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Chamberlain College of Nursing
NR439: RN Evidence-Based Practice
Week 6: Reading Research Literature Worksheet
Name:
Date:
Complete the required worksheet after reading the assigned article for the session. The NR439
Reading Research Literature Worksheet Rubric must be used to answer each of the graded
criterion for the following:
Purpose of the
Study
Type of Research
& the Design
Sample
Data Collection
NR439_RRL_Worksheet_5.21_ST
1
Chamberlain College of Nursing
NR439: RN Evidence-Based Practice
Data Analysis
Limitations
Findings/Discussion
Reading Research
Literature
NR439_RRL_Worksheet_5.21_ST
2
RESEARCH
“I WAS HERE FIRST, WHY DID THEY GO BEFORE
ME”: EXAMINING PATIENTS’PERCEPTIONS OF
PRIORITY IN A PSYCHOMETRIC STUDY OF
EMERGENCY DEPARTMENT TRIAGE
Authors: Joshua Ray Tanzer, PhD, Marlene Dufault, PhD, RN, Linda Roderick Rioux, BS, RN, Jason Machan, PhD,
Kathy Bergeron, MS, GCNS, RN, and Anthony Napoli, MD, MHL, Providence, Kingston, and Newport, RI
Contribution to Emergency Nursing Practice
What is already known on patient satisfaction is that
there is a significant interplay between patient expectations and perceptions, with patients generally expecting
faster service than is realistic within the emergency
department.
The main finding of this paper is that the Patient Perception of Priority to Be Seen Survey can reliably measure
patient subjective experience, and a verbal explanation
of common triage procedures could standardize patient
expectations.
Recommendations for translation of the findings of this
paper into emergency clinical practice include using the
Patient Perception of Priority to Be Seen Survey in
research, quality improvement projects, and interventions to improve patient-nurse communication in the
emergency department.
Abstract
Introduction: Unrealistic patient expectations for wait times
can lead to poor satisfaction. This study’s dual purpose was: (1)
to address disparities between patients’ perceived priority level
and the Emergency Severity Index (ESI) assigned by emergency
room triage nurses; and (2) to evaluate validity and reliability of
using the Patient Perception of Priority to be Seen Survey
(PPPSS) to investigate patient expectations for emergency
department urgency.
Methods: A two-group pretest-posttest quasi-experimental
approach compared patient urgency opinions to nurse urgency
ratings with and without a scripted educational intervention.
This tested how closely patient perceptions were related to
triage nurse ratings.
Results: Reliability for the PPPSS was acceptable (reliability
¼ 0.75). Patients who were rated lower urgency on the ESI
by triage nurses tended to self-report higher urgency (rho ¼
0.44, P < .01). Attitudes were more consistent in the posttest patient group who were exposed to the scripted verbal description of emergency department procedures (x2 (1, N ¼ 352) ¼ 8.09, P < .01). Patients who disagreed with emergency nurse scores tended to be younger on average (eg, < 40 years old; rho ¼ 0.69, P < .01). Male identified patients tended to be rated both by nurses and themselves as higher urgency (beta ¼ 0.18, P ¼ .02). Discussion: We recommend the PPPSS for nurses and re- searchers to quickly assess patient expectations. Additionally, promoting patient understanding through a scripted educational Joshua Ray Tanzer is a Biostatistician, Lifespan Biostatistics, Epidemiology, Research Design, Informatics Core, Providence, RI. Department of Emergency Medicine, Newport Hospital Emergency Department, Newport, RI. Marlene Dufault is Professor and Nursing Consultant, University of Rhode Island, Department of Nursing, Kingston, RI. For correspondence, write: Joshua Ray Tanzer, PhD, Lifespan Biostatistics, Epidemiology, Research Design, Informatics Core, 130 Plain Street, Providence, RI 02903; E-mail: jtanzer@lifespan.org Linda Roderick Rioux is Staff Nurse Newport Hospital Emergency Department, Department of Emergency Medicine, Newport, RI. Jason Machan is Director of the Lifespan ClinTECH Center and Lifespan Biostatistics, Epidemiology, and Research Design Core, Providence, RI. Kathy Bergeron is Clinical Nurse Educator, Newport Hospital and Adjunct Faculty, Department of Nursing, Salve Regina University, Newport, RI. Anthony Napoli is Professor of Emergency Medicine, Department of Emergency Medicine, Warren Alpert School of Medicine at Brown University and Chair, 294 JOURNAL OF EMERGENCY NURSING J Emerg Nurs 2023;49:294-304. Available online 24 December 2022 0099-1767 Copyright Ó 2022 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jen.2022.09.017 VOLUME 49 ISSUE 2 March 2023 Tanzer et al/RESEARCH strategy about the ESI system may also result in improvements in communication between patients and nurses. Key words: Emergency