As Emergency Medical Service Act was amended, all EDs in Korea have been using KTAS to classify emergency patients since January 2016 [10]. This task is handled by nurses in most EDs. Many previous studies have reported that KTAS classification results might be different among evaluators. However, it is difficult to find studies suggesting a way to improve the inter-rater agreement among triage nurses. Therefore, this study attempted to improve the agreement among triage nurses' self-efficacy for severity classification and inter-rater agreement among triage nurses through PBL meeting. Whether the improved agreement might affect the length of ED was also examined. Based on the results of this study, we would like to discuss ways to improve the professionalism of ED triage nurses.
In this study, self-efficacy for emergency patient severity classification was improved after PBL led by ED triage nurses. This result cannot be directly compared to previous results because there is no previous research applying PBL. However, results of the study [30] were similar to results of the present study. They compared self-efficacy by developing and applying a web-based KTAS learning program with a control group [30]. Self-efficacy has been found to be improved after education compared to that before and after education in a study comparing HIRAID (History, Identify, Red flags, Assessment, Interventions, Diagnostics, reassessment and communication) framework developed to provide ED nurses with a structured and systematic approach to emergency patient assessment as a simulation training program [31]. The present study confirmed that the self-efficacy was improved through PBL led by triage nurses. However, previous studies have evaluated self-efficacy by applying web-based self-learning program or simulation program. We speculate that self-education, repetitive learning, and meetings to discuss learner-led clinical cases might have raised the self-efficacy of triage nurses' KTAS classification.
CTAS and KTAS, unlike ESI which predicts and classifies emergency medical resources to be used, are tools that can classify patients based on their complaints [10]. In the first stage, patients are classified by age. In the second stage, patients are classified according to symptoms that patients complain. In the third stage, detailed symptoms included in the major classification are selected. In step 4, the KTAS level is determined by checking the pain or symptom of detailed symptoms selected in step 3. Finally, the place of treatment of the patient is determined according to the possibility of infectious disease that can transmit the disease [10]. Worldwide, emergency patients are classified by nurses in most EDs [9, 32]. Thus, KTAS classification results should be carefully classified because they can be directly linked to the calculation of emergency medical care fees. They are also important for the safety of patients. However, several previous studies have reported differences in classification among evaluators. The Kappa coefficient was .659 in a study of Rahmani et al. to determine the agreement of ESI classification between nurses and emergency physicians. In the study of Choi et al., classification was conducted by two research nurses for a total of 233 patients [15]. These patients were also reassessed by 10 triage nurses. They found that the weighted Kappa coefficient was 0.79. The weighted Kappa coefficient was 0.721 in a study of Kim et al., confirming the inter-rater agreement between nurses and medical students [16]. In addition, a weighted Kappa factor of 0.77 was reported in a study confirming the agreement between an expert group consisting of KTAS instructors and triage nurses for severity classification of ED pediatric patients [17]. The interpretation presented by Landis and Koch can be interpreted as a ‘substantial agreement’ [16]. However, there were some differences between the evaluators. In this study, the weighted Kappa coefficients were identified 0.687 and 0.67 respectively, before PBL meeting between triage nurses and Gold Standard nurses. After the PBL meeting was conducted, these weighted Kappa coefficients were improved significantly to 0.823 and 0.835, respectively, showing almost perfect agreement according to Landis and Koch's interpretation [18]. Results of the present study could not be directly compared to results of previous studies because there is no such previous research. However, results of this study were similar to results of Rankin, Then, & Atack showing that online learning could help triage nurses improve their severity classification accuracy for emergency patients [33].
Barrows has proposed PBL method that can be conducted in small groups of student-led learning for medical students [19]. It is a learning method that learners can present their problems and learn knowledge and skills to solve problems through discussions in small groups so that they can develop reasoning skills and critical thinking skills to cope with given similar situations [19]. Previous studies have reported that learning attitude [20, 21], critical thinking skill [22, 23], problem solving ability [21, 24], and knowledge [25, 26] of nursing students and medical students are improved after the implementation of PBL. In the present study, learner-led PBL meeting was held with triage nurses working on the KTAS classification task to discuss cases that needed further discussion. In doing so, a consensus was reached and shared among ED nurses. These shared results might have helped their decision making for similar situations later and inter-rater agreement among triage nurses is likely to improve.
However, there was a slight decrease in the ED LoS before and after PBL, although the decrease was not statistically significant. This was different from previous studies [5, 6] showing that the ED LoS was reduced due to accurate patient classification. In the study of Jobé, Ghuysen, & D'Orio, accurate patient classification helped reduce the ED LoS for patients who came to the ED for chest pain [6]. Direct comparisons, not pre-post comparisons, were difficult. However, Erimsah, Yaka, Yilmaz, Kama, & Pekdemir and Kim et al have reported that adequate patient classification can help reduce the ED LoS [34, 35]. Pierce & Gormley have also reported that primary and secondary assessments can improve the classification of emergency patients, resulting in a shorter ED LoS as a result of applying a more accurate and appropriate patient classification system [36]. In the present study, the ED LoS was reduced approximately 30 minutes after the PBL meeting, although such reduction was not statistically significant. Various factors may exist to explain the reduction in the ED LoS. It would be hard to say that the improvement in the consistency of KTAS classification only affected the reduction in the ED LoS. Further studies will be needed to determine whether the agreement of emergency severity classification affects the ED LoS.
This study has some limitations. First, the inter-rater agreement of KTAS classification might have improved as nurses' experiences in patient classification work increased after PBL meeting compared to those before PBL meeting. On the other hand, some nurses may start a new work of classifying emergency patients before or after the investigation. Thus, the agreement might have declined. Second, the participation rate was very high, although PBL meeting for nurses was voluntary. However, there were also a small number of nurses who showed low participation frequency. For nurses who did not participate in the problem based-learning meeting, results of the meeting were shared using SNS 'Band' application, 'Groupware email', and 'Shared Note'. Third, in this study, the inter-rater agreement between triage nurses and Gold Standard nurses was evaluated. However, we did not determine agreements among the three evaluators. Such information might provide more accurate classification results. Lastly, this study was a single-center study conducted at a general hospital in Seoul. Thus, it is difficult to generalize results of this study to other settings.