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2-14-2012

Accuracy of Emergency Department Nurse Triage Level Designation and Delay in Care of Patients with Symptoms Suggestive of Acute Myocardial Infarction
Susan S. Sammons
Georgia State University, suzn911@hotmail.com

Follow this and additional works at: http://digitalarchive.gsu.edu/nursing_diss Recommended Citation

Sammons, Susan S., "Accuracy of Emergency Department Nurse Triage Level Designation and Delay in Care of Patients with Symptoms Suggestive of Acute Myocardial Infarction" (2012). Nursing Dissertations. Paper 27.

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ACCEPTANCE This dissertation, ACCURACY OF EMERGENCY DEPARTMENT NURSE TRIAGE LEVEL DESIGNATION AND DELAY IN CARE OF PATIENTS WITH SYMPTOMS SUGGESTIVE OF ACUTE MYOCARDIAL INFARCTION by Susan Sanders Sammons was prepared under the direction of the candidates dissertation committee. It is accepted by the committee members in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Nursing by the Byrdine F. Lewis School of Nursing and Health Professions, Georgia State University. ____________________________________ Cecelia M. G. Grindel, PhD, RN, FAAN Committee Chairperson ____________________________________ Ptlene Minick, PhD, RN Committee Member ____________________________________ Holli DeVon, PhD, RN Committee Member ____________________________________ Date This dissertation meets the format and style requirements established by Byrdine F. Lewis School of Nursing and Health Professions. It is acceptable for binding, for placement in the University Library and Archives, and for reproduction and distribution to the scholarly and lay community by University Microfilms International. _________________________________ Joan Cranford, EdD, RN Assistant Dean for Nursing Byrdine F. Lewis School of Nursing and Health Professions _________________________________ Cecelia M. G. Grindel, PhD, RN, FAAN Professor & Interim Dean Byrdine F. Lewis School of Nursing and Health Profession

AUTHORS STATEMENT In presenting this dissertation as a partial fulfillment of the requirements for an advanced degree from Georgia State University, I agree that the Library of the University shall make it available for inspection and circulation in accordance with its regulations governing materials of this type. I agree that permission to quote from, to copy from, or to publish this dissertation may be granted by the author or, in his/her absence, by the professor under whose direction it was written, or in his/her absence, by the Assistant Dean for Nursing, Byrdine F. Lewis School of Nursing and Health Professions. Such quoting, copying, or publishing must be solely for scholarly purposes and will not involve potential financial gain. It is understood that any copying from or publishing of this dissertation which involves potential financial gain will not be allowed without written permission from the author. ____________________________________ Susan Sanders Sammons

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NOTICE TO BORROWERS All dissertations deposited in the Georgia State University Library must be used in accordance with the stipulations prescribed by the author in the preceding statement. The author of this dissertation is: Susan Sanders Sammons The director of this dissertation is: Dr. Cecelia M. G. Grindel Professor Byrdine F. Lewis School of Nursing and Health Profession Georgia State University P.O. Box 3995 Atlanta, GA 30302-4019 Users of this dissertation not regularly enrolled as students at Georgia State University are required to attest acceptance of the preceding stipulations by signing below. Libraries borrowing this dissertation for the use of their patrons are required to see that each user records here the information requested. NAME OF USER ADDRESS DATE TYPE OF USE (EXAMINATION ONLY OR COPYING)

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VITA Susan S. Sammons ADDRESS: EDUCATION: PhD MSN BSN ADN 1417 Dale Drive Savannah, GA 31406 2012 2005 2005 1984 Georgia State University Atlanta, Georgia Armstrong Atlantic State University Savannah, Georgia Armstrong Atlantic State University Savannah, Georgia Florida State College Jacksonville, Florida

PROFESSIONAL EXPERIENCE: 2011 - Present 2007 2011 2001 2011 1996 2001 1994 1996 1989 1994 1986 1989 1985 1986 1984 1985

Emergency Services Clinical Nurse Specialist, St. Josephs Candler Health System Assistant Professor, Armstrong Atlantic State University Staff Nurse, Senior Nurse, Clinical Nurse Specialist, Emergency Department, Memorial University Medical Center Staff Nurse, Compliance Manager, Hospice Savannah Staff Nurse, Oncology Unit, Candler General Hospital Charge Nurse, Medical/Surgical Unit, Memorial University Medical Center Director of Nursing, Helping Hands Home Care Staff Nurse, Candler Home Health Services Staff Nurse, Oncology Unit, Memorial University Medical Center

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PROFESSIONAL ORGANIZATIONS AND CERTIFICATIONS: 2007 Present Certification in Emergency Nursing (CEN) 2002 Present Emergency Nurses Association (ENA) 2012 Present President, ENA Coastal Empire Chapter 2001 - Present Sigma Theta Tau International, Rho Psi Chapter 2005 Present Georgia Nurses Association (GNA) HONORS: 2010 2011 Kaiser-Permanente Evidence-Based Practice Research Award Armstrong Atlantic State University, Brockmeier Faculty Award Nominee

ABSTRACT ACCURACY OF EMERGENCY DEPARTMENT REGISTERED NURSE TRIAGE LEVEL DESIGNATION AND DELAY IN CARE OF PATIENTS WITH SYMPTOMS SUGGESTIVE OF ACUTE MYOCARDIAL INFARCTION by SUSAN S. SAMMONS More than 6 million people present to emergency departments (EDs) across the US annually with chief complaints of chest pain or other symptoms suggestive of acute myocardial infarction (AMI). Of the million who are diagnosed with AMI, 350,000 die during the acute phase. Accurate triage in the ED can reduce mortality and morbidity, yet accuracy rates are low and delays in patient care are high. The purpose of this study was to explore the relationship between (a) patient characteristics, registered nurse (RN) characteristics, symptom presentation, and accuracy of ED RN triage level designations and (b) delay of care of patients with symptoms suggestive of AMI. Constructs from Donabedians Structure-Process-Outcome model were used to guide this study. Descriptive correlational analyses were performed using retrospective triage data from electronic medical records. The sample of 286 patients with symptoms suggestive of AMI comprised primarily Caucasian, married, non-smokers, of mean age of 61 with no prior history of heart disease. The sample of triage nurses primarily comprised Caucasian females of mean age of 45 years with an associates degree in nursing and 11 years experience in the ED. i

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. The patient with chest pain reported at triage was also twice as likely (OR 2.55) to have an accurate triage than the patient with no chest pain reported at triage. Electrocardiogram (ECG) delay was significantly greater in the patient without chest pain and when the RN had more experience in ED nursing. Triage delay was significantly related to patient gender and race/ethnicity, with female patients and non-Caucasian patients experiencing greater delay. An increase in RN years of experience predicted greater delay in triage. Further studies are necessary to understand decisions at triage, expedite care, improve outcomes, and decrease deaths from AMI.

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ACCURACY OF EMERGENCY DEPARTMENT REGISTERED NURSE TRIAGE LEVEL DESIGNATION AND DELAY IN CARE OF PATIENTS WITH SYMPTOMS SUGGESTIVE OF ACUTE MYOCARDIAL INFARCTION by

SUSAN S. SAMMONS A DISSERTATION

Presented in Partial Fulfillment of Requirements for the Degree of Doctor of Philosophy in Nursing in the Byrdine F. Lewis School of Nursing and Health Professions Georgia State University

Atlanta, Georgia 2012

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Copyright by Susan S. Sammons 2012

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ACKNOWLEDGMENTS This dissertation is the culmination of years of hard work and perseverance both from my family, my committee, and myself. I must thank first Dr. Laura Kimble who planted the seed of what could be. She gave me direction in the very early stages of my research in emergency cardiac care and allowed me to pursue my passion. Each of my committee members, Drs. Grindel, Minick, and DeVon, have given of their time and expertise to guide me, and for that I am grateful. A sincere thank you to my friends and colleagues who have watched me each step of the way, class after class after class. You have asked, and truly seemed to care, about my topics and homework all along the way. You emergency nurses are my inspirationI watch you work magic daily, and I am proud to be among you. A cohort of doctoral students traveled this path with me, driving mile after mile, reading and having philosophical discussions at every turn. The road less traveled was made less lonely because of them. To Dee Tanner, Jean Pawl, and Janeen Amason, I am thankful for each of you. My family has been there for me, faithfully taking whatever I dished out, literally and metaphorically. I love you totally.

TABLE OF CONTENTS Section Page

List of Tables...................................................................................................................x List of Figures ............................................................................................................... xi List of Abbreviations .................................................................................................... xii I. INTRODUCTION ...............................................................................................1

Statement of Problem ......................................................................................................1 Purpose and Aims ............................................................................................................2 Significance .....................................................................................................................2 Standards of Emergency Cardiac Care ............................................................2 Standards of ED RN Triage ............................................................................3 Importance Of Accurate Triage Level Designation .........................................6 Theoretical Framework ....................................................................................................7 Selection of a Theoretical Framework ............................................................7 Overview of Donabedians Model ..................................................................8 Use of Donabedians Model in Studies ......................................................... 10 Strengths of Donabedians Model................................................................. 12 Summary ....................................................................................................................... 14 II. REVIEW OF LITERATURE ............................................................................. 15

Accuracy Rates in Triage ............................................................................................... 15 Delay in Emergency Care .............................................................................................. 18 Patient Characteristics ................................................................................................... 21 RN Education, Experience, and Triage .......................................................................... 24

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Symptom Presentation ................................................................................................... 26 Summary ....................................................................................................................... 28 III. METHODOLOGY ............................................................................................ 30

Research Design ............................................................................................................ 30 Setting 30 Sample31 Measures and Instruments.............................................................................................. 32 Variables of Interest ..................................................................................... 33 Accuracy ...................................................................................................... 33 Symptoms Suggestive of AMI ...................................................................... 33 Triage Level Designation ............................................................................. 35 Patient Characteristics .................................................................................. 35 RN Characteristics ....................................................................................... 36 Delay ........................................................................................................... 36 Data Collection .............................................................................................................. 36 Data Analysis ................................................................................................................ 38 Protection of Human Subjects ........................................................................................ 38 Summary ....................................................................................................................... 39 IV. RESULTS .......................................................................................................... 40

Preliminary Screening Procedures ................................................................................. 41 Descriptive Statistics ..................................................................................................... 45 Description of the Sample of Patients ........................................................... 45 Description of the Sample of RNs ................................................................ 47

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Statistical Analysis ........................................................................................................ 49 Predictors of Accuracy of Triage Level Designation ..................................... 49 Predictors of Delay of ECG .......................................................................... 50 Predictors of Amount of Delay of Care ......................................................... 52 Summary ....................................................................................................................... 54 V. DISCUSSION AND CONCLUSION ................................................................. 57

Accuracy ....................................................................................................................... 57 Accuracy and Patient Characteristics ............................................................ 58 Accuracy and RN characteristics .................................................................. 59 Triage Delay .................................................................................................................. 61 Triage Delay and Patient Characteristics ...................................................... 62 Triage Delay and RN Characteristics ............................................................ 63 ECG Delay .................................................................................................................... 63 ECG Delay and Patient Characteristics ......................................................... 64 ECG Delay and RN Characteristics .............................................................. 65 Accuracy and Delay....................................................................................................... 65 Conclusions ................................................................................................................... 67 Limitations .................................................................................................................... 68 Implications for Nursing Practice................................................................................... 69 Future Research ............................................................................................................. 70 REFERENCES .............................................................................................................. 72 APPENDICES ............................................................................................................... 88 Appendix A: Registered Nurse Demographics Tool ....................................................... 88

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Appendix B: Selection of Electronic Medical Records ................................................... 90 Appendix C: Informed Consent ..................................................................................... 92 Appendix D: Institutional Review Board Approval ........................................................ 94

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LIST OF TABLES Table 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Page Triage Scale and Maximum Wait Times in Minutes .............................................5 Data List ............................................................................................................ 34 Skewness and Kurtosis Statistics ........................................................................ 43 Patient Demographics ........................................................................................ 46 Patient Medical History...................................................................................... 47 Characteristics of Registered Nurses .................................................................. 48 Electronic Medical Record Matched Registered Nurse Demographics ................ 48 Accuracy of Triage Level Designation Model .................................................... 50 Delay of Electrocardiogram Model .................................................................... 51 Minutes of Delay in Care ................................................................................... 52 Correlation of Registered Nurse Age and Experience ......................................... 53 Amount of Delay of Triage Model ..................................................................... 54

LIST OF FIGURES Figure 1. 2. Page Donabedians model. ...........................................................................................9 Model of emergency department registered nurse triage of patients with symptoms suggestive of acute myocardial infarction. ...........................................9 3. 4. 5. 6. Histogram for minutes to triage. ......................................................................... 43 Histogram for minutes to triage (transformed). ................................................... 44 Registered nurse years of experience in emergency department. ......................... 44 Registered nurse years of experience in emergency department (transformed). ... 45

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LIST OF ABBREVIATIONS ACC ACS ADN AHA AMI ATS BMI BSN CABG CHD CPR CTAS DTN DTB ECG ED EMR ENA ESI IHI American College of Cardiology Acute Coronary Syndrome Associate Degree in Nursing American Heart Association Acute Myocardial Infarction Australasian Triage Score Body Mass Index Bachelor of Science in Nursing Coronary Artery Bypass Graft Coronary Heart Disease Cardiopulmonary Resuscitation Canadian Triage and Acuity Scale Door-to-Needle Door-to-Balloon Electrocardiogram Emergency Department Electronic Medical Record Emergency Nurses Association Emergency Severity index Institute for Healthcare Improvement xii

IRB LPN MCAR MTS NCHS NHAMES NHLBI NSTEMI PAWS PCI RN RNDT SES STEMI UA

Institutional Review Board Licensed Practical Nurse Littles Missing Completely at Random Manchester Triage Scale National Center for Health Statistics National Hospital Ambulatory Medical Care Survey National Heart Lung and Blood Institute Non-ST segment Elevation Predictive Analytics Software Percutaneous Coronary Intervention Registered Nurse Registered Nurse Demographic Tool Socioeconomic Status ST-segment Elevation Myocardial Infarction Unstable Angina

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CHAPTER I INTRODUCTION This chapter provides an overview of the significance of rapid cardiac care in the emergency department (ED). The standards of emergency cardiac care are identified as well as the standards of ED triage and the importance of accurate triage and rapid cardiac care. The aims of this study are identified. Donabedians Structure-Process-Outcome model (Donebedians model; Donabedian, 1966) is presented as a theoretical framework to investigate accuracy and delay in triage of patients with symptoms suggestive of acute myocardial infarction (AMI). Statement of Problem Coronary heart disease (CHD) is the leading cause of death in the US (Murphy, Xu, & Kochanek, 2012). More than 6 million patients present to EDs across the US every year with a chief complaint of chest pain; 6 million more present with possible symptoms of CHD such as dizziness, nausea, or shortness of breath (National Center for Health Statistics [NCHS], 2008). Annually in the US, 1 million patients are diagnosed with AMI, and 350,000 of those die during the acute phase (Institute for Healthcare Improvement [IHI], 2009). Accurate and timely triage level designation in the ED can reduce mortality and morbidity, yet data indicate that accuracy rates are low and delays in patient care are high. The current economic downturn is associated with more people seeking primary care from EDs than ever before, leading to overcrowding. ED overcrowding means that the role of the triage registered nurse (RN) in evaluating those

