Nurse Inquiry Synthesis Paper

Carrie Brooks, Nicole Ferrel, Maddie Gedra,

Moriah Rahnavard- Tehrani, Taylor Smith, Kimberly Stoessel
James Madison University
NSG 450
 Table of Evidence
Group 3: Carrie Brooks, Nicole Ferrel, Maddie Gedra, Moriah Rahnavard- Tehrani, Taylor
Smith, Kimberly Stoessel
PICO: In adult patients in the ED, is the Emergency Triage Assessment and Treatment protocol
by the W.H.O. or the Emergency Severity Index most effective at decreasing patient mortality?

Author, YR Sample Description Intervention Instruments Results/ Summary/

and Size with Validity Statistical Evidence Conclusion
and Reliability

Baumann, M. 929 adults ages 65+ in Ensuring use of Used Kendalls Hospitalization was also The use of a
(2007) Maine who presented to Emergency T-B analysis: strongly associated with standardized
Maine Medical Center Severity Index at ESI and ESI triage category Emergency severity
LOE:4 ED from May 13, 2004- ED triage for all hospitalizations: assignment in this cohort Index to determine
June 12 2004 who were patients (Kendalls - of ED geriatric patients how a patient should
NOT a repeat visit or b=0.476; 95% The percentage of be triaged is
direct admission to the CI 0.524 to subjects hospitalized and associated with
hospital, with a 0.425) their ESI categorization better patient
completed medical were inversely outcomes.
record. proportional, and the
predictive ability of ESI
and hospitalizing is 77%
with a 95.5 CI

Amir, M. A total of 19 studies Electronic Agreement was higher ESI triage scales
(2015) from 6 countries. research with the latest and adult showed an
databases were versions of the scale and acceptable level of
LOE: 1 searched and two among expert raters. overall reliability.
researches
examined and
categorized
results.

Martin, A. The data was collected Examining This experiment This study revealed that In conclusion,
(2014) from 64 nurses and nurses attitudes used a ESI scores assigned by evidence produced
1,644 triage events at 3 when using the descriptive, nurse participates did not from this study
LOE: 1 different ERs. Those ESI score in ED exploratory differ significantly from support that nurses
studied completed triage. Whether design. The the Nurse clinical experts with minimal ED
demographic data, ESI score is CNPI-23 assigned ESI score. experience and an
attitude, and triage data assigned (Caring Nurse understanding of the
collection tools. correctly or not. Patient ESI level triage
Comparing the Interaction) algorithm posses the
ESI score of a survey was used. ability to safely
clinical nurse Clinical nurse triage patients in the
expert with that experts reviewed ED.
 of a nurse with charts that had
minimal ED already been
experience. assigned an ESI
score to
compare.

Hategekimana, C. 374 healthcare workers They used a pre The pre and Only 77 (20.6%) This study showed a
et al. (2016) were included in the post test study post test. participants achieved a positive impact on
study. around the score of 50% or more on taking this ETAT
LOE: 4 ETAT course to the pre-course knowledge course and
test for the assessment, versus 292 improving
improvement of (78.0%) on the post- knowledge related to
knowledge. course knowledge emergency pediatric
assessment. and neonatal care.

Mirhaghi, A. et al. Of the data collected Training of The true triage This study revealed The ESI is a valid
(2015) only 866 high risk twenty nurses score was correct triage decisions and reliable triage
emergency department and eight reported based among clinicians were tool to improve
LOE: 4 patients who had physicians to be on patients increased after the desirable outcomes
cardiopulmonary able to properly paper-based implementation of the in the Emergency
resuscitation, ICU, implement the scenario ESI. department;
CCU, Cardiac unit and Emergency questionnaire, however, this tool
Operating room Severity Index the Chi-square may have even
admission were Triage. test, and Kappa greater outcomes in
included in the study. statistics were more developed
used for the countries than in
statistical developing
analysis. countries.

Ahmad, Z. P. et al. Preintervention: The WHOs A statistical After the intervention, Simple, inexpensive
(2012) n=7,781 Emergency process control early mortality decreased interventions to
Triage chart was from 47.6 to 37.9 deaths improve pediatric
LOE:1 Postintervention: Assessment and created by using per 1000 admissions. emergency care at
n=7, 505 Treatment MiniTab to Total mortality also this under resourced
(ETAT) compare all decreased from 80.5 to hospital were
guidelines were available early 70.5 deaths per 1000 associated with
chosen as the death data over admissions after the decreased hospital
basis of our time and in intervention. mortality rates.
triage process to relation to the
improve care. intervention.
 Synthesis Paper

Introduction

In emergency nursing, the protocol in which nurses follow to treat patients can be the

difference between life and death as the window of opportunity dissolves. It is imperative that

this protocol is efficient and concise in order to provide the best healthcare possible. Given this,

there are different emergency room protocols that work to efficiently sort patients according to

medical priority. We created a PICO to address this; In adult patients in the ED, is the

Emergency Triage Assessment and Treatment protocol by the W.H.O. or the Emergency

Severity Index most effective at decreasing patient mortality? The Emergency Triage

Assessment and Treatment (ETAT) is a course created by the World Health Organization that

aims to provide nurses with the guidelines and knowledge needed in order to properly triage

patients based on medical need. The Emergency Severity Index (ESI) is an emergency room

algorithm that divides patients into five groups ranging from 1 being the most urgent, to 5, which

is the least urgent. This tool is unique in that it focuses on both acuity and resource needs. This

research project aims to find out what emergency room protocol is most effective at decreasing

patient mortality: ETAT or ESI?

