International Emergency Nursing (2013) 21, 103–112

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Comparing triage evaluation of adultdyspneic patients between emergency nursesand doctors using simulated scenarios

Lim Beng Leong MBBS (UNSW), MRCS (A&E), FAMS (Consultant)*,Eunice Tay Zhi Rui BNurs, MHsc Ed (Nurse Clinician),Alicia Vasu BSc (Biomedical Sciences), MPH (Senior Research Executive),Kenneth Heng Wei Jian MBBS (Singapore), FRCS (A&E),FAMS (Senior Consultant)

Tan Tock Seng, Emergency Department, Singapore

Received 4 March 2012; received in revised form 6 June 2012; accepted 11 June 2012

17ht

*

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KEYWORDSSimulator;Triage nurses;Emergency department

55-599X/$ - see front matttp://dx.doi.org/10.1016/j.i

Corresponding author. Add578777; fax: +65 62543772.

E-mail address: Beng_Leon

er ª 201enj.2012

ress: Tan

g_Lim@t

Abstract

Objective: Although registered nurses frequently perform triaging in many emergencydepartments (EDs), little is known regarding the agreement between nurses and doctors intriaging dyspneic patients. The aim of our study was to compare the effectiveness of trainedED nurses with doctors in the evaluation of dyspneic patients at triage using the SimMan 3Gsimulator.Methods: We compared eight nurses who underwent a structured training/accreditation pro-gram with eight doctors. Two assessors evaluated them through seven common and/or impor-tant cardiorespiratory simulated scenarios. Each scenario had an evaluation instrument thatscored participants on triage assessment and management. Each nurse was also surveyed overa six-point Likert scale (0–5) on their confidence in triaging dyspneic patients after the study.Data was analyzed using descriptive statistics with statistical significance set at p < 0.05.Data/results: There were no statistically significant differences between the mean assessmentor management scores across all scenarios between doctors versus nurses (p ranging from 0.070to 0.798). Six nurses felt they could evaluate ED dyspneic patients alone (score of 4) and theremainder with supervision (score of 2–3).

2 Elsevier Ltd. All rights reserved..06.003

Tock Seng, Emergency Department, 11, Jalan Tan Tock Seng, Singapore 308433, Singapore. Tel.: +65

tsh.com.sg (B.L. Lim).

Table 1 Patient Acuity Category

PAC Criteria

1 In or with imminent cardior2 Not in imminent cardioresp3 Ambulatory patients with m4 Non-emergency patients wh

104 B.L. Lim et al.

Conclusion: Trained ED nurses; when compared to doctors; could triage and evaluate dyspneicpatients effectively on a simulator.

ª 2012 Elsevier Ltd. All rights reserved.

Introduction

Triage is an essential function in the emergency department(ED) where many patients present with undifferentiatedcomplaints. Dyspnea is a common presenting complaintand common causes include decompensated heart failure,pneumonia, chronic obstructive pulmonary disease (COPD)and asthma (Ray et al., 2006). Patients also present withvarying severities of these illnesses. The principle of ED tri-age is to identify patients who need emergent or urgentinterventions from those who do not need such care andcan safely wait.

Background

ED triage of the dyspneic patient requires a rapid decisionmaking process using limited clinical information and tar-geted physical examination including vital signs and pul-monary auscultation. This process informs decision makingabout urgency of care, Patient Acuity Category (PAC) assign-ment and triage initiated treatments and investigations likethe electrocardiogram or chest radiograph. The study EDuses a four point PAC system to categorize all patientsaccording to the guidelines established by the SingaporeSociety of Emergency Medicine (Society for EmergencyMedicine in Singapore, 2010). The criteria for the variousPAC categories are shown in Table 1.

The roles of emergency nurses (ENs), especially emer-gency nurse practitioners (ENPs), have been expandingand in many centres, they are not confined to manage minorillnesses or injuries and follow up reviews (Lowe, 2011;Steiner et al., 2008). In this study, we attempted to explorethe ED nursing role in triaging the dyspneic patient in ourcentres which requires critical decision making skills.

