RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCESKARNATAKA, BANGALORE

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS

FOR DISSERTATION

1. / Name of the candidate and address / JAINMOL M AUGUSTINE
FIRST YEAR M.SC. NURSING
CITY COLLEGE OF NURSING
CITY ENCLAVE
SHAKTHINAGAR
MANGALORE – 575 016.
2. / Name of the Institution / CITYCOLLEGE OF NURSING
SHAKTHINAGAR
MANGALORE – 575 016.
3. / Course of study and subject / M. Sc. NURSING,
PAEDIATRICNURSING
4. / Date of admission to the course / 1.6.2009
5. / Title of the study:
EFFECTIVENESS OF PLANNED TEACHING PROGRAMME ON EMERGENCY TRIAGE ASSESSMENT AND TREATMENT (ETAT) OF CHILDREN AMONG FINAL YEAR BSC NURSING STUDENTS IN SELECTED COLLEGE OF NURSING AT MANGALORE.
6. / BRIEF RESUME OF THE INTENDED WORK
Introduction
Successful transition from old ways of thinking and behaving to new ways of thinking and behaving is the form of celebrating success. Improvement in child health is not necessarily dependent on the use of sophisticated and expensive technologies, but rather on effective strategies that are based on a holistic approach.
Emergency Triage Assessment and Treatment (ETAT) is a crucial step associated with “Integrated management of neonatal and childhood illness” (IMNCI) to reduce underfive mortality. Triage is the process of rapidly screening sick children when they first arrive in the hospital and of placing them in one of the groups like those with emergency signs (who require immediate treatment), those with priority signs (who should be given priority while waiting in the queue, so that they can be assessed and treated with out delay) and those with non-urgent signs (who have neither emergency nor priority signs)1
As the proverb says “time and tide will wait for no man,” time is a crucial factor in an emergency situation. Appropriate “triage” categorization helps to prevent delay in initiating the care of sick child. So all staff involved in care of sick children should be trained to carry out the triage and if possible to give initial emergency treatment.
6.1Need for the study
Every year, more than 10 million children die almost all in low income countries or poor areas of middle income countries2. After the neonatal period the main cause of deaths are pneumonia, diarrhoea, malaria, measles and malnutrition accounting for about 70% of childhood deaths.3 Very often these children do not receive good quality care, both at the level of ambulatory and institutional care. Surveys reveal that many sick children are properly assessed, treated and that their parents are poorly advised by their health care providers4. For more severely ill children who require care in hospitals, inadequate triage assessment, poor inpatient treatment and insufficient monitoring adversely affect the outcomes of a significant proportion of hospitalised children and result in unnecessary suffering or avoidable death for many children 5.
The underfive mortality rate in India remains to be 72/1,000 live births6.The IMRcontinues to be high, 54/1,000 live births6. The percentage of underfive with diarrhoea (2000-2007) in India i.e. 337. According to UN common data base, the malaria related mortality rate in children between 0-4 years in India is 6 per 1,00,000 live births8.
As a part of the IMNCI, an algorithm and simplified emergency treatment instructions have been developed by the WHO to improve the triage of sick children, presenting to the hospital. The aim is to provide immediate treatment of children with signs of life threatening condition and to identify those requiring priority assessment1.Training of health workers in the use of those guidelines is a vital importance to improve the triage.
A cross sectional study was conducted to compare the triage assignment in paediatric emergency department among registered nurses (RNs) and paediatric emergency physicians (PEPs), using mailed questionnaire survey method. The result shows that there was 100% response rate (39 RNs, 24 PEPs). The mean percentage of current response (+/- 1SD) for RNs was 64.2% (+/-8.0%) and for the PEPs was 53.5% (+/-8.1%, P< 0.01). There was significant difference within groups by experience level, or by the type of work schedule. The study concluded that the level of agreement and accuracy of triage assignment was only moderate for both RNs and PEPs. Triage is a crucial step in emergency care which requires improved measurements9.
A study was conducted among nurses to evaluate the performance of simplified algorithm and treatment instructions for emergency triage assessment and treatment of children presenting to hospital in developing countries. The nurses ETAT assessment was compared to standard emergency advanced paediatrics life support. The result of the study showed that ETAT algorithm was used by nurses identified 731/3837 patient (19.05%), 98 patients (2.6%) were classified as needing emergency treatment and 633 (16.5%) as needing a priority assessment. Nurse administrators treatment was appropriate in 94/102 (92.2%) emergency condition. The study concluded that ETAT instruction when carried out by nurses after a specific training period performed well as screening tool to identify priority cases and as a treatment guide for emergency conditions 10
From the literature review, the investigator understood that ETAT is not well set in nursing profession and majority of the nurses have only limited knowledge regarding ETAT.
Although WHO and UNICEF developed IMNCI during the mid 1990s, it has been implemented in the nursing curriculum recently. And several studies show that planned teaching programmes are effective in improving the knowledge. From all these the investigator felt that this is the right time and right opportunity to throw light on the ETAT through conducting a planned teaching programme for the final year B. Sc. nursing students.
6.2Review of literature
