Window of opportunity closing… Winter on its way

The practical part of research on Emergency Department systems grinds to a standstill when the winter rush starts. Nurses and Consultants are far too busy dealing with the winter influx of patients to help.

 

Fortunately both the clincal trial work involving volunteer nurses and the expert review of patients’ records by our three ED consultant volunteers have been completed so the Somerset team are now able to analyse the data while ED staff focus on their hectic ‘day job.’

What we had asked the consultants to do was to review the patients’ triage records and ED discharge or hospital admission records. Together they reached a concensus about the best acuity score for each patient. They were of course blinded to acuity scores set both by the Imperial College triage nurse and our nurses using SortEDâ tablet to assess the same patient.

 

Two fundamentally different systems

 

Imperial College Healthcare NHS Trust use a computerised version of Manchester Triage System which scores acuity 1 (Red) to 5 (Green). SortED aslo uses a five level scale but there the similarity ends.

 

MTS is a two step ‘Trump Card’ procedure:

 

1. Select a presentation from a list of circa 50 presentations
2. Select a single ‘discriminator’  from a colour coded list which automatically sets the acuity

 

SortED uses more steps, gathers much more information and is a ‘Hand of Cards’ approach.

1. Identify or exclude any life threats i.e Acuity = 1 situations
2. Enter basic observations (pulse, respiratory rate, SaO2, temparature, systolic BP, AVPU score etc.) into a special age-appropriate ‘One-click’ panel. Clinically significant abnormalities are identified and their severity stratified
3. Enter the pain score 0-10
4. Use the graphic interface which assists choosing the best presentation for each patient
5. On the colour-coded checklist displayed, click all items (signs, symptoms, history) which apply to the patient
6. Consider the ‘Hand of cards’ which SortED has used to build the acuity suggestion
7. Accept or modify the recommendation

 

SortED does much more than set the acuity, it prompts for early investigations and treatments, giving a comprehensive ‘pit-stop’ approach to initial patient assessment, but more of that later.

 

Was allowing nurses control over acuity (step 7) a good idea?

 

What we have done this week is to use the consultant’s ‘gold standard’ acuties to see how well our nurses got on when modfying the basic acuity. 49 (of 529) records were marked as modified-by-nurse. For most the revised acuity either matched (27; 55.1%) or moved towards (5;10.2%) the consultant acuity. In a further 6 patients (12.2%) the move was in the right direction but an over correction. Only in 7 (14.3%) did the correction worsen the result. In the remaining 4 patients, the intention to modify the acuity was logged but the final acuity chosen was unchanged.

 

As I mentioned in my blog 27 September 2017, ICHT nurses had obviously attempted to ‘control’ the acuity score by selecting ‘Moderate pain’ (a discriminator associated with acuity 3 in MTS) even in patients with pain scores of zero. Overuse of the catch all presentation “Unwell adult” was also a concern.

 

Gillie Francis – Oct 2017