Setting

Triaging is commonly performed by nurses in many EDs.However, little is known regarding the agreement betweennurses and doctors in triaging dyspneic patients. Our ED tri-age system of the dyspneic patient uses a combined assess-ment by doctors and nurses in contrast to other EDs. Thereason for this combined approach is that there has notbeen a formal training and accreditation process for triaging

(PAC) system as recommended

espiratory arrest requiring immiratory arrest but require earlyild to moderate symptomso can be managed in the prima

complex complaints like dyspnea for our nurses in a busy ED.Our existing workflow requires the adult dyspneic patient tobe auscultated by an emergency doctor (specialist or non-specialist) who will relate the findings and any necessarytreatment or investigations (including the need for emer-gent or urgent treatment) to the triage nurse. The nurse willsubsequently assign a PAC category to the patient and exe-cutes the triage treatment and investigations.

Our department has trained a group of eight triage nursesthrough a structured clinical evaluation, pulmonary auscul-tation training and accreditation program in order to reduceor eliminate the requirements for doctors to contribute tothis triage process. The teaching and accreditation programhas been vetted by our emergency physicians (EPs) in ourdepartment.

We designed this exploratory pilot study to compare theeffectiveness and safety of these trained triage nurses andED doctors in evaluating dyspneic patients at triage usinga simulation model.

Methods

Overview

Our hospital is a 1000 bed acute adult tertiary hospital. ItsED receives patients from all regions of the country andhad an annual census of 161,719 patient visits in 2010.

Triage nurses who had undergone a structured trainingand accreditation program to evaluate dyspneic patientswere asked to participate in this study. The study was per-formed in strict accordance with the institutional reviewboard guidelines and was approved by the National Health-care Group ethics committee.

Participants

Before the study, eight triage nurses from our ED weretrained from September to December 2009 to perform acompetent evaluation of dyspneic patients at triage. Thesenurses had 6–10 years of experience in emergency patientcare. They underwent a structured program that includeda series of lectures, bedside teaching sessions and accredi-tation. The lectures were conducted by experienced EPswho taught on basic sciences of the respiratory system, clin-ical evaluation and management of common respiratory

by Society of Emergency Medicine of Singapore.

ediate attentionattention (within 80 min); failing which deterioration is likely

ry care setting

Comparing triage evaluation of adult 105

conditions like asthma, COPD, pneumonia, decompensatedheart failure, pneumothorax and upper airway obstruction.Separate bedside teaching was also conducted by the EPs onreal ED dyspneic patients. This teaching concentrated onpulmonary auscultation as well as the assimilation of auscul-tatory findings with limited clinical information (general pa-tient appearance and vital signs) to make rapid triagedecisions on patient management. The nurses were taughtto identify normal breath sounds and common adventitialsounds like rhonchi, crepitations and stridor.

Following these teaching sessions, the nurses were re-quired to verify their pulmonary auscultatory and clinicaldecision making on 10 real-time ED dyspneic patients withemergency doctors as a means of accreditation. All eightnurses had successfully completed this accreditationprocess.

Eight doctors were selected from our ED pool of doctorsand asked to participate in the study. They form a groupwith two members each from the pools of rotating non-spe-cialists, resident non-specialists, emergency medicine (EM)specialists in training and nationally accredited EPs. Theyhad between 2 to 23 years of clinical experience amongthem.

Two EPs (Lim, B.L., and Kenneth Heng, W.J.) were theassessors in the study and they were not selected fromthe cohort of participating doctors. They are the core fac-ulty member and program director respectively of our emer-gency medicine (EM) residency program. They have vastexperience in teaching and mentoring EM trainees andnurses as well as involved as examiners in the College ofEM (United Kingdom) membership and local specialist exitexaminations. One EP (Lim, B.L.) was involved in the teach-ing sessions of the participating nurses.

Mrs C is a 65 year old lady with past medichypertension. She presents with one day historyCurrent vitals: T: 37 degrees Celsius, BP 230/190% on room air. Assessment: Alert but diaphoretic.

Dyspneic at rest; cannot speak shLungs: Bibasal crepitations; wide

ASSESSMShould do Scoring Assessment Ask for vitals 25 Ask for general appearance 25 Auscultation Identify bibasal crepitations 25 Identify widespread rhonchi 25 Sum Assessment Score

MANAGEMShould do Scoring Escalate to resuscitation room

50

Administer oxygen 15 State will ask doctor to see patient

15

State will perform ECG in resuscitation room

10

Administer bronchodilators 10 Sum Management Score

T: temperature; BP: blood pressure; mmHg: millimetre mercusaturation; %: percent; ECG: electrocardiogram; P2: Patient Acuit

Fig. 1 Scoring instrument for dyspnea from Acute Pulmonary Oed

The simulator and study scenarios

We used the SimMan 3G simulator to conduct the study. Themanikin is a portable and advanced patient simulator thatcan reproduce normal and common abnormal breath soundsincluding stridor, rhonchi and crepitations (SimMan 3G,2007).

