You are on page 1of 4


International Journal of
of Hospital Research 2016,4(4):
Research2015, 5(4):155-160
122-125 doi 10.15171/ijhr.2016.22

Research ARTICLE

Impact of Training
Evaluation of theon Performance
Effect of
of Additive
Triage: A Comparative
Metformin Study inon
to Progesterone Tehran
with Endometrial Hyperplasia
Open Access
Emergency Department
Mahdie Abdoos,1 Seyed Hossein Seyed Hosseini Davarani 2,* Hooman Hosseini Nejad 2
Afsaneh Tehranian 1, Nasim Zarifi 1*, Akram Sayfolahi 2, Sara Payami 2, Faezeh Aghajani 2
Department of Emergency Medicine. Iran University of Medical Sciences, Modarres Hospital, Tehran, Iran. Department

of Emergency Medicine, Tehran University of Medical Sciences, Imam Khomeini Hospital, Tehran, Iran.

Department of Gynecology and Obstetrics, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran 2 School of Medicine, Tehran
First Published
University onlineSciences,
of Medical December 3, 2016
Tehran, Iran

Background and Objectives: Emergency departments should adapt the most updated standards in order to
maximize their capability in delivering urgent health services. In the present study we assessed the effect of
training of triage nurses in Tehran Emergency Department on efficiency and accuracy of triage decision making.
Background In this
Objectives: Endometrial study, 100 nurses with
hyperplasia (EH)mean
is an age of 27 years
abnormal was randomized
overgrowth of endometrium into 2that
to group received
endometrial training
cancer, based on
especially a new
when triage international
accompanied by atypia.guideline and the second
The treatment of EH is (control) group and
challenging, was
left studies
untrained. Thereport
of trainedresults.
in decision (dimethyl
makingbiguanide) is an anti-diabetic
and classifying and insulin
the complications sensitizer
was compared
with whichwho
nurses is supposed
followed to have
the antiproliferative
current and protocol.
routine triage anticancerThe effects and the potential
categorical variablestowere
decrease cell growth
compared in
by chi-
square test. While some studies have evaluated the anticancer effect of metformin, studies on its potential effect
on endometrial hyperplasia are rare. To address this gap, in this comparative trial study, we evaluate the effect of
Findings: The totaltofrequency
additive metformin progesterone of dispatches
in patients based
with EH. on new international guideline was significantly lower than
based on the routine protocol (84% vs. 46%) (P < .001). In addition, the proportion of correct dispatches was found
toMethods: In thishigher
be significantly clinicalthan
64 women
by thewith EH were
untrained grouprandomized
(75% vs. in two(P
20%) groups. The
< .001). progesterone-alone
Further, group
frequency of correct
triage progesterone
by trained 20 mg out
group turned dailyto(14
be days/month, from the
significantly higher 14thby
than menstrual day) based
the untrained group on the vs.
(80% type30%)
of hyperplasia,
(P < .001).
and the progesterone-metformin group received metformin 1000 mg/day for 3 months in addition to progesterone.
Conclusions: Our study
Duration of bleeding, providesbody
hyperplasia, direct evidence
mass for theand
index (BMI), positive impact(BS)
blood sugar of updated training
of the patients wereonthen
pared between
performance the twoprocess
of triage groups. and encourages similar interventions to achieve higher efficiency in emergency
Findings: NA mean age of 44.5 years, mean BMI of 29 kg/m2 and mean duration of bleeding of 8 days were calcu-
lated for theTriage,
Keywords: study sample.
Dispatch,There was no significant
Guideline, Training, difference in age, BMI, gravidity, bleeding duration, and duration of
Nurse, Performance
disease at baseline between the two groups. While all patients in the progesterone-metformin group showed bleeding
and hyperplasia improvement, only 69% of the progesterone-alone patients showed such an improvement, with the
difference between the two groups being significant (P = 0.001). Although the difference between two groups in the
post treatment endometrial thickness was not significant (P =ies 0.55), post treatmentseveral
BMI in the progesterone-metformin
Background and Objectives have identified factors
group was significantly lower than in the progesterone-alone group (P = 0.01). In addition, the BS reduction in the
that influence triage de-
Triage progesterone-metformin
is the first point of referral group was for significantly
patients requiring cision-making,
larger than that such as patient
in the progesterone-alone group number,
(P = 0.001). nurses’ char-

