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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1.Name of the
candidate and
address
ELDHOSE VARGHESE
M.Sc NURSING 1 YEAR
Dr. SYAMALA REDDY COLLEGE OF NURSING
#111/1 SGR MAIN ROAD,
MUNNEKOLALA,
MARTHAHALLI,
BANGALORE-560037.
2.Name of the
Institution
3.Course of study
and subject
Dr. Syamala Reddy college of Nursing
M.Sc nursing 1 year.
MEDICAL –SURGICAL NURSING
4. Date of admission JUNE 2010
to course
5. Title of the study A study on assessment of knowledge and attitude regarding emergency
severity index triage among B.Sc nursing students in selected colleges of
nursing at Bangalore.
.
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BRIEF RESUME OF THE INTENDED WORK
APPROPRIATE ATTENTION IN A SUITABLE LOCATION
6.0. INTRODUCTION
The term “triage” originates from the French word “Trier”
which means to sort, pick out, classify or choose. The triage principle of prioritizing care
to large groups of peoples has been adapted from its military origin for use in the civilian
context of initial emergency department care. In the emergency department context,
triage is formal process of immediate assessment of all patients who present seeking
emergency care. Triage assessment findings are then used to priorities or classify patients
on the basis of illness or injury severity and need for medical and nursing care.
An effective triage system aims to ensure that
emergency department patients “receive appropriate attention, in a suitable location, with
the requisite degree of urgency “. Triage ensures that emergency care is initiated in
response to clinical need rather than order of arrival. Triage aims to promote the safety of
patient by ensuring that timing of care and resource allocation is requisite to the degree
of illness or injury4.
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Triage is the point at which emergency care begins. The
Australian college for emergency medicine [ACEM] state that triage should be performed
by a “suitably experienced and trained registered nurse or medical practitioners”. The
Commonwealth Department of Health and Family Service and ACEM [1997] advocate
that patients presenting to the emergency department should be triaged by “an
appropriately skilled health care professional “ACEM acknowledge that triage is usually
performed by an “appropriately experienced registered nurse5 “
Emergency severity index triage is a modified triage system .It
is an emergency department triage algorithm that provides clinically relevant
stratification of patients in to five groups from most urgent to lead urgent on the basis of
acuity and resource needs [AHRQ]1. The agency for health care and resource funded
initial work on emergency severity index triage system.[agency for health care research
and quality]. The emergency severity index [ESI] is a five level triage scale developed by
emergency department physicians Richard Wuerz and David Eitel in united states [
Gilboy..1999; Wuerz,Milne, Eitel, Travers and Gilboy ,2000;]3, the two originators
believed that a principal rple in emergency department triage instrument is to facilitates
the prioritization of patients based on the urgency of patient conditions. The triage nurse
determines priority by posing the question, “who should be seen first?” Drs. Wuerz and
Eitel realized, however, that when more than one top priority patient is present
simultaneously, the operating question becomes, “how long can everybody wait?”.
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The professionals who are associated with health care delivery
system, they have challenge on updating their knowledge based up on the technological
advancement and innovative modifications of health care aspects. Agency
for health
care research and quality [AHRO] is doing great job in the field of advancing excellence
in health care system.1
In our country health sector always face the research
crunch. The government of India utilize only of 0.9% of GDP on health where as other
country’s like Srilanka and Bangladesh. They utilize 1.6% and 1.8% of their GDP on
health system.[Gargi Roy]2
In India the emergency department sometimes termed
emergency room, emergency ward, accident and emergency ward or casualty department
of hospitals. Primarily some of which may be life threatening and require immediate
attention. Emergency department developed during 20th century in response to increased
need for rapid assessment and management of critical illness. The emergency medical
service serves the community as well as society at any time they need.
Emergency as a situation as which patient requires urgent
and high quality medical and nursing care. Due to increased number of road traffic
accidents, rapid industrialization, bioterrorism and other terroristic activities, natural and
manmade disasters are fast increasing and which are to be complex in nature.
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.
A Well implemented triage program will help
hospital emergency department rapidly identify patients needs of immediate attention,
better identify patients who are could safely and more efficiently be seen in fast track
urgent care. Emergency severity index five level triage system include resuscitation,
emergent, urgent, none urgent, referral. The triage system helps to evaluate patient acuity
and resource. The emergency severity index is a promising new tool for triage acuity
assessment in emergency department .it has been shown to be reproducible across
emergency departments, including urban and rural setting and academic and community
hospitals.[Eitel, Travers, Gilboy, Wuerz ,2003]6.
The nursing professionals aware of these types of
resources for improve the quality of nursing care in a fast track manner. The process of
categorizing emergency department patients using the emergency severity index is acuity
judgments are
addressed first based on the stability of patients vital functions and the
likelihood of an immediate life or organ threat. The expected resource needs are
addressed for stable patients based on triage nurse prediction of the resources needed to
get the patient to an emergency department disposition.