Prior to the study, we conducted a separate session eachfor our participating nurses and doctors to orientate andfamiliarize themselves on the features of the SimMan 3Gsimulator.

The two assessors designed the scenarios before thestudy. They developed a pool of common and/or importantcardiorespiratory conditions that would present to the EDwith dyspnea together with their spectrum of severities.This pool was derived from personal practitioner experi-ence, surveying the collective opinion of specialist (n = 19)and non-specialist doctors (n = 50) in the department andreview of a reference guide on common respiratory emer-gencies written for EPs (Wolfson et al., 2010). The condi-tions included asthma, decompensated heart failure,COPD, pneumonia, pneumothorax and upper airwayobstruction.

Each scenario included a short history, pertinent vitalsigns and brief description of the overall clinical appearanceof the patient. Participants would then evaluate the simu-lated patient by auscultation.

Each scenario was accompanied by an evaluation instru-ment that separately scored participants on triage assess-ment and management. The assessment portion in eachscenario included pulmonary auscultation of the simulatoraiming to test the participants’ competency to identifythe abnormal pulmonary findings. The management portion

al history of ischemic heart disease and of dyspnea and cough. 00 mmHg, PR 120/min, RR 25/min, SaO2

ort sentences spread rhonchi

ENT Shouldn’t do Scoring

ENT Shouldn’t do Scoring Put in P2 or P3 area - 50

Perform ECG at triage -10 Failure to administer oxygen

-10

ry; PR: pulse rate; RR: respiratory rate; SaO2: oxygen y Category 2; P3: Patient Acuity Category 3

ema (APO) with bilateral crepitations and rhonchi.

Mr G is a 20 year old gentleman, previously healthy, complains of 2 hours’ history of chest pain worse on inspiration and dyspnea. Current vitals: T: 37 degrees Celsius, BP 80/50 mmHg, PR 110/min, RR 20/min, SaO2 94% on room air Assessment: Alert and communicative.

Dyspneic when speaking Lungs: Reduced air entry of the left lung.

ASSESSMENT Should do Scoring Shouldn’t do Scoring Assessment Ask for vitals 25 Ask for general appearance 25 Auscultation Identify (L) reduced air entry 50 Sum Assessment Score

MANAGEMENT Should do Scoring Shouldn’t do Scoring Escalate to resuscitation room

50 Put in P2/P3 area - 50

Administer oxygen 30 Failure to administer oxygen

- 10

State will ask doctor to see in resuscitation room

20 Failure to perform CR at resuscitation room

- 10

Sum Management Score T: temperature; BP: blood pressure; mmHg: millimetre mercury; PR: pulse rate; RR: respiratory rate; SaO2: oxygen saturation; %: percent; (L): left; P2: Patient Acuity Category 2; P3: Patient Acuity Category 3; CR: chest radiograph

Fig. 2 Scoring instrument for dyspnea from tension pneumothorax with unilateral reduction in air entry.

106 B.L. Lim et al.

tested the participants on their ability to assimilate theauscultatory findings, vital signs and general patient appear-ance to formulate a safe management plan at triage.

The maximum points attainable for the assessment ormanagement portion for each scenario were 100. The scor-ing methodology allowed for differential weighting of vari-ous aspects of patient assessment and management tosimulate the study scenarios as close to reality as possible.For example, a critical maneuver of escalation to the resus-citation room in a dyspneic patient with stridor would beweighted at 50 (out of 100) points, whereas a less criticalintervention (providing oxygen supplement) would only beweighted at 25 points. Furthermore, if a dangerous manage-ment decision like assigning a PAC of >1 in the same patient,50 points would be deducted. The scenarios and scoringsheets were vetted by the EPs of our department. Thescoring charts for two of the scenarios are shown in Figs.1 and 2.