department; Triage; Patient perception; Psychometrics; Educational intervention Introduction patient-reported subjective urgency scores with the ESI scores rated by the triage nurse. In addition, we used a quasi-experimental approach to see whether or not informing patients of ED triage procedures through a scripted educational intervention improves patient-reported expectations for wait times. Finally, we use expert knowledge from more than 35 years’ nursing experience to verify that the patients whom we thought would have unrealistic expectations for wait times did demonstrate such discrepancies empirically. This provided a multifaceted validation of the Patient Priority to be Seen Survey and an estimation of reliability. Discussion is provided of how to interpret individual scores, possible clinical applications, and how this could be used in research on patient satisfaction. PROBLEM DESCRIPTION Current best practice policies for triaging patients seeking care in hospital emergency departments are aimed to assure that emergency nurses, in collaboration with medical staff, provide triage assessments with a high level of accuracy for those seeking rapid, emergent treatment.1 The goal of triaging in the emergency department is to assess each patient in an expedient manner and to prioritize their care. The emergency severity index (ESI) based on joint Emergency Nurses Association/American College of Emergency Physicians standards is often used as a tool for facilitating efficient triage.2 The 5-level emergency triage algorithm provides clinically relevant prioritization of patients into 5 groups from 1 (requires immediate intervention) to 5 (least urgent). Triage nurses are responsible for this assessment using a rapid, systematic collection of data relevant to the patient’s chief complaint, age, allergies, and vital signs to obtain sufficient information to determine the ESI level and to be seen by the emergency provider.3 Although ESI triage procedure provides an efficient algorithm for designating patient urgency, it may not always be apparent to patients in the waiting room, which risks patient confusion and dissatisfaction. To inform patient provider communication, in 2013, Toloo et al4 developed the Patient Perception of Priority to Be Seen Survey (PPPSS), although it has received very little use in research or clinical settings. The full scale includes 11 questions about patient health and demographics, including one question directly asking about how quickly a patient expects to be seen by a provider. This item seems an intuitive way to calibrate how realistic patient expectations are for ED efficiency; however, its lack of use raises concern about its reliability and validity. The original project that developed the scale emphasized the face validity of questions. They also did find positive correlations with pain and seriousness reported by ambulatory patients, supporting validity of the Patient Priority to be Seen Survey as a measure of urgency during a crisis.4 Reliability was not estimated. In this report, we review some of the challenges in patient communication and psychometric theory and provide an evaluation of the Patient Priority to be Seen Survey for use in the emergency department to facilitate nurse-patient communication. We accomplished this by comparing March 2023 VOLUME 49 ISSUE 2 AVAILABLE KNOWLEDGE Emergent patients often perceive their throughput time more favorably than those with less emergent needs.5 Previous research has found that shorter wait times are positively associated with patient satisfaction.6-9 Beyond subjective quality of care, prolonged wait times in the emergency department also have been associated with increased morbidity and mortality, especially among critical care patients.10 Ensuring an efficient emergency department is important for quality patient care. An evidence summary table of the studies we reviewed is provided in Online Supplement 1. Educational interventions have demonstrated some efficacy in raising triage nurses’ understanding regarding priorities to be seen;11 however, less well-studied is the great misunderstanding in patient’s perception about standard triage procedures and how this can be ameliorated. Previous research has shown a discrepancy between patient and practitioner perceptions of priority of need to be seen.12 In addition, triage communication of expected wait time has demonstrated an association with overall ED satisfaction.8 At this project location, a recent quality improvement survey indicated only 9% agreement between triage nurses’ ratings of urgency and patients’ self-reported perceptions of priority to be seen. The balance between patient expectations and what is realistic was emphasized by Maister13 who conceptualized what constitutes patient satisfaction. Maister