessions as the impetus for practice change, minimum standards for documentation were modied so the
primary assessment was documented in its entirety. That
is, for all presentations it was expected that documentation addressing; airway, breathing and circulation were
included. In addition, participants were expected to address
disability, however, a neurovascular assessment was only
required when the child presented with a limb injury. Triage
nurses were directed to use the terminology of the PPDT to
describe alterations from normal physiology with intact
being an acceptable term used for a child whose physiological parameters were within normal parameters for their
age.14 The triage nurses were instructed to document the
presenting problem succinctly along with any known risk
factors.

Statistical analysis
It was calculated that 200 charts were required to be
selected from each year to detect a between-year difference in the percentage of records in which parallel

The researchers extracted 200 triage records from each


of the three years under investigation. In 2007, the triage
records of 34 triage nurses were audited (median records
per nurse = 4, range 127). In 2008, the triage records of
35 nurses were audited (median records per nurse = 4, range
118) and in 2010, the triage records of 36 triage nurses
were audited (median records per nurse = 4, range 112). In
total, 61 different triage nurses were audited over a threeyear period (n = 78% of triage trained nurses and 64% of total
ED nurses employed during the study months). There were
71 different primary complaints, the most common of which
were fever (14%), difculty breathing (9%) and vomiting
(8%).
The number of triage records in which parallel decisionmaking could not be utilised by the researchers decreased
signicantly according to the year of presentation. In 2007,
112 (56%) triage records did not have enough assessment data documented for the researcher to allocate
a triage score. In 2008, the number decreased slightly
to 106 (53%). In 2010 after the education sessions and
change of minimum documentation standards, the number of triage records in which parallel decision-making
could not be applied was reduced signicantly to only 13
(7%); (P < 0.001, chi-squared test for trend). This pattern
was similar when presentations were separated into injury
(63%, 60%, 15% from 2007 to 2010) and illness (53%, 54%,
4%).
When the parallel decision-making process could be facilitated, 54% of the primary triage scores matched in 2007,
with 21% over triaged and 24% under triaged. In 2008 there
was agreement on 69% of occasions, with over triaging occurring on 15%, and under triaging on 16%, of occasions. In
2010 there was agreement on 72% of occasions with over
triaging occurring on 20%, and under triaging on 8%, of occasions. The percentage of scores correctly matched increased
signicantly over time (P = 0.01, chi-square test for trend).
Between 2007 and 2010 children were signicantly less
likely to be under-triaged (risk ratio = 0.34; 95% condence
interval = 0.180.62), while the proportion of children overtriaged remained similar (risk ratio = 0.97; 95% condence
interval = 0.581.60).
Table 1 demonstrates how, when data were analysed by
the characteristics of the primary survey, documentation
improved across time. Improvement was most signicant
for the airway assessment; from 12% in 2007 to 92% in
2010 (P < 0.001, chi-square test for trend). Documentation
related to an assessment of breathing also signicantly
improved from 24% in 2007 to 93% in 2010 (P < 0.001, chisquare test for trend). The circulation and neurological
assessments 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. Differences
between groups assessed using the Chi-square test for trend.

Airway
Breathing
Circulation
Neurological
Neurovasculara
Pain

2007
n (%)

2008
n (%)

2010
n (%)

P-value

25 (12.5)
49 (24.5)
162 (81.0)
164 (82.0)
3 (9.6)
33 (16.5)

26 (13.0)
44 (22.0)
182 (91.0)
180 (90.0)
16 (61.5)
22 (11.0)

185 (92.5)
187 (93.5)
193 (96.5)
186 (93.0)
15 (44.1)
44 (22.0)

P < 0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.005
P < 0.14

a Neurovascular outcomes considered only when neurovascular compromise was considered a potential at initial triage (n = 31 in 2007,
n = 26 in 2008, n = 34 in 2010).

change of practice so relatively modest, yet still statistically signicant improvements were seen in these areas
(Table 1).
Primary triage category allocation, or the category allocated by the triage nurse, is displayed in Table 2. As shown,
the distribution of categories one to ve was similar between
2007 and 2008. However, in 2010 there was a signicantly
higher percentage of category 1 and 2 allocations (P < 0.001,
chi-square test for trend). The category most likely to
concord between the primary triage score and the PPDT
guidelines was category ve with 100% concordance, this
means that all patients categorised as ATS 5 at presentation, who could be allocated according to the PPDT, were
correctly categorised. In categories 1, 2, and 3 concordance
between the primary allocation and the PPDT was 68%, 77%,

Table 2

Allocation of triage categories by year.

