ORIGINAL RESEARCH

Risk classification in an emergency care unit: the nurses' discourse

Patrícia Madalena Vieira Hermida^I; Walnice Jung^II ; Eliane Regina Pereira do Nascimento^III; Natyele Rippel Silveira^IV; Diego Leonardo Fortuna Alves^V; Thisa Barcellos Benfatto^VI

^I Nurse. Postdoctoral student in Nursing, at the Federal University of Santa Catarina. Florianópolis, Santa Catarina, Brazil. E-mail: patymadale@yahoo.com.br
^II Nurse. PhD student in Nursing at the Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil. E-mail: walnicejung@gmail.com
^III Nurse. PhD in Nursing. Professor at the Federal University of Santa Catarina. Florianópolis, Santa Catarina, Brazil. E-mail: eliane.nascimento@ufsc.br
^IV Nurse. Master's degree in Nursing from the Federal University of Santa Catarina. Florianópolis, Santa Catarina, Brazil. E-mail: naty_rippel@hotmail.com
^V Nurse. Nursing degree from the Federal University of Santa Catarina. Florianópolis, Santa Catarina, Brazil. E-mail: dilebass@hotmail.com
^VI Nurse. Nursing degree from the Federal University of Santa Catarina. Florianópolis, Santa Catarina, Brazil. E-mail: thisa.enf@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.19649

ABSTRACT

Objective: to examine nurses' perceptions of risk classification in an emergency unit. Method: in this qualitative, descriptive study, nine nurses at an emergency unit in Florianópolis underwent semi-structured interviews between April and June 2014. Collective Subject Discourse was used as an organizational and data analysis technique. The project was approved by the Research Ethics Committee (Protocol No. 17041613.8.0000.0121). Results: two discourses emerged with the core ideas: risk assessment, in addition to prioritizing critical patient care, gives health personnel more security; and each nurse assesses, classifies and records in a particular way. Conclusion: although nurses consider risk classification important in the emergency unit, they find difficulty as regards standard conduct in implementing it and in recording, which signals a need for continuous education actions to improve care organization.

Keywords : Nursing; emergency nursing; triage; risk classification.

Frustration with emergency health care in Brazilian society led the country to establish the National Policy for Emergency Care ( Política Nacional de Atenção às Urgências or PNAU), under which emergency care units (Unidade de Pronto Atendimento or UPAs) are the main component of fixed pre-hospital care. These units have become an import point of access to the health system, serving as intermediary services between basic health care and hospital emergency care¹.

Ordinance/GM # 342 of March 4, 2013 specifies that UPAs should work 24 hours a day, 7 days a week, and have the physical infrastructure and interdisciplinary multiprofessional team that is compatible with the UPA's size². Ordinance/GM # 1601 of July 7, 2011 sets a policy that UPAs, jointly with the basic healthcare units, family health units and hospital units, should make up an organized urgent care network. These units should be installed on strategic places of the emergency healthcare network³.

The main strategy for regulating services in urgency care units, proposed by the Ministry of Health, through the National Humanization Policy ( Política Nacional de Humanização or PNH), is Triage with Risk Classification (Acolhimento com Classificação de Risco or ACCR). During triage, patients are evaluated by nurses⁴. Managers are in charge of implementing this strategy to identify patients needing prompt intervention and to prioritize care according to the degree of suffering or severity of the case².

Risk classification systems are employed in other countries to manage clinical risk and safely organize patient flow whenever need exceeds capacity⁵.

The relevance of risk classification (RC) is supported by studies showing that high-priority patients present higher rates of hospitalization and death⁶ and that there is a direct relation between severity of a patient's illness as defined by classification and length of hospitalization. Therefore, risk classification systems implemented by nurses are considered good predictors of death and hospitalization ⁷.

Another factor that supports the importance of and interest in the present study is related to the shortage of scientific production about risk classification in UPAs, since this service has only recently been implemented. Moreover, UPAs are supported by rules recommending that these units develop their work in line with the RC.

Therefore, the guiding question of this research was: What are the perceptions of nurses about risk classification in a UPA? Therefore, it aimed to get to know the perception of nurses of a UPA regarding risk classification.

LITERATURE REVIEW

Among the most popular risk classification systems in the world, the following are worthy of notice: the North American scale, in use since 1999 – the Emergency Severity Index (ESI); the Australian scale developed in the mid-1970s – the Australasian Triage Scale (ATS); the Canadian protocol – the Canadian Triage Acuity Scale (CTAS), created in 1998; and the Manchester Triage System (MTS), developed by the Manchester Triage Group in England. Emergency care units started in 1996 in the United Kingdom and in 2008 in Brazil⁸.