Immediately after the study, the participating nurseswere asked to rate their confidence in performing triageevaluation and critical decision making of ED dyspneic pa-tients. These confidence ratings were ranked on the follow-ing six-point Likert scale adapted from a previous study onthe use of simulated pages to prepare medical studentsfor internship (Schwind et al., 2011). The various ratingswithin the Likert scale were shown as follows.

I can perform a competent evaluation and make safedecisions of the ED dyspneic patient at triage:

� 0 = Not at all.� 1 = Maybe with complete supervision walking me throughit step by step.� 2 = I still need someone right at my side.� 3 = I think I could do it with someone nearby.

� 4 = I think I can do it myself.� 5 = I can do it myself and can teach others.

Study procedure

The study was conducted first on the participating doctorsin April 2011 followed by the nurses in June 2011. The twosessions were 6 weeks apart to minimize impacts on man-power issues and service delivery in our ED. We briefedthe participants before the study not to communicate witheach other regarding study complements in order to ensureblinding. The two assessors decided on a 6 week lapse be-tween the two sessions to ensure a sufficient ‘‘washout’’period for any small but unavoidable risk of inadvertentcommunication between the two groups of participants.

For each session, each participant was exposed to theSimMan 3G simulator, program engineer and two assessorsin an isolated room. The engineer and assessors had re-hearsed through the series of auscultatory sounds beforethe session. No communication occurred between the twoassessors and the engineer during the conduct of each sce-nario. One assessor would introduce each scenario to theparticipant with only information of the presenting com-plaints. The following was an example of the opening pre-sentation of a scenario: ‘‘Mr. A is a 40 year old gentlemanwho complained of one day history of dyspnea, sore throat,hoarse voice and fever.’’

The participant would then be asked regarding what otherinformation he/she would wish to know (i.e. general appear-ance and vital signs) before proceeding to perform the pul-monary auscultation. Following auscultation, he/she wouldbe questioned regarding the triage management. No feed-back was given to the participants throughout the session.

Table 2 Nurses’ scores for assessment and management of each of seven scenarios (n = 8).

Scenario Domain Assessor Mean SD Median Min Max IQR r p Value

1. Epiglottitis with stridor Assessment 1 82.5 13.9 80.0 60 100 23 0.723 0.0432 83.1 17.7 82.5 50 100 25

Management 1 100.0 0.0 100.0 100 100 0 – –2 98.8 3.5 100.0 90 100 0

2. Stable CCF with bilateral crepitations Assessment 1 87.5 18.9 100.0 50 100 25 0.738 0.0372 81.3 17.7 75.0 50 100 25

Management 1 100.0 0.0 100.0 100 100 0 – –2 100.0 0.0 100.0 100 100 0

3. APO with bilateral crepitations and rhonchi Assessment 1 68.8 11.6 75.0 50 75 19 0.69 0.0582 68.8 17.7 75.0 50 100 25

Management 1 93.8 5.2 90.0 90 100 10 0.894 0.0032 90.0 10.4 90.0 75 100 21

4. COPD with CO2 retention and bilateral rhonchi Assessment 1 75.0 0.0 75.0 75 75 0 – –2 81.3 17.7 75.0 50 100 25

Management 1 85.0 34.6 100.0 0 100 10 0.718 0.0452 79.4 34.3 95.0 0 100 29

5. Stable asthma with bilateral rhonchi Assessment 1 90.6 18.6 100.0 50 100 19 1 <0.0012 90.6 18.6 100.0 50 100 19

Management 1 81.3 42.2 100.0 �20 100 23 0.819 0.0132 80.0 41.7 97.5 �20 100 24

6. Stable pneumonia with unilateral crepitations Assessment 1 78.1 16.0 75.0 50 100 19 0.873 0.0052 81.3 11.6 75.0 75 100 19

Management 1 100.0 0.0 100.0 100 100 0 – –2 97.5 7.1 100.0 80 100 0

7. Tension pneumothorax with unilateral reduction in air entry Assessment 1 87.5 18.9 100.0 50 100 25 0.611 0.1072 87.5 18.9 100.0 50 100 25

Management 1 100.0 0.0 100.0 100 100 0 – –2 100.0 0.0 100.0 100 100 0

The maximum score for the assessment or management portion is 100. SD: Standard Deviation; Min: Minimum; Max: Maximum; IQR: Interquartile range; r: Spearman’s rho correlationcoefficient; –: The correlation coefficient cannot be calculated because at least one of the variables is constant; p value: measures the statistical significance of r; CCF: Congestive CardiacFailure; APO: Acute Pulmonary Oedema; COPD: Chronic Obstructive Pulmonary Disease; CO2: Carbon Dioxide.