A study was conducted to describe the triage of children in a sample of mixed and paediatric emergency departments to measure the inter-reliability of the national triage scale when used by triage nurses for triage of paediatric patient. A questionnaire was used and triage nurses were asked to assess 25 paediatrics patients to profile and to assign appropriate triage categories to each profile. The results showed that 94% of patients’ profile were triaged within one category of their modal response. Nurses in paediatric emergency department (a concurrence greater than 50% for 79% of responses) were significantly more consistent in their use of the national triage scale compared with nurses in mixed emergency department (concurrence greater than 50% for 50% of responses) The study concluded that the use of the national triage scale for the triage of paediatric patients by triage staff is not consistent and there are significant difference between the triage practices of paediatrics and mixed emergency department11.
A study was conducted to compare triage categorisation as measure of perceived patient acuity on presentation to the emergency department by paediatric emergency medicine attending physicians, nurses and paediatrics residents with their general emergency medicine counterparts. A questionnaire method was used and participants were asked to use a 3 tier triage system (emergent, urgent, non urgent) to assign a triage level for each patient scenario. The result showed that response rate was 99%. The k level of agreement was highest (0.39) among the PEM physicians. Significantly more GEM attending physicians, the fowling scenarios at a higher acuity level as compared with PEM attending with a trend towards emergent triage. Simple febrile seizure 50% versus 7.7 %. 18 month old with fever and bumps on lips, 21% verses 0% and 15 month old well appearing child with high fever, 50% Versus 7.7%. The study concluded that level of agreement for triage assignment with each group was only fair.12
A study was conducted to measure inter-rater reliability and agreement rates within and between groups of paediatrics emergency medicine physicians and paediatric triage (PT) nurses using ESIv4 in a paediatric population. Paediatric emergency medicine physician and PT nurses completed ESIv4 training and a survey of 20 paediatric case scenarios, requiring them to assign a triage category to each case. Ten results showed that 16 physicians and 17 nurses completed the study. The group had a mean of 10.2 (+/- 7.7) years experience in paediatrics. Nurses had a mean of 7.6(+/- 8.7) years experience in triage. Unweighted k for physicians and nurses was 0.9 to 0.93, respectively. The agreement rate among physicians and nurses with the standardized response to case scenery was 83%. The study concluded that ESIv4 is a reliable tool for triage assessments in paediatric patients when used by experience paediatric emergency medicine and PT nurses. It is triage system with high agreement between physician sand nurses when used by experienced paediatrics emergency medicine physicians and PT nurses. It is a triage system with high agreement between physicians and nurses.13
A study was conducted to design a triage assessment tool that predicts acidosis in children with vomiting, diarrhoea and dehydration. A convenience sample of patients aged 3 month to 7 years with vomiting and diarrhoea were enrolled in the triage area of paediatrics hospital emergency departments. A parental questionnaire was used. The result of the study showed that 29% of patients had acidosis. Univariate predictors of acidosis were younger age (mean 1.7 Vs 3.1 years, P=0.002), previous evaluation by the primary care physicians (66% Vs 33%, P= 0.008) and being sent in by primary care physicians (66% Vs. 33% P= 0.002), and a verse overall appearance based on the triage nurses mark on a 0-cm. (alert/playful) to 10 cm (“lethargic/limp”) visual analogue scale (3.7 {2.8} vs. 2.4{ 2.2}cm, P= 0.013).The study concluded that identifying patients with acidosis early in their ED courses allows the treating ED physicians to focus more attention and resources towards rehydrating this at risk population of patients with gastroenteritis.14
A perspective study was conducted in an urban tertiary care ED to assess the effect of training on nurse agreement using an electronic triage system. In phase I, eTRIAGE was deployed after a 3 hour training course for 24 triage nurses, who were asked to share this knowledge during regular triage shifts with the colleagues who had not received training
(n= 77). In phase II, a targeted group of 8 triage nurses underwent further training with eTRIAGE. The results of the study shows that 9 in phase I, 569 patients were enrolled with 513 (90.2%) complete records, 577 patients were enrolled in phase 2 with 555(96.2%) complete records. Inter-rater agreement during phase I was moderate (weighted?= 0.55; 95% confidence interval 0.49 – 0.62) ; agreement improved in phase 2 (weighed?= 0.65; 95% CI 0.60-0.70)manual overrides of eTRIAGE score were infrequent (approximately 10%) during both periods. The study concluded that agreement between study nurses and duty triage nurses, both using eTRIAGE, was moderate to good, with a trend towards improvement with additional training. Continued attempt to refine the triage process and training appear warranted.15
6.3Statement of the problem
Effectiveness of planned teaching programme on Emergency Triage Assessment and Treatment (ETAT) of children among final year B. Sc. nursing students in selected college of nursing at Mangalore.
6.4Objectives of the study
  1. To determine the pre-test knowledge of final year B. Sc. nursing students on emergency triage assessment and treatment in selected college of nursing of Mangalore as measured by structured knowledge questionnaire.
  2. To evaluate the effectiveness of planned teaching programme on emergency triage assessment and treatment in terms of gain in knowledge score among the final year B. Sc. nursing students.
  3. To find the association of pre-test knowledge score of final year B. Sc. nursing students on emergency triage assessment and treatment of children with selected demographic variables.

