Study population
In total, 36 nurses were interviewed, 17 from ED1 and 19 from ED2. The demographics of the participants are provided in table 1.
Overall, participants from ED2 were older and had more years of experience compared to those from ED1. The youngest participant was 22, and the oldest was 62 years of age. At ED2, the median number of years of experience in the profession was 10, with a range from 1 to 43. In contrast, at ED1, this number was 5 years, with a range of 2 to 16 years. There was a significant difference in the gender distribution of participants between the two sites. At ED2, there were three times more female participants compared with ED1, where the female participants outnumbered the males by a factor of two (Table 1).
Table 1. Characteristics of the study population
Nurses
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ED1
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ED2
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Participants (n/N)
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17/36
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19/36
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Age, years, median (range)
|
33(25–51)
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38(22–62)
|
Years in profession, years, median (range)
|
5(2–16)
|
10(1–43)
|
Female/male
|
12/5
|
14/5
|
Overall response
In general, the Likert scale summation of participants' level of agreement indicates that ED1 exhibited a positive response to the implementation of the new triage system, viewing it as an effective working tool. Respondents from ED1 perceived the system to have more positive than negative characteristics (Figure 2). On the other hand, ED2 displayed more conflicting responses regarding the implementation and the new triage system. However, they still regarded WEST as more accurate than RETTS© in identifying severely ill patients (as shown in Figure. 2).
The change (Implementation of WEST)
The summation of all participants' responses to the dimension of implementation on a five-point Likert scale is presented in Table 2. Overall, differences between the two EDs were identified across all areas of implementation, including information, motivation, education, and organization. The mean value of these areas at ED2 was relatively approving, ranging from 3.9 to 4.0 (SD 0.8 to 1.1), while participants at ED1 expressed more dissatisfaction, scoring the same items between 2.9 and 3.3 (SD 1.2 to 1.4).
Table 2. The change (Implementation of WEST), Mean on Likert scale 1–5 (SD)
Questions
|
ED1
|
ED2
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Q1: Information strategies
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4.4 (0.9)
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3.0 (1.2)
|
Q2: Motivation and consensus strategies
|
4.3 (0.9)
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3.3 (1.4)
|
Q3: Educational strategies
|
4.2 (1.1)
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2.8 (1.2)
|
Q4: Organizational strategies
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4.6 (0.8)
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2.9 (1.3)
|
Information strategies
Almost every participant at ED1 found the information provided about the new triage system to be sufficient. However, half of participants of ED2 believed the information was insufficient, delivered abruptly, and not comprehensive enough (Figure. 2).
We were informed months before the implementation on many different occasions, via email and verbally. (Nurse, ED1)
Criticisms from ED2 related to the perception that the implementors did not adequately disseminate information. However, there was a circulating rumor suggesting that ED1 had already initiated the new triage system, with ED2 next in line for its implementation.
There was a situation of non-existent information that nurtured rumors at the ED. (Nurse, ED2)
Participants from ED2 expressed a need for clear information and a transparent process from the implementors regarding the new system. They raised questions about the system, requested opportunities for briefings, and desired a platform to voice their opinions. Additionally, there was a lack of information about the new system for physicians working at the ED and connected units (such as outpatient or inpatient departments). Participants also observed that some ED physicians were unaware of the new triage system or changes in the laboratory routines.
Motivational strategies
In general, participants from ED1 as well as ED2 were motivated to adopt the WEST system based on the many critiques of RETTS©.
We have a lot of over-prioritizations, and the WEST system reduces the number of patients prioritized at the orange triage level. It would facilitate the identification of the most severely ill individuals. (Nurse, ED2)
However, nurses at ED2 mentioned that the implementation was not well-received by the staff, resulting in poor motivation to replace the existing system. They also noted that the information regarding the background of the system and the reasons for a change in the triage system even occurring were insufficient. Similarly, the planned changes in laboratory routines were not adequately communicated, leaving the staff feeling unprepared. Unfortunately, the implementation of both the new laboratory routines and WEST coincided, and both change processes were poorly prepared.
The reduction in laboratory services, driven by cost-saving measures, along with the introduction of new routines without consulting the ED staff, is not very motivating. (Nurse, ED2)
Educational strategies
Analysis of the comments showed a discrepancy in the experience of the educational strategies among nurses between ED 1 and 2. Nurses in ED1 reported having sufficient time for education. They appreciated the opportunity for feedback, where staff could comment on how the system worked. Conversely, nurses in ED2 reported experiencing insufficient education. Despite having sufficient time for education, the participants from ED2 noted a lack of support from a supervisor during the actual triage process.