2 who need urgent care and those who can wait is more pressing than ever before. Therefore, there is a need to investigate conditions involved in ED RN triage level designations. Purpose and Aims The purpose of this study was to explore the relationship between (a) patient characteristics (gender, age, race/ethnicity, symptom presentation), (b) RN characteristics (age, years of experience, years of ED experience, and education), (c) accuracy of ED RN triage level designations, and (d) delay of care of patients with symptoms suggestive of AMI. Specifically, the aims of this study were 1. to determine if patient characteristics (gender, age, race/ethnicity) and RN characteristics (age, years of experience, years of ED experience, and education) predict accuracy of ED RN triage level designation of patients with symptoms suggestive of AMI, and 2. to determine if patient characteristics (gender, age, race/ethnicity, symptom presentation), RN characteristics (age, years of experience, years of ED experience, and education), and triage level designation predict delay of care of patients with symptoms suggestive of AMI. Significance Standards of Emergency Cardiac Care AMI is defined as a sudden lack of oxygen to the cardiac muscle due to a clot or atherosclerotic changes that occlude a coronary artery. Cardiac cell death is not immediate but can occur within 20 minutes and up to 2 hours after the initial occlusion (Thygesen, Alpert, & White, 2007). The American College of Cardiology (ACC) and the

3 American Heart Association (AHA) recommend in national guidelines that health care providers meet certain emergency cardiac care goals: obtain an electrocardiogram (ECG) within 10 minutes of arrival, have a patient evaluated by a physician within 10 minutes, and initiate thrombolytic medications within 30 minutes or provide percutaneous coronary intervention (PCI) within 90 minutes of point of entry into the ED with symptoms of AMI (Krumholz et al., 2008). The initiation of intravenous thrombolytic medications is also called door-to-needle (DTN), and the provision of PCI is designated as door-to-balloon (DTB). Rapid assessment and treatment are crucial to restoring blood flow to the heart, preserving cardiac function, and saving lives. Because of their ability to recognize the AMI patient and take quick action, ED triage RNs are in the best position to directly affect early intervention and care. Standards of ED RN Triage ED administrators, RNs, and physicians struggle with how to handle the volume of patients arriving for healthcare (Derlet & Richards, 2000). Determining the severity of illness and urgency of care required are the main functions of the triage RN. Triage RNs in the ED have a responsibility to identify patients with cardiac emergencies who need prompt care. However, triage is not straightforward and few, if any, diagnostic tests are conducted in triage to aid in that decision. Triage level designation is a subjective decision based on input from several directions. Along with observational data collected during a brief nursing assessment, numerous pieces of information, such as previous medical history and symptoms, are elicited from the patient, and sometimes family, before the triage level designation is decided. A decision is made to assign the patient to one of several categories or levels of priority. Although there are no nationally

4 established time parameters to complete the triage process itself, the goal during triage is to assess the patient and make a triage level designation indicating urgency of symptoms within 2 to 5 minutes (Travers, 1999). In the US, there is no standard set of triage guidelines; however, most hospitals in the US have adopted a three or five level system for triage. Many hospitals use the Emergency Severity Index (ESI; Gilboy, Tanabe, Travers, Rosenau, & Eitel, 2005), a five level system. The Emergency Nurses Association (ENA; 2010) supports the use of this five level triage system. In the ESI, patients are assigned a triage level based on the following scale: Level 1-resuscitation needed, Level 2-emergent, Level 3-urgent but stable and can safely wait in the waiting room, Level 4-nonurgent, and Level 5-referable to another provider of care such as a clinic setting. The triage RN must first assess whether the patient has a life-threatening issue, noted as a high triage level designation (ESI Level 1 or 2). Level 1 asks the question: Is this patient dying (i.e., not breathing and in need of cardiopulmonary resuscitation [CPR])? Level 2 asks the question: Is this a patient who should not wait? If the patient can wait without harm, then the triage RN moves to a decision regarding estimation of number of resources needed for the physician to determine a diagnosis or disposition (Level 3, 4 or 5). The ESI system does not mandate specific time frames (i.e., how long a patient can wait to see a physician). However, symptoms of AMI must always be considered a Level 2-emergent in the ESI system so that national guidelines for cardiac emergencies can be met and prompt care can begin. Hospitals in other countries use five level triage systems, including the Canadian Triage and Acuity Scale (CTAS; Beveridge et al., 1999), the Australasian Triage Score

5 (ATS; Australasian College for Emergency Medicine [ACEM], 2000), or the Manchester Triage Scale (MTS; Manchester Triage Group, 1997). All three scales use a numbering system with Level 1 designating the most critical patient situation. The ATS, the CTAS, and the MTS set maximum wait times for patients in each level (see Table 1).

Table 1 Triage Scale and Maximum Wait Times in Minutes Scale Australasian Triage Scale Canadian Triage and Acuity Scale Manchester Triage Scale Level 1 0 0 0 Level 2 10 15 10 Level 3 30 30 60 Level 4 60 60 120 Level 5 120 120 240

In synthesizing the current research of accuracy in ED RN triage level designations, an emerging issue is inconsistency in the type of triage scales used. Portions of the EDs in the US do not use the ESI scale but instead use a three-level system: Level 1-emergent, Level 2-urgent, and Level 3-non-urgent. Both three-level and five-level systems are in use in the United Kingdom, Canada, Australia, and other countries. Comparing the accuracy of assessments in triage systems is problematic because of the inconsistency in the number of triage levels in the differing systems (three versus five). Travers, Waller, Bowling, Flowers, and Tintinalli (2002) compared the five-level and the three-level systems. A triage level designation assigned a lesser urgency than needed was denoted as under-triage in the study and a triage level designation assigned higher than the necessary urgency was denoted over-triage. The under-triage rate for the three-level systems was 28% but improved to 12% when the five-level ESI was used. The

6 ability to correctly identify those patients who required urgent care was 23% in the threelevel systems, but 75% in the five-level ESI. Travers et al. (2002) concluded that the fivelevel ESI was superior for triage of patients in the ED. Importance Of Accurate Triage Level Designation A growing body of evidence points to the association between early intervention and decreased mortality in patients with AMI. Studies have demonstrated associations between time to PCI and mortality risk. In a study reviewing the medical records of 27,080 patients with AMI and PCI at 661 hospitals, Cannon et al. (2000) found a median DTB time of 116 minutes. An increase in DTB time increased in-hospital mortality by 40-60%, with an increase in mortality higher with DTBs greater than 120 minutes. In a study of 1,791 patients with ST-segment elevation myocardial infarction (STEMI) treated with angioplasty, DeLuca, Suryapranata, Ottervanger, and Antman (2004) found risk of dying within 1 year of AMI increased by 7.5% for every 30 minutes of delay. More importantly, any increase in DTB time equaled an increase in 1-year mortality, and the longer the duration of the occlusion, the larger the degree of infarct. In a retrospective database analysis, McNamara et al. (2006) found increased DTB times that were associated with increase in hospital mortality in patients ( N = 29,222) with STEMI and PCI. As DTB time increased so did in-hospital mortality. In a study investigating DTB times and mortality in STEMI patients ( N = 43,801), 42.1% of patients were delayed past the 90-minute mark, with 18.8% being delayed greater than 2 hours (Rathore et al., 2009). The overall mortality rate for the study cohort was 4.6%. A significant trend was noted in mortality in that the longer the DTB time, the higher the mortality rate.

7 As demonstrated in the literature, time to initiation of PCI or fibrinolytic medication administration is critical. Any action that increases that time is potentially harmful. Accurate triage level designation is one tool ED RNs can use to facilitate early intervention and affect patient outcomes. Theoretical Framework The individual ED triage process involves a patient presenting to an ED for medical care. Thus, the patient presenting already has decided that a healthcare need exists based on symptoms. Once the patient and the triage RN interact, data gathering by the RN begins. This may be (a) physical evidence such as pale skin, diaphoresis, active bleeding, or labored breathing or (b) symptoms the patients report, such as pain, weakness, or fatigue. In either instance, a degree of uncertainty exists. The unknown in this situation is the seriousness and urgency of the underlying condition responsible for causing the signs and symptoms. Obtaining symptom progression information and a health history are part of the triage process for the purpose of data gathering. Initial diagnostics, such as obtaining a blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation level, begin in triage. It is unknown whether the patients gender, age, and race/ethnicity or RN experience and education affect this process. For this study, understanding what happens during the process of ED triage required a framework that speaks to the processes involved. Donabedians model (Donabedian, 1966) was used to address this process. Selection of a Theoretical Framework The Donabedian model is useful in framing studies examining ED RN triage of AMI patients and factors associated with accuracy of triage level designation and delay

8 of care. The use of this framework in this study was appropriate because the framework mirrors ED triage in that it has a data input point of multiple factors possibly affecting a process, which in turn affects the output or outcome. Overview of Donabedians Model Donabedians model evolved from Donabedians work in health services quality and patient outcomes. The primary goal of quality assurance processes is improvement in outcomes directly related to patient care. The key concepts in the model are structure, process, and outcome. As demonstrated in Figure 1, Donabedians model proposes that each component has an effect or direct influence on the next (Donabedian, 1980). Characteristics of the healthcare setting, the healthcare provider, or the healthcare encounter have the potential to influence both process and outcome. Donabedians model provides a way of understanding the ED RN-patient encounter at triage and the effect of accuracy of triage level designation and delay in treatment of AMI. Figure 2 demonstrates the application of Donebedians model in this study. The concept of structure refers to attributes of the healthcare setting, the healthcare provider, or the healthcare encounter in which care is delivered and may include (a) patient characteristics and RN characteristics; (b) environmental factors that compose the setting (e.g., day of the week and time of day), and (c) extrinsic factors (e.g., staffing levels, unit patient volume, overcrowding, and boarding of admitted patients). Measurement of extrinsic factors was beyond the scope of this project. Factors that compose the attributes of the setting in ED RN triage were defined in this study as (a) the patient characteristics of gender, age, race/ethnicity, and symptom presentation and (b) the RN characteristics of age, years of experience, years of ED experience, and education.

Structure

Process

Outcomes

Figure 1. Donabedians model.

Structure
Patient characteristics gender age race/ethnicity symptom presentation RN characteristics age race/ethnicity symptom presentation

Process
Triage level designation decisions of patients presenting with symptoms suggestive of AMI

Outcomes
Accurate triage level designation; time to triage and time to ECG

Figure 2. Model of emergency department registered nurse triage of patients with symptoms suggestive of acute myocardial infarction.

10 Process refers to the interpersonal aspects of activities between service providers and their clients. In ED triage, process is the action that is occurring on the patients behalf and involves the interaction between the ED triage RN and the patient presenting for care. In this study, process was defined as the triage interaction between patient and RN and the resulting triage level designation. In Donabedians model, the outcome is the result of the structure and process. Outcomes in most quality assurance programs are generally described in terms of better survival rates, lower infection rates, quality of life indicators, or some measure of benefit to the recipient of care, the patient. In this study, the outcome, or measure of benefit to the recipient of care, was defined as accuracy of ED RN triage level designation of patients with symptoms suggestive of AMI and delay or no delay in care as measured by triage and obtainment of ECG within 10 minutes of arrival. Use of Donabedians Model in Studies Donabedians model has been used extensively to frame studies examining (a) the performance of community organizations (Chen, Hong, & Hsu, 2007), (b) radiation oncology services (Christian, Adamietz, Willich, Schafer, & Micke, 2008), (c) AMI treatment in Germany (Wubker, 2007), (d) compliance with infection control strategies (Chou, Yano, McCoy, Willis, & Doebbeling, 2008), and (e) medical care for depressed elders (Hong, Morrow-Howell, Proctor, Wentz, & Rubin, 2008). Using a sample of 195 community organizations in Taiwan, Chen et al. (2007) conducted a correlational study examining relationships between community organization capacity characteristics and performance scores validating the theoretical relationships among concepts identified in the Donabedian model. The model focused on the relationships between structure and

11 outcome. The performance outcomes were directly influenced by structure factors such as funding type, designated department, full-time worker, funding linkage, partnership score, multiple committee use, attitude toward participation, number of volunteers, education level of volunteers, and position and age of administrator. Using the Donabedian model in a study of continuing after-hours emergency radiation therapy services in Germany, Christian et al. (2008) described outcomes which were based on the characteristics of each institution providing services (N = 140), reasons for treatment (structure), day and time treatment occurred, dosage delivered, and equipment used (process). Outcomes were reported in percentages of improvement in patient indicators. No relationship was identified between structure variables, process variables, and outcomes leading the authors to re-evaluate continuation of emergency radiation services. Donabedians model also helped the researchers identify the need to begin formation of national benchmarks. Wubker (2007) used the Donabedian model to assess outcomes associated with diagnostics and treatment of AMI patients in 16 German federal states. Structure was defined as the number of cardiologists and the number of catheterization facilities; process was defined as the number of coronary angiography and coronary artery bypass grafts (CABG) in a 10 year period and adherence to medical standards of care; and outcomes were mortality rates and potential years of life lost. The study hypothesis was based on the premise that the better the structure and process, the better the outcome. However, data revealed only the structure variable of the number of catheterization facilities was significantly related to better outcomes. Other factors, mainly socioeconomic factors and risk factors, were found to have an influence on outcomes.

12 Using Donabedians model as a guide in a study of antimicrobial resistance (Chou et al., 2008), infection control professionals (N = 448) were surveyed about structural factors such as hand washing policies, operating room procedures, and administrator support, along with process factors such as the culture of the hospital and communication. The outcome was the degree of adherence to national guidelines to optimize antimicrobial use as well as strategies to detect, report, and prevent antimicrobial resistance. Researchers found numerous structural and process factors (administrator support, feedback systems, forms, formal processes, policy distribution, formularies, and computer support) significantly related to the outcome of adherence to national guidelines to optimize antimicrobial use. Hong et al. (2008) used Donabedians model to assess medical care for depressed elders (N = 110) and found that only about 70% of patients received the minimum needed medical care for co-morbidities with 22% of depressed elders receiving less than half of care needed. Significant correlations were noted between insurance coverage, marital status, income (structure factors) and medical services provided (process factor) indicating that quality outcomes were related to the functions of structure and process. In these studies, Donabedians model allowed for evaluation of the effectiveness of a current process or the consideration of a new process based on expected outcomes. Donabedians model also allowed for the identification of factors not initially included as structure or process variables to be considered or reconsidered for further studies. Strengths of Donabedians M odel Using a systematic approach for assessing the usefulness of a model, as defined by Chinn and Kramer (1995), familiarity, simplicity, and effectiveness were examined to

13 determine the usefulness of Donabedians model in examining ED triage of the patient with symptoms suggestive of AMI. First noted is the widespread familiarity with the Donabedians structure-process-outcome model and its simple structure. The diagram itself is simplistic. Secondly, diagrams illustrating structure-process-outcome are used effectively to demonstrate links between concepts. The model allows for the identification of independent variables that can be included. Possible independent variables that can be investigated include (a) the patient characteristics of gender, age, race/ethnicity, socioeconomic status (SES), marital status, symptom presentation, and medical history, (b) the RN characteristics of knowledge, years of experience, years of ED experience, gender, age, degree, and clinical experience, and (c) the unit environmental factors of crowded waiting rooms, staffing pattern, acuity of patients, time of day, available beds, RN/physician communication patterns, culture of the unit, autonomy of the RN, and protocol use. Many identified research studies investigating ED triage accuracy and delay lack a conceptual or theoretical framework. This theory gives direction to begin to understand the relationships and connections of concepts vital to understanding triage, such as decision-making, delay, accuracy, symptom presentation, and patient and RN demographic factors. Donabedians model focuses on structure and process with an overall goal of achieving a positive outcome. Donabedians model can be used to identify possible factors affecting ED RN triage level designation. The model can be linked to empirical indicators testing theoretical relationships and can be used to identify gaps in the literature. The model can also be used as an organizing framework for ED RN triage of patients with possible AMI to inform future recommendations for triage in the ED.