associated of acteristics,
progesterone 20emergency
mg/day plusdepartment workload,
mg/day and
11-14 15,16
urgent health servicesOur
results decisions areadministration
indicated that metformin 1000
can significantly
with medical decrease
interventions, and bleeding duration,
thus correct hyperplasia,
triage deci- BMI and BS
financial in women17with
incentives. EH.
International medical guidelines
sion making Endometrial
is crucial for saving hyperplasia, Metformin,
the life of patient. 3-6 are continuously updated to enhance the standards of
The Progesterone
triage decision-making is a complex clinical process and clinical processes, including triage. Studies have shown
is often done under limited time, stress, uncertainty, and that training of triage personnel can improve the accu-
very small margin of error. Moreover the emergency de- racy of their decisions and hence patients’ comfort and
Background and Objectives
partment personnel are often exposed to heavy workload
and oligomenorrhea is about 20% [2]. Body mass
outcome.18 Hence, this study was conducted to evaluate
index (BMI) and nulliparity are two main risk factors
due to the largehyperplasia (EH) isthat
number of patients anneed
abnormal over-
categoriza- the effect of training triage nurses of Tehran Emergen-
for EH. Other risk factors include chronic anovula-
tion of endometrium
and evaluation, 7
whichthat may the
increase lead to ofendometrial
risk error. cy Department based on a newly released international
tion, early menarche, late onset of menopause and
cancer, especially when accompanied by evaluation
atypia [1]. guideline
The primary triage decisions mostly include diabetes on[3],efficiency
which areof triage process.
related to increased circulat-
and the effect
classification appears
of the onlybased
patients in 5%onof their
health ing estrogen [4]. The treatment of EH is challenging
atic patients, its prevalence in patients with PCOS Methods
problem and prioritizing allocation of medical resources and previous studies report conflicting results [5].
based on patient complication severity.3-6,8 Previous stud- Age, quasi-experimental
This fertility, and severity of enrolled
study EH in histology
100 nursesarefrom
most important
Tehran Emergency factors determining
Triage. The nursesthe were
treatment op-
*Corresponding author: Afsaneh Tehranian, Department of Gynecology and
Ob-stetrics, Arash
*Corresponding Women's
Author: Hospital,
Mahdie Abdoos,Tehran UniversityofofEmergency
Department Medical Sciences,
Med- tion [5].
ized into Most
trainedstudies have groups.
and control addressedThe hysterectomy
trained group
IranIran, P.O.Box:of 1653915981, Tel: +98 21 77719922, Fax:Tehran,
+98 21 in patients with based
on EH [5], particularly
international those
icine, University Medical Sciences, Modarres Hospital,
Iran. Tel: +98 E-mail:
21 22297695, Email: received training the new triage
with PCOS, and have led to conflicting results [5-11].

Abdoos Aetetal;al.;licensee
University of
of Medical
Thisis is
Open Access
open accessarticle distributed
article under
distributed a Cre-
under a
ative Commons
Creative Attribution-NonCommercial
Commons Attribution-NonCommercial 3.0 Unported License
3.0 Unported (,
License (, which allows
unrestricted use, distribution,
allows unrestricted and reproduction
use, distribution, in any medium,
and reproduction asmedium,
in any long as the
as original
long aswork is cited properly.
the original work is cited properly.
Impact of Training on Performance of Triage Abdoos et al