The WEST education included seminars and discussion. We got the opportunity to get help in the triaging process with a supervisor during the first weeks of implementation. We had the opportunity to give comments on the pros and cons of the new way of working. (Nurse, ED1)
The education was limited to some basic information about the new triage system and a review of the warning signs in the WEST booklet. (Nurse, ED2)
We had a power point presentation lasting a maximum of one hour. Terrible! Those who were going to train us afterwards did not know the system themselves; if you had questions, there were no answers. You had to learn the system by yourself. (Nurse, ED2)
The main educational challenges that needed to be addressed included the necessity for more interactive, team-based training, such as simulation exercises, tabletop exercises, and study materials with practical examples. Nurses requested scheduled training sessions, workshops on real patient cases to highlight the differences between RETTS© and WEST, followed by conclusive discussions. Additionally, they sought reviews with physicians and experienced nurses, hands-on supervision during the triaging process, and feedback after the implementation. Even though the National Institute of Health Stroke Scale (NIHSS) and Glasgow Coma Scale (GCS) were introduced within the WEST system, no additional education was provided, leaving several staff members unfamiliar with NIHSS and GCS.
Organizational strategies
When the new triage system and laboratory routines were implemented at ED2, the COVID-19 pandemic was in an intensive phase. These new routines coincided with the new and challenging daily practices aimed at protecting an overly strained ED infrastructure while ensuring the delivery of medical treatment. Staff at ED1 felt better prepared compared to those at ED2, as they were already acquainted with the laboratory routines.
In fact, the organization didn’t need to adapt, despite the absence of the WEST in other hospitals and the ambulance services. We just transitioned from using RETTS© to WEST in our medical journals. (Nurse, ED1)
Perhaps it might not be ideal for nurses to be immediately thrown into triage duties. However, given the current circumstances, there may be no alternative option available. (Nurse, ED2)
The system (Performance of WEST)
Most of the participants believed that WEST was both flexible and more accurate than RETTS© in identifying the severely ill patients (Figure 2). However, they also thought that WEST required more experienced nurses compared to RETTS©. Some nurses found the system to be difficult and somewhat unclear. The staff at ED2 was, however, less impressed with WEST (Mean 2.9–3.6, SD 1.0) compared to those at ED1 (Mean 3.2–3.8, SD 0.5–1.1) (Table 3).
Table 3. The system (Performance of WEST), Mean on Likert 1–5 (SD)
Questions
|
ED1
|
ED2
|
Q5: Flexibility
|
4 (0.7)
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3.2 (1.0)
|
Q6: Clarity
|
3.3 (1.1)
|
2.9 (1.0)
|
Q7: Accuracy
|
4.5 (0.5)
|
3.6 (1.0)
|
Flexibility
As many as 21 out of 36 participants thought WEST was more flexible compared to RETTS© (Figure 2). The system allowed triage nurses to apply their clinical knowledge and experience. Consequently, many nurses perceived it as challenging for less experienced nurses to perform triage using WEST compared to RETTS©.
For me, the flexibility of the system is advantageous, especially with the pocket version, which is convenient to use bedside. However, it can pose challenges for new nurses, particularly those lacking experience in triage, as certain aspects of the process require clinical training. In contrast, RETTS© was foolproof - if you followed it mechanically, mistakes were unlikely. (Nurse, ED1)
Without prior experience, there are potential pitfalls when using WEST, making it potentially dangerous. However, on the other hand, with experienced staff who have undergone extensive training, WEST offers a simpler and more flexible alternative compared to RETTS©. (Nurse, ED2)
The participants emphasized that the main challenge was the increased difficulty that inexperienced nurses faced with the new system, which required prior knowledge. The pocket version of WEST lacked some components, and there was no online version available. Additionally, clarity was lacking regarding when to take blood samples and when to refrain from doing so.
Clarity
In terms of clarity, several participants thought RETTS© was on the same level as WEST. Some regarded RETTS© to be more distinct and straightforward compared to WEST (Table 3).
Being a new or recently graduated nurse and working in the triage is not particularly easy. RETTS© proves to be simpler than WEST, especially for inexperienced individuals. The RETTS© binder served as a comprehensive guide, like a Bible, containing all the necessary information, including referrals. (Nurse, ED1)
One critique was that WEST sometimes seemed poor in narrative and used just a few words to describe some urgent conditions.
At times, only a single word is used to describe a condition, like "ongoing bleeding," which lacks clarity. It becomes crucial to have additional support from the system, especially when you find yourself alone, to ensure clarity and understanding in such situations. (Nurse, ED2)
WEST was perceived as somewhat unclear. Certain symptoms, particularly neurological ones, were grouped together, causing confusion when trying to identify specific symptoms within that category. This made it challenging for inexperienced nurses to rely on their clinical judgment. Unlike RETTS©, WEST lacked a referral system, requiring nurses to be familiar with parameters and risk factors by memory.
Accuracy
30 out of 36 participants believed that WEST was more accurate compared to RETTS© when identifying severely ill patients (Figure 2).
