Nicki Gilboy

The emergency severity index triage algorithm version 2 is reliable and valid.

OBJECTIVES Initial studies have shown improved reliability and validity of a new triage tool, the Emergency Severity Index (ESI), over conventional three-level scales at two university medical centers. After pilot implementation and validation, the ESI was revised to include pediatric and updated vital signs criteria. The goal of this study was to assess ESI version (v.) 2 reliability and validity at seven emergency departments (EDs) in three states. METHODS In part 1, interrater reliability was assessed using weighted kappa analysis of written training cases and postimplementation by a random sampling of actual patient triages. In part 2, validity was analyzed using a prospective cohort with stratified random sampling at each site. The ESI was compared with outcomes including resource consumption, inpatient admission, ED length of stay, and 60-day all-cause mortality. RESULTS Weighted kappa analysis of interrater reliability ranged from 0.70 to 0.80 for the written scenarios (n = 3289) and 0.69 to 0.87 for patient triages (n = 386). Outcomes for the validity cohort (n = 1042) included hospitalization rates by ESI triage level: level 1, 83%; 2, 67%; 3, 42%; 4, 8%; level 5, 4%. Sixty-day all-cause mortality by triage level was as follows: level 1, 25%; 2, 4%; 3, 2%; 4, 1%; and 5, 0%. CONCLUSIONS ESI v. 2 triage produced reliable, valid stratification of patients across seven sites. ESI triage should be evaluated as an ED casemix identification system for uniform data collection in the United States and compared with other major ED triage methods.

Assessment of inter-observer reliability of two five-level triage and acuity scales: a randomized controlled trial

INTRODUCTION The Emergency Severity Index (ESI) is an initial measure of patient assessment in the emergency department (ED). It rates patients based on acuity and predicted resource intensity from Level 1 (most ill) to Level 5 (least resource intensive). Already implemented and evaluated in several US hospitals, ESI has yet to be evaluated in a Canadian setting or compared with the five-level Canadian Emergency Department Triage and Acuity Scale (CTAS). OBJECTIVE To compare the inter-observer reliability of 2 five-level triage and acuity scales. METHODS Ten triage nurses, who had all been trained in the use of CTAS, from 4 urban, academic Canadian EDs were randomly assigned either to training in ESI version 3 (ESI v.3) or to refresher training in CTAS. They independently assigned triage scores to 200 emergency cases, unaware of the rating by the other nurses. RESULTS Number of years of nursing practice was the only significant demographic difference found between the 2 groups (p = 0.014). A quadratically weighted kappa to measure the inter-observer reliability of the CTAS group was 0.91 (0.90, 0.99) and not significantly different from that of the ESI group 0.89 (0.88, 0.99). An inter-test generalizability (G) study performed on the variance components derived from an analysis of variance (ANOVA) revealed G(5) = 0.90 (0.82, 0.99). CONCLUSIONS After 3 hours of training, experienced triage nurses were able to perform triage assessments using ESI v.3 with the same inter-observer reliability as those with experience and refresher training in using the CTAS.

Use of a Computerized Forcing Function Improves Performance in Ordering Restraints

STUDY OBJECTIVE We evaluate the effect of a computerized order entry system forcing function on improving timely renewal of restraint orders. METHODS In this prospective study of 2 successive interventions, physicians received computerized reminders to renew or discontinue restraint orders before their expiration. The initial intervention allowed acknowledgement of this reminder without further consequence, changing at 6 months to deny computer access until addressed. We performed chart review on emergency department visits with restraint orders in 3 consecutive 6-month periods (A, B, C) separated by these 2 interventions, determining time to order renewal, number of restraint orders, renewal orders per hour in restraints, and time in restraints and evaluating variability in these values across study intervals. Statistical analysis for our primary outcome used the Mann-Whitney and variance ratio tests. RESULTS Median time to order renewal decreased in periods B and C versus A by 64 and 56 minutes, respectively, with variability in this measure decreasing across all periods. Mean number of restraint orders in periods B and C significantly increased versus those in A (1.46 to 1.89 to 2.34), with corresponding increases in variability. Mean renewal orders per hour in restraint significantly increased in period C versus A and B, from 0.08 to 0.23 to 0.89, with increasing variability across all periods. Decreases in median time spent in restraints observed in periods B and C versus A of 45 and 105 minutes, respectively, trended toward but did not achieve significance, with significantly decreasing variability compared with baseline. CONCLUSION The forcing function improved restraint reordering and variability in practice and may have contributed to nonsignificant reductions observed in time in restraint.