focused on the discrepancy between patient perceptions and expectations. He goes so far as to suggest that improving the WWW.JENONLINE.ORG 295 RESEARCH/Tanzer et al experience while waiting for care may decrease the perceptions of wait times and increase satisfaction without an actual change in the wait time. This is important, because target ED wait times are often not met, likely because of contextual factors that are not easy to change.14 If better patient-nurse communication can improve patient perceived wait times, this provides a much simpler avenue to improve patient satisfaction. RATIONALE We propose the PPPSS to help to facilitate better research and quality improvement projects on subjective patient experiences and nurse-patient communication. In addition, if reliable and valid, this instrument could be used as part of an intervention during the patient triage process to produce higher quality, safe, and expedient care that promotes satisfaction both for patients and nurses. In particular, we used concurrent validity testing against the validating criterion of urgency scored by trained triage nurses using the ESI. Thus, the PPPSS was compared as the extent to which its scores were similar to the “gold standard” ESI criterion. Previous research has indicated the ESI provides valid estimates of patient urgency and has strong inter-rated reliability when used by triage nurses (reliability estimates ranged from 0.83-0.94),15-17 although some concerns have been raised that measurement is less reliable in less developed countries.18 If triage nurse ratings demonstrate concordance with patient-reported urgency, this would support the use of the PPPSS as a measure of subjective patient urgency. In addition, we examine construct validity through the use of a quasi-experimental design. For the first half of data collection, a pretest group of patients were simply asked to report their opinions on the PPPSS in a nonstandardized way. During the second half of data collection, posttest patients were provided with a brief scripted standardized verbal description of the ESI triage protocol before completing the questionnaire. If the PPPSS validly measures patient expectations for when they will be seen, then directly informing their expectations should result in more standard scoring. SPECIFIC AIMS We aim to better understand patient experiences in the emergency department, to validate the PPPSS as a tool for evaluating patient subjective urgency. We hypothesized that patients who perceived their needs as urgent on the PPPSS would tend toward lower urgency scores assigned 296 JOURNAL OF EMERGENCY NURSING by triage nurses using the ESI, as has been suggested previously.4,13 We estimated reliability and validity contextualized by nurse ratings, demographic variables, general health status, and health care usage behavior. To inform how to interpret PPPSS scores in research and clinical settings, we estimated the relationships among observed triage scores, patient health traits, and individual uniqueness. Finally, we hypothesized that there would be greater agreement between nurse and patient urgency and need to be seen when patients were provided a verbal description of ED procedures by the triage nurse. Methods SETTING Data were collected at an emergent care unit situated in a community magnet-designated hospital in New England. At capacity, the hospital can care for 40,000 patients annually, although most years there are closer to 33,000. The ED staff consisted of 43 registered nurses. Of these, 29 (67.44%) were credentialed to perform triage nursing functions using the ESI. This site has used the ESI since 2005 and all triage nurses received updated training following ESI revisions in 2012. All nurses were required to have at least a Bachelor of Science in Nursing, and only those nurses with a year or 2 of emergency nursing experience are trained to be triage nurses. Training to use the ESI includes a 2-hour structured didactic course and on-the-job training. In addition, nurses are encouraged to pursue continuing education opportunities on nursing in general at discounted rates in collaboration with universities in the area, to maintain familiarity with best practices in nursing. DATA COLLECTION DESIGN AND QUASI-EXPERIMENTAL To test the validity of using the PPPSS as a measure of subjective patient urgency, we compared scores with the ESI as a test of concurrent validity. In addition, we used a quasiexperimental design, with data collected before and after providing posttest patients with the standardized scripted verbal description of what to expect. If discrepancies between patient and nurse triage ratings are because patients have improper expectations for ED procedures, then simply informing patients of what to expect