14 According to Donabedian (1980), structural characteristics of the setting in which care takes place have a propensity to influence the process. Similarly, changes in the process of care will influence outcome. This sets the stage for correlational studies that examine the relationship of structure and process factors and the rapid treatment of patients with possible AMI. There are limitations to the use of Donabedians framework for the study of ED RN triage level designations for patients with symptoms suggestive of AMI. While Donabedians model can identify relationships and associations between structure, process, and outcomes, it is not helpful in determining causality. However, understanding how structure and process affect delay in treatment of AMI patients has important implications that may affect policy, education, and training of staff in the ED. Summary In this chapter, the standards of emergency cardiac care were identified, and the significance of rapid cardiac care was discussed. The aims of the study were identified and a theoretical model proposed as a framework to study accuracy and delay in the ED. The Donabedian model has been presented, and its usefulness to examine healthcare work processes, specifically ED RN triage of the patient with symptoms suggestive of AMI, has been discussed. Key concepts have been identified and strengths and limitations analyzed. The theoretical framework of structure-process-outcome (Donabedian, 1980) was used to investigate ED RN triage accuracy and delay and the relationship to patient and RN characteristics.

CHAPTER II REVIEW OF LITERATURE This review of the literature includes a discussion of previous research investigating accuracy of ED RN triage level designations and delay in ED care. Patient characteristics as well as RN characteristics in relation to patient care have been identified in studies and are discussed in this literature review. A discussion of symptom presentation differences addressed in nursing research studies is included in this review. Accuracy Rates in Triage Kosowsky, Shindel, Liu, Hamilton, and Pancioli (2001) hypothesized that ED triage RNs would be able to identify patients whose condition was serious enough to warrant hospital admission. Triage RNs were asked to predict during the triage process which patients would be admitted. RNs (N = 39) in the study had a 62% accuracy rate in predicting general hospital admission. The researchers found that RNs were only able to identify patients who were ill enough to need a critical care bed admission 50% of the time. Arslanian-Engoran (2004) also examined accuracy of the ED triage RN in a study predicting hospital admission. Registered Nurses (N = 13) in the study exhibited poor accuracy with a 58% sensitivity and failed to identify acute coronary syndrome (ACS) in 44% during triage of patients who were admitted with a diagnosis of ACS. Holdgate, Morris, Fry, and Zecevic (2007) examined accuracy of triage RNs in predicting hospital admission in 1,342 triages. RNs in the study had a 76% accuracy rate, but in 36% of the cases, the ED RN did not answer the prediction question, leading one to surmise that the 15

16 RN was unsure. The accuracy rate for patients in the study with cardiovascular disease was only 59%. In a study of US trends and predictors of wait times, Wilper et al. (2008) found that 30% of patients with a diagnosis of AMI had an incorrect triage level designation. The study retrospectively analyzed National Hospital Ambulatory Medical Care Survey (NHAMES) data pertaining to 92,173 adult visits to EDs from 1997-2004. Considine, Ung, and Thomas (2000) in a study of RN (N = 31) consistency in triage level designation noted a 58% accuracy rate when scoring 10 written vignettes. In a study comparing paper versus computer vignettes to test ED triage RN performance, Considine, LeVasseur, and Villanueva (2004) found an overall accuracy rate of 61% when RNs (N = 322) scored written vignettes (N = 4,614) depicting all types of illnesses in adult and pediatric cases. Atzema, Schull, and Tu (2011) identified an accuracy rate at triage of 67.6% in patients (N = 680) with AMI who also happened to have a charted history of depression. In a study of ED RN accuracy in triage level designation, Goransson, Ehrenberg, Marklund, and Ehnfors (2005) noted a mean accuracy rate of 57.6%, with a range of 2289% accuracy per RN (N = 423) in responding to written vignettes (N = 7,550) using CTAS. In a retrospective review of electronic medical records (EMRs), Atzema, Austin, Tu, and Schull (2009) investigated triage accuracy in the care of patients with AMI (N = 3,088) and identified a 50% accuracy rate. In a study of 55 RNs and emergency medical technicians (EMT), Wuerz, Fernandes, and Alarcon (1998) found poor interrater agreement ( k = 0.347) in deciding triage levels using a 3-level ESI scale in five written vignettes. In test-retest reliability,

17 participants scored five vignettes initially and the same five vignettes 4 to 6 weeks later with only 24% of the participants assigning the same triage level at time 2. In studies testing the reliability, validity, and inter-observer agreement of specific triage scales, researchers found inaccuracies and inconsistencies. In a study testing agreement using the CTAS, Manos, Petrie, Beveridge, Walter, and Ducharme (2002) noted a good inter-rater agreement (k = 0.77). In the study, five RNs, five physicians, five EMTs, and five paramedics scored 41 vignettes with an accuracy rate of 63.4%. In a study testing reliability of triage using CTAS (Worster, Sardo, Eva, Fernandes, & Upadhye, 2007), researchers compared written vignettes versus direct observation of triage. RNs (N = 9) triaged a total of 90 patients while being observed (Time 1) and triaged the exact scenario 6 months later (Time 2) by written vignette. Triage level assignment was found to be significantly different from Time 1 to Time 2 with a higher triage level scored on the written vignette. It is possible that RNs assign a higher ED triage level score when there is more time to make a decision than during live triage of actual patients. Numerous studies have identified inaccuracies in triage level designations and an inability of the ED triage RN to consistently identify patients with emergent symptoms. Accurate triage level designations by the ED triage RN determine how rapidly a patient receives medical care in the ED, that is, whether or not the patient is taken straight to a treatment area or sent back to the waiting room. However, current nursing research has continued to identify inaccuracies in triage RN decisions. Urgent cases assigned nonurgent status put patients at risk for delayed treatment and poor outcomes. In the field of cardiac emergency care, specifically AMI, the consequences can be permanent cardiac

18 muscle damage and even death. Patients are sometimes judged not to have a medical emergency when one exists. When this occurs, the patient is said to be under-triaged, meaning the patient was assigned a lower triage level than is actually warranted. Patients are also over-triaged, assigned a triage level higher than necessary, which may cause a stable patient to be seen ahead of a patient with a medical emergency and fill treatment areas needed for those emergent patients. A large portion of these studies identified a descriptive method of exploration to identify the degree of accuracy at triage without an attempt to investigate the source of inaccuracies. Atzema et al. (2009), however, used a correlational design investigating a possible association between inaccurate triage and delay in care of patients with AMI. Atzema et al. investigated the accuracy of triage as a possible factor in delay of care for patients with AMI (N = 3088) in a total of 87 EDs. Of the patients, 50% were assigned a lower triage score of Level 3, 4 or 5. Median door-to-ECG time was 12 minutes, with only 45.9% of patients having an ECG within 10 minutes. Time from arrival to thrombolytic medication administration, also called DTN time, was 40 minutes with only 35.6% of patients care meeting the DTN goal time of 30 minutes. Incorrect triage level designation was found to be significantly associated with delay in door-to-ECG and DTN time. Delay in Emergency Care Delay in care of patients with cardiac symptoms is determined by assessing the time of arrival, the time of triage, the time of ECG completion, and the time of assessment by a physician or other healthcare provider. The standard for emergency cardiac care, set by ACC/AHA guidelines, is an ECG obtained within 10 minutes of

19 arrival to an ED. In a study of adherence to ACC/AHA guidelines for AMI care, ED RNs were asked if they initiated specific steps in the rapid care of patients with symptoms suggestive of AMI (Arslanian-Engoren, Eagle, Hagerty, & Reits, 2011). The participants (N = 158) were specifically asked about nine steps that together make up the ACC/AHA AMI guidelines. Questions about the guidelines included items such as rapid ECG, intravenous (IV) access, lab work, minutes to cardiac catheterization, oxygen and aspirin administration. Only 27% of the participants stated they initiate all nine steps every time. ODonnell, Condell, Begley, and Fitzgera ld (2005) investigated delays in ED care of patients with AMI (N = 890). Several points of care were assessed and times identified: door to triage, 6-7 minutes; triage to first medical assessment, 10-19 minutes; door to first medical assessment, 20-30 minutes; first medical assessment to thrombolytic medication administration, 31-45 minutes; and DTB, 103-148 minutes. There are no specific time frames for the first four steps identified; however, the DTB guideline is < 90 minutes. Delays of even a few minutes at the first points of care will generate an overall delay in DTN and DTB and must be avoided. Weber, McAlpine, and Grimes (2011) noted unsafe delays in high-acuity patients (N = 3,932) who were assigned a Level 1 or Level 2 triage designation. Less than half completed the triage process in an appropriate time frame of 10 minutes or less and 35% spent >20 minutes in the overall triage process, both waiting to be triaged and during the triage process itself. Venkat et al. (2003) investigated delay in handling a patient with a chief complaint of chest pain when presenting to an ED. A registry of patients (N = 7,935) with chest pain was used to generate the sample. ECG within 10 minutes of ED presentation was successfully met in approximately 30-40% for patients with AMI and in

20 approximately 33% of patients with unstable angina or non-STEMI. In a study of 63,478 patients (Diercks, Peacock, et al., 2006) found ECG delay in 65.2% of the sample with a median delay of 25 minutes. Pearlman, Tanabe, Mycyk, Zull, and Stone (2008) conducted a study of patients presenting to an ED with a chief complaint of chest pain ( N = 214). Median ECG time was noted to be 29 minutes (intra-quartile range 17-52 minutes). In a secondary analysis of 425 patients (Zegre-Hemsey, Sommargren, & Drew, 2011), researchers reported that only 41% of patients with ischemic symptoms received an ECG within 10 minutes. Delays other than the ECG window are important to investigate as the factors influencing each point of care may differ. These points of time are minutes waiting to be seen by the triage RN, triage to first physician assessment, and time to aspirin administration. Few researchers have conducted studies in these areas. Only ODonnell, et al. (2005) investigated some of these specific times in delay of ED care in the triage of patents with AMI. In this study, at several points of care, gender-based delays were identified; however, triage levels were not identified nor were possible inaccuracies leading to these delays addressed. Atzema et al. (2009) did specifically investigate the association between inaccuracy and delay at two specific time points in a secondary analysis. The odds of achieving the goal of less than 10 minutes to ECG and less than 90 minutes to PCI were 0.54 and 0.44, respectively, and were independently associated with an inaccurate triage level assignment. These odds are troubling in the care of patients with AMI and require further research into the contributing factors. Wilper et al. (2008) conducted a secondary analysis of NHAMCS data, which included 92,173 adult visits to EDs from 1997-2004. Mean wait time to see a physician

21 was 27 minutes for patients with AMI and 23 minutes for overall Level 2 patients. In a study investigating wait times to see a physician in over 151,000 patients (Horwitz & Bradley, 2009), the median wait time to see a physician for Level 1 and Level 2 patients combined was 15 minutes. Only 48% of patients in this combined emergent category were seen in the appropriate amount of time. Patient Characteristics Patients with symptoms suggestive of AMI are experiencing delays in treatment in EDs (ODonnell et al., 2005). Factors including gender, age, race/ethnicity, socioeconomic status (SES), and other factors have been reported in the literature. In a study by Diercks, Peacock, et al. (2006), the sole predictor of delay in obtaining an ECG in the ED in patients with non-ST-elevation ACS was female gender. African American patients of both genders and Caucasian women experience greater delays in ECG obtainment (Blomkalns et al., 2005; Diercks, Kirk, et al., 2006; ODonnell et al., 2005; Pearlman et al., 2008; Takakuwa, Shofer, & Hollander, 2006; Zegre-Hemsey et al., 2011), aspirin administration (Blomkalns et al., 2005; Enriquez, Pratap, Zbilut, Calvin, & Volgman, 2008; ODonnell et al., 2005), initiation of PCI (Kaul, Chang, Westerhout, Graham, & Armstrong, 2007; ODonnell et al., 2005; Roger et al., 2000), thrombolytic therapy (Blomkalns et al., 2005; Roger et al., 2000), hospital admission (ArslanianEngoran, 2001; Kaul et al., 2007; ODonnell et al., 2005; Pope et al., 2000), and administration of beta blockers and statin drugs (Blomkalns et al., 2005; Enriquez et al., 2008). The possibility that RNs include patient characteristics during the assignment of triage level designations was not examined in these studies for a possible relationship to accuracy and delay.

22 Investigation of accuracy and delay related specifically to ED RN triage level designations based on patient characteristics are minimal, with only two studies addressing these issues. In the first regarding delay in the ED, ODonnell et al. (2005) reported a significant difference in length of time spent by the RN in triage based on patient gender with ED RN triage taking twice as long for women. In the second, Arslanian-Engoran (2001) investigated accuracy using written vignettes and found a significant difference based on gender and age. The 43 year old female patient vignette was less likely to be given an urgent triage level designation compared to the 43 year old male patient vignette or the 66 year old patient vignette of either gender despite evidence of the same symptoms suggestive of AMI. Studies were identified that investigated age as a possible factor in ED RN triage accuracy and delay. Arslanian-Engoren (2000) conducted focus group sessions with ED RNs and found that RNs held different perceptions based on the age of the patient. Age biases were identified ranging from considering the patient over 70 years old to be more believable to being more skeptical of symptoms in a younger patient. RNs in these focus groups admittedly did not consider AMI as a first diagnosis in middle-aged women despite presenting symptoms. In a study attempting to identify predictive factors influencing triage level designation during RN-patient triage interactions (N = 334), Garbez, Carrieri-Kohlman, Stotts, Chan, and Neighbor (2011) found age of the patient was a significant factor (p = 0.013) influencing triage level designations. Participants (N = 18) in that study completed a survey immediately after each triage selecting factors used in the triage decision. No data is given as to which age group influenced the nurses decisions in triage level designations. Platts-Mills et al. (2010) identified triage

23 inaccuracies in a study of triage accuracy in the elderly population, defined as the > 65 age group, with only 57.7% of those needing immediate lifesaving measures being assigned a Level 1. Platts-Mills et al. cited high rates of comorbidities and triage by proxy, i.e., obtaining information from a family member instead of the patient, as reasons for possible incorrect triages of the elderly. Pope et al. (2000) found patients were less likely to be hospitalized if they were less than 55 years old and nonwhite. In fact, the risk of being sent home despite an AMI was 4 times higher for nonwhite patients. Pearlman et al. (2008) investigated gender, age, and race/ethnicity in door-to-ECG times for patients with chest pain and found a median delay of 29 minutes overall. No significant difference was found in gender and race/ethnicity, but door-to-ECG time was significantly greater (p = .002) for patients in age categories of 18-39 and 40-59. This might be expected in the younger age group but not in the 40-59 age category, as the incidence of AMI is greater in this age group. In a recent study of cardiac triage decision-making (Arslanian-Engoren, 2009), RNs were found to hold cultural biases and stereotypes. Specific cues utilized in triage decision-making included past medical history, patient demographics, attitudes, perceptions, cultural beliefs, and the specific complaint of chest pain. Using focus group methodology, the researcher reported that statements elicited from RNs (N = 12) reflected a lack of believing the patient and doubting what the patient told the triage RN. Also reported was the notion that females who took time to apply makeup prior to the ED visit caused the RN not to consider the symptoms as being serious in nature. This suggests that the RN does not trust the female patient to be truthful in reporting symptoms or that the symptoms were not sufficiently severe to initiate an immediate patient response.