Study Commonalities

After reviewing numerous studies conducted on ETAT and ESI protocols, several

commonalities have become apparent. Several studies conducted on both ETAT and ESI

protocols established similar objectives to determine the reliability and validity of each tool to

triage patients appropriately (Baumann & Strout, 2007; Robison et al., 2012). The overall goal of
a majority of the studies was to improve patient mortality rates by prioritizing treatment based on

life-threatening and non-life-threatening conditions. Most of the studies, including Robison

(2012), used simple inexpensive interventions, such as implementing triage protocols, to achieve

successful outcomes. Although many of these studies included different protocols and a diverse

sample of participants, there have been similar improvements in outcomes such as decreased

patient mortality and a decreased length of stay in the emergency department.

Study differences

Considering that ETAT and ESI are different triage methods, many differences in studies

have also resulted. The main differences in studies came from the five different levels involved

in ESI, compared to the studies on ETAT that centered on three levels. The methods of training

were different as well, due to the different levels. Even though ETAT can be used on all ages,

our studies used it on only pediatric cases, mainly newborns and young children (Ahmad, 2012).

The ESI studies included a variety of ages from pediatric to geriatric. Our location of studies

vary from specific states in the U.S., such as Maine (Baumann, 2007), to international countries

such as Rwanda and Malawi. All research was also conducted in different years, ranging from

2007 to 2016 (Hategekimana).

Going into more specifics of the differences between studies, each researcher had

different credentials as well and some worked in group research, while others did not, such as

Martin in 2014. The ETAT research studies used was not conducted in the U.S., while the

majority of the ESI research was done in the U.S. The articles for the ETAT had results only on

pediatric emergency cases, where our ETAT articles included a variety of different general

emergency departments admissions. This could be explained by the differences in the length of

studies. Some studies were as short as 30 days, as in Baumanns (2017) case, while others were
as long as three years (Amir, 2015). The tools to measure the results were on different scales as

well, being based on something such as mortality rate per 1000 admissions, such as in Ahmads

case in 2012, or based on health care professionals increase examination rates (Hategekimana,

2016).

Inconsistencies or gaps among the studies

The inconsistencies between the studies are evident in desired outcomes of each study,

the geographic location of the study, and sources of patient mortality statistics. Ideally, the

literature review would have been most effective if the research occurred in the same country.

The ESI system is utilized in the United States, whereas the ETAT by the World Health

Organization is not. The studies of ETAT efficacy took place in Rwanda (Hategekimana, 2016)

and Malawi (Ahmed, 2012), whereas all ESI reviews took place in the United States presenting

cultural, economic, and resource differences between triage indications.

The diction in predicted outcomes varied between the studies, which can lead to

inconsistencies in article interpretation. In ETAT analysis, Hategekimana (2016) examined the

effect that ETAT training implementation had on triage accuracy, measured by standardized pre

and post test scores of training participants. Ahmad (2012) examined the effect of early ETAT

specific interventions on pediatric mortality rates. The connotated degree of severity was

inconsistent between the two articles as patient mortality was not truly at risk for

Hategekimanas participants but it could be inferred that the implementation of ETAT training

will decrease patient mortality since triage accuracy scores improved after training according to

the study. The ESI outcomes varied between examining patient outcomes, actual patient

mortality rates, reliability of the ESI tool itself, and whether or not novice nurses could triage as

effectively as experienced nurses using the ESI tool. Again, the context of the study differed.
Ideally, all of the articles would be reflective of patient mortality outcomes with correct

implementation of ESI, yet Martin and Mirhagi looked at nurse triage ability after ESI tool use,

which leads to the inference that improved triage reliability decreases patient mortality rates,

without actually confirming mortality rates from patients triaged by the nurses in question.

Several time gaps exist between the research articles as publishing dates range from 2007

to to 2016. This gap impacts the validity of our conclusions, as they may not account for changes

in triage system protocols that particular hospitals took into practice as further articles in ESI

efficiency were published. Another gap that may be related to the time of research was the exact

subject matter that was being examined in relation to ESI and ETAT usage. Articles written in

2014 and 2015 examined how different versions of ESI protocols affected both nurses

perception and patient outcomes, whereas earlier articles such as Triage of geriatric patients in

the emergency department: Validity and survival with the Emergency Severity Index by

Baumann & Strout (2007) aimed to look at the overall efficacy of using a particular version of

ESI over a one month period.