It is worth mentioning that these four systems share common features, notably: the goal of identifying and quickly intervening in situations that pose risk to life, differentiating them from situations where patients can safely wait for medical care; emergency cases that are classified from 1 (most urgent) to 5 (least urgent); and performance of risk classification by nurses⁸.

Nurses are the best professionals to evaluate and classify the risk of patients coming to emergency care units, oriented by a driving protocol ^9,10. Generally speaking, the use of scales and protocols is recommended to stratify different levels of risk, because they are more reliable, valid and trustworthy for evaluating the clinical condition of patients⁹.

METHODOLOGY

Descriptive study with a qualitative approach carried out in an emergency care unit (UPA) in the municipality of Florianópolis, Santa Catarina. The UPA health team was made up of physicians, nurses, practical nurses, dentists, a social assistant, and a pharmacist, among other professionals. It is worth mentioning that Florianópolis currently has two UPAs: UPA-North, opened in 2009, and UPA-South, opened in 2008.

Nurses were invited to participate in the study because they were the professionals in charge of RC in the UPAs, in accordance with the main RC systems used globally and Resolution # 423/2012 of the Federal Council of Nursing¹¹. Of the 13 nurses working in the UPA, nine met the inclusion criteria so participated in the study: belonging to the UPA professional staff; having at least one year of professional experience and working in RC; and being on duty at the time of data collection.

To evaluate and classify patient risk, UPAs use an adapted version of the RC protocol from the municipality of Belo Horizonte, adapted from the Manchester Triage System.

Data were collected from April to June 2014 through semi-structured individual interviews. The following characteristics of the selected participants were noted: sex, age, and length of work in the UPA. Participants were asked to talk about their perceptions of risk classification in the UPA. Interviews were carried out in a private room in the healthcare unit, and lasted 40 minutes on average. The interviews were recorded and transcribed by the researchers.

The interview transcripts were organized and analyzed following the collective subject discourse (CSD) technique, which employs four methodological figures: key expressions (KE); core ideas (CI); anchoring (AC); and the collective subject discourse (CSD) itself. Key expressions are excerpts from individual statements that depict the essential content of the discourse about an issue. The core idea describes the senses of individual statements and of the set of the participants' responses with the same sense. Anchoring describes the ideologies, values and beliefs found in the individual or grouped speech. The collective subject discourse is made up of KE with similar or complementary CI¹². The present study did not find anchoring in individuals' speech.

The following steps were used to build the Collective Subject Discourses (CSD): careful reading of each interview, highlighting the KEs of each statement; identification of the CI of each KE; grouping KEs of similar or complementary senses; naming of the CI of each group of similar KEs. These groupings gave rise to the CSDs, each with one CI. Therefore, two CSDs came about with their respective core ideas (CIs): one related to positive aspects of utilizing RC; the other related to its negative aspects. In order to protect participants' anonymity in the CSDs, researchers adopted the initial E (for "enfermeiros," which is "nurse" in Portuguese), followed by the number corresponding to the sequence in which interviews were carried out (E1, E2, E3…).

The project was approved by the Research Ethics Committee of the Federal University of Santa Catarina (UFSC) under Protocol # 425197/2013, CAAE: 17041613.8.0000.0121. It also followed the recommendations of Resolution # 466/2012 issued by the Brazilian Health Council, and all participants signed the Free and Informed Consent Form.

RESULTS AND DISCUSSION

Regarding the characteristics of the nine participants, seven were women; participants ranged in age from 31 to 42 years old. Regarding length of work in the UPA, eight nurses had worked between five and six years, i.e., since the unit was opened.

The CSD analysis gave rise to two topics: one about the positive aspects of RC, and the other about its negative aspects. Each topic is related to a CI.

For nurses in this study, RC had a positive effect on the UPA's everyday services; facilitated care and its dimensioning by the team; was an important tool for prioritizing severe cases; and gave confidence to the nurses, since patients waiting for medical care had been previously evaluated. See Figure 1.

FIGURE 1: Positive aspects of risk classification. Florianópolis, Santa Catarina, 2014.