24 RN Education, Experience, and Triage Studies investigating the RN role in patient care outcomes identify RN education level and years of experience as two main variables of interest. Benner and Tanner (1987) hypothesized that the novice RN is hesitant and slow in assessment of patients in their care, and the experienced RN is rapid and fluid in problem solving in patient situations. Although Benners work (Benner, 1984) emphasized stages of knowledge from novice to expert, it is unclear whether these stages influence ED triage accuracy. In a study of RN staffing models in Canada, researchers found that the less experienced the RN, the higher the number of wound infections (McGillis-Hall, Doran, & Pink, 2004). In examining structures and processes of patient care for 46,993 patients in Canada, Tourangeau et al. (2007) found a higher percentage of bachelor of science in nursing (BSN) staff associated with lower 30-day mortality rates. The correlations between increased RN education and decreased mortality rates were also noted in an analysis of Canadian hospital outcome data for 18,142 patients (Estabrooks, Midodzi, Cummings, Ricker, & Giovannetti, 2005). Aiken, Clarke, Cheung, Sloane, and Silber (2003) investigated the association between RN educational preparation and patient outcomes in a study of 168 U.S. hospitals. Data indicated that as the percentage of nurses with BSN degrees increased, patient mortality decreased; however, years of experience in nursing was not found to be associated with decreased mortality. In a study of ED RN triage decisions, Arslanian-Engoran (2004) found no association between years of experience and triage accuracy. Registered Nurses in the study were said to be at the expert level with a mean 12 years of experience. As this was a small convenience sample (N = 13), the results must be interpreted with caution.

25 Studies testing experience level and the possible association to accuracy with a larger participant sample are warranted. In a national survey of 69 EDs in Sweden, Goransson, Ehrenberg, and Ehnfors (2005) found that qualifications to perform in the triage role varied greatly from basic nursing training to special education sessions about triage. In fact, 87.5% of the EDs surveyed had no special requirement or training when assigning RNs in the triage role for the shift. These researchers reported that only 3 (4.3%) of the 69 EDs in their study reported criteria limiting new graduate RNs from being in the triage role. Once the degree of training was surveyed, the authors attempted to identify a relationship between accuracy of ED triage and RN characteristics of education, age, and experience. Goransson, Ehrenberg, Marklund, and Ehnfors (2006) noted an accuracy rate of 57.6%, with a range of 22-89% accuracy per RN (N = 423) responding to written vignettes using CTAS. The researchers were unable to identify a relationship between RN age, triage education, years of experience in general nursing or emergency nursing, and accuracy of ED triage. A limitation of the study was that CTAS was not part of the daily practice of the RNs in this Swedish study. Worster et al. (2004) found experience was not related to consistency in triage level designations in a study of 10 Canadian RNs who scored 400 scenarios, half using the ESI scale and half using the CTAS scale. The ESI group had more years of experience (M = 25.2 v. 14.4) but triaged with the same degree of consistency as the CTAS group (kappa = .91 and .89 respectively). A limitation of this study was that none of the RNs were experienced in using the ESI 5-level triage system, as it was not part of

26 their daily practice. Actual accuracy of triage level designation decisions was not identified, only consistency. Considine et al. (2000) hypothesized that if a triage scale is valid, a patient should be triaged to the same level designation regardless of which RN is assigning the triage level. The researchers found a 58% accuracy rate among 31 RNs in two Australian EDs using the National Triage Scale. Despite 35.5% of the participants being either an ED CNS or ED manager, no correlation was identified between accuracy and years of experience. Educational preparation was also assessed in a secondary analysis (Considine, Ung, & Thomas, 2001) and the researchers noted a positive correlation between BSN-degreed RNs and accuracy; however, no significant relationship was found between accuracy and ED training or critical care training. The sample size was small (N = 31). Correlations between educational preparation and triage accuracy need to be tested in larger samples of participants. Symptom Presentation The AHA and the National Heart, Lung, and Blood Institute (NHLBI) provide a description of a classic AMI as central chest discomfort that may be described as pressure, fullness, squeezing, or pain with radiation to the arms, neck, jaw, back, and abdomen. These symptoms may be accompanied by shortness of breath, nausea, lightheadedness, and sweating (AHA, 2010; NHLBI, 2010). The ED triage decision is made more difficult because patients present with varying symptoms, some considered to be typical of AMI and some atypical. The patient that presents with a classic set of signs and symptoms suggestive of a heart attack (i.e., clutching the chest, short of breath, pale, and diaphoretic), will undoubtedly get the attention of the ED triage RN. This immediate

27 recognition of an AMI will generally result in an accurate triage level assignment and a rapid ECG, a cardiac monitor, and evaluation by an emergency physician. As previously noted, not all patients present with easily recognizable symptoms and are seen so rapidly. Previous studies have found the incidence of a classic set of symptoms during an AMI to be as low as 67% (Canto et al., 2000; Gupta, Tabas, & Kohn, 2002; Horne, James, Petrie, Weinman & Vincent, 2000). It is concerning that patients without classic symptoms may be inaccurately triaged. A recent study of symptoms of AMI found shortness of breath, weakness, and fatigue as the most frequently occurring acute symptoms in women (McSweeney et al., 2010). Also identified were racial differences, with 15 symptoms differing significantly (p = .001) by race/ethnicity after adjustment for cardiovascular risk factors. The symptoms were unusual fatigue, dizzy or faint, flushed, indigestion, heart racing, numbness in hands, vomiting, loss of appetite, new vision problems, headache, coughing, choking sensation, and pain in 10 specific sites. African American women reported more flushing and indigestion. Hispanic women had the highest rates of pain in all body locations. Studies identifying gender-specific symptoms in ACS are noted in the literature (DeVon, Ryan, Ochs, & Shapiro, 2008; McSweeney, Cody, & Crane, 2001; McSweeney, et al. 2003). Further studies included (a) differences in the symptoms between unstable angina (UA) and AMI (DeVon, & Zerwic, 2004), (b) symptom differences in patients with and without diabetes in UA and ACS (DeVon, Penckofer & Larimer, 2008; DeVon, Penckofer, & Zerwic, 2005), and (c) symptom clusters in AMI (Ryan et al., 2007). DeVon and Zerwic (2003) found females with UA to have significantly higher rates of

28 reported weakness, nausea, shortness of breath, anorexia, and upper back pain. Patients with UA and diabetes were noted to have less nausea, less squeezing, and less aching pain (DeVon et al., 2005). Older diabetics reported less pain and more fatigue (DeVon, Penckofer, et al., 2008). Atypical (or less typical) symptoms may impact triage decisions (Albarran, Clarke, & Crawford, 2007; Arslanian-Engoran et al., 2006; Carmin, Ownby, Wiegartz, & Kondos, 2008; Dorsch et al., 2001) highlighting the complexity of patient assessment and the variations in individuals. Symptoms are frequently attributed to another less serious cause such as the presence of neck and back pain as reported by women in a study by McSweeney et al. (2001). In studies about unstable angina and acute myocardial infarction, DeVon and Zerwic (2003, 2004) identified symptoms of ACS which were used in this study: chest pressure, chest discomfort, chest pain, shoulder pain, arm pain, upper back pain, lightheadedness, shortness of breath, sweating, unusual fatigue, nausea, palpitations, and indigestion. Patients frequently present with symptoms that are not classic, potentially making triage level designations more complex and prone to inaccuracies. Summary Disparities in emergency cardiac care and diagnostic treatments related to gender, age, and race/ethnicity exist but have not been investigated thoroughly in relation to ED RN triage level designations. Studies identify limited accuracy in triage level designations and the inability of the ED triage RN to consistently identify the patient with symptoms of possible AMI. Studies thus far have not examined the relationships between delay in care and accuracy of triage decisions, coupled with patient characteristics.

29 Further studies investigating RN education, experience, and accuracy of triage level designations are needed. Numerous studies exist that examine differences in rapid cardiac care from time to ECG to the administration of aspirin to cardiac interventional procedures. However, few studies were identified that included inaccurate RN triage level designations as a contributor to delay. The rapid, accurate triage of patients with symptoms suggestive of AMI remains a challenge in emergency care. There is a need to investigate delay and inaccuracy of triage decisions to decrease patient wait time for urgent symptoms, improve morbidity and mortality of patients with AMI, and possibly lead to changes in ED triage RN educational preparation and training.

CHAPTER III METHODOLOGY This chapter introduces the research design and methodology. The study setting and sample are described. Measures, instruments, and variables are identified. Procedures used to collect data and methods used to protect human subjects are addressed. Research Design This study of ED RN triage was a correlational study using retrospective data from EMRs. The relationships between (a) patient characteristics (gender, age, race/ethnicity, symptom presentation), RN characteristics (age, years of experience, years of ED experience, and education), and (b) delay in ECG obtainment and accuracy in triage level designations made by ED triage RNs were examined. The dependent variables were accuracy of triage level designations, time to triage, and time to obtainment of ECG. The independent variables were patient characteristics (gender, age, race/ethnicity, symptom presentation), RN characteristics (age, years of experience in nursing, years of experience in ED nursing, and education level). Setting EMRs from a regional healthcare system in the southeast were used to generate the data needed for this study. The study was conducted at a 660-bed general acute care not-for-profit health system operating EDs at two separate geographical locations, designated Site 1 and Site 2 for purposes of this study. At the time of this study, Site 1

30

31 employed 55 ED RNs and logged approximately 50,000 ED visits a year. Site 1 is only blocks away from a Level 1 trauma center ED reporting a high volume of uninsured patients. At the time of this study, Site 2 employed 37 ED RNs and logged about 32,000 ED visits a year. Site 2 advertised heavily as a heart hospital and boasted of delivering rapid cardiac care. Combined, the two sites averaged approximately 2,200 AMI/ruled out AMI patients per year. Protocol at the sites dictated that the charge RN at the start of the shift assigns RNs to the triage role, with both sites generally assigning the same RN each shift. New RN graduates are not assigned to the triage role until each has gained 1 year of experience. Before they are assigned triage roles, new graduates receive triage training from an ED educator as well as hands-on experience with their preceptor. Licensed practical nurses (LPNs) were not employed in either ED. Paramedics, who were employed in one of the two EDs, did not perform in the triage role. Both facilities had a line of patients waiting to be triaged at most times of the day and night. Sample Inclusion criteria for the selected medical records included (a) patients with symptoms suggestive of AMI and (b) patients ages 21 years of age and older. Exclusion criteria include (a) patients who were in critical condition, required immediate intubation, or had a severely altered level of consciousness; (b) patient records indicating triage by an RN orienting in the role; (c) patients arriving via ambulance; and (d) patients with a documented traumatic event. Some patients were excluded from this study. Patients in critical condition, requiring immediate intubation, or those with a severely altered level of consciousness require immediate assistance and triage is deferred. Patients triaged by a RN orienting

32 with another RN is not the standard triage situation. Having two RNs triaging a patient may change the outcome. Patients who arrive via ambulance are triaged immediately and may be assigned an urgent level during the triage assessment solely based on mode of arrival. Patients with a documented traumatic event also were excluded, as the source of their symptoms is typically thought to be traumatic in nature rather than cardiac. Based on calculations for determining sample size suggested by Field (2005), with nine predictor variables, a minimum sample size of 113 was necessary to test individual predictors in this study. A medium effect size was chosen for this study based on the earlier described literature review of studies investigating accuracy in triage and delay in ED care. Online power analysis calculation (Soper, 2004) using a maximum of nine predictor variables, a medium effect size, and an alpha of < 0.05, with a power of 0.80, also confirmed a minimum sample size of 113 patient triages were needed for the study. Retrospective data were collected going back approximately 4 months prior to the month of data collection. No ED documentation system updates occurred during that time period. Measures and Instruments Abstraction of data from the EMR was chosen as the method to capture data pertaining to time points of care in ED triage and care of patients with symptoms suggestive of AMI as well as patient demographics. A convenience sample of patient EMRs was used to obtain variables related to ED triage taken from a general acute care health system operating two separate EDs. To pull EMRs, the director of health information systems provided a query with the following criteria: (a) the date of the ED patient visit was in the 4-month time period prior to data collection and (b) the presenting

33 complaint was chest pain or discomfort, shortness of breath, weakness, nausea, vomiting, syncope, palpitations, or diaphoresis. Variables of Interest Variables of interest (patients chief complaint, final diagnosis, triage level assigned, patient gender, patient age, patient race/ethnicity, triage RNs name, and clock times at specific points of care) were obtained from data abstracted from the EMR (see Table 2). Information regarding RN characteristics was obtained via the RN demographics tool (RNDT; see Appendix A), which was completed by participating RNs. The triage level designation decision was the main unit of measure, not the specific ED triage RN, so that each triage level designation stood alone. Triage level designations from EMRs were investigated in this study. Accuracy Accuracy was determined based on whether or not a patient with symptoms suggestive of AMI was assigned a Level 2 triage designation. Delay was identified as actual clock time in minutes from arrival until triage and ECG obtainment with delay designated as greater than 10 minutes. The clock time was the time recorded by various personnel in the EMR. Other possible delay points such as minutes to physician assessment also were collected. Also collected during the EMR review was day of the week, time of day, and shift. Symptoms Suggestive of AMI Symptoms suggestive of AMI, for purposes of this study, were defined as those symptoms as defined by Hollander et al. (2004) which included chest discomfort or pain, shortness of breath, weakness, nausea or vomiting, syncope, palpitations, and diaphoresis.

34 Table 2 Data List

Datum Patient Day of visit to ED Chief complaint Co-morbidities Triage level designation Gender Age Race/ethnicity Marital status Payor source Time of arrival Time of triage Busyness of unit Time of MD assessment Time of ECG Registered Nurse Name Gender Age Race/ethnicity Education Years of experience Years of ED experience First and last name Male, Female Continuous ages 1-5 Diploma, ADN, BSN, MSN Actual years Actual years Nominal Nominal Interval Nominal Categorical Interval Interval Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday As defined by Hollander et al. (2004) Diabetes, heart disease, obesity, smoking 1, 2, 3, 4, 5 Male, Female Continuous ages 1-7 Single, Married, Widowed, Divorced 1-5 Clock time as entered in EMR at first point of contact Clock time as entered in EMR Minutes from arrival time to triage time Clock time as entered in EMR Clock time as entered in EMR and ECG Nominal Nominal Nominal Ordinal Nominal Interval Nominal Nominal Nominal Interval Interval Interval Interval Interval Measure Type of measure

Note. ED = emergency department; MR = electronic medical record; MD = medical doctor (physician); ECG = electrocardiogram; AND = associate in nursing degree; BSN = bachelor of science in nursing; MSN = master of science in nursing.

35 EMRs indicating a patient presentation of any of these symptoms, in the absence of trauma, were considered for this study. It was expected that the patients chief complaint might be one or more of these symptoms. It was also expected that the vague symptoms of nausea and vomiting might be, in fact, a gastrointestinal complaint and possibly not a cardiac event. Triage Level Designation The triage level designation was the level assigned by the ED triage RN during the triage process. Triage levels were coded as Level 1, critical; Level 2, emergent; Level 3, urgent but stable; Level 4, nonurgent; and Level 5, minor (Gilboy et al., 2005). The triage level designation determines which patient is seen next and whether immediate treatment will be initiated or if the patient will be asked to wait in the waiting room. Patients presenting with symptoms suggestive of AMI must have been given a triage Level 2 designation. If this did not occur, the triage level designation was coded as inaccurate for the purposes of this study. This dependent variable was dichotomously coded as yes (accurate) or no (not accurate). Because the ED triage RN is unable to determine for certain, at the point of first contact and without an ECG, whether a triaged patient truly has a cardiac diagnosis such as AMI, the end diagnosis was not considered as a variable in this study. Only presenting symptoms were considered. Patient Characteristics Gender was recorded as male or female, and age of the patient was recorded in years. Race/ethnicity was recorded in one of the following seven categories as designated by Health Information Systems of the participating site: Caucasian, African American, American Indian/Alaskan Native, Asian, Hispanic or Latino, multiracial, or unknown.