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The student nurses are become
future high quality
care providers. They have unique role of future implementation of emergency severity
index triage and emergency care by hospitals by different areas of the country, by
university and community, and by teaching and none teaching sites. They are the future
emergency department managers and researchers.
The nurses in future, they need to have advanced
knowledge about the innovations and advancement in health care system. They need to
have a particular attitude towards emergency severity index triage system.
6.1. NEED FOR THE STUDY
Triage is the first step in the evaluation of a patient presenting to an
emergency department .this include assessment of patient’s clinical needs and priority for
care.
Actual need of triage system is “connect every patient to the
right resources at the right place and in the right amount of time according to [Jean
Prochl]
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There are more than 110 million visits U.S
emergency department each year [Mc Caig and Burt , 2004] 7 there are very little
aggregate data about those visits on the local , regional, or national level. it is difficult to
answer important questions such as “Which emergency departments see the sickest
patient ?”.And how does patient acuity affect emergency department overcrowding?”.
There is growing interest in the establishment of standards for emergency department
data in the U.S to support clinical care. Emergency department surveillance,
benchmarking and research activities [Barthell,Coonan, Finnel,and Cochrane 2004;
national center for injury prevention and control[NCIPC], 1997: Zimmermann, 2001]8
A study was presented in 30th international symposium on
intensive care and emergency medicine that is the knowledge of nursing students
regarding triage emergency method shows 64% have adequate knowledge regarding
triage.
One important Emergency Department data element is
triage acuity , which has been defined by the data elements for emergency department
system Task force as ; classification of patient acuity characterize the degree to which
the patient’s condition is life threatening , and whether immediate treatment is needed to
alleviate symptoms.[NCIPC,1997,p 94]9
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In united states the National Centre for health statistics
plans to replace four level triage data with five-level triage data in future national
benchmarking surveys of U.S emergency departments. This decision was based up on
the growing evidence that five-level triage acuity data are more reliable and valid than
three – level systems [personal communication, Linda McCaig, national center for health
statistics, October, 6, 2004. In a paper published by the task force in 2005, both the ESI
and Canadian triage and acuity scale were recommended as valid and reliable triage
systems10.
National hospital Ambulatory Medical care survey 2002.
Emergency department survey report an estimated 110 million visits where made
department in 2002 [Mc Caig and Buet 2004]7. It result there is increase in emergency
visits.
The emergency severity index triage is unique in that it also
requires the triage nurses anticipate expected resource need [e.g diagnostic test and
procedure] in addition to acuity to determine the triage category. The process of
categorizing the patient using the ESI on the basis of acuity and resource need .
In a pilot study of ESI rating for 493 triage encounters at two
Bosten hospitals in 1998 , researchers found that the system was valid and reliable
.[Wuerz, Etal 2000]10triage levels strongly associated with
resources used
in the
emergency department and with outcomes such as hospitalization . Higher
acuity
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patients consumed more resources and where more likely to be admitted to the hospital
than
low resource patients .interacted reliability
between the research and
the
investigator was found to be good , with 77% exact agreements and 22% within one
triage level.
Triage is typically the first step in the evaluation of a patient
presenting to an emergency department. This process involves a brief assessment that
focuses on the patient’s clinical needs and priority for care. The triage nurse then assigns
the patient a place in quick and to an appropriate treatment.
In most recent study of the ESI triage, the validity of ESI. In
an evaluation of outcome for 571 ESI level -2 patients at a five hospitals, it was found 20
% of level 2 patients received immediate, life saving interventions. The authors
concluded that such patients would benefit from being classified as ESI level-1.
The nurse nursing assessment is the important activity of a
triage nurse[Gilboy , Etal 1999].nurses using the ESI triage have reported that the tool
facilitates the communication of patient acuity more effectively than other systems. The
triage nurse tell the charge nurse, “I need a bed for a level 2 patient “ and through this
common language , the charge nurse understand what is needed without a detailed
explanation of the patient by the triage nurse.
Nursing students are the future care providers they are aware of the
modified and advanced technique and modified versions of triage system. That should be
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the future emergency care on the basis of patient acuity level and resource need. The
nursing students have particular attitude towards the emergency care as well as
emergency severity index triage system.
6.2.REVIEW OF LITERATURE
Review of the literature is an important step in the development of research project .the
investigator carried out an extensive review of literature on the research topic to gain
deeper insight in to the problem and to collect maximum relevant information for
building up the study in a scientific manner so as to achieve the desire result.
Literature related to the topic are organized and presented under the following heads
1. Definition of emergency severity index.
2. Primary survey
3. secondary survey
4. Related study reviews
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1. Emergency severity index
It is a five level emergency department triage algorithms that provide clinically
relevant stratification of patients in to five groups from most urgent to least urgent on the
basis of acuity and resource needs.[AHRQ]
2. Primary survey
It focuses on airway, breathing, circulation, and disability and serves to identify
life threatening conditions. So that appropriate Intervention can initiated.