should standardize scoring. This tests construct validity, using a script written by the principal investigator read to patients. If the PPPSS is a valid measure of patient subjective urgency, VOLUME 49 ISSUE 2 March 2023 Tanzer et al/RESEARCH discrepancies between patient- and nurse-reported urgency will be larger in the pretest nonstandardized group of patients. The principal investigator was responsible for data collection using paper and pencil scoring. Patients were oriented to the study when they entered the emergency department after their initial triage assessment. The purpose of the study was explained and patients verbally consented and were asked to complete a short survey, the 11-question PPPSS (Supplementary Appendix A), read to them by the triage nurse investigator. Patients were not informed as to the triage nurse assessments. Nurses had pre-existing ongoing nurse-initiated protocols, which were added to the list. For the verbal description condition, after more urgent needs were addressed, nurses explained the triage standard of care to patients, script provided in Supplementary Appendix B. All responses were kept confidential and measures were taken to ensure anonymity of the patients by not linking patient demographic variables to patient names or ID numbers. Two independent samples were collected in the same emergency department. This directly evaluated patient expectations for triage procedures, to compare expectations with ESI triaged urgency, with and without the scripted verbal description provided. PARTICIPANTS Patients were recruited on a walk-in basis over the course of 4 months broken into 2 groups: 2 months of nonstandardized observation (76 patients recruited) and 2 months with the scripted verbal intervention (100 patients recruited; total sample 176 patients). Samples were independent of each other except for the chance possibility that a patient entered the emergency department twice, with and without the verbal description. Although patients were allowed to participate regardless of the time they entered the emergency department, most patients were enrolled in the morning and afternoon, when most people visit the emergency department. All patients were English-speaking conscious adults, at the age of 18 years and older. Exclusion criteria for this sample were patients with dementia, children, or those unable to answer the short survey. After hearing the study goals, we asked patients in the emergency department to participate with no direct benefit to individual patients provided. MEASURES Developed in an earlier study by Toloo et al,4 the PPPSS full survey includes 11 questions regarding factors that could explain patients’ perceived urgency such as demographics March 2023 VOLUME 49 ISSUE 2 (age, sex, ethnicity, socioeconomic status), health beliefs and preferences (perceived health status, urgency, previous ED visits), and perceived acuteness including reasons for seeking care in the emergency department (Supplementary Appendix A). We focused on the question asking about patient expectations for wait time. Patients were asked by the triage nurse to rate the urgency of their needs in time they thought they could wait on a scale from 1 (representing “within 2 hours”) to 5 (representing “immediately”). We sought to validate this question on the PPPSS for the purpose of assessing patient expectations for ED procedures and subjective urgency. Patient ethnic identity was measured only as Hispanic and not Hispanic self-reported by patients owing to this emergency department’s patients being primarily white and a lack of ethnic diversity within the community. We had thought Hispanic ethnic identity might be a more cogent single social group than the inclusion of many underrepresented racial categories. No other race or ethnicity questions were asked. Although a sample of more diverse respondents would be preferred, this measurement scheme is consistent with recommendations on how to conceptualize ethnicity.19 PSYCHOMETRIC THEORY More detailed discussion of psychometric theory and statistical estimation are included in Online Supplement 2. We estimated reliability for the PPPSS as internal consistency from intraclass correlation coefficient for individual patient traits within a generalizability theory framework and mixed effects modeling estimation.20-22 Reliability greater than 0.70 is considered acceptable, although values greater than 0.80 are preferred. Reliability at this level would indicate that repeated use of the PPPSS would tend to produce similar scores for similar patients at least 70% of the time depending on the level of reliability. Previous work has used the PPPSS measure in research settings; however, its psychometric properties were not the emphasis of the project.4 This will document the