Finally, the sample sizes differed between studies which creates a limitation of how each

articles findings can be applied to hospitals of different capacities. Martins article could be

applied to larger hospitals because it involved 16,444 patients with varying diagnoses whereas

Miragis only examined outcomes based on 866 patients who were admitted to the ICU or CCU

from the Emergency Department.

 Conclusion

Further research is certainly needed to bridge the gap between nurse ESI use and

mortality rates, and where each tool would be most geographically effective. Our PICO

previously stated In adult patients in the ED, is the Emergency Triage Assessment and

Treatment protocol by the W.H.O. or the Emergency Severity Index most effective at decreasing

patient mortality. While we were able to find some commonalities between the two systems,

such as their goal to decrease patient mortality by prioritizing patients, there were many

differences. The ETAT was used more internationally while the ESI studies focused on its use in

the United States. We are advocating for a modified ESI protocol that is specific for each

hospital. Some hospitals have limited resources and this would need to be taken into

consideration with their implementation. Also, nurses would need to be educated on their

specific protocol so that they can effectively use it as needed. Hopefully we will see a modified

ESI protocol established in emergency rooms leading to a decrease in patient mortality.

Linking Evidence To Practice

To quickly prioritize medical acuity by using various emergency protocols, the following

actions should be implicated by nurses.

Recommendations Nursing Expertise Needed Usefulness to Patients and

to Implement Families
Recommendations
Education: Seek additional
training and education with
the desire to decrease patient
mortality in the ED
Research: Engage in further
research to determine the best
implication of the ESI
protocols
Advocacy: Advocate for a
modified ESI design to
accommodate emergency
departments with limited
resources.
Staffing: Comprise a team of
on-call, supplemental staff to
promote a balance in nurse to
patient ratio.
Resources: Provide
appropriate resources to
efficiently carry out the ESI
protocols.
Nurses should receive Patients and families
specific training will have greater
regarding the ETAT confidence in the
and ESI nursing staff if they
Nurses should be know how to
required to partake in accurately implement
training activities to a triage process.
gain experience
working with these
triage methods.
It is the nurses With the nursing staff
responsibility to stay better prepared in
up to date on current using the most up to
and appropriate triage date protocols, this
methods performed will ensure that
within their hospital. patients receive the
It is the hospitals job best possible care.
to evaluate the
effectiveness of their
triage protocols.
Nurses need to be With the
knowledgeable on the implementation of a
types of resources modified ESI design,
necessary for ESI to there would hopefully
be implemented be a lowered patient
appropriately. mortality rate.
Nurses should
advocate for a
modified ESI program
to be implemented in
their unit.
All nurses should be If a better patient to
trained in the modified nurse ratio would be
ESI so that when they implemented, patients
are on call, they can would have better
be an asset. outcomes.
It is the nurses role to With the appropriate
advocate for the resources, patients
appropriate resources. will receive effective
care with the use of
the ESI protocol.
 References

Amir, M., Abbas, H., Reza, M., & Farzaneh, H. (2015). Reliability of the Emergency Severity Index: Meta-analysis.

Sultan Qaboos University Medical Journal, 15(1), 71-77.

Baumann, M., & Strout, T. (2007). Triage of geriatric patients in the emergency department: Validity and survival

with the Emergency Severity Index. Annals Of Emergency Medicine, 49(2), 234-240.

Doi: 10.1016/j.annemergmed.2006.04.011

Hategekimana, C., Shoveller, J., Tuyisenge, L., Kenyon, C., Cechetto, D. F., & Lynd, L. D. (2016). Correlates of

performance of healthcare workers in emergency, triage, assessment and treatment plus admission care

(ETAT+) course in rwanda: context matters. Plos ONE, 11(3), 1-17. doi:10.1371/journal.pone.0152882

Martin, A., Davidson, C. L., Panik, A., Buckenmyer, C., Delpais, P., & Ortiz, M. (2014). An examination of ESI

triage scoring accuracy in relationship to ED nursing attitudes and experience. JEN: Journal Of

Emergency Nursing, 40(5), 461-468. doi:10.1016/j.jen.2013.09.009

Mirhaghi, A., Kooshiar, H., Esmaeili, H., & Ebrahimi, M. (2015). Outcomes for Emergency Severity Index triage

implementation in the emergency department. Journal Of Clinical & Diagnostic Research, 9(4), 4-7.

doi:10.7860/JCDR/2015/11791.5737

Robison, J. A., Ahmad, Z. P., Nosek, C. A., Durand, C., Namathanga, A., Milazi, R., Thomas, A., Soprano, J. V.,

Mwansambo, C., Kazembe, P. N., & Torrey, S. B. (2012). Decreased pediatric hospital mortality after an

intervention to improve emergency care in Lilongwe, Malawi. Official Journal of the American Academy

of Pediatrics, 130(3), 676-682. doi:10.1542/peds.2012-0026