When used correctly, WEST is more accurate compared to RETTS©. RETTS© tended to overprioritize, whereas with WEST, patients categorized as red or orange were genuinely ill. The system's reliability simplifies teamwork in the ED. Furthermore, WEST demonstrates improved prioritization for frail elderly individuals. While RETTS may be more convenient for inexperienced nurses, WEST's accuracy makes it a preferred choice for reliable patient assessments. (Nurse, ED1)
Out of the 36 participants, six believed that WEST was less accurate compared to RETTS©. One of these six nurses provided this critique:
WEST is less accurate, and you need experience to prioritize patients correctly. This lack of precision leads triage nurses to rely on their intuition rather than purely observational data. In contrast to RETTS©, where the orange triage level required monitoring, WEST extends monitoring to yellow and green priority levels. This results in an increased number of patients requiring monitoring, making it progressively challenging to maintain an overall view of those being monitored. (Nurse, ED2)
Driving forces (advantages of WEST)
Overall, the majority of the participants found WEST to be advantageous compared to RETTS©, as indicated in Table 4. Nurses from ED1 generally perceived the system as compatible with existing routines and not overly complex to comprehend or utilize. However, ED2 exhibited conflicting results, particularly regarding compatibility, as shown in figure 2. The ED1 participants rated the advantages higher (Mean 3.6–3.8, SD 0.5–1.1) compared to ED2 (Mean 3.2–3.6, SD 1.1–1.3).
Table 4. Driving forces (advantages of WEST), Mean on Likert 1–5 (SD)
Questions
|
ED1
|
ED2
|
Q8: Relative advantage
|
4.5 (0.5)
|
3.4 (1.3)
|
Q9: Compatibility
|
3.9 (1.1)
|
3.3 (1.2)
|
Q10: Complexity
|
4.3. (0.7)
|
3.8 (1.1)
|
Relative advantages and disadvantages
Overall, respondents viewed WEST as more accurate, making it easier to identify severe illnesses compared to RETTS©. Additionally, WEST triaged fewer patients to the orange triage level than RETTS©, resulting in fewer laboratory tests being conducted. Respondents also considered WEST to be cost-effective.
Fewer orange-prioritized patients result in fewer unnecessary blood samples (which is more cost-effective) and facilitates more accurate and easier identification of seriously ill patients. (Nurse, ED2)
Participants highlighted challenges associated with WEST, including a lack of clarity in certain warning symptoms and recommended blood sampling. There suggested the need for a more comprehensive handbook outlining symptoms and providing guidance on referrals to other healthcare providers, such as primary care. Several nurses emphasized that, during stressful situations, they could overlook warning signs due to the system's complexity. WEST appeared to place additional strain on triage staff, raising concerns. Additionally, the early version of the WEST handbook was described as a booklet that was difficult to handle in clinical settings.
The pages of the booklet keep falling out, and I hope for improved quality. (Nurse, ED1)
Compatibility
Nurses from both ED1 and ED2 expressed concerns regarding the blood sampling routine, citing its incompatibility with established routines such as "Deep Vein Thrombosis" and "Subarachnoid Hemorrhage," as well as with other fast-track patients. Furthermore, they observed that the routine lacked a comprehensive referral system similar to that of RETTS©.
The blood sampling routine in the triage underwent changes with WEST, becoming more scaled down. Initially, this change led to longer waiting times due to inadequate guidelines recommending a minimum number of blood tests. However, presently, I find myself collecting more samples than WEST recommends. (Nurse, ED1)
Complexity
The majority of nurses, 28 out of 36, found WEST to be a straightforward triage system (Figure 2), although there were concerns about inexperienced nurses using it. Participants identified a challenge with the WEST handbook, noting that it lacked substantial textual guidance for triaging staff in the process.
The system is straightforward and not difficult to follow, but it requires a lot from the nurse. There are no cheat sheets provided by the system, so it is crucial to have experienced personnel in the triage. (Nurse, ED2)
Participants requested more detailed information on symptoms, an online version for educational purposes, and improvements to make the booklet easier to read and navigate when searching for symptoms.
Overall comments
Performing triage with WEST demands more from the individual due to the system's lack of comprehensiveness. In some cases, additional explanations are necessary, requiring medical expertise to fully understand the process. Therefore, more experience is essential for effectively utilizing WEST. (Nurses, ED2)
Triage education becomes crucial, especially during system transitions. We need an online version for accessibility. Additionally, continuous education is essential, covering topics like chest pain with vegetative symptoms, NIHSS, NEWS2, and GCS. (Nurses, ED1)
This new system requires anticipating what will be required; you have to think creatively. It demands experience but has significant potential. (Nurses, ED2)
Due to its distinct setup, the WEST system was considered having the potential to identify critically ill patients without excessive over prioritization. In comparison to RETTS©, WEST reduced over-triage by allocating fewer patients to the second highest triage level, orange. It was also perceived as more straightforward, allowing triage nurses to re-prioritize based on clinical judgment. However, WEST lacked as many sub-categories as RETTS©, making it more challenging to access specific guidance for patient management. Moreover, implementing the WEST system required significant training, procedural adjustments, and extensive experience. Participants also noted that the system was still in a provisional state, with the printed version resembling a compendium and lacking online versions.