1. Airway with cervical spine stabilization with and\or
immobilization –nearly all immediate trauma deaths occur
because of airway obstruction. Saliva, body secretions, vomits,
laryngeal trauma, dentures, facial trauma, fractures and the tongue
can obstruct the airway. If an airway is not maintained,
obstruction of airflow occurs and hypoxia, acidosis and death may
result.
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2. Breathing-Adequate airflow through the upper airway does not
ensure adequate ventilation. Breathing alterations are caused by
many conditions, including fractured ribs, pneumothorax,
penetrating injury, allergic reactions pulmonary emboli and
asthma attacks.
3. Circulation- an effective circulatory system includes the heart,
intact blood vesicles, and adequate blood volume. Uncontrolled
internal and \or external bleeding places a person at risk for
hemorrhagic shock.
4. Disability- A brief neurologic examination complete in primary
survey. The degree of disability is measured by the patient’s level
of consciousness.
3. Secondary survey
It is brief systematic process that is aimed at identifying all injuries. That includes
Exposure\environmental control, full set of vital signs\five interventions, give comfort
measure, history and head to toe assessment, inspect the posterior surface.
1. Exposure \environmental control- All trauma patients should
have their cloth removed so that a thorough physical
assessment can performed.
2. Full set of vital signs\ five interventions- A complete set of
vital signs, including blood pressure, heart rate, respiratory
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rate and the temperature should be obtained after the patient is
exposed.
3. Give comfort measures-Provision of comfort measures is of
paramount importance when caring for patients in the
Emergency department.
4. History and head to Toe assessment- The history of the
incident, injury, or illness provide clues to the cause of the
crisis and suggests specific assessment and intervention needs.
5. Inspect the posterior surfaces- the trauma patient should
always be log rolled [while maintaining cervical spine
immobilization] to inspect the patients posterior surfaces.14
4. Related study reviews
A study conducted on asses the reliability of a new triage emergency methods among
nursing students .Hospital Santa Masia , Delk, scaletta lnola, Bologne Italy.
Observational study method is adopted. The finding is, students have 64% of knowledge
reliability Disagreement s zero12.
A study conducted on 2002. Reliability of emergency severity index. Using kappa static
measure, the time series design is used to compare the reliability of triage rating using
three level scales. Findings are the reliability is improved11.
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Another study conducted on 2003 examined the reliability and validity of emergency
severity index at seven hospitals in Northeast and Southeast .more than 200 triage nurses
at the seven sites were asked to rate 40 case studies using ESI . The study result
indicated the substantial inter rater reliability.
A study conducted on1999, the association between ESI triage status and short term
survival using stratified random sampling. The study reveals that ESI triage strongly
associate with vital statistics.
A study conducted 2004, to examine the relationship or differences between patient and
nurse characteristics, satisfaction with triage nurse caring behavior. The ED located on
400 bedded teaching hospitals in small southern city. The finding is acuity rating and
patient perception of condition had a positive relationship13.
A study conducted on 2010 , to the construct validity of ESI by measuring the
association between the ESI triage patients vital signs at triage prospective observational
method was adopted an emergency Department in Netherlands, the finding is association
found between ESI triage categories and patients vital signs.
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6.3. STATEMENT OF THE PROBLEM
A study on assessment of knowledge and attitude regarding emergency severity index
triage among B.Sc nursing students in selected colleges of nursing at Bangalore.
6.4. OBJECTIVES
1. To assess the level of knowledge regarding emergency severity index triage
among B.Sc nursing students.
2. To identify the level of attitude regarding emergency severity index triage among
B.Sc nursing students.
3. To find out the relationship between the levels of knowledge regarding
emergency severity index triage and selected socio demographic variables.
4. To determine the relationship between the levels of attitude regarding emergency
severity index triage and selected socio demographic variables.
6.5. HYPOTHESIS
H 1: There is a significant
relationship between the level of knowledge and level of
attitude of student nurses regarding emergency severity index triage.
H 2: There is a significant association between the level of knowledge regarding
emergency severity index triage and selected socio demographic variables. .
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H 3: There is significant relationship
between the level of attitude and selected socio
demographic variables.
6.6. OPERATIONAL DEFINITIONS
Assessment: It is the process of measuring the level of knowledge of student nurses
regarding emergency severity index triage using structured self administered
questionnaire
Knowledge: It is the information possessed by nursing students regarding emergency
severity index triage using structured self administered questionnaire.
Attitude: It is relatively constant predisposition, readiness or behavior towards
emergency severity index triage using structured self administered questionnaire.
Emergency severity index triage: It is the modified form of five level triage algorithms.