The literature supports what the nurses said in relation to risk-based prioritization of patients. A study performed with professionals in a UPA in Rio Grande do Norte showed that, despite the constraints of implementing RC, the first come first served model was replaced by care based on clinical severity, giving priority to care for patients with higher risk of death, thus improving care delivery¹³.

In another study, the nurses in UPAs in the South region of Brazil highlighted the prioritization of care for patients with potential grievous risk as one of the contributions of the RC, which ensures emergency care and reduces the risk of worsening and sequels resulting from long waiting times¹⁴. However, the work overload damages the prioritization of emergency care, as shown in a survey developed in UPAs in Santa Catarina ¹⁵.

{0>No cenário hospitalar, estudo desenvolvido em serviços de emergência do Paraná identificou que a priorização dos pacientes graves para o atendimento foi o item melhor avaliado pelos profissionais de enfermagem em relação à CR, o que indica que esta tem alcançado seu principal objetivo no que se refere ao atendimento inicial aos pacientes que procuram pelas emergências hospitalares, substituindo o modelo tradicional de atendimento por ordem de chegada¹⁶.<}0{>In the hospital setting, a study performed in emergency care units in Paraná found that prioritization of severely ill patients was the item to which nurses gave the best evaluations regarding RC. This is evidence that RC reaches its main goal in relation to initial care for patients who come to hospital emergency units, replacing the traditional first come first served model¹⁶.<0} {0>

This change in the care delivery model, which is now based on priority, has also taken place in the emergency care unit of a public hospital in Santa Catarina, signaling an advance in the service organization¹⁷. <}0{><0}

In Piauí the nursing team in an emergency care unit disclosed that some professionals proved to be aware about the RC, as shown by prioritizing care delivery according to patient risks and vulnerability¹⁸. Nursing professionals^17,19 and nurses²⁰ in hospital emergency care units also refer to the safety of RC-based care provided to patients by UPA nurses, which was also found in the current study. This is an indication that the positive aspects of RC are compatible with different settings for emergency care. One study pointed out that RC provides safety to patients, since the evaluation and prioritization of care allow more efficacious intervention, avoiding grievances and sequels¹⁴.

The positive aspects of RC shown in the current study and supported by literature contribute to improved work organization in urgent and emergency care units in Brazil. This is a desirable aspect if we consider the critical situation of these services. The initial remarks of nurses, similar to the findings of other studies, are coherent with the ACCR as proposal in the National Humanization Policy (PNH, as per its acronym in Portuguese). It is also a sign that the PNH is consolidated in the different realities of emergency care units through the implementation of the National Policy on Emergency Care. However, some negative aspects of RC in UPAs deserve attention and were found in the nurses' remarks. See Figure 2.

FIGURE 2: Negative aspects of risk classification. Florianópolis, Santa Catarina, 2014.

These findings reveal that, although the UPA had a RC system, not every nurse used it as guidance to classify the severity of the situation of patients seeking the service; rather, classification was often based on the experience and convenience of professionals.

Driving protocols²¹ should be used to inform nurses' evaluation of RC and reduce the subjectivity bias inherent in the clinical decision-making process, as disclosed in the present study. Regarding implementation of protocols, research has pointed out that these standardize the conduct of professionals²² and are the main facilitators of nurses' work in RC, because they guide clinical practice ⁴.

Although studies have pointed to positive results when referring to the implementation of RC protocols, the occurrence of sub-classification and super-classification of severity²³ is worthy of notice. These aspects are in line with the remarks of nurses included in this research when they mentioned that each professional evaluates and classifies in a different way. A systematic review of the Manchester Triage System found that the validity and reliability of this classification system were good, but safety was low due to the high rate of under-triage and low sensitivity for predicting higher urgency levels²⁴.

Nurses' evaluations of patients must be coherent with their condition, since those classified as high priority for care have 2.5 times more chance of progress to death than those with low priority²⁵. This illustrates the relevance of implementing RC protocols in nurses' clinical practice in UPAs. This implementation, however, was shown to be negatively impacted in the reality of the present study, despite the existence of a driving protocol. Therefore, decisions about priority were random, subjective, and lacked well-defined criteria.

One of the negative aspects revealed in nurses' remarks was disagreement among nurses referring to RC, which is also pointed out in a similar study that found differences of opinion between nurses and physicians, giving rise to conflicts¹⁴.