2007
PPDT

Primary triage category

allocation

ATS 1

ATS 2

ATS 3

ATS 4

ATS 5

Total

14

25

58

12

112

11

21

12

25

10

12

11

12

25

31

47

92

24

200

No
category
ATS 1

ATS 2

ATS 3

ATS 4

ATS 5

Total

1 category over-

1 category under-

triaged

triaged

>1 category over-

>1 category under-

triaged

triaged

Correct triage

and 64% agreement respectively. Category 4 was relatively


poorly matched at only 48% agreement.

Discussion
The introduction of ETEK into this ED improved triage performance in this tertiary paediatric hospital. Most improvement
occurred after nurses had received ETEK-based education
sessions. The PPDT was included in ETEK so that novice
triage nurses were able to reect on their primary triage
decisions6 however; this study has shown that the PPDT has
a much broader use. In this study it was shown to be effective as a framework to guide triage documentation and this

ETEK and paediatric triage

55

Table 2 (Continued )
2008
Primary triage category
ATS 1

ATS 2

ATS 3

ATS 4

ATS 5

Total

13

28

50

15

106

17

13

21

15

19

25

34

24

53

80

40

200

No
category

ATS 1

ATS 2

ATS 3

ATS 4

ATS 5

Total

Correct triage

category

over-

triaged
>1

category under-

triaged

category

over-

triaged

>1 category undertriaged

2010
PPDT

Primary triage category

allocation

ATS 1

ATS 2

ATS 3

ATS 4

ATS 5

Total

13

11

12

37

52

44

57

28

39

11

14

27

20

50

63

52

15

200

No
category

ATS 1

ATS 2

ATS 3

ATS 4

ATS 5

Total

1 category over-

1 category under-

triaged

triaged

>1 category over-

>1 category under-

triaged

triaged

Correct triage

56
facilitated parallel decision-making for the purpose of audit
and quality management.

The physiological assessment


Physiological data such as that contained within the PPDT
underpin the triage nurses primary assessment and has been
found to provide a high degree of objectivity.16 Physiological
discriminators have been used as valuable indicators of clinical urgency at triage.6,17,18 Prior to the publication of ETEK,
triage decisions for children were inconsistent1113 In an
attempt to introduce greater consistency, the PPDT with its
more prescriptive physiological data, was included. The format of the PPDT facilitates decision-making through graded
physiological discriminators ranging from no deviation from
normal paediatric parameters (ATS 5) to discriminators indicating the critically ill or injured child (ATS 1). This study
has shown that the PPDT and the adoption of its terminology have coincided with a more consistent application of the
ATS.

Triage categories
A signicant increase in ATS 1 and 2 was identied in 2010.
Analysis of data obtained from EDIS conrms the upward
trend in these two categories.19 Key statistics demonstrate
that for the total number of patients presenting to the ED in
July, the percentage of children receiving an ATS 2 rose from
6.8% (n = 165) in 2008 to 13.7% (n = 314) in 2010.19 Similarly,
for ATS 1 patients, the percentage of presentations rose from
0.2% (n = 4) in 2008 to 0.8% (n = 18) in 2010.19 While the cause
is likely to be multifactorial; it is possible that some ATS 1
and 2 patients were previously being under triaged.
Over triage is dened as the allocation of an ATS category that is higher than the true measure of urgency.14 In
this study, over triage represented any presentation that was
rated as more urgent than the PPDT indicated. In 2010, over
triage was most common for category ve patients with 45%
(n = 12) allocated a higher category. This number takes into
account the potential for the ATS category to be increased
when a co-morbidity or risk factor is present but in this study,
neither factor was present in this cohort. While over triage
decreases the waiting time of the patient, it may inappropriately direct the ED resources and adversely affect the
waiting time of other patients.10 It is for this reason that
steps should be taken to explore this nding in more detail.
Conversely, under triage is the term used when a triage
allocation is lower than the true measure of urgency.14 Under
triage can have signicant consequences when taking into
account the fact that children are waiting for treatment
longer than their true urgency indicates. This can lead to
poor patient outcomes and potentially adverse events.10 The
strategy used to change practice showed the risk of under
triage decreased signicantly, while the proportion of children over-triaged remained similar.