guideline. The most common complications and contacts the nurses in trained group were significantly higher than
(by telephone) to the Tehran Emergency Department were that by the control group. In line with our results, several
extracted and the nurses were asked to make triage de- studies have shown the positive correlation between train-
cision. Then the ability of the 2 groups in decision making ing and accuracy of triage decision making.19-21
and classifying the complications was compared. In Addition to knowledge which could be acquired by
training, the importance of experience in correct triage
Statistical Analyses decision making has been highlighted in the literature.22-25
Categorical data were presented as percentage (%), and In our sample, the difference between the experience of
continuous data as mean ± standard deviation (SD). Chi- trained and untrained groups was insignificant, which pre-
square exact test was used to compare categorical vari- vented us to examine the impact of experience in compar-
ables. The agreement between 2 protocols was examined ison to training. Andersson et al22 and Hicks et al,23 have
by the Kapa test. P < .05 was considered as statistical emphasized on personnel experience as the major deter-
significance. The data were analyzed using SPSS version minant of efficient triage. However, Cone et al showed that
22.0 software package (SPSS Inc, Chicago, IL). training can improve the accuracy of decision making be-
ginner and experienced triage nurses, irrespective of ex-
Results perience level.26 Notable, Considine et al who compared
The total dispatch by the trained group was significantly the impact of experience and knowledge on triage deci-
lower than the group that followed the present protocol. sion making found knowledge as the dominant factor.18
The frequency correct dispatch by training group was sig- These studies both corroborate our results and emphasize
nificantly higher than by untrained group (Table 1). The the unique role of up-to-date training in improved perfor-
frequency of correct triage in training group was signifi- mance of triage.
cantly higher than in untrained group (Table 1). Agree- Apart from knowledge and experience, previous stud-
ment between 2 protocols was moderate (K = 0.23, P =  ies have also identified other factors which can affect effi-
.03) (Table 1). ciency of triage, including nurse characteristics, number of
patients, facilities, and environment.8-11,18,27 A recent study
Discussion on 157 participants in Iran identified personnel character-
The purpose of this study was to examine the effect of istics as the most important factor affecting the triage de-
training on standard guidelines on the performance of tri- cision making.28 Others have shown a positive correlation
age. The nursing group that received training on interna- between nurse skills and right triage decision-making.24,25
tional guideline gained significantly higher ability to make The moderate consistency between the new triage
triage decision makings with lower total dispatches and guideline and current protocol indicates that the triage
lower wrong dispatches. Moreover, the right dispatches by guideline is significant updated. This finding together with

Table 1. Comparison of Routine Protocol and New International Guideline

Routine Protocol New International Guideline P

Sex, n (%) .43
Female 35 (70) 33 (66)
Male 15 (30) 17 (34)
Age, mean ± SD 27.37 ± 3.51 26.85 ± 3.74 .21
Experience, mean ± SD 4.25 ± 0.23 4.31±0.19 .53
Dispatch, n (%) .001
No 8 (16) 27 (54)
Yes 42 (84) 23 (46)
Right dispatch, n (%) .001
No 40 (80) 13 (26)
Yes 10 (20) 37 (74)
Triage, n (%) .001
Right 15 (30) 40 (80)
Wrong, n (%) 35 (70) 10 (20)
Kapa agreement 0.23 .03