Additionally, another study revealed that lack of awareness about the protocol among other health team members also hindered work with RC ⁴. However, this argument does not support the differences of opinion found in the present study, because they occurred in the same professional category (nurses). It appears that in this situation, everyone was familiar with the protocol but used it at their convenience. Another relevant aspect in the UPA where this investigation was developed was that the protocol was used only for care of non-surgical adult patients, excluding pediatric emergency care. This aspect was considered to be negative and limiting to the service.

The implementation of risk classification protocols by institutions is important, but professionals should also consider other strategies or tools. One study pointed out that the implementation of protocols, per se, does not ensure better services because it accounts just for this side of care. In health care for the elderly, for example, meeting their needs and being networked are some aspects that could improve the quality of services provided²⁶. Even the Ministry of Health admits that RC protocols are useful and necessary instruments for organizing evaluation; however, they are not sufficient, because they do not capture subjective, affective, social and cultural aspects that must be understood in order to effectively evaluate each individual's risk and vulnerability²⁷.

The difference between clinical priority and clinical management should be clarified. The first demands getting enough information to assign patients to one of the risk categories, and defines the maximum waiting time for medical evaluation. Clinical management, in turn, refers to the characteristics of patients that affect their therapy and ordering of services of various types, such as elderly, people with disabilities, prisoners, and intoxicated or drugged individuals. Each unit is oriented to develop means capable of dealing with such situations⁸.

As referred to in the second CI as a negative RC factor, the fact that each nurse evaluates and classifies in a different way should be interpreted with caution. One study emphasized that an important component of classification systems is the evaluation of pain, which entails subjective and complex aspects that involve both patients and professionals ⁸. The accurate evaluation of pain by nurses in RC is crucial to properly define patients' care priority levels²⁸.

Regarding the issue of pain, which was also mentioned by the nurses in this study, the institutional protocol of the Clinics Hospital of Porto Alegre has advanced and currently provides for medicating patients while they wait for medical appointments in the emergency care unit. To that, nurses must be sensitive to patients' complaints of pain and apply the protocol ²⁶.

The nurses' speech also highlighted that nurses record RC in different ways. The UPA uses the SAMPLE, a simplified interview model for pre-hospital care; the letters signify: S = signs and symptoms; A = allergies; M = medications; P = past medical history (ongoing medical therapy); L = liquids and food; and, E = events related to the trauma or illness. This demands discussion and review of professional practice, since RC reporting by nurses, as provided for in Resolution #423/2012 of the Federal Council of Nursing¹¹, should be performed in the context of the nursing process, according to Resolution # 358/2009²⁹.

The investigated UPA used an automated system of the municipality (InfoSaúde) to record the care delivered. In that system, items to fill in RC are standardized. However, nurses got no specific training on the use of this tool to standardize entry of care data, so some fields and items of the system are not filled in by the time care is delivered. This incompleteness of data negatively affects care quality and hinders the continuous work of the team, also jeopardizing any reliable evaluation of the service.

This aspect should also be reviewed in RC practice, since the electronic health record can be accessed, not only in the UPA, but also in other health services that are part of the municipal network. Thus, complete records of care delivered could contribute to integral care at the municipal level, since health professionals could access information whenever the patient needed assistance.

Although studies of RC do not emphasize registration, in the UPA in question it seemed to be a concern among nurses, since it appeared in the current research and in another study performed in the same unit, where registration was linked to difficulties in implementing systematization of nursing care³⁰.

Still in relation to registration, a study with patients classified according to the Manchester Triage System showed the need for training nurses to record pain more accurately. Data on the beginning, duration, irradiation of pain, and any inciting and aggravating factors, could contribute to nurses' planning of care, enhancing patients' trust in the therapy as it considers their complaints²⁸.

CONCLUSION

Nurses' perceptions of risk classification is related to both positive and negative ideas. Positive perceptions are focused on ensuring priority care to more severely ill patients, while negative perceptions are focused on risk identification by professionals. This relates to how nurses perform evaluation, classification and registration of care, which differs among professionals and hinders care delivery.

The present study points out highly relevant issues for emergency care unit managers regarding the everyday work of nurses who carry out risk classification in UPAs, and could subsidize the planning of actions for ongoing education about this topic. Moreover, the present study is innovative, in that it points out the need to review RC registration in health records, and to increase professionals' commitment to put it into practice, mainly considering its relevance to continuation of care delivery. A limitation of the current study is that it approached only nurses. Learning about patients' perceptions of risk classification implementation, for example, could extend and improve the current study and lead to new contributions.

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