6.5Operational definitions
  1. Effectiveness: In this study the effectiveness refers to the extent to which the planed teaching programme has attained the desired gain in knowledge score as measured by knowledge questionnaire.
  2. Knowledge: In this study knowledge refers to the scores obtained by the students by giving correct responses to knowledge questionnaire.
  3. Emergency Triage Assessment and Treatment: Emergency triage assessment and treatment refers to the process of rapidly screening sick children when they first arrive in the hospital and of placing them in one of the groups like those with emergency signs, those with priority signs and those with non urgent cases and giving initial emergency treatment. The dimensions of emergency conditions include diarrhoea and malaria.
  4. Final year B. Sc. nursing students: It refers to those who are studying in the 4th year.

6.6Assumptions
The study assume that:
  1. Final year B. Sc. nursing students have some knowledge on emergency triage assessment and treatment in children.
  2. Knowledge on emergency triage assessment and treatment of children is effective in reducing the mortality of sick children.
  3. Planned teaching programme is one of the effective methods in improving the knowledge.

6.7Delimitations
The study is delimited to:
  1. Final year B. Sc. nursing students of a selected college of nursing of Mangalore.
  2. Students who are present in the college at the time of data collection.
  3. Students who are willing to participate in the study.

6.8Hypotheses
The hypothesis will be tested at 0.05 level of significant.
H1:The mean posttest knowledge of the students will be significantly higher than their mean pre-test knowledge scores.
H2:There will be significant association of pre-test knowledge scores with the selected demographic variables.
7. / Material and methods
7.1Sources of data
In this study the data will be collected from final year B. Sc. nursing students of selected college of nursing at Mangalore.
7.1.1Research design
One group pre-test post-test research design will be adopted for the study as the investigator is trying to find out the effectiveness of planned teaching programme on emergency triage assessment and treatment of children among final year B. Sc. nursing students.
Day 1 / Day 1 / Day 7
O1 / X / O2
O1 – Pre-test
X – Intervention (planned teaching programme)
O2 – Post-test
7.1.2Setting
The study will be conducted at selected college of nursing of Mangalore.
7.1.3Population
Population includes final year B. Sc. nursing students.
7.2Method of data collection
7.2.1Sampling procedure
Sample for the study will be selected by simple random sampling technique.
7.2.2Sample size
Sample will comprise 50 final year B. Sc. nursing students.
7.2.3Inclusion criteria
  1. Final year B. Sc. nursing students.
  2. Students who are willing to participate in the study.

7.2.4Exclusion criteria
  • Final year B. Sc. nursing students who are have not cleared till third year.

7.2.5Instruments intended to be used
  • Structured knowledge questionnaire

7.2.6Data collection method
  • Permission will be obtained from selected college of nursing at Mangalore
  • By using simple random sampling, 50 final year B. Sc. nursing students will be selected.
  • Purposes of the study will be explained and consent will be taken from the subjects.

  • Participants’ pre-test knowledge will be assessed by administering a structured knowledge questionnaire and on the same day planned teaching programme will be given to them.
  • The post-test will be conducted using the same knowledge questionnaire on the seventh.

7.2.7Data analysis plan
  • The pre-test and post test will be analysed using mean, median and standard deviation.
  • The effectiveness of PTP will be analyzed using paired ‘t’ test.
  • The association of pre-test knowledge score with demographic variable will be analyzed using chi–square test.

7.3Does the study require any investigation or intervention to be conducted on patients or other humans or animals?
Yes, the investigator needs to evaluate the effectiveness of planned teaching programme on emergency triage assessment and treatment in children among final year B. Sc. nursing students.
7.4Has ethical clearance been obtained from your institution in case of 7.3?
Yes, ethical clearance has been obtained from the institution.
Bibliography
  1. Emergency triage assessment and treatment (editorial). Nightingale Nursing Times 2005 