Trauma Notebook
An Integrative Review: Triage Protocols and the Effect on ED Length of Stay

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The purpose of this integrative review is to identify the effectiveness of using triage protocols to decrease ED length of stay. The review method described by Ganong was used to guide the review process. Data sources included CINAHL (Cumulative Index to Nursing and Allied Health Literature), Medline, the Cochrane Library, Mosby's Nursing Consult, and the National Guideline Clearinghouse. In addition, reference lists of all articles were reviewed, 3 authors of previous articles were contacted for more current or updated work, and a hand search of the Journal of Emergency Nursing was conducted. The search generated 56 articles, 8 of which met inclusion criteria. Data were interpreted and evaluated by use of a data summary sheet. Key conclusions drawn from the appraisals included that a decrease in length of stay was related to protocol use and nurses were able to initiate diagnostic testing and treatments appropriately. These conclusions apply to acuity levels 3 and 4, which require either little or no testing or require testing to facilitate a disposition decision. The implications for nursing are that appraisals of evidence lead to better practice decisions, protocols can provide greater nursing autonomy and satisfaction, and protocols are able to increase the facilitation of patient care in the emergency department.

Section snippets

Design

An integrative review was conducted by use of the guidelines described by Ganong17 (Table 1). The sample was collected through a systematic search of online databases from 1992 to 2010 and included CINAHL (Cumulative Index to Nursing and Allied Health Literature), Medline, the Cochrane Library, Mosby's Nursing Consult, and the National Guideline Clearinghouse. The reference lists of all pertinent literature were reviewed for topic similarity and possible evidence to support the clinical

Results

Of the studies reviewed, 4 were evidence level II,1, 3, 8, 12 3 were evidence level IV,5, 6, 10 and 1 was evidence level VI14 (Table 3). Overall, 3 studies focused solely on using protocols to decrease ED LOS.3, 8, 10 Four studies examined decreasing LOS as well as the ability of nurses to follow set protocols appropriately.2, 5, 6, 12 One study examined multiple factors (ie, diagnostic imaging, treatments, and consultations) affecting ED LOS rather than specifically focusing on use of

Length of Stay

An acuity system used in the emergency department generally creates a bell curve in relation to LOS.14 Higher–acuity level patients (levels 1 and 2) receive more immediate treatment as described by Gilboy et al.2 (Table 4), shortening LOS. Lower–acuity level patients (levels 4 and 5) do not require any testing or require very little testing, allowing them to be discharged immediately after their encounter with the medical provider. Those patients in the middle of the acuity rating system (level

Conclusion

The literature reports that patients designated to acuity levels 3 and 4 were subjected to the longest LOS, and diagnostic imaging and laboratory tests were associated with the longest increases in ED LOS.14 This review provides a much-needed synthesis of data published on triage protocols that showed reduced ED TLOS and most significantly reduced LOS-PPA by earlier intervention in triage. Time savings created by initiating protocols in triage may range widely; however, any amount of time

Dana J. Robinson is Clinical Assistant Professor, University of Arizona, Tucson, AZ.

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Dana J. Robinson is Clinical Assistant Professor, University of Arizona, Tucson, AZ.

Section Editor: Kathryn Moore, RN, DNP, CCRN, CEN, ACNP-BC, ANP-BC, GNP-BC

Submissions to this column are encouraged and may be sent to Kathryn Moore, RN, DNP, CCRN, CEN, ACNP-BC, ANP-BC, GNP-BC [email protected]

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