Impact of a Nursing Triage Line on the Use of Emergency Department Services in a Military Hospital, The

Military Medicine, Dec 2003 by O'Rourke, Kathleen M, Roddy, Mary, King, Rosemary, Custer, Michael, Et al

Methods

A cross-sectional design was used to compare the acuity of TAN referrals with non-TAN referrals. Records from all patients who received ED medical care during October and November 2000 were eligible to be included in the study population. There were no exclusions based on age, sex, insurance coverage, military status, or any other factors.

Sampling Procedure

The hospital ED generates monthly reports that include the triage category of all patients evaluated in the ER. The researchers reviewed the ED chart for each TAN referral during the study period. The chart of the next patient seen in the ED after the TAN-referred patient was selected for review as a comparison. In the event that two TAN-referred patients were seen in a row, then the next two non-TAN-referred patient charts were reviewed. During the 2-month time frame, the charts of 600 ER patients were selected. After excluding charts for which triage level was missing, there were 563 patients included in the study; 286 were TAN referrals and 277 were non-TAN users. These study numbers provide sufficient power to detect a 15% difference in acuity level between the referral groups using a significance level of 0.05.

Study Variables

Patient acuity was the dependent variable under investigation in this study. Patient acuity was defined as the triage level assigned by the ED nurse when the patient was evaluated in the ED. There are five triage levels:

1. Patients who need immediate care to prevent loss of life, limb, or eyesight;

2. Patients who require prompt care to prevent life-threatening deterioration;

3. Patients with stable conditions that require timely treatment;

4. Patients with stable conditions that require treatment when available (nonurgent); and

5. Patients with stable conditions that do not require ER treatment.

For the purposes of this study, patients in categories 1 through 3 were designated as appropriate users of ED resources (high acuity). This included patients with urgent dispositions (categories 1 and 2) as well as those with emergent conditions (category 3). Patients in categories 4 and 5 were deemed inappropriate users of the ER resources (low acuity), as the triage guidelines indicate they could have been directed to make an appointment with their primary provider to meet their medical needs.

The referral source (TAN vs. non-TAN) was the primary independent variable under investigation. At the study site, TAN nurses have a shortage of clinic appointments available and, at times, referred patients to the ED even though the nursing assessment indicated a primary disposition for a clinic appointment. Thus, within the TAN referrals, there were two subgroups: (1) those who the nurse assessed to have a primary ED disposition and (2) those who the nurse sent to the ED because, although they were given a primary clinic disposition, no clinic appointments were available.

Potential confounding variables of age, sex, and family code were also evaluated. Family code was defined as the relationship of the patient to the military sponsor. An additional analysis of patients who left ED without being seen was conducted in terms of type of referral as well as acuity level.