6.7. ASSUMPTIONS
1. Knowledge and attitude of student nurses differ from the person to person.
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2. Knowledge and attitude of student nurses is influenced by selected socio
demographic variables.
3. Mass media influences the level of knowledge and attitude of student nurses.
4. Knowledge and attitude of student nurses regarding emergency severity index
triage influence each other.
7.0. MATERIALS AND METHODS
7.1. SOURCES OF DATA: The student nurses in selected colleges of nursing at
Bangalore.
7.2. METHOD OF DATA COLLECTION PROCEDURE

RESEARCH APPROACH
Non experimental approach

RESEARCH DESIGN
It is descriptive correlational design using structured self administered questionnaire to
determine the level of knowledge and attitude regarding emergency severity index
triage among student nurses.
SAMPLING TECHNIQUE
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The sample will be collected using none probability convenience sampling
technique.
SAMPLE AND SAMPLE SIZE
The sample of 100 student nurses at selected colleges of nursing at Banglore.

SETTING OF THE STUDY
A descriptive correlational study will be conducted in selected colleges of
nursing at Bangalore. The colleges are in private sector.
7.2.1. CRITERIA FOR SAMPLE SELECTION
1. Final year B.Sc nursing students who are willing to participate in the study.
2. Final year B.Sc nursing students who are present at the time of data collection.
7.2.2. DATA COLLECTION TOOL
Structured self administered questionnaire will be prepared to assess knowledge and
attitude regarding emergency severity index among student nurses in selected colleges of
nursing at Bangalore.
Questionnaire will consist of 3 sections
Section A: section A consists of questionnaire on socio –demographic
variables such as age, sex, family members, friends, relatives etc.
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Section B: section B consists of questionnaire on level of knowledge regarding
emergency severity index triage among student nurses in selected colleges of nursing at
Bangalore.
Section C: section C consists of attitude scale will be used to assess the attitude of
student nurses .
VALIDITY: The validity of the tool will be ascertained in consultation with guide and
other experts from various fields like nursing, physician and biostatistician. Reliability of
tool will be established by split half method.
7.2.3. DATA ANALYSIS METHODS;
Data analysis will be done by descriptive and inferential statistics .The descriptive
statistics used will be frequency distribution table, percentage, mean and standard
deviation. The inferential statistics used will be Chi-square and correlation coefficient.
7.3. DOES THE STUDY REQUIRE ANY INVESTIGATION OR
INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMAN
OR ANIMALS?
No, only a structured questionnaire will be used for data collection .No other invasive
Physical or laboratory procedures will be conducted on the samples.
7.4.. HAS ETHICAL CLEARENCE BEEN OBTAINED?
Yes. Confidentiality and anonymity of the subjects will be maintained.
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Prior to the study consent will be taken from the student nurses regarding their
Willingness to participate in the study.
REFERNCES
1. AHRQ, Agency for healthcare research and quality, www.ahrq.gov
2. E-journal [Mrs Gargi Roy] an ideal emergency unit
3. Journal of Academic emergency medicine.
4. Journal of Victoria’s Emergency department.
5. Australian College for Emergency Medicine [2002]. The Australian
triage scale [ATS]. Retrived july 17,2002, from
http:\www.acem.org.au\open\document\triage .htm
6. Eitel DR, TraversDA, Rosenau A, Gilboy N,Wuerz RC [2003]
Academic emergency medicine
7. Mc Caig LF and Burt [2004]. National hospital ambulatory medical care
survey: 2002 emergency department summary. Advance data from vital
and health statistics .Hyattsville, MD: national centre for health
statistics.
8. Zimmermann PG [2001] . The cause for universal, reliable 5 tier triage
acuity scale for U.S emergency departments. Journal for emergency
nursing
20
9. National center for injury prevention and control [NCIPC]. Data
elements for emergency department systems, release 1.0 Atlanta GA:
Centers for disease control and prevention.
10. Wuerz R, Milne LW, Etiel DR, Travers D, Gilboy [2000], Academic
emergency medicine
11. Canadian Asssociation of Emergency physicians [CAEP]. The Canadian
triage and acuity scale for emergency departments.Rd april 5, 2002 from
http:\www.caep.ca\002. Policies\002-02.ctas.htm.
12. Suppliment 30th international symposium on intensive care and
emergency medicine. http:\ccforum.com\content\14
13. J Nurs Care Qual.2004jul-sep[Pubmed-index for MEDLINE]
14. Lewis text book of Medical surgical nursing 7th edition, [1822-1827]
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9.
Signature of Candidate
10.
Remarks of the Guide
11.
Name and Designation
1. Guide
2. Signature
3. Co-guide
4. Signature
11.5
Head of the
Department
6.
Signature
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12
1. Remarks of the
Chairman and
Principal
2. Signature
s
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