36 Other demographic information collected during the EMR review included payer source and marital status. Co-morbidities such as diabetes, obesity, smoking status, and previous heart disease also were collected. RN Characteristics The registered nurse demographics tool (RNDT; Appendix A) created by the researcher was used to collect RN characteristics: gender, age, race/ethnicity, years of experience in nursing, years of experience in ED nursing, and education level (assessed as the highest degree in nursing obtained at the time of participation in the study). The RNDT included a tear away portion to separate the RN demographic information from the participants name, providing a sense of privacy and confidentiality. Delay Time points of care included time of arrival to the ED, time to triage, time to ECG, and time to physician assessment. All times were recorded in minutes using military time notation. The time of arrival in the ED was documented automatically when the patients name was entered into the computer system at the walk up desk in the ED lobby. Time to ECG was calculated by subtracting the time of arrival from the time electronically stamped on the ECG itself. If the electronically stamped ECG time was different from the time charted in the EMR by the ED staff, the ECG stamp was the accepted time for this study. Time to physician assessment was obtained from the physicians handwritten first notation documented during that first patient interaction. If the physician did not note the time of assessment, then the time documented in the computer was used. Data Collection

37 Once institutional review board (IRB) approval was received from both the healthcare system and Georgia State University, the director of health information management provided a list of patient records to review for possible study inclusion. An electronic data file was created to hold all data abstracted from the EMR. A working copy was made of the database. No identifying information was recorded in this working file. Data abstracted from the EMR included patient gender, age, race/ethnicity, mode of arrival, and reason for ED visit as well as times associated with arrival to the ED, triage by the RN, ECG performed, and physician evaluation. Triage level designation assigned as well as the name of the triage RN were collected during the EMR review. RN demographics were linked to the initial data file. Once the list of RN names was available, consent was obtained from participating RNs. A flyer was posted in both EDs, and a locked box was placed in the area as a receptacle for the completed surveys and informed consent documents. The study topic, research aims, and risks and benefits of the study also were discussed at several staff meetings. Each consenting RN completed the RNDT, which took approximately 2 minutes per RN. The researcher was given a separate cubicle in the medical records department as a private place to access the computer system for the purposes of collecting variables for this study. Between May 2011 and June 2011, 559 records were reviewed. Dates of ED visit were from January 1, 2011 thru May 7, 2011. Records indicating that the patient arrived by ambulance were excluded, which removed 175 records. An additional 98 records were excluded due to the chief complaint being other than cardiac in nature, such as syncope related to seizure, asthma exacerbation, and chest pain due to trauma. The remaining 286 records were included in this study, and data were recorded on the RNDT

38 for analysis. The triage level designation decision was the main unit of measure (i.e., not the specific ED triage RN) so that each triage level designation stood alone. Triage level designations from 286 EMRs were investigated in this study representing 40 triage RNs. An even distribution of triage level designations among the RNs was not the goal of this study. Data Analysis After collecting data for this study, the researcher conducted various analyses. In order to describe the variables, the researcher first conducted descriptive statistics on both the patients and the nurses. Frequencies and percentages were calculated for the patient characteristics gender, race/ethnicity, marital status, and medical history (smoker, body mass index [BMI], diabetes, previous cardiac disease, chest pain triage). Means, standard deviations, and ranges were calculated for the RN characteristics age, years of experience, and years of ED experience. The researcher then conducted inferential statistics. These analyses included Pearsons correlations and logistic regression. Protection of Human Subjects Selected data were coded and entered into an electronic data file. Patient and RN identifiers were kept confidential. Information was kept private to the extent allowed by law. There was no compensation for RNs participating in this study. All RN and patient identifier information were removed from the data, and unique case numbers were assigned to data so that no actual patient or RN names were on study records. The data were stored in a locked file cabinet in the office of the researcher and on a computer with password and firewall protection. Only the researcher had access to the uncoded data. The confidentiality of patients, clinicians, and institutions was maintained.

39 Summary The purpose of this study was to explore the relationship between (a) patient characteristics (gender, age, race/ethnicity, symptom presentation), (b) RN characteristics (age, years of experience, years of ED experience, and education), (c) accuracy of ED RN triage level designations, and (d) delay of care of patients with symptoms suggestive of AMI. Specifically, the aims of this study were to determine the predictive nature of (a) patient and RN characteristics on the accuracy of ED RN triage level designations of patients with symptoms suggestive of AMI, and (b) patient and RN characteristics, and accuracy of ED RN triage level designations on delay of care of patients with symptoms suggestive of AMI. Exploration of this relationship was conducted via retrospective EMR review and data abstraction from one hospital system in the Southeastern US operating two EDs. RN demographic information was collected via survey, the RNDT, after obtaining written consent and confidentiality was maintained.

CHAPTER IV RESULTS The purpose of this study was to explore the relationship between (a) patient characteristics (gender, age, race/ethnicity, symptom presentation), (b) RN characteristics (age, years of experience, years of ED experience, and education), (c) accuracy of ED RN triage level designations, and (d) delay of care of patients with symptoms suggestive of AMI. Specifically, the aims of this study were 1. to determine if patient characteristics (gender, age, race/ethnicity) and RN characteristics (age, years of experience, years of ED experience, and education) predict accuracy of ED RN triage level designation of patients with symptoms suggestive of AMI, and 2. to determine if patient characteristics (gender, age, race/ethnicity, symptom presentation), RN characteristics (age, years of experience, years of ED experience, and education), and triage level designation predict delay of care of patients with symptoms suggestive of AMI. Data were obtained from the EMRs of a health system in a Southeast region of the US. In this chapter, preliminary screening procedures and results are described. Following that, a description of the sample and the variables used in the study are presented. In the last section, results are elucidated.

40

41 Preliminary Screening Procedures Descriptive statistics, frequencies for the categorical variables, and descriptives for the continuous variables were calculated to determine (a) whether there were missingvalues and (b) the distribution of the data. A 2-tailed p value of .05 was considered significant in all analyses. Predictive Analytics Software (PAWS; Version 18.0) software package for statistical analysis was used for all analyses. There were 92 RNs listed as staff members in the two EDs at the time of the study. However, only 66 of the RNs in the two EDs were identified in EMRs selected for inclusion in the study. Of those, 40 RNs consented to participate, giving an overall response rate of 60.6%. The final sample of 40 RNs consisted of 28 females (70%) and 12 males (30%). The triage level designation decision was the main unit of measure (i.e., not the specific ED triage RN), so that each triage level designation stood alone. Triage level designations from 286 EMRs were investigated in this study representing 40 triage RNs. An even distribution of triage level designations among the RNs was not the goal of this study. Of the nurses who agreed to participate (N = 40), the range of triages conducted was 1 to 22, with five RNs in the study triaging 10 or more patients (range 10-22). For a portion of Aim 1, considering nurse demographics, the total sample was 192 EMRs; for the remainder, considering accuracy and delay and patient demographics, the total sample of EMRs was 286 (see Appendix B). There were missing values for the following RN characteristics: ethnicity, education, age, years of experience, and years of ED experience. Accordingly, Littles Missing Completely at Random (MCAR) test was conducted to determine whether the pattern of missing data was random or systematic. Results indicated that the pattern was

42 missing at random (2 (3) = 4.17, p = .243). In addition, cross-tabulation procedures between cases with and without missing values and the dependent measures were all nonsignificant. Values for the continuously measured variables were thus imputed using the expectation-maximization method (Tabachnick & Fidell, 2007). The distributions of the variables measured on either an interval or ratio scale were assessed for normality by inspecting histograms and skew indices, i.e., skewness statistic/SE. When the distribution of the variable resembles a normal curve (Tabachnick & Fidell, 2007) and its skew index is below three (Kline, 2005), then the distribution is deemed to be normal. As seen in Table 3 and in Figures 3 and 4, the distribution of the minutes to triage was highly skewed as was years of ED experience (see Table 3, Figures 5 and 6). Accordingly, these two variables were transformed using the natural log function (Tabachnick & Fidell, 2007). After the variables were transformed, the skew indices fell below three (see Table 3). The transformed variables were used in subsequent inferential analysis although descriptive statistics are reported in their original metric to facilitate interpretation. All continuously measured variables were standardized. Cases whose standardized values fell above the absolute value of 3.29 were identified as outliers (Tabachnick & Fidell, 2007). Three cases had extremely low standardized values for RN experience in the ED (z-score for each case was -3.40) and thus were deleted from the data set.

43 Table 3 Skewness and Kurtosis Statistics Variable Patient Age Minutes to triage Minutes to triage (transformed) Registered nurse Age Years of experience Years of ED experience Years of ED experience (transformed) .04 -.03 1.28 -.348 .34 -1.49 .48 8.89 2.42 .20 3.41 .198 -.32 16.22 23.68 1.375 Skew Kurtosis Skew indices

Note. N = 286. SE for kurtosis = .29; SE for skew indices = .144; ED = emergency department.

Figure 3. Histogram for minutes to triage.

44

Figure 4. Histogram for minutes to triage (transformed).

Figure 5. Registered nurse years of experience in emergency department.

45

Figure 6. Registered nurse years of experience in emergency department (transformed).

Descriptive Statistics Description of the Sample of Patients Patients (N = 283) were between 26 and 95 years old; the mean age was 61.44 (SD + 13.02). The frequencies and percentages of the variables describing the sample of patients are displayed in Table 4. Slightly more than half of the patients were female (51.9%). The majority of patients were Caucasian (67.1%); a minority were African American (31.1%) or other ethnicity (0.8%). Most were married (59.4%), with the remaining being single (11%), divorced (14.5%), or widowed (14.1%).

46 Table 4 Patient Demographics Variable Gender Male Female Race/ethnicity Caucasian African American Hispanic or Latino Multiracial Missing Marital Status Single Married Divorced Widowed Missing Note. N = 283. 31 168 41 40 3 11.0 59.4 14.5 14.1 1.1 190 88 1 1 3 67.1 31.1 .4 .4 1.1 136 147 48.1 51.9 Frequency Percentage

Clinical characteristics of the sample are presented in Table 5. Most of the patients were non-smokers (74.6%). Just less than half of the patients had a BMI over 29 (48.1%). One third (30.4%) of the patients had diabetes, and 43.1% reported a history of cardiac disease. A majority of the patients (88.7%) reported experiencing chest pain in addition to their other symptoms at triage, which was unexpected.

47 Table 5 Patient Medical History Variable Smoker No Yes Body mass index > 29 No Yes Missing Diabetes No Yes Previous cardiac disease No Yes Chest pain triage No Yes Note. N = 283. 32 251 11.3 88.7 161 122 56.9 43.1 197 86 69.6 30.4 129 136 18 45.6 48.1 6.3 211 72 74.6 25.4 Frequency Percentage

Description of the Sample of RNs The descriptive statistics without the imputed values for the demographic variables measured are displayed in Table 6. Age of RNs (N = 194) ranged from 26 to 64 years with a mean age of 45.46 (SD + 11.72). Years of nursing experience ranged from 3 to 35 years (M = 17.96; SD + 10.43). Similarly, years of ED nursing experience ranged from 3 to 35 years (M = 10.98; SD + 8.51). As previously discussed, RN demographic data were determined to be MCAR and therefore did not affect the results of this study.

48 Table 6 Characteristics of Registered Nurses Variable Age Years of experience Years of ED experience N 194 193 194 Range 26-64 335 3-35 M 45.46 17.96 10.98 SD 11.72 10.43 8.51

The frequencies and percentages of the variables describing the sample of RNs are displayed in Table 7. The majority of the RNs were female (70.3%), and all of those whose ethnicity were reported were Caucasian. A majority had an ADN (45.6%), while the remainder had a BSN (19.1%) or were diploma RNs (3.5%). No nurses participating in the study had an advanced practice nursing education.

Table 7 Electronic Medical Record Matched Registered Nurse Demographics Variable Gender Male Female Race/ethnicity Caucasian Missing Level of education Diploma Associate degree Bachelor degree Missing 10 129 54 90 3.5 45.6 19.1 31.8 204 79 72.1 27.9 84 199 29.7 70.3 Frequency Percentage

49 Statistical Analysis Predictors of Accuracy of Triage Level Designation All patients should have been coded as a triage Level 2 (or Level 1 if truly in need of immediate resuscitation). If they were coded a Level 3, the triage was considered inaccurate. The overall accuracy rate was 54%. Aim 1 was to determine if patient characteristics (gender, age, and race/ethnicity, and symptom presentation) and RN characteristics (age, years of experience, years of ED experience, and education) predict accuracy of ED RN triage level designation of patients with symptoms suggestive of AMI. Two logistic regression procedures were conducted. RN level of education data was missing in 90 cases; therefore, only 196 cases were included in the regression model. Accordingly, two logistic regression procedures were conducted, one with level of education and one without level of education. Because level of education did not significantly predict accuracy of triage level designation, only the findings of the second logistic regression procedure (that does not include the education variable) are presented in Table 8. Patients race/ethnicity and symptom presentation and RNs age significantly predicted accuracy of triage level designation. Non-Caucasians were more likely to receive an accurate triage level designation than Caucasians (OR = 2.07, p = .010). Patients who experienced chest pain were more likely to receive an accurate triage level designation than patients who did not experience chest pain (OR = 2.55, p = .022). The older the RN, the greater the likelihood that the triage level designation was accurate ( = .07, p = .037).

50 Table 8 Accuracy of Triage Level Designation Model Variable Patient Gender Caucasian vs. non-Caucasian patient No chest pain vs. chest pain Registered Nurse Age Years of experience Years of ED experience .07 -.03 -.05 .03 .03 .27 4.34 .53 .04 1.07 .98 .95 -.37 .73 .94 .26 .28 .41 2.07 6.58 5.24 .69 2.07 2.55 B SE Wald OR

Note. N = 283. OR = odds ratio. Overall model 2 (7) = 25.44, * p = .001.

Predictors of Delay of ECG A majority of patients (82.6%) did not receive an ECG within the ACC/AHA guidelines of 10 minutes. Three logistic regression procedures were conducted to address Aim 2. Aim 2 was to determine if patient characteristics (gender, age, race/ethnicity, and symptom presentation), RN characteristics (years of experience, years of ED experience, and education), and triage level designation predict delay of ECG for patients with symptoms suggestive of AMI. RNs level of education data were missing in 90 cases. Only 196 cases were included in the regression model. Thus, a regression procedure with RNs level of education was conducted and a second procedure was conducted without the level of education variable. Because the second logistic regression procedure did not converge, a third procedure was conducted. Because the coefficient and standard error of

51 the main symptom presentation variable (i.e., chest pain or discomfort) were very high and unlikely, this variable was not included in the third procedure. Given that level of education did not significantly predict delay of ECG, only the findings of the third logistic regression procedure are presented in Table 9. The findings revealed that only the number of years spent working as a RN significantly predicted the odds of delay of ECG. The more experienced the RN, the greater the probability that there would be a delay in ECG ( = .10, p = .026).

