Abstract

Introduction: Abdominal pain is the most common symptom with which patients present to the emergency department (ED), and overall visits to EDs in the U.S. are growing twice as fast as the overall population. Interventions that can safely mitigate such a high usage of ED resources would be a great asset in the delivery of effective and efficient ED care. One such intervention is a secondary triage of patients calling 911 for an ambulance who were subsequently triaged as a non-urgent low-acuity caller. Emergency medical services (EMS) using secondary nurse triage to manage low-acuity calls from 911 or other three-digit emergency numbers will benefit from this study. By appropriately selecting the correct protocol and achieving the most appropriate care disposition for the patient with abdominal pain, best practices are confirmed. This can be particularly challenging for the nurse when multiple symptoms accompany abdominal pain.

Objectives: The primary objective of this study was to determine the ability of an Emergency Communication Nurse (ECN) to appropriately identify the Abdominal Pain Chief Complaint Protocol to use to triage patients in low-acuity cases. The secondary objectives were to establish the most frequently used primary triage code (Medical Priority Dispatch System™ (MPDS®) Determinant Codes), triggering the use of the Abdominal Pain Chief Complaint Protocol in the Emergency Communication Nurse System™ (ECNS™), as well as the percentage of these calls resulting in a Recommended Care Level (RCL) of "emergency ambulance response" and "ED as soon as possible."

Methods: The retrospective and non-controlled descriptive study analyzed audio recordings of 100 randomly selected ECNS cases (50 from each of the two centers) where the Abdominal Pain Chief Complaint Protocol was the selected protocol to triage the patient's symptoms. The specific data elements extracted from the ECNS database were: call types (entry via 911 or 7-digit nurse triage line), if abdominal pain was the correct protocol choice, the choice of protocol by the case reviewers performing quality assurance, the final disposition (RCL) reached by the ECN and the reviewer, date and time of call, and if the call came via 911, the MPDS Determinant Code that was reached.

Results: Of the 100 randomly selected cases, the mean age was 41.6 years, and more than two-thirds of the patients were female. The reviewers agreed with the decision of the ECNs on their selection of the Abdominal Pain Chief Complaint Protocol as the most appropriate protocol 72% of the time. The reviewers agreed on the RCL reached by the ECNs 22% of the time. Of the 30 calls classified by the ECNs as needing an ambulance to take them to the hospital, the reviewers found only five patients requiring ambulance transport to the hospital (a 6-fold difference). The ECNs reached the "Seek Emergency Care as soon as possible" disposition more than three times as often as the reviewers.

Conclusion: Abdominal pain was selected as the correct Chief Complaint Protocol less than 75% of the time, with reviewers agreeing with the Emergency Communication Nurses (ECNs) on the Recommended Care Level only 22% of the time, which is lower than was expected with a significant over-triage by ECNs on this Protocol. The findings showed the mitigating potential a secondary triage system might have on the burden of growing demand emergency medical dispatchers are experiencing. It also highlighted several areas for potential improvement for the ECNs in their triage skills.