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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. . 1 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. 2 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?”. 3 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. 4 . 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. 5 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] 6 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 7 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 8 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 9 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 10 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. 11 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 12 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. 13 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. 14 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. . 15 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. 16 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 17 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. 18 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. 19 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] 21 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 22 12 1. Remarks of the Chairman and Principal 2. Signature s 23