Table 9 Delay of Electrocardiogram Model Variable Patient Age Gender Caucasian vs. non-Caucasian patient Registered Nurse Age Years of experience Years of ED experience -.05 .10 -.26 .04 .04 .39 1.59 4.98 .45 .95 1.10 .77 -.02 .35 .75 .01 .33 .40 1.65 1.11 3.58 .98 1.42 2.12 B SE Wald OR

Note. N = 283. OR = odds ratio. Overall model 2 (6) = 13.32, *p = .038.

Because chest pain was not included in the final logistic regression model, a logistic regression procedure with only the chest pain variable was conducted. This procedure still yielded very unlikely parameters. Thus, a chi-square procedure was

52 conducted to determine whether there would be a significant relationship between symptom presentation and delay of ECG. The chi-square procedure revealed that there was a significant relationship between symptom presentation and delay of ECG, 2 (1) = 7.56, p = .006. The difference between delay and no delay for those patients who did not experience chest pain was significantly higher than the difference for those patients who experienced chest pain. Accordingly, the probability that there would be a delay in ECG was higher for those patients who did not experience chest pain than for those who experienced chest pain. Predictors of Amount of Delay of Care Delay of care was defined as the number of minutes a patient waited to be triaged and the number of minutes a patient waited to have an ECG performed. Those time points are identified in Table 10. The mean time to triage was 11.78 minutes, with women waiting a mean of 14.01 minutes and non-Caucasian patients waiting a mean of 12.73 minutes. At a mean of 46.32 minutes, the minutes to ECG time was significantly outside of the recommended 10 minutes for the patient group in this study.

Table 10 Minutes of Delay in Care Variable Minutes to triage Male Female Caucasian Non-Caucasian Minutes to electrocardiogram M 11.78 9.36 14.01 11.31 12.73 46.32 1-326
+

Range 0-116
+

SD 14.9

50.7

53 To determine if patient characteristics, RN characteristics, and triage level designation would predict the amount of delay of care, three linear regression procedures were conducted. Because RNs level of education could not be imputed, only 196 cases were included in the regression model. Accordingly, one regression procedure was conducted with the level of education variable. Another procedure was conducted without the level of education variable. Bivariate associations among variables were evaluated using Pearsons product moment correlation (Table 11). Lastly, because RN age, experience in nursing, and experience in ED nursing were highly correlated with each other, a third procedure, with only the significant RN characteristic predictor of years of experience, was conducted.

Table 11 Correlation of Registered Nurse Age and Experience 1 1. Age 2. Years of experience 3. Years of ED experience **p < .01 --2 .904** --3 .585** .510** --M 45.46 17.96 10.98 SD 11.72 10.43 8.51

Because level of education did not significantly predict amount of delay of ECG, only the results of the regression without level of education are presented. The findings in Table 12 reveal that patients gender significantly predicted the amount of delay of triage, F (1, 277) = 5.53, p = .019). In particular, female patients waited for triage longer (M = 14.01, SD + 17.39) than male patients (M = 9.36, SD + 11.23). Patients race/ethnicity also

54 significantly predicted amount of delay of triage, F (1, 277) = 4.43, p = .036). NonCaucasians waited for triage longer (M = 12.73, SD + 12.58) than Caucasian patients (M = 11.31, SD + 15.94). Lastly, RN experience in years also predicted the amount of delay of triage, F (1, 277) = 29.90, p = .001); the more experienced the RN, the longer the delay in triage ( = .31).

Table 12 Amount of Delay of Triage Model Variable Patient Age Gender Caucasian vs. non-Caucasian patient Level 2 TLD vs. Level 3 TLD Registered nurse Years of experience .03 .01 .31 29.90** .97 -.00 .25 .24 .09 .00 .11 .11 .11 -.02 .14 .12 .05 .14 5.53* 4.43* .75 .98 .96 .93 .94 B SE F TOL

Note. N = 283. TLD = triage level designation; TOL = Tolerance. Overall model F (5, 277) = 8.08, p = .001. * p < .05. ** p < .001.

Summary EMR review revealed 286 triage level designations conducted by predominantly white females. Of the potential participants, 40 ED RNs consented to participate in the study, representing 194 triage decisions. The remaining 89 were MCAR and therefore did not affect the results of the study. All RNs reporting race/ethnicity were Caucasian, and 70.3% were female. The mean age of the RN participants was 45.46 years. A minority

55 (19.1%) of the RNs held a BSN. The mean number of years experience as an RN was 17.96 years, with 10.98 years working in the ED. Patients in the sample (N = 286) had a mean age of 61.44, and gender was evenly distributed (48.1% male; 51.9% female). Of the sample, 67% (n = 190) was Caucasian, and a majority (59.1%) were married. A majority of the patients did not smoke (74.6%). About a third (30.4%) of the patients had diabetes, and 43.1% reported a history of cardiac disease. A majority of the patients (88.7%) reported some type of chest symptom, described by participants as pain, pressure, discomfort, heaviness, or squeezing. Accuracy in triage level designations was significantly related to race/ethnicity of the patient with the non-Caucasian patient twice as likely (OR 2.07) to be triaged accurately. The patient with chest pain was 2.5 times as likely ( OR 2.55) to be accurately triaged than the patient with no chest pain. Age and gender were not found to be significant predictors of accuracy of triage level designation. ECG delay was significantly greater in patients without chest pain. ECG delay was not related to the patient characteristics of gender, age, or race/ethnicity. Triage delay was significantly related to the patients gender and race/ethnicity with female and non-Caucasian patients waiting longer than male and Caucasian patients. Triage delay was not significantly related to the patients age. RNs in the study had an overall accuracy rate of 54% in triage level designations of patients with symptoms suggestive of AMI. Neither RN level of education nor years of experience predicted accuracy of triage level designation; however, older RN age was predictive of accuracy. The RN demographic of age was significantly related to accuracy in triage level designations. However, level of education, experience in nursing, and

56 experience in ED nursing were not significant predictors of accurate triage level designation. ECG delay times were also significantly greater when the RN had more experience in nursing. ECG delay was not related to RN age, level of education, or years of experience in ED nursing. Triage delay was significantly related to the RN years of experience in nursing.

CHAPTER V DISCUSSION AND CONCLUSION In this study, the researcher examined patient and RN characterisitcs that may be associated with accuracy of ED RN triage level designation and delay in care of patients with symptoms suggestive of AMI. This chapter includes a discussion of the study results and conclusions of the study. Implications for future research are explored. Accuracy Of the patient records (N = 286) included in the study, only 155 (54.1%) had an appropriate triage level designation of Level 2 required for a patient with symptoms suggestive of AMI. This triage level designation is crucial in determining how quickly the patient receives an ECG and is examined by a healthcare provider. Thus, an accuracy rate of 54% is concerning. It is possible that RNs had trouble determining if symptoms represented ACS. Previous studies of triage accuracy have identified accuracy rates of 50% to 76 % (Arslanian-Engoren, 2004; Atzema et al., 2009; Considine et al., 2004; Considine et al. 2000; Goransson, Ehrenberg, Marklund, et al., 2005; Holdgate et al., 2007; Kosowsky et al., 2001; Wilper et al., 2008). In this study, variables were identified that may be predictive of accuracy in triage level designations. Of the eight patient and RN variables investigated, only patient race/ethnicity and symptom presentation and RN age were identified as significant in predicting accuracy in triage.

57

58 Accuracy and Patient Characteristics A significant relationship was found between accuracy and patient race/ethnicity in that non-Caucasian patients in the study were more likely to be accurately triaged. This was an unexpected finding based on the literature. Arslanian-Engoran (2004) found no difference in accuracy in triage based on race/ethnicity. However, in a study of painrelated decision-making, Hirsh, George, and Robinson (2009) found that race/ethnicity was a significant contributor during assessment of pain, with older African American females perceived by RNs as having and expressing more pain. Although Hirsh et al. did not identify accuracy of triage level designation, the visual portrayal of pain by patients was noted as a significant decision point for the RNs (N = 54) in that study. Although the accuracy rate was only 54%, a significant relationship was found between accuracy and patient report of chest pain, in that the patients reporting chest pain as one of their symptoms were more likely to be accurately triaged. It was expected that more patients would present with atypical symptoms and not report chest pain; however only 11.3% reported with no chest pain and other symptoms such as shortness of breath, weakness, nausea or vomiting, syncope, palpitations, and diaphoresis. Chest pain was identified in the initial triage documentation for 88.7% of the patients in the study. It could be that upon questioning by the triage RN about chest pain, patients gave a positive response hoping that they would be seen sooner or be believed as having a true emergency. Chest pain is the hallmark symptom of cardiac ischemia; therefore, it is surprising that these patients were not triaged correctly 46% of the time. Of the patients triaged correctly, recognizing chest pain as a classic symptom of possible cardiac

59 ischemia most likely led to the Level 2 triage level designation for patients in this study, resulting in increased triage accuracy for patients with chest pain. Neither gender nor age of patient was found to be a significant predictor of accuracy in the study. This is contrary to previous studies by Arslanian-Engoren (2000, 2001) who identified gender as a predictor of accuracy with men more likely than women to be triaged to an accurate triage level designation despite identical symptoms generated in a vignette. Arslanian-Engoren (2000) also identified age biases in triage decisions when considering the AMI diagnosis. Similarly, Garbez et al. (2011) and Hirsh et al. (2009) found increased patient age a significant factor influencing patient assignment of a triage Level 2 designation instead of a stable to wait Level 3 designation. Although older patients may be more likely to have CHD, it is possible that the high number of patients presenting with chest pain increased the accuracy rate and overrode the possible predictors of patient gender and age. Accuracy and RN characteristics The RN characteristic of age was found to be a significant predictor of accuracy in triage level designation of patients with symptoms suggestive of AMI. The older the RN, the greater the likelihood of an accurate triage level designation. This may be explained by the high correlations between age and experience. Older RNs may have better assessment skills, better critical thinking skills, and be able to synthesize history and clinical presentation. It is possible that the older RN may have personal or family experiences with cardiac related events leading to the more accurate triage level designation for patients triaged. However, age does not necessarily equate to years of experience in nursing as more adults enter the field of nursing as a second career.

60 During qualitative focus groups of RNs (N = 12) with a mean age of 42, Arslanian-Engoren (2000) found that RNs tended not to think of AMI in patients who matched their own age group using the rationale that if it could happen to the patients, it could happen to the RNs. Nurses in that study perceived the older patient (70 to 80 years) to be more believable and the younger patients (30 to 40 years) to be more dramatic. Age of the nurse performing triage has not been identified as a factor in accurate triage decisions in nursing research studies. In fact, only one study of triage accuracy identified nurse age as a study variable. In a study of 423 ED triage RNs in 48 EDs, Goransson et al. (2006) found no relationship between accuracy and nurse age. Although studies identify the BSN education level as positively affecting overall patient outcomes (Aiken et al., 2003; Considine et al., 2001; Estabrooks et al., 2005; Tourangeau et al., 2007; Tourangeau, Giovannetti, Tu, & Wood, 2002), RN education was not identified as a predictor of accuracy in triage level designations in this study. Triage level designation decisions are a nursing function that could lead to poor patient outcomes. Nearly half of the patients in this study (n = 139) were triaged by an RN with a level of nursing education at below the BSN level (see Table 7). Neither RN experience in ED nursing nor nursing experience in general was a predictor of accuracy in triage of patients with symptoms suggestive of AMI. This is consistent with findings by Arslanian-Engoren (2004) specifically addressing acute coronary syndromes. Studies have consistently failed to identify a link between experience in nursing and accuracy in triage level designations (Considine et al., 2000, 2001; Goransson et al., 2006; McGillis-Hall et al., 2004; Worster et al., 2004).

61 Atzema, Austin, Tu, and Schull (2010) defined RN experience as triaging a high volume of patients and suggested that high volume EDs were better at recognizing AMI patients and assigning the appropriate triage level designation. Quite possibly the opposite may be true. The repetitive nature of triaging the same type patient symptoms over and over may desensitize the nurse to the urgent need and actually result in inaccuracy by choosing an incorrect triage level. It is possible that the years of experience in nursing, and ED nursing especially, may color the judgment of the experienced RN such that more obvious patient deterioration during presentation at triage is deemed necessary for an RN to decide a true emergency exists and assign a Level 2 designation. There may also be other factors involved in the decision to choose a Level 3 designation instead of a Level 2 designation for a patient presenting with symptoms suggestive of AMI. Triage Delay Many studies identify overall delay in the ED for patients with AMI (Diercks, Peacock, et al., 2006; ODonnell et al., 2005; Pearlman et al., 2008; Venkat et al., 2003; Weber et al., 2011; Zegre-Hemsey et al., 2011). However, only a few separate waiting to be triaged as a specific portion of delay in care when investigating overall delay (Lyons, Brown, & Wears, 2007; ODonnell et al., 2005; Weber et al., 2011). This study addressed delay in the waiting room. Although rapid recognition is crucial to the initiation of interventions to reperfuse cardiac muscle, patients with symptoms suggestive of AMI waited, prior to being seen by an RN to begin the triage assessment, a mean of 11.78 minutes (range 0-116 minutes).

62 Numerous studies have identified overall ED wait times that are lengthy and fall outside the ESI level recommendations to ensure proper care and best results. Horwitz and Bradley (2009) found wait times to be dangerously long for patients categorized as Level 1 and 2, with only 48% of those patients being seen by a physician within 15 minutes. Wilper et al. (2008) noted mean wait times of 27 minutes for patients with AMI. ODonnell et al. (2005) specifically identified a time delay of 26 minutes in the triage process. Lyons et al. (2007) also identified a delay to triage of 14 minutes regardless of severity of chief complaint. Triage Delay and Patient Characteristics Non-Caucasians waited significantly longer for triage (M = 12.73 minutes). This is consistent with previous literature. Studies have associated race/ethnicity with delay in care with non-Caucasian patients waiting longer for care in EDs (James, Bourgeois, & Shannon, 2005; Wilper et al., 2008). In addition, James et al. (2005) suggested that provider-related variables such as stereotyping, cultural unawareness, and prejudices may play a role in delay of care. However, Wilper et al. (2008) did not find triage biases as causative for excessive delay in the non-Caucasian ED patient population. These variables were not investigated in the current study. Regression analysis revealed that female patients waited longer (14.01 minutes) to be triaged (p < .001) than male patients. This is consistent with the literature. Numerous studies have identified delay in the care of females (Concannon et al. 2009; DeLuca et al., 2004; Diercks, Peacock, et al., 2006; ODonnell et al., 2005; Wilper et al., 2008) relating to several points of care, from pre-hospital care to post intervention and critical care placement, but no studies were identified that specifically quantified triage delay and

63 gender. Researchers have identified that females are more likely to present with atypical symptoms during ACS (Albarran et al., 2007; DeVon, Ryan, et al., 2008; DeVon & Zerwic, 2002, 2003), which may affect the recognition of the possible AMI. However, in this study, 88.4% of females and 89.2% of males reported chest pain. Patient age was not found to be a significant predictor of delay in triage. It is possible that the RN identifies additional co-morbidities in the older population, resulting in more timely care. This is not consistent, however, with a study by DeLuca et al. (2004) who found delay in ED treatment for AMI patients in the > 70 year old patient population. Also, Elkum, Fahim, Shoukri, and Al-Madouj (2009) identified patient age as one predictor of delay in ED care with the > 65 age group waiting longer. Triage Delay and RN Characteristics Experience in nursing was a significant predictor of triage delay. The more experienced the RN, the more delay in triage. Studies investigating delay in care generally do not include demographics pertaining to the ED triage RN. Like accuracy, the experienced RN may have a higher threshold as to what constitutes an emergency, which may unnecessarily cause delay in a patient with symptoms suggestive of AMI. ECG Delay Of the patient characteristics of gender, age, race/ethnicity, and symptom presentation and the RN characteristics of age, years of experience in nursing, years of ED experience in nursing, and education, only patient symptom presentation and RN experience in nursing were found to be significant predictors of delay in ECG obtainment. Of the patient records (N = 286) included in this study, only 51 (17.8%) patients received an ECG within the recommended 10 minutes of arrival. Mean wait time