Comparin

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evalu

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Table 3 Doctors’ scores for assessment and management of each of seven scenarios (n = 8).

Scenario Domain Assessor Mean SD Median Min Max IQR r p Value

1. Epiglottitis with stridor Assessment 1 92.5 11.3 100.0 75 100 21 1 <0.0012 92.5 11.3 100.0 75 100 21

Management 1 87.5 18.9 100.0 50 100 25 0.378 0.3562 90.6 18.6 100.0 50 100 19

2. Stable CCF with bilateral crepitations Assessment 1 84.4 12.9 75.0 75 100 25 �0.25 0.5562 81.3 17.7 75.0 50 100 25

Management 1 98.8 3.6 100.0 90 100 0 0.54 0.1672 95.6 9.0 100.0 75 100 8

3. APO with bilateral crepitations and rhonchi Assessment 1 68.8 25.9 75.0 25 100 44 0.936 0.0012 71.9 28.2 75.0 25 100 50

Management 1 86.9 5.9 90.0 75 90 8 0.54 0.1672 88.8 3.5 90.0 80 90 0

4. COPD with CO2 retention and bilateral rhonchi Assessment 1 78.1 8.8 75.0 75 100 0 0.378 0.3562 87.5 13.4 87.5 75 100 25

Management 1 76.8 33.4 82.5 �1 100 25 0.701 0.0532 78.7 33.5 90.0 0 100 25

5. Stable asthma with bilateral rhonchi Assessment 1 93.8 11.6 100.0 75 100 19 0.745 0.0342 90.6 12.9 100.0 75 100 25

Management 1 34.9 48.8 0.0 0 100 95 0.744 0.0342 34.9 48.8 0.0 0 100 95

6. Stable pneumonia with unilateral crepitations Assessment 1 87.5 13.4 87.5 75 100 25 0.956 <0.0012 81.3 25.9 87.5 25 100 25

Management 1 100.0 0.0 100 100 100 0 – –2 100.0 0.0 100.0 100 100 0

7. Tension pneumothorax with unilateral reduction in air entry Assessment 1 96.9 8.9 100.0 75 100 0 0.655 0.0782 93.8 11.6 100.0 75 100 19

Management 1 96.3 10.6 100.0 70 100 0 – –2 100.0 0.0 100.0 100 100 0

The maximum score for the assessment or management portion is 100. SD: Standard Deviation; Min: Minimum; Max: Maximum; IQR: Interquartile range; r: Spearman’s rho correlationcoefficient; –: The correlation coefficient cannot be calculated because at least one of the variables is constant; p value: measures the statistical significance of r; CCF: CongestiveCardiac Failure; APO: Acute Pulmonary Oedema; COPD: Chronic Obstructive Pulmonary Disease; CO2: Carbon Dioxide.

108B.L.

Limetal.

Comparing triage evaluation of adult 109

The scoring was performed in real time by each of thetwo assessors on printed copies of the score sheets; blindedto each other’s scores. The assessors would also debriefeach participant and summarize the recommended diagnos-tic and therapeutic manoeuvres after the study for maximaleducational benefits. Upon completion of all scenarios,each nurse was also asked to fill in the survey using a six-point Likert scale of their confidence in evaluating and mak-ing safe decisions at triage of the adult ED dyspneic patient.The participant would then be ushered out of the room withno chance of meeting the next participant.

The hard copies of the scoring sheets were maintained infolders and the data transferred to an electronic SPSS 13.0database (SPSS Inc., Illinosis, USA) spreadsheet after thestudy.

Data analysis and statistical methods

We collected data on each participant’s scores on assess-ment and management for all seven scenarios as evaluatedby both assessors. Post study self report measures of confi-dence levels on triaging ED dyspneic patients were also col-lected from all eight nurses.