applicability and extend interpretability of this measurement tool to a clinical setting. By performing a validity analysis, the results can inform how to interpret individual PPPSS scores, so far as they relate to nurse-rated urgency and other personal health and demographic information. We focus on concurrent validity relative to the ESI and construct validity contextualized by the quasi-experimental design and patient demographic information. Finally, we incorporated expert opinion into the analysis to ensure face validity, described in detail in Online Supplement 2. Face validity is the extent to which an WWW.JENONLINE.ORG 297 RESEARCH/Tanzer et al instrument appears to be an adequate measure, and typically not considered critical, we believed it could be important if patients’ resistance to being measured reflects their view that the scale is of no significance to their problem. Led by the principal investigator, the research team categorized patients by how likely they were to agree with the triage nurse and by how subjectively stressful their symptoms were. This allowed for consideration within the analysis of those patients for whom there was concern that they may not have appropriate expectations or patients who may have reasons to feel that their needs are urgent. If the PPPSS is valid for understanding subjective patient needs, then patients expected to disagree with the triage nurse or patients with subjectively unpleasant conditions should demonstrate the largest improvements in concordance between nurse- and patient-reported ratings when the verbal description is provided.20-22 We tested this empirically. ANALYSIS PLAN We determined significance as P < .05. The sample included 176 individuals (76 nonstandardized pretest and 100 with the scripted verbal description of ED protocol). For each patient, there were 2 scores, 1 ESI rating and 1 PPPSS patient-reported urgency rating, resulting in a total sample of 352 observations. First, we examined the correlation matrix and performed discriminant function analysis.23 This helps to understand the characteristics of the expertdetermined patients who may have unrealistic expectations of ED efficiency, testing concurrent validity.20,21 Observed discrepancies between patient and nurse triage ratings being categorized by the expert as likely to disagree with the nurse would support the validity of the PPPSS. In addition, subjective discomfort of admitting condition is an intuitive reason patients might disagree with the triage nurse. Finally, based on the observation while collecting data that younger patients seemed more likely to disagree, age also was included in the analysis. Next we compared PPPSS scores with and without the verbal description of ED procedures, a direct test of construct validity. Out of concern that some patients may have a better intuition for standard triage procedures than others, a specific comparison was made between participants categorized as likely agreeing with nurse ratings and those who would likely disagree. This amounted to a 2 3 2 3 2 repeated measures analysis of variance design with interactions comparing quasi-experimental condition (unstructured pretest or posttest with verbal description of ED procedures provided), rater of urgency (nurse or patient), and patient type (agree or disagree with nurse). If the PPPSS 298 JOURNAL OF EMERGENCY NURSING is valid for the purpose of understanding patient experiences, then the interaction between scripted intervention condition and rater would be significant, indicating that patient ratings were more standard with the verbal description but not nurse ratings, which should be consistent regardless. To further assess concurrent validity, the analysis included a number of covariates, specifically age, gender, ethnicity, enrollment with a primary care physician, reported knowledge of the ED triage system, use of the emergency department in the past 6 months, patient-reported health ratings, and categorized rating of how subjectively stressful the patient’s condition may be. Finally, several random effects accounted for the known structure to the data and model sources of variation (eg, heterogeneous variances and correlation between nurse ESI and patient PPPSS ratings), as is consistent with generalizability theory methods.21 Estimating power indicated that this analytic framework could likely detect at least a moderate effect size demonstrated by the manipulation (see Online Supplement 2).24-26 ETHICAL CONSIDERATIONS The hospital’s Human Subjects Safety Committee deemed the study, which followed a quality improvement project, to be exempt from review. As stated earlier, responses were kept confidential and measures were taken to ensure anonymity of the patients by not linking patient demographic variables