64 for an ECG was 46.32 minutes. A small number of patients in the study received an ECG prior to being seen by a physician, but most waited for an assessment by a physician and an order to do an ECG leading to a further delay in ECG. As with triage delay, ECG delay was also significantly predicted by RN general experience in nursing. Delay in ECG may be related to perceptions of autonomy and the older RN may feel less autonomous especially if this is a change in performance expectation for that RN. If autonomy has increased as a unit expectation, it could be that the older RN has not blended that into clinical practice. Experience may not be the factor that matters in triage level designation decisions. In an unpublished qualitative study (Sammons & Minick, 2012) ED RNs were asked to describe triage. Nurses identified two main processes that they used to work toward the right decision: a) connecting with the patient, which included caring enough to ask the right questions and b) reading between the lines to identify the salient features of a patients history or signs and symptoms. ECG Delay and Patient Characteristics Patients not reporting chest pain waited longer for an ECG, which was an expected finding. Studies link atypical presentations to delay in identification of AMI including a diagnostic ECG (Atzema et al., 2009; Canto et al., 2000). Atypical symptom presentation, generally discussed as symptoms other than chest pain, may increase the difficulty of recognizing an AMI at triage. Although not identified in this study, gender and race/ethnicity have been previously identified in the literature as predictors of delay in various points of care including ECG (Diercks, Kirk, et al., 2006; Diercks, Peacock, et al., 2006; Takakuwa et al., 2006; Zegre-Hemsey et al., 2011). There are few studies

65 evaluating age as a possible factor in ECG delay; however, Pearlman et al. (2008) identified age differences in ECG times with a median ECG time of 29 minutes and a significant delay noted in the 18-39 and 40-59 age groups as compared to the > 60 age group. ECG Delay and RN Characteristics Increased RN experience was noted as a significant predictor of ECG delay. Because triage occurred before ECG in a majority of the cases in the study, this ECG delay may be, in fact, due to the triage delay that occurred. The experienced RN may have a higher threshold as to what constitutes an emergency, which may unnecessarily cause delay in obtaining an ECG for a patient with symptoms suggestive of AMI. In other words, if the triage RN has seen numerous patients do well who presented with shortness of breath, diaphoresis, or other symptoms suggestive of AMI, the nurse may decide the next patient can wait, which delays ECG obtainment. Previous studies investigating delay in obtaining an ECG did not include RN demographics for comparison and no studies were identified investigating a specific relationship between ECG delay and RN experience. The experienced RN may be less likely to participate in ongoing education in the ED leading to a knowledge deficit regarding atypical symptom presentation. If this RN then becomes the preceptor for new RNs, this lack of knowledge could be perpetuated. Accuracy and Delay Accuracy was not correlated with decreased delay. Accurately choosing a triage level designation of Level 2 for the patient with symptoms suggestive of AMI did not guarantee that the patient would receive an ECG within 10 minutes of arrival. The RN

66 may assign a Level 2 designation but not actively seek an ECG or possibly let the patient continue to wait in the waiting room. This delay may be due to overcrowding in the ED or processes in the ED itself such as the physical location of the triage booth or availability of personnel to perform an ECG. For the triage RN to stop the triage process for the remaining waiting room patients is not appropriate, yet there may not be additional personnel available to perform this crucial diagnostic test. Choosing an inaccurate triage designation of Level 3 for the possible AMI may result in prolonged delay before treatment, especially when there is a high volume of patients in the ED. Having a large number of Level 3 patients is not uncommon in any ED on any given day. To inaccurately include the possible AMI in this group is dangerous and could be deadly. Studies were identified that did identify an association between assigning an incorrect triage level designation and delay in care of patients with AMI. Atzema et al. (2009) found an independent association between incorrect triage level designations and delay in ECG for patients (N = 3,088) diagnosed with AMI. In a subsequent study, Atzema et al. (2011) found an association between inaccurate triage level designations and ECG delay in AMI patients (N = 6,784) with a past medical history of depression. It is possible in those studies that the Level 2 patient is always taken straight to a treatment room. It is also possible that the Level 3 patient is also able to get a room quickly thereby decreasing ECG times. There are several specifically measured time points of care in the ED: from arrival by ambulance or by public or private vehicle to triage; from triage to ECG; from triage to physician assessment; from physician assessment to diagnosis, generally noted as disposition; and from disposition to initiation of interventions to reestablish cardiac

67 muscle perfusion. The total of these time points equals the DTB and DTN times frequently discussed in cardiac literature. Delay at any point decreases the chances of meeting the ACC/AHA goal of < 90 minutes DTB or < 60 minutes DTN for establishment of cardiac muscle reperfusion. Conclusions In this study, the accuracy rate of triage level designations for patients with symptoms suggestive of AMI was 54%. Triage was delayed a mean of 11.78 minutes and ECG was delayed a mean of 46.32 minutes. Female gender of patient was predictive of triage delay but not ECG delay nor accuracy of triage level designations. Patient age was not predictive of accuracy or delay. Patient race/ethnicity was not predictive of ECG delay but was a predictor in accuracy of triage level designations and triage delay. A report of chest pain was predictive of increased accuracy and decreased delay in ECG. RN age played a role in accuracy but not in delays for triage and ECG. RN experience played no role in accuracy and was predictive of increased delays in both triage and obtainment of ECG. Neither RN ED experience nor level of education was predictive of accuracy and delay. In patients with symptoms suggestive of AMI, delays in individual segments of care may result in a significant delay in emergent cardiac care. In this study, 11.78 minutes from door to triage plus 46.32 minutes to obtain an ECG led to a prolonged delay in emergent cardiac care. This study adds to the body of evidence regarding ED triage of patients arriving by private vehicle with symptoms suggestive of AMI. However, inconsistency in nurse triage decisions may be due to other condition not yet explored,

68 such as RN critical thinking skills, intelligence, and executive functions. A further investigation is warranted to assess factors affecting triage level designations. Limitations A limitation of this study is that portions of the data were gathered by retrospective electronic chart review. Patients may have reported additional symptoms that were not documented by the nurse at time of triage. Missing information in a medical record has been previously identified in the literature (DeVon, Ryan & Zerwic, 2004). This missing information could be the report of symptoms such as dizziness or nausea reported by the patient or family to the triage RN but not documented in the EMR during triage. This missing information may also have led to the exclusion of some EMRs in the study, as data collection was dependent on RN documentation of chief complaint. A second limitation is related to the nurses participation in the research study. A portion (n = 26) of the nursing staff in the two EDs did not wish to disclose their demographic information, citing reasons such as a constant barrage of computerized surveys required of staff by other departments and upper management. Also noted by the researcher during conversations with staff was a fear of reprisal, a suspicious approach to research in general, a mistrust of how data are used, and a general reluctance to participate. Reluctance to participate was also identified by Arslanian-Engoren (2000) in a study of ED triage nurse decisions. Other variables not identified in this study may have an impact on ECG delay times and triage times such as ED overcrowding, physical limitations of the units, and resource availability. These structure variables were not addressed in the study and should be variables of interest for future research.

69 Implications for Nursing Practice A 54% accuracy rate was identified in this study. A triage delay of 11.78 minutes was also noted, and a majority of the patients in the study (82.6%) received an ECG outside of the recommended 10 minute window despite symptoms suggestive of possible AMI. Strategies must be exploredand implementedthat will improve accuracy and decrease delay. Targeted educational interventions aimed at increasing awareness of AMI multi-symptom presentations is an appropriate starting point and should be required periodically for all ED RNs. In a survey of ED triage nurses, nurses reported provision of (a) targeted educational information in the form of PowerPoint presentations, (b) discussions of evidence in nursing literature, and (c) memory aids as useful in increasing accuracy in cardiac triage decisions (Arslanian-Engoren, Hagerty, Antonakos, & Eagle, 2010). Initial education and ongoing competency assessment regarding the symptoms of ACS for both the new graduate and the experienced nurse must occur. The ability to recognize shortness of breath, weakness, nausea, vomiting, syncope, palpitations, or diaphoresis as indicators of possible AMI is a crucial skill in triage. Further studies are essential to explore the other features of decision making in triage that may affect accuracy and delay of care in the ED. An exploration of RN perceptions of the AMI patient population may give insight into nurse biases related to triage that could be addressed. Studies exploring the cues nurses use to make decisions in triage are numerous (Arslanian-Engoran, 2005, 2009; Edwards & Sines, 2007; Lyneham, Parkinson, & Denholm, 2008; Pugh, 2002), yet no single solution exist. Providing information to ED RNs regarding the differences in individual patient outcomes when rapid care occurs could be a catalyst to increasing expediency of care in

70 the ED of patients with symptoms suggestive of AMI. This could take the form of follow up information or case review of patients cared for in the ED who went on to receive care in the acute care hospital setting and rehabilitation area. Patient safety indicators often demand acceleration in care without adequate resources. As pressures in EDs across the nation increased to care for more and more patients while improving efficiency, streamlined processes for obtaining rapid ECGs must be explored and instituted. Processes to improve ED RN triage practice such as clinical case review and supervision as well as documentation audits may need to be developed. Future Research Further studies investigating the impact of ED overcrowding and resource availability are warranted. Meeting professional guidelines for patients presenting to an ED with symptoms suggestive of AMI is imperative; however, the task is difficult due to the multiple variables inherent in the processes surrounding emergent care. Studies must focus on the factors surrounding inaccuracy and delay in ED care of patients with AMI. This study investigated variables associated with triage RN inaccuracy and delay in care. Further studies are necessary to begin to understand decisions at triage and improve the expedience of care, which will preserve cardiac muscle, improve outcomes, and decrease deaths from AMI. A review of the current literature on the topic of ED cardiac emergency care of patients with AMI failed to identify studies that examined mode of patient arrival in relation to accuracy of ED RN triage and delay of treatment in the ED. The processes that occur in the care of a patient who arrives via ambulance are not the same as that of

71 patients who arrive by public or private vehicles. Further studies specifically identifying mode of arrival are needed. Secondly, there is little evidence of the role continuing ED education and ED orientation of the novice RN and the experienced RN plays in accuracy of triage and delay of care. Studies are needed that examine this possible predictor of accurate triage decisions in the ED and could be conducted by identifying EMRs per nurse so that an appropriate sample size could be obtained representing each triage RN equally. Lastly, studies investigating patient outcomes in those who are inaccurately triaged are needed. This gap in the current literature provides an opportunity to improve emergency care of all patients with heart disease. There are three considerations in the research of triage RN accuracy and delay of care in the ED for patients with suspected AMI: (a) exploring whether or not inaccuracies and delays exist, (b) identifying possible contributing conditions, and (c) possible interventions to improve the accuracy and decrease delay. Numerous studies have addressed the first phase. This study begins to address the second component of possible factors contributing to inaccuracy in triage and delay of care. The last phase will need to take the form of intervention studies to identify what strategies are effective in improving accuracy of ED RN triage of the AMI patient based on data obtained from the second component of research.

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78 Diercks, D., Peacock, W., Hiestand, B., Chen, A., Pollack, C., Kirk, J. . . . Roe, M. (2006). Frequency and consequences of recording an electrocardiogram > 10 minutes after arrival in an emergency room in non-ST segment elevation acute coronary syndromes (from the CRUSADE initiative). American Journal of Cardiology, 97, 437-442. doi:10.1016/j.amjcard.2005.09.073 Donabedian, A. (1966). Evaluating the quality of medical care. The Milbank Memorial Fund Quarterly Part 2, 44, 166-203. doi:10.2307/3348969 Donabedian, A. (1980). Methods for deriving criteria for assessing the quality of medical care. Medical Care Research and Review, 37, 653-698. http://mcr.sagepub.com/ Dorsch, M., Lawrance, R., Sapsford, R., Durham, N., Oldham, J., Greenwood, D., . . . Hall, A. (2001). Poor prognosis of patients presenting with symptomatic myocardial infarction but without chest pain. Heart, 86, 494-498. doi:10.1136/ heart.86.5.494 Edwards, B., & Sines, D. (2007). Passing the audition - The appraisal of client credibility and assessment by nurses at triage. Journal of Clinical Nursing, 17, 2444-2451. doi:10.1111/j.1365-2702.2007.01970.x Elkum, N., Fahim, M., Shoukri, M., & Al-Madouj, A. (2009). Which patients wait longer to be seen and when? A waiting time study in the emergency department. Eastern Mediterranean Health Journal, 15(2), 416-424. Retrieved from http://www.emro .who.int/publications Emergency Nurses Association. (2010). Standardized ED triage scale and acuity categorization: Joint ENA/ACEP statement. Retrieved from http://www.ena.org/SiteCollectionDocuments/Position%20Statements/

79 Enriquez, J., Pratap, P., Zbilut, J., Calvin, J., & Volgman, A. (2008). Women tolerate drug therapy for coronary artery disease as well as men do, but are treated less frequently with aspirin, beta-blockers, or statins. Gender Medicine, 5, 53-61. doi: 10.1016/S1550-8579(08)80008-3 Estabrooks, C., Midodzi, W., Cummings, G., Ricker, K., & Giovannetti, P. (2005). The impact of hospital nursing characteristics on 30-day mortality. Nursing Research, 54, 74-84. doi:10.1097/00006199-200503000-00002 Field, A. (2005). Discovering statistics using SPSS (2nd ed.). London: Sage. Garbez, R., Carrieri-Kohlman, V., Stotts, N., Chan, G., & Neighbor, M. (2011). Factors influencing patient assignment to level 2 and level 3 within the 5-level ESI triage system. Journal of Emergency Nursing, 37, 526-532. doi:10.1016/j.jen.2010.07 .010 Gilboy, N., Tanabe, P., Travers, D., Rosenau, A., & Eitel, D. (2005). Emergency severity index, Version 4: Implementation handbook. Rockville, MD: Agency for Healthcare Research and Quality. Goransson, K., Ehrenberg, A., & Ehnfors, M. (2005). Triage in emergency departments: A national survey. Journal of Clinical Nursing, 14, 1067-1074. doi:10.1111/j .1365-2702.2005.01191.x Goransson, K., Ehrenberg, A., Marklund, B., & Ehnfors, M. (2005). Accuracy and concordance of nurses in emergency department triage. Scandinavian Journal of Caring Sciences, 19, 432-438. doi:10.1111/j.1471-6712.2005.00372.x Goransson, K., Ehrenberg, A., Marklund, B., & Ehnfors, M. (2006). Emergency department triage: Is there a link between nurses personal characteristics and