Noninvasive Monitoring of End-Tidal Carbon Dioxide in the Emergency Department

Noninvasive monitoring of end-tidal carbon dioxide (ETCO2) is not new technology but its routine use in the emergency department is a recent development. It is a better tool to evaluate ventilation when compared to oximetry because it provides the caregiver with breath-to-breath information. End-tidal carbon dioxide reflects the production, transportation, and elimination of CO2. This technology has been used to evaluate endotracheal tube placement. Now with both side stream and mainstream monitoring available, emergency departments can use ETCO2 in a variety of situations. The emergency nurse needs to be able to evaluate the configuration of the waveform in addition to the numeric value.

Compliance With Hand Hygiene Guidelines

The Research to Practice column attempts to serve 2 purposes: (1) fine-tune the research critique skills of advanced practice nurses and (2) suggest strategies to translate findings from a research study into bedside practice. For each column, a topic and a particular research study are selected. The stage is set by introducing the importance of the topic. The research paper is then reviewed and critiqued, and finally, the implications for translation into practice are discussed. In this column, T. Eckmans, J. Bessert, M. Behnke, P. Gastmeir, and R. Henning (2006) investigate the effect of having a trained observer assess for compliance with antiseptic hand rub use in intensive care units. The implications of these findings for advanced practice nurses are discussed.

Comprehension of discharge instructions.

The Research to Practice column attempts to serve two purposes: (1) fine-tune the research critique skills of advanced practice nurses and (2) suggest strategies to translate findings from a research study into bedside practice. For each column, a topic and a particular research study are selected. The stage is set by introducing the importance of the topic. The research paper is then reviewed and critiqued, and finally, the implications for translation into practice are discussed. This particular column reviews the article: Engel, K., Heisler, M., Smith, D., Robinson, C., Forman, J., & Ubel, P. (in press). Patient comprehension of emergency department care and instructions: Are patients aware of when they do not understand? Annals of Emergency Medicine.

Who Is Leaving the Emergency Department Without Being Seen

The Research to Practice column selects a research article with important meaning for the advanced practice nurse. The column first discusses why the topic is important, and then provides a summary and critique of the research methods. Finally, the findings from the research article are then discussed, and implications for advanced practice emergency nurse are framed. In this column the following research article is reviewed: B. H. Rowe, P. Channan, M. Bullard, S. Blitz, L. D. Saunders, R. R. Rosychuk, et al. (2006). The topic of patients who leave before a medical screening examination is introduced; the research article is reviewed and critiqued, and implications and opportunities for the advanced practice nurse are discussed.

Can Different Types of Central Venous Catheters Be Used to Measure Central Venous Pressure in an Emergent Situation

“CAN I monitor CVP from a PICC line?” asks a nurse caring for a frail 72year-old woman admitted with a fever to the emergency department (ED) from a skilled nursing facility. The patient was recently discharged from the hospital following abdominal surgery complicated by a wound infection. Prior to hospital discharge, a peripherally inserted central catheter (PICC) was placed for the administration of longterm antibiotics. On arrival to the ED, the patient is hypotensive (BP = 88/56), tachycardic (HR = 132), and has a temperature of 38.6◦C (101.4◦F). The nurse tells you that she was able to start one peripheral intravenous line and has sent all laboratory studies including blood and urine cultures. Antibiotics are infus-

Transporting Low-Risk Chest Pain Patients—Do You Need an RN and a Monitor/Defibrillator?

IN order to provide the best care to patients, nurses need to base their practice on the evidence. Nursing needs to move away from the opinions, rituals, and traditions that have traditionally governed practice and begin to critically evaluate “what we have always done” and “how we have always done it.” Nursing practice should be based on data or evidence. This evidence should come from research and when research is not available, case reports, quality improvement (QI) data, and expert consensus may be used. The ultimate goal is to provide excellent, safe, costeffective care to patients. In the last 10 years, evidence-based practice has become an expectation in nursing. Many hospitals have chosen to join the national movement to improve the professional image of nursing, and are striving to attain Magnet status (Lash & Monroes, 2005). Basing nursing practice on research or data is the right thing to do, and is an important component of Magnet status.

Recovering and Reporting Medical Errors in the Emergency Department

The Research to Practice column attempts to serve 2 purposes: (1) fine-tune the research critique skills of advanced practice nurses and (2) suggest strategies to translate findings from a research study into bedside practice. For each column, a topic and a particular research study are selected. The stage is set by introducing the importance of the topic. The research article is then reviewed and critiqued, and finally, the implications for translation into practice are discussed. In this column, the following article has been reviewed: Henneman, Blank, Gawlinski, and Henneman (2006). Qualitative methods were used to conduct 4 focus groups with emergency department nurses to understand how nurses recover medical errors.