to patient names or ID numbers. Results Respondents spanned the age range, most between 18 and 60 years old (see Table). All respondents were patients; none were caregivers. There were similar proportions of male- (48.86%) and female- (51.14%) identifying respondents. The majority did not identify as Hispanic (90.91%). Most respondents indicated that they did have a primary care provider (60.80%) but did not know about the ED triage system (73.30%) and had not been to the emergency department recently (68.18%). Rated from 1 (“poor”) to 5 (“excellent”), most respondents indicated good or very good health, with a mean of 3.88 (SD ¼ 0.73). There were a wide variety of reasons respondents came to the emergency department, from allergic reactions to abnormal laboratory test results. Most patient needs were rated as moderately stressful (M ¼ 2.07 rated from 1 [“low stress”] to 3 [“high stress”], SD ¼ 0.64). Most respondents thought they should be seen within about 20 minutes, VOLUME 49 ISSUE 2 March 2023 Tanzer et al/RESEARCH TABLE Respondent characteristics (N [ 176) Variable Demographic variables Age Sex Ethnicity Health variables Do you have a primary care provider? Do you know about the ED triage system? Have you used the ED in the last 6 mo? How is your general health? Emergency circumstance stress expert rating Patient ratings: I should be seen Nurse triage rating Predicted agreement with triage nurse Level N % 18-29 y 30-49 y 50þ y Female Male Not Hispanic Hispanic 73 52 51 90 86 160 16 41.48 29.55 28.98 51.14 48.86 90.91 9.09 No Yes No Yes No Yes Poor Fair Good Very good Excellent Low stress 69 107 129 47 120 56 0 3 49 90 34 30 39.20 60.80 73.30 26.70 68.18 31.82 0.00 1.70 27.84 51.14 19.32 17.05 Moderate stress High stress Within 2 h Within 60 min Within 30 min Within 10 min Immediately Nonurgent Semiurgent Urgent Emergent Highest priority Agree Disagree 104 42 6 26 35 65 44 0 0 0 148 28 81 95 59.09 23.86 3.41 14.77 19.89 36.93 25.00 0.00 0.00 0.00 84.09 15.91 46.02 53.98 ED, emergency department. March 2023 VOLUME 49 ISSUE 2 WWW.JENONLINE.ORG 299 RESEARCH/Tanzer et al FIGURE Differences in triage urgency ratings. Note: Nurse ESI scores were reversed so a higher number represents higher urgency, as is the scoring on the PPPSS. ESI, Emergency Severity Index; PPPSS, Patient Perception of Priority to Be Seen Survey. at most an hour (M ¼ 22.61 minutes, SD ¼ 26.97 minutes). Patients were consistently rated as high urgency by nurses (M ¼ 4.16, SD ¼ 0.35; reverse scored so a larger value indicates higher urgency). The discriminant function analysis indicated observed agreements between nurse and patient urgency ratings tended to be independently classified as likely agreement by the expert (lambda ¼ 0.83), supporting concurrent validity of the measurements (Wilks’ lambda ¼ 0.52, F(5, 170) ¼ 32.01, P < .01). Older patients also tended to agree with the nurse, corroborating the anecdotal observation (lambda ¼ 1.37). Contrary to expectations, subjective discomfort operationalizing patient subjective stress had minimal relationship to agreement or disagreement (lambda ¼ 0.10). Figure plots the scoring tendencies with and without verbal description of ED procedures, comparing between patients expected to agree with the nurse and patients expected to disagree with the nurse. During the unstructured pretest, ratings were close between nurses and patients for the patients expected to agree with the triage nurse (nurse, M ¼ 4.19, 95% confidence interval [CI] 3.92-4.46; patient, M ¼ 3.87, 95% CI 3.01-4.74). For patients expected to disagree with the triage nurse, there was a discrepancy during the unstructured pretest period (nurse, M ¼ 4.06, 95% CI 3.81-4.31; patient, M ¼ 3.33, 95% CI 2.54-4.11; x2 (1, N ¼ 352) ¼ 14.61, P < .01). 300 JOURNAL OF EMERGENCY NURSING However, during the scripted intervention posttest after rounding, ratings by nurses were identical for agree and disagree classified patients (nurse, M ¼ 4.16, 95% CI 3.88-4.45), and patient-reported ratings also were very close (agree, M ¼ 3.62, 95% CI 2.80-4.43; disagree, M ¼ 3.66, 95% CI 2.83-4.48). This is evidence that ratings were more standard with scripted verbal description of ED procedures, supporting construct validity of the PPPSS as a measure of patient expectations (x2 (1, N ¼ 352) ¼ 8.09, P < .01). Estimating internal consistency reliability, the ratio of individual variance to total variance for each rater, across nurse ESI ratings (reliability ¼ 0.73) and patient PPPSS ratings (reliability ¼ 0.75), both demonstrated acceptable reliability (reliability > 0.70). Examining the correlations
between observed ratings and model implied true patient urgency, both rating systems indicated large and nearly identical correlations (nurses, rho ¼ 0.54; patients, rho ¼ 0.55).