80 accuracy in triage decisions? Accident and Emergency Nursing, 14, 83-88. doi: 10.1016/j.aaen.2005.12.001 Gupta, M., Tabas, J., & Kohn, M. (2002). Presenting complaint among patients with myocardial infarction who present to an urban public hospital emergency department. Annals of Emergency Medicine, 40, 180-186. doi:10.1067/mem.2002 .126396 Hirsh, A., George, S., & Robinson, M. (2009). Pain assessment and treatment disparities: A virtual human technology investigation. PAIN, 143, 106-113. doi:10.1016/j .pain.2009.02.005 Holdgate, A., Morris, J., Fry, M., & Zecevic, M. (2007). Accuracy of triage nurses in predicting patient disposition. Emergency Medicine Australasia, 19, 341-345. doi: 10.1111/j.1742-6723.2007.00996.x Hollander, J., Blomkalns, A., Brogan, G., Diercks, D., Field, J., Garvey, J., . . . Jackson, R. (2004). Standardized reporting guidelines for studies evaluating risk stratification of ED patients with potential acute coronary syndromes. Academic Emergency Medicine, 11, 1331-1340. doi:10.1197/j.aem.2004.08.033 Hong, S., Morrow-Howell, N., Proctor, E., Wentz, J., & Rubin, E. (2008). The quality of medical care for comorbid conditions of depressed elders. Aging & Mental Health, 12, 323-332. doi:10.1080/13607860802121118 Horne, R., James, D., Petrie, K., Weinman, J., & Vincent, R. (2000). Patients interpretation of symptoms as a cause of delay in reaching the hospital during acute myocardial infarction. Heart, 83, 388-393. doi:10.1036/heart.83.4.388 Horwitz, L., & Bradley, E. (2009). Percentage of U.S. emergency department patients

81 seen within the recommended triage time. Archives of Internal Medicine, 169, 1857-1865. doi:10.1001/archinternmed.2009.336 Institute for Healthcare Improvement. (2009). Improved care for acute myocardial infarction. Retrieved March 3, 2012, from http://www.ihi.org/IHI/Programs/ Campaign/AMI.htm James, C., Bourgeois, F., & Shannon, M. (2005). Association of race/ethnicity with emergency department wait times. Pediatrics, 115, e310-314. doi:10.1542/peds .2004-1541 Kaul, P., Chang, W., Westerhout, C., Graham, M., & Armstrong, P. (2007). Differences in admission rates and outcomes between men and women presenting to emergency departments with coronary syndromes. Canadian Medical Association Journal, 177, 1193-1199. doi:10.1503/cmaj.060711 Kline, R. (2005). Principles and practice of structural equation modeling (2nd ed.). New York, NY: The Guilford Press. Kosowsky, J., Shindel, S., Liu, T., Hamilton, C., & Pancioli, A. (2001). Can emergency department triage nurses predict patients dispositions. American Journal of Emergency Medicine, 19, 10-14. doi:10.1953/ajem.2001.20033 Krumholz, H., Anderson, J., Bachelder, B., Fesmire, F., Fihn, S., Foody, J., . . . Nallamothu, B. (2008). ACC/AHA 2008 performance measures for adults with ST-elevation and non-ST-elevation myocardial infarction. Circulation, 118, 25962648. Lyneham, J., Parkinson, C., & Denholm, C. (2008). Explicating Benners concept of expert practice: Intuition in emergency nursing. The Journal of Advanced

82 Nursing, 64, 380-387. doi:10.1111/j.1365-2648.2008.04799.x Lyons, M., Brown, R., & Wears, R. (2007). Factors that affect the flow of patients through triage. Emergency Medicine Journal, 24, 78-85. doi:10.1136/emj.2006 .036764 Manchester Triage Group. (1997). Emergency triage. Plymouth, UK: BMJ Publishing Group. Manos, D., Petrie, D., Beveridge, R., Walter, S., & Ducharme, J. (2002). Inter-observer agreement using the Canadian emergency department triage and acuity scale. Canadian Journal of Emergency Medicine, 4(1), 16-22. Retrieved from http:// www.cjem-online.ca/ McGillis-Hall, L., Doran, D., & Pink, G. (2004). Nurse staffing models, nursing hours, and patient safety outcomes. Journal of Nursing Administration, 34, 41-45. doi: 10.1097/00005110-200401000-00009 McNamara, R., Wang, Y., Herrin, J., Curtis, J., Bradley, E., Magid, D., . . . Krumholz, H. (2006). Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction. Journal of the American College of Cardiology, 47, 2180-2186. doi:10.1016/j.jacc.2005.12.072 McSweeney, J., Cody, M., & Crane, P. (2001). Do you know them when you see them? Womens prodromal and acute symptoms of myocardial infarction. The Journal of Cardiovascular Nursing, 15(3), 26-38. Retrieved from http://journals.lww.com/ jcnjournal/pages/default.aspx McSweeney, J., Cody, M., OSullivan, P., Elberson, K., Moser , D., & Garvin, B. (2003). Womens early warning symptoms of acute myocardial infarction. Circulation,

83 108, 2619-2623. doi:10.1161/01.CIR.0000097116.29625.7C McSweeney, J., OSullivan, P., Cleves, M., Lefler, L., Cody, M., Moser, D., . . . Zhao, W. (2010). Racial differences in womens prodromal and acute symptoms of myocardial infarction. American Journal of Critical Care, 19, 63-73. doi:10.4037/ ajcc2010372 Murphy, S. L., Xu, J., Kochanek, K. D. (2012). Preliminary data for 2010. National Vital Statistics Reports, 60(4). Retrieved from http://www.cdc.gov/nchs/nvss.htm National Center for Health Statistics. (2008). National hospital ambulatory medical care survey, emergency department, triage status. Table 10. 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. Retrieved from http://www.cdc.gov/nchs/ahcd/web_tables.htm#2008 National Heart Lung and Blood Institute. (2010). Heart attack warning signs. Retrieved March 3, 2012, from http://www.nhlbi.nih.gov/actintime/haws/haws.htm ODonnell, S., Condell, S., Begley, C., & Fitzgerald, T. (2005). In-hospital care pathway delays: Gender and myocardial infarction. Journal of Advanced Nursing, 52, 1421. doi:10.1111/j.1365-2648.2005.03559.x Pearlman, M., Tanabe, P., Mycyk, M., Zull, D., & Stone, D. (2008). Evaluating disparities in door-to-EKG time for patients with noncardiac chest pain. Journal of Emergency Nursing, 34, 414-418. doi:10.1016/j.jen.2007.07.002 Platts-Mills, T., Travers, D., Biese, K., McCall, B., Kizer, S., LaMantia, M., . . . Cairns, C. (2010). Accuracy of the emergency severity index triage instrument for identifying elder emergency department patients receiving an immediate life-

84 saving intervention. Academic Emergency Medicine, 17, 238-243. doi:10.1111/j .1553-2712.2010.00670.x Pope, J., Aufderheide, T., Ruthazer, R., Woolard, R., Feldman, J., Beshansky, J., . . . Selker, H. (2000). Missed diagnosis of acute cardiac ischemia in the emergency department. New England Journal of Medicine, 342, 1163-1170. doi:10.1056/ NEJM200004203421603 Pugh, D. (2002). A phenomological study of flight nurses clinical decision-making in emergency situations. Air Medical Journal, 21(2), 28-36. doi:10.1067/mmj.2002 .122906 Rathore, S., Curtis, J., Chen, J., Wang, Y., Nallamothu, B., Epstein, A., . . . Hines, H. (2009). Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: National cohort study. British Medical Journal, 338, 1807-1813. doi:10.1136/bmj.b1807 Roger, V., Farkouh, M., Weston, S., Reeder, G., Jacobsen, S., Zinsmeister, A., . . . Gabriel, S. (2000). Sex differences in evaluation and outcome of unstable angina. Journal of the American Medical Association, 283, 646-652. doi:10.1001/jama .283.5.646 Ryan, C., DeVon, H., Horne, R., King, K., Milner, K., Moser, D., . . . Zerwic, J. (2007). Symptom clusters in acute myocardial infarction. Nursing Research, 56, 72-81. doi:10.1097/01.NNR.0000263968.01254.d6 Sammons, S., & Minick, P. (2012). The right decision and the complexities of triage. Unpublished manuscript. Soper, D. (2004). Free a-priori sample size calculator for multiple regression [Online

85 calculation program]. Published instrument. Retrieved from http://www .danielsoper.com/statcalc/calc01.aspx Tabachnick, B., & Fidell, L. (2007). Using multivariate statistics (5th ed.). San Francisco, CA: Pearson. Takakuwa, K., Shofer, F., & Hollander, J. (2006). The influence of race and gender on time to initial electrocardiogram for patients with chest pain. Academic Emergency Medicine, 13, 867-872. doi:10.1111/j.1553-2712.2006.tb01740.x Thygesen, K., Alpert, J., & White, H. (2007). Universal definition of myocardial infarction. European Heart Journal, 28, 2525-2538. Retrieved from http:// eurheartj.oxfordjournals.org/ Tourangeau, A., Doran, D., McGillis Hall, L., OBrien Pallas, L., Pringle, D., Tu, J., & Cranley, L. (2007). Impact of hospital nursing care on 30-day mortality for acute medical patients. Journal of Advanced Nursing, 57, 32-44. doi:10.1111/j.13652648.2006.04084.x Tourangeau, A., Giovannetti, P., Tu, J., & Wood, M. (2002). Nursing-related determinants of 30-day mortality for hospitalized patients. Canadian Journal of Nursing Research, 33(4), 71-88. Retrieved from http://cjnr.mcgill.ca/ Travers, D. (1999). Triage: How long does it take? How long should it take? Journal of Emergency Nursing, 25, 238-240. doi:10.1016/S0099-1767(99)70213-8 Travers, D., Waller, A., Bowling, J., Flowers, D., & Tintinalli, J. (2002). Five-level triage system more effective than three-level in tertiary emergency department. Journal of Emergency Nursing, 28, 395-400. doi:10.1067/men.2002.127184 Venkat, A., Hoekstra, J., Lindsell, C., Prall, D., Hollander, J., Pollack, C., . . . Gibler, W.

86 (2003). The impact of race on the acute management of chest pain. Academic Emergency Medicine, 10, 1199-1208. doi:10.1111/j.1553-2712.2003.tb00604.x Weber, E., McAlpine, I., & Grimes, B. (2011). Mandatory triage does not identify highacuity patients within recommended time frames. Annals of Emergency Medicine, 58, 137-144. doi:10.1016/j.annemergmed.2011.02.001 Wilper, A., Woolhandler, S., Lasser, K., McCormick, D., Cutrona, S., Bor, D., & Himmelstein, D. (2008). Waits to see an emergency department physician: U.S. trends and predictors, 1997-2004. Health Affairs, 27, w84-w95. doi:10.1377/ hlthaff.27.2.w84 Worster, A., Gilboy, N., Fernandes, C., Eitel, D., Eva, K., Geisler, R., & Tanabe, P. (2004). Assessment of inter-observer reliability of two five-level triage and acuity scales: A randomized controlled trial. Canadian Journal of Emergency Medicine, 6, 240-245. Retrieved from http://www.cjem-online.ca/ Worster, A., Sardo, A., Eva, K., Fernandes, C., & Upadhye, S. (2007). Triage tool interrater reliability: A comparison of live versus paper case scenarios. Journal of Emergency Nursing, 33, 319-323. doi:10.1016/j.jen.2006.12.016 Wubker, A. (2007). Measuring the quality of healthcare. Disease Management and Health Outcomes, 15, 225-238. doi:10.2165/00115677-200715040-00004 Wuerz, R., Fernandes, C., & Alcaron, J. (1998). Inconsistency of emergency department triage. Annals of Emergency Medicine, 32, 431-435. doi:10.1016/S0196-0644(98) 70174-4 Zegre-Hemsey, J., Sommargren, C., & Drew, B. (2011). Initial ECG acquisition within 10 minutes of arrival at the emergency department in persons with chest pain:

87 Time and gender differences. Journal of Emergency Nursing, 37, 109-112. doi:10 .1016/j.jen.2009.11.004

APPENDICES APPENDICES APPENDIX A REGISTERED NURSE DEMOGRAPHICS TOOL

88

89 REGISTERED NURSE DEMOGRAPHICS TOOL Please circle one in each category: Gender: M F African American ADN BSN Hispanic MSN Asian other Code _____ (to be assigned by researcher)

Race: Caucasian

Education: diploma Age: ___________

doctoral level

Month and year of first RN licensure: _________________________ Years of experience as an RN: _______ years _______ months Years of experience in any Emergency Department: _______ years _______ months

Please print your name on the lower portion of this form. ________________________________________________ _________
Researcher to tear away here after coding.

NAME OF NURSE: ___________________________________________

(This form will be given a code and your name will be removed from the data)

Created: 02-10-2010 Revised: 05-18-2011

APPENDIX B SELECTION OF ELECTRONIC MEDICAL RECORDS

90

91

Selection of EMRs
559 EMRs (list generated by Medical Records)

Arrival mode POV?

175 ambulance (excluded)

384 private vehicle

S/SX of AMI 98 other obvious source (excluded) 286 yes, S/SX suggestive of AMI RN consent

92 EMRs, no RN consent (26 RNs)

194 EMRs with RN consent (40 RNs)

APPENDIX C INFORMED CONSENT

92

93

APPENDIX D INSTITUTIONAL REVIEW BOARD APPROVAL

94

95

INSTITUTIONAL REVIEW BOARD Mail: P.O. Box 3999 Atlanta, Georgia 30302-3999 Phone: 404/413-3500 Fax: 404/413-3504 In Person: Alumni Hall 30 Courtland St, Suite 217

May 16, 2011

Principal Investigator: Grindel, Cecelia Marie Student PI: Susan Sammons Protocol Department: B.F. Lewis School of Nursing Protocol Title: Accuracy of Emergency Department Nurse Triage Level Designation and Delay in Care of Patients with Symptoms Suggestive of Acute Myocardial Infarction Funding Agency: Kaiser Permanente Submission Type: Protocol H11455 Review Type: Expedited Review Approval Date: May 13, 2011 Expiration Date: May 12, 2012 The Georgia State University Institutional Review Board (IRB) reviewed and approved the above referenced study and enclosed Informed Consent Document(s) in accordance with the Department of Health and Human Services. The approval period is listed above. Federal regulations require researchers to follow specific procedures in a timely manner. For the protection of all concerned, the IRB calls your attention to the following obligations that you have as Principal Investigator of this study. 1. 2. When the study is completed, a Study Closure Report must be submitted to the IRB. For any research that is conducted beyond the one-year approval period, you must submit a Renewal Application 30 days prior to the approval period expiration. As a courtesy, an email reminder is sent to the Principal Investigator approximately two months prior to the expiration of the study. However, failure to receive an email reminder does not negate your responsibility to submit a Renewal Application. In

96

addition, failure to return the Renewal Application by its due date must result in an automatic termination of this study. Reinstatement can only be granted following resubmission of the study to the IRB. 3. 4. Any adverse event or problem occurring as a result of participation in this study must be reported immediately to the IRB using the Adverse Event Form. Principal investigators are responsible for ensuring that informed consent is obtained and that no human subject will be involved in the research prior to obtaining informed consent. Ensure that each person giving consent is provided with a copy of the Informed Consent Form (ICF). The ICF used must be the one reviewed and approved by the IRB; the approval dates of the IRB review are stamped on each page of the ICF. Copy and use the stamped ICF for the coming year. Maintain a single copy of the approved ICF in your files for this study. However, a waiver to obtain informed consent may be granted by the IRB as outlined in 45CFR46.116(d).

All of the above referenced forms are available online at https://irbwise.gsu.edu. Please do not hesitate to contact Susan Vogtner in the Office of Research Integrity (404-413-3500) if you have any questions or concerns. Sincerely, Susan Laury, IRB Chair

Federal Wide Assurance Number: 00000129