Documentation
Nursing documentation must reect the physiological assessment that has been completed. The quality of triage

L. Malyon et al.
documentation may inuence practice and patient outcomes so it is important that it accurately reects the
assigned triage category.3,20,21 Further, it can be used as evidence in a court of law for either clinical or professional
accountability.
Initially, documentation anomalies in this study included
incomplete documentation of signicant and relevant primary assessment data and phrasing such as no work of
breathing when what was meant was no increased work
of breathing. In addition, non-standardised abbreviations
or the inclusion of irrelevant information also impeded parallel decision-making. These ndings are consistent with
those of a cross-sectional audit of general nursing documentation undertaken in 2011.20 The study conducted by Wang
et al., 2011 identied that documentation can be improved
when there is education and organisational support for the
introduction of standardised language; ndings that are supported in this study.
Documentation of the primary assessment was shown
to improve after the PPDT was introduced. This nding is
important for a number of reasons. Comprehensive documentation of the initial assessment using a standardised
format and physiological descriptors facilitates transparent
decision-making. This is helpful for the purpose of audit and
quality improvement. For the triage nurse, the identication of strategies to improve performance can be linked
to reective practice and education.8 For children, it is
important because it means that the ATS will be more consistently applied and more accurately reect their clinical
urgency.

Audit
The accuracy of and consistency in which a triage score
is allocated largely underpins the quality management
process.8 Auditing clinical decision-making is the ideal measure of accuracy and consistency and is best achieved if
parallel decision-making occurs.8 In this study, the use of
the PPDT and ATS simultaneously was found to contribute
to the consistency of triage nurses decisions. Together with
the change in documentation standards to reect the full
primary assessment and terminology of the PPDT, the ability of the researchers to use parallel decision-making as a
tool to scrutinise concordance at the point of triage greatly
improved.
The most signicant improvement was evident in the discriminators for airway and breathing. Prior to this study,
triage nurses in this ED documented circulation and neurological assessments in some form and therefore there
was only a moderate improvement over time. For these
characteristics, the greatest change was observed in the
improvement in the use of standardised physiological discriminators.
Pain is a common reason for accessing emergency care
and the amount of pain experienced by a patient directly
inuences urgency and resource allocation.8 Despite this, it
was the discriminator least often reported. Auditing of the
Manchester Triage Scale in the United Kingdom has shown
similar results with the most common documentation omission being the failure of the triage nurse to record a pain
score.8 Studies conducted by Considine et al., 2006 and

ETEK and paediatric triage


Wang et al., 2011, concur. These studies described ongoing
low levels of reporting pain, even after an intervention such
as education.20,22 The assessment of pain ensures appropriate pain relief is provided in reasonable time and while
some improvement was seen in this study, further work is
required.14

57
Queenslands Human Research Ethics Committee. Approval
HREC/09/QRCH/32.

Provenance and conict of interest


There is no conict of interest. This paper was not commissioned.

Limitations
This research was limited to a single site, tertiary referral
hospital. However, the nature of the hospital allowed for
specialist paediatric nurses to test the tool. Further study is
required to explore whether these results can be generalised
to other paediatric and mixed EDs.

Conclusion
This study has demonstrated that ETEK has had a signicant
impact in this ED. Further, the introduction of the PPDT has
had a number of positive outcomes. Triage nurses now document the complete primary assessment; Airway, Breathing,
Circulation and Disability which is a true reection of the
assessment undertaken at the point of triage. This and the
adoption of similar terminology as that used in the PPDT
have provided a framework for triage nurses to link physiological descriptors for illness and injury to ATS categories.
These steps facilitated parallel decision-making for the purpose of auditing. Auditing led to reective practice, a more
consistent use of the ATS and improved inter-rater agreement. Most importantly, the ndings of this study have had
a direct benet for the child. That is, improved performance
ensures that children receive an ATS allocation commensurate with their level of clinical urgency.

Funding source
This paper is part of a larger study that was funded by the
Royal Childrens Hospital Foundation Research Skills Development 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 statistical expertise. L.M., A.W. and R.W. were responsible for
drafting the manuscript and L.M., A.W. and R.W. made critical revisions for important intellectual content. R.W. and
A.W. supervised the study.

Ethical approval
This paper reports the ndings of a research study that
adhered to the National Statement on the Conduct of
Human Research by the Australian National Health and
Medical Research Council, and has been approved by the
Royal Childrens Hospital, Brisbane and the University of

Acknowledgements
The authors would like to acknowledge Dr. Samantha Keogh,
Senior Research Fellow, Grifth University for her contribution to the studys original conception and design.
The authors would also like to thank the following members of the expert panel who piloted the audit tool: Judy
Harris, Nurse Unit Manager, Redcliffe Hospital (ED), Therese
Oates, Clinical Nurse Consultant, Royal Childrens Hospital
(ED) and Leanne Philips, Clinical Nurse, Royal Childrens Hospital (ED).

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