Int J Hosp Res 2016, 5(4):122-125

124 Abdoos et al Impact of Training on Performance of Triage

positive effect of training of the nurses based on the for- Emerg Nurs. 1999;7:50-57.
mer strongly recommends similar interventions to alleviate 5. Williams G. Sorting out triage. Nurs Times. 1992;88(30):34-
inaccuracy and inefficiency in Iranian emergency depart- 36.
ments. 6. Cioffi J. Triage decision making: educational strategies.
Accid Emerg Nurs. 1999;7:106-111.
Study Limitations 7. Gottschalk S. Triage - a South African perspective.
The small sample size and short duration of the present Continuing Medical Education Journal. 2010;22(6):325-327.
study limit generalization of the results. Further large-scale 8. Gerdtz M, Bucknall T. Australian triage nurses’ decision
investigations with longer duration may help validate our making and scope of practice. Aust J Adv Nurs.
findings. 2000;18(1):24-33.
9. Crellin DJ, Johnston L. Poor agreement in application of
Conclusions the Australasian Triage Scale to paediatric emergency
Our study showed that the efficiency of triage can be department presentations. Contemp Nurse. 2003;15(1-
significantly improved by training the staff based on up- 2):48-60.
dated international guidelines. The moderate agreement 10. Considine J, LeVasseur S, Villanueva E. The Australasian
between the new and present protocols suggests that the Triage Scale: examining emergency department nurses
improving observed is not merely the result of training, but performance using computer and paper scenarios. Ann
also the impact of the updated guideline. Therefore, Ira- Emerg Med. 2004;44:516-523.
nian emergency departments should adopt similar inter- 11. Wuerz R, Fernandes C, Alarcon J. Inconsistency
vention in order to alleviate inaccuracy in triage decision of emergency department triage. Ann Emerg Med.
making. 1998;32:431-435.
12. Jelinek G, Little M. Inter-rater reliability of the National Triage
Authors’ Contributions Scale over 11,500 simulated occasions of triage. Emerg
The authors made similar contributions to this study. Med. 1996;8:226-230.
13. Dilley S, Standen P. Victorian triage nurses demonstrate
Competing Interests concordance in the application of the National Triage Scale.
The authors declare no competing interests. Emerg Med. 1998;10:12-18.
14. Considine J, Ung L, Thomas S. Triage nurses’ decisions
Acknowledgments using the National Triage Scale for Australian emergency
We would like to thank the nursing, the administrative and departments. Accid Emerg Nurs. 2000;8:201-209.
secretarial staff of the emergency department of Tehran for 15. Richardson D. No relationship between emergency
their contribution to the maintenance of our patient record department activity and triage categorization. Acad Emerg
without which this project would have been impossible. Med. 1998;5:141-145.
16. Hollis G, Sprivulis P. Reliability of the National Triage Scale
References with changes in emergency department activity level. Emerg
1. Giesen P, Ferwerda R, Tijssen R, et al. Safety of telephone Med. 1996;8:231-234.
triage in general practitioner cooperatives: do triage 17. Cameron P, Kennedy M, McNeil J. The effects of bonus
nurses correctly estimate urgency? Qual Saf Health Care. payments on emergency service performance in Victoria.
2007;16(3):181-184. DOI:10.1136/qshc.2006.018846 Med J Aust. 1999;171:243-246.
2. Hansen EH, Hunskaar S. Telephone triage by nurses in 18. Considine J, Cert E, Dip G, Botti M, Thomas S, PubPol D.
primary care out-of-hours services in Norway: an evaluation Knowledge and Experience Have Specific Roles in Triage
study based on written case scenarios. BMJ Qual Saf. Decision-making? Acad Emerg Med. 2007;14:722-726.
2011;20(5):390-396. Doi:10.1136/bmjqs.2010.040824 doi:10.1197/j.aem.2007.04.015.
3. Considine J, LeVasseur S, Charles A. Consistency of Triage 19. Fernandes C, Wuerz R, Clark S, Djurdjev O. How reliable
in Victoria’s Emergency Departments: Guidelines for Triage is emergency department triage? Ann Emerg Med.
Practice and Education: Monash Institute of Health Services 1999;34:141-159.
Research. Report to the Victorian Department of Human 20. Smart D, Pollard C, Walpole B. Mental health triage in
Services, 2001. emergency medicine. Aust N Z J Psychiatry. 1999;33:57-66.
htm. Accessed February 2006. 21. Smith A, Cone KJ. Triage decision--‐making skills. J
4. Gerdtz M, Bucknall T. Why we do the things we do: applying Nurses Staff Dev. 2010;26(1):E14-E199. doi:10.1097/
clinical decision making frameworks to practice. Accid NND.0b013e3181bec1e6.

Int J Hosp Res 2016, 5(4):122-125

Impact of Training on Performance of Triage Abdoos et al

22. Andersson AK, Omberg M, Svedlund M. Triage in the making, and preparation of ED triage nurses. J Emerg Nurs.
emergency department--a qualitative study of the factors 2002;28(5):401-406.
which nurses consider when making decisions. Nurs 27. Considine J, Ung L, Thomas S. Clinical decisions using
Crit Care. 2006;11(3):136-145. doi:10.1111/j.1362- the National Triage Scale: how important is postgraduate
1017.2006.00162.x. education? Accid Emerg Nurs. 2001;9:101-108.
23. Hicks FD, Merritt SL, Elstein AS. Critical thinking and 28. Dadashzadeh A, Abdolahzadeh F, Rahmani A, Ghojazadeh
clinical decision making in critical care nursing: a pilot M. Factors affecting triage decision-making from the
study. Heart Lung. 2003;32(3):169-80. doi:10.1016/S0147- viewpoints of emergency department staff in Tabriz
9563(03)00038-4 hospitals. Iran J Crit Care Nurs. 2013;6(4):269-276.
24. Thompson C, Dowding D. Clinical Decision Making and
Judgement in Nursing. Edinburgh: Churchill Livingstone;
Please cite this article as:
Abdoos M, Seyed Hosseini Davarani H, Hosseini Nejad H.
25. Ferrario CG. The association of clinical experience and
Impact of training on performance of triage: a comparative
emergency nurses’ diagnostic reasoning. Rush University,
study in Tehran Emergency Department. Int J Hosp Res.
College of Nursing; 2001.
2016;5(4):122-125. doi:10.15171/ijhr.2016.22.
26. Cone KJ, Murray R. Characteristics, insights, decision‐

Int J Hosp Res 2016, 5(4):122-125