That said, the correlation between these 2 rating systems
was moderate to large and negative (rho ¼ 0.38). This
supports the reliability and concurrent validity of the
PPPSS, which demonstrated consistent measurements of
patient urgency. That said, when patients rated themselves
as more urgent, it was likely a nurse would rate them as
less urgent.
Finally, contrary to expectations, only one additional
measure of concurrent validity demonstrated significant association at alpha ¼ 0.05. Patients identified as female
VOLUME 49 ISSUE 2
March 2023
Tanzer et al/RESEARCH
tended to be rated as lower urgency (t(163) ¼ 2.23, P ¼
.02), a small magnitude of difference (beta ¼ 0.18).
Discussion
SUMMARY AND INTERPRETATION
We estimated reliability and considered ways to make valid
interpretations of the PPPSS as a tool for understanding patient subjective experience.13 Using a modern analytic
framework drawing from generalizability theory, reliability
for the measure was acceptable. The quasi-experimental
design targeting patient understandings of triage procedures
supported validity. When patients were explicitly informed
of ED triage procedures, PPPSS scores across patient groups
were nearly identical. This suggests that by directly informing patients of what to expect, this may have standardized
rating systems. By being aware of standard ESI procedures,
all patients received and reported similar ratings of urgency.
This supports the validity of the PPPSS and also demonstrates why clear communications of expectations may
improve ED efficiency.
The concordance between all of patient ratings, triage
nurse ratings, and independent expert ratings supported
convergent concurrent validity. When patients and nurses
gave similar urgency ratings, the expert also tended to indicate that they would likely have agreed. We originally
thought that subjective discomfort may be a primary aspect
of why patients disagree with the triage nurse; however,
there was little evidence of this. Instead, age grouped patients the most. Younger patients tended toward worse expectations for standard ED procedures.
Another finding that was counter to expectations was
that nurses tended to rate patients as higher urgency on
average, which is inconsistent from findings by Toloo
et al.4 This highlights the reasons for performing validity
analysis: to inform how to interpret a measurement for an
intended purpose. There was an inverse relationship between nurse scores and patients scores. As such, no matter
how urgent patients are rated in an absolute sense, to understand patient subjective experiences, PPPSS scores should
only be interpreted relative to standard urgency within a
specific emergency department. For the purpose of triaging
patients, ESI scores are determined based on their ordered
scaling, but the average may differ between emergency departments or by time of day. An example of this scaling
problem is the coronavirus disease 2019 pandemic, wherein
intensive care units were overwhelmed with high urgency
patients.
March 2023
VOLUME 49 ISSUE 2
The issue of scaling complexity is particularly relevant
in the case of the PPPSS, for which discrepancies among patient needs are a likely cause of improper expectations.
Scores should be considered relative to the urgency of
most other patients at the same emergency department
based on what is a typical patient urgency. A low urgency
patient could easily feel like somebody cut in line if they
are not familiar with ESI standards and see other patients
triaged sooner. The severity of this problem may depend
on the unique urgency of the emergency department at a
given moment. Seeking to communicate with these patients
about their likely wait time may improve satisfaction. We
recommend the PPPSS for implementing an intervention
with this target or as a tool for resear