Data was analyzed using descriptive statistics. For eachscenario, we reported mean, median, minimum and maxi-mum assessment and management scores with their Stan-dard Deviations (SDs) and interquartile ranges (IQRs) forthe two groups of nurses and doctors. Spearman’s rho corre-lation coefficients (r) were computed to assess interraterreliability between the assessors on their evaluation of theparticipants’ assessment and management of each simu-lated scenario as scores might not follow a normal distribu-tion. We used the Mann Whitney U test to investigate thedifferences in scores between the groups for each of the

Table 4 Comparison of average assessment scores by both asses

Scenario

1. Epiglottitis with stridor

2. Stable CCF with bilateral crepitations

3. APO with bilateral crepitations and rhonchi

4. COPD with CO2 retention and bilateral rhonchi

5. Stable asthma with bilateral rhonchi

6. Stable pneumonia with unilateral crepitations

7. Tension pneumothorax with unilateral reduction in air entry

Each of the mean, SD, median min, max, IQR scores was computed bySD: Standard Deviation; Min: Minimum; Max: Maximum; IQR: Interquacomparison between the mean scores of the doctors versus nurses inCardiac Failure; APO: Acute Pulmonary Oedema; COPD: Chronic Obstr

scenarios. All tests were two tailed and results were consid-ered statistically significant if p < 0.05.

Data/results

Table 2 shows the details of the assessment and manage-ment scores across all seven scenarios for both assessorsin the group of nurses.

The mean scores on the assessment portion were lowestfor scenario three [Acute Pulmonary Oedema (APO) withbilateral crepitations and rhonchi]. They were 68.8 ± 11.6and 68.8 ± 17.7 for assessor one and two respectively. Thesescores were highest for scenario five (stable asthma withbilateral rhonchi) where both assessors assigned a score of90.6 ± 18.6.

The mean scores on the management portion were low-est for scenario five and they were 81.3 ± 42.2 and80.0 ± 41.7 for assessor one and two respectively. Similarly,these scores were highest for scenarios two [stable Conges-tive Cardiac Failure (CCF) with bilateral crepitations] andseven (tension pneumothorax with unilateral reduction inair entry) where both assessors assigned scores of100.0 ± 0.0. Both assessment and management scores weremore evenly distributed in this group with IQR ranging from0 to 25. The correlation coefficients between the assessorsranged from 0.611 to 1.000 and these values reached statis-tical significance for most scenarios except for the assess-ment portion in scenario three and seven.

Table 3 reveals the details of the assessment and man-agement scores across all seven scenarios for both assessorsin the group of doctors.

There was a wider distribution of scores among the par-ticipating doctors with IQR ranging from 0 to 95. The mean

sors for doctors (n = 8) versus nurses (n = 8).

Domain Mean SD Median Min Max IQR p Value

Doctors 92.5 11.3 100.0 75 100 21 0.167Nurses 82.8 15.0 83.8 55 100 23

Doctors 82.8 9.3 81.3 75 100 13 0.544Nurses 84.4 17.4 87.5 50 100 25

Doctors 70.3 26.7 75.0 25 100 47 0.703Nurses 68.8 13.4 75.0 50 88 22

Doctors 82.8 9.3 81.3 75 100 13 0.386Nurses 78.1 8.8 75.0 63 88 13

Doctors 92.2 11.5 100.0 75 100 22 0.798Nurses 90.6 18.6 100.0 50 100 19

Doctors 84.4 18.6 87.5 50 100 25 0.452Nurses 79.7 13.3 75.0 62 100 19

Doctors 95.3 9.3 100.0 75 100 9 0.303Nurses 87.5 17.7 93.8 50 100 22

averaging the respective scores assigned by assessor one and two.rtile range; p value: measures the statistical significance of theeach scenario using the Mann Whitney U test; CCF: Congestive

uctive Pulmonary Disease; CO2: Carbon Dioxide.

Table 5 Comparison of average management scores by both assessors for doctors (n = 8) versus nurses (n = 8).

Scenario Domain Mean SD Median Min Max IQR p Value

1. Epiglottitis with stridor Doctors 89.1 16.9 93.8 50 100 13 0.073Nurses 99.4 1.8 100.0 95 100 0

2. Stable CCF with bilateral crepitations Doctors 97.2 5.3 100.0 88 100 8 0.144Nurses 100.0 0.0 100.0 100 100 0

3. APO with bilateral crepitations and rhonchi Doctors 87.8 4.1 90.0 80 90 6 0.244Nurses 91.9 7.4 90.0 83 100 16

4. COPD with CO2 retention and bilateral rhonchi Doctors 77.8 33.1 88.8 0 100 24 0.418Nurses 82.2 34.0 95.0 0 100 17

5. Stable asthma with bilateral rhonchi Doctors 34.9 48.5 �0.01 0 100 90 0.07Nurses 80.6 41.9 98.8 �20 100 23

6. Stable pneumonia with unilateral crepitations Doctors 100.0 0.0 100.0 100 100 0 0.317Nurses 98.8 3.5 100.0 90 100 0

7. Tension pneumothorax with unilateral reduction in air entry Doctors 98.1 5.3 100.0 85 100 0 0.317Nurses 100.0 0.0 100.0 100 100 0

Each of the mean, SD, median min, max, IQR scores was computed by averaging the respective scores assigned by assessor one and two.SD: Standard Deviation; Min: Minimum; Max: Maximum; IQR: Interquartile range; p value: measures the statistical significance of thecomparison between the mean scores of the doctors versus nurses in each scenario using the Mann Whitney U test; CCF: CongestiveCardiac Failure; APO: Acute Pulmonary Oedema; COPD: Chronic Obstructive Pulmonary Disease; CO2: Carbon Dioxide.

110 B.L. Lim et al.

scores on the assessment portion were lowest for scenariothree. They were 68.8 ± 25.9 and 71.9 ± 28.2 as assignedby assessor one and two respectively. These scores werehighest for scenario seven. They were 96.9 ± 8.9 and93.8 ± 11.6 for assessor one and two respectively. The meanscores on the management portion were lowest for scenariofive. Both assessors assigned scores of 34.9 ± 48.8. Five outof eight doctors had 50 points deducted by both assessorsfor inappropriate assignment of PAC status in a stable asth-matic patient who received bronchodilators (PAC 2 insteadof 1). The mean management scores were also highest inscenario six (stable pneumonia with unilateral crepitations)where both assessors assigned a score of 100 ± 0.0. As com-pared to the nurses, the level of correlation of assessmentand management scores in this group of doctors was weakerbetween the two assessors with r ranging from �0.247 to1.000 and r not reaching statistical significance in half (7/14) of these observations.

As demonstrated in Tables 2 and 3, we also observed con-sistently high management scores (P75) in both groups forsimulated scenarios that required classification as emer-gent. These scenarios were acute epiglottitis, APO, COPDwith Carbon Dioxide (CO2) retention and tension pneumo-thorax. With the exception of the scenario on APO, our par-ticipants also attained assessment scores P75 for theseemergent conditions.

We next reported the comparison of the assessment andmanagement scores between the nurses and doctors. Table 4reveals the details of the comparison of the assessmentscores between the two groups. The averages of the meanassessment scores assigned by both assessors were margin-ally higher for doctors compared to nurses in all scenariosexcept scenario two (stable CCF with bilateral crepitations).There were, however, no statistical significant differencesbetween these assessment scores of doctors versus nurses

across all scenarios. Table 5 reveals the comparison of themanagement scores between doctors versus nurses. Theaverages of the mean management scores assigned by bothassessors were higher for the nurses compared to the doc-tors in most scenarios except in scenario six. There were,however, no statistical significant differences betweenthese management scores of doctors versus nurses acrossall scenarios.

The median score of the nurses’ confidence level to tri-age and evaluate ED dyspneic patients after the study wasfour on a Likert scale from 0 to 5. Six out of eight participat-ing nurses felt they could perform this task by themselves(score of 4). They had 6–8 years’ experience in EM nursing.The remaining two; each with 10 years’ experience in EMnursing; felt they could do it with supervision. One nursefelt she could do it with someone nearby (score of 3) andthe other felt she could do it with someone right by her side(score of 2).

Discussion

Our study suggested that appropriately trained ED nursescould triage and evaluate dyspneic patients as effectivelyas ED doctors on simulated patient scenarios. We haveshown that, at least on a simulator, ENs were able to per-form more frontline patient evaluation and managementthat involves accurate diagnostic and management skills.This role progression of trained ENs and ENPs is importantto improve staff allocation with increasing ED workloadsand worsening overcrowding with aging populations in mostmetropolitan cities (Hoot and Aronsky, 2008).

We also observed that our nurses attained consistentlyhigh scores in both assessment and management of scenar-ios where timely escalation of the patients to emergent care

Comparing triage evaluation of adult 111

was required. These scenarios included acute epiglottitis,APO, COPD with CO2 retention and tension pneumothorax.These scores were comparable to ED doctors without statis-tical significant differences between the two groups. Thesefindings suggested that patient safety would not be compro-mised when triage was performed by appropriately trainednurses. In addition, the scores of our nurses in these scenar-ios were not widely distributed with small IQRs, suggestingthat there was consistency in their performances in thesescenarios. Early and consistent recognition of emergent, lifethreatening cardiorespiratory conditions is the most impor-tant goal in any triage system and guideline (Bullard et al.,2008; Australasian College for Emergency Medicine, 2005;Mackway, 1997) as failure to do so will compromise patientsafety.

In our study, the participating doctors showed a widerdistribution of assessment and management scores acrossall scenarios. This was likely due to the wider variation ofclinical experience and grades among the doctors. In addi-tion, doctors scored poorly in their management of the sta-ble asthmatic patient with rhonchi. This poor performanceis likely a result of a major deduction of points resultingfrom an inappropriate assignment of PAC status. Our ED as-signs a PAC 1 status to asthmatic patients who require bron-chodilators at triage and believe that such patients shouldbe assessed the soonest possible.

Correlation between assessors was observed to be betterin the nursing versus doctors’ group. We recognize thatweaknesses in the evaluation instrument could explain atleast, in part, the discrepancy between the two assessorsfor both doctors and nurses. Although vetted by our EPs,there would be parts of the evaluation instrument that in-volved varying degrees of subjectivity in assigning scores.Besides this, we also postulated that the better correlationbetween the two assessors in the nurses’ group was likelydue to the more uniform distribution of nursing experience(6–10 years) within this group. For the doctors, we postu-lated that this discrepancy between the two assessors waslikely a reflection of their biases in perception of clinicalcompetency. There were greater variations in doctors’grades and clinical experience (2–23 years) and these dif-ferences could translate into varying styles of presentationand confidence levels in delivering the assessment and man-agement portions of each scenario.

Our study suggested that high fidelity simulated patientscenarios using the SimMan 3G simulator constitute aneffective method to assess the competency of healthcareproviders in performing an integrated and complex taskespecially in comparison with the existing ‘‘gold standard’’providers. Our findings concurred with previous studies(Tubbs et al., 2009; Overly et al., 2007; Bryne et al.,2002; Ali et al., 2000) that demonstrated the effectivenessof high fidelity medical simulation to assess trainees in sev-eral stressful emergency situations like acute contrast reac-tions, pediatric intubations, anesthetic crises and traumaticresuscitation. We used the SimMan 3G simulator which canreproduce a wide variety of adventitial pulmonary soundsand together with a spectrum of cardiorespiratory condi-tions and severities, we were able to assess our participantsin their abilities to incorporate clinical evaluation with theirexperience to rapidly make critical decisions at the triagepoint. This approach could assess competencies in patient

care, medical knowledge, practice-based learning and pro-fessionalism in accordance with the recommendations ofthe Accreditation Council for Graduate Medical Education(Lyss-Lerman et al., 2009).

We are currently validating our findings by comparing theevaluation and critical decision making of our eight nurseswith ED doctors on real time dyspneic patients at triage ina sufficiently powered prospective study. We also proposeto use and review the SimMan 3G patient simulated scenar-ios as a tool for assessment and accreditation of futurenurses in the triage evaluation and decision making of thedyspneic patient.

Limitations

We recognize some important limitations of our study.Although our scenarios were created from collective opin-ions of our entire staff cohort and recommended guidelines,the weightings used in our scoring instruments were subjec-tive. These could add biases to our study. Although we hadrecruited every trained nurse, our study population was stillsmall and it remained possible that our results arise bychance alone. We were also unable to simulate the busyand often unexpected work schedule of ED staff that re-quires them to multi-task effectively amidst constant dis-tractions. We understand that the triage nurse or doctorcan be faced with more than one dyspneic patient at a par-ticular time and prioritising is a skill that we did not assessin this study. Finally, we also did not investigate whetherour nurses’ structured training and simulated patient sce-narios result in error reduction or decrease in adverse pa-tient events.

Conclusions

Our findings suggested that trained ED nurses could effec-tively evaluate and make critical decisions on dyspneic pa-tients at triage when compared to doctors, at least onsimulated patient scenarios. We propose to validate ourfindings on real time ED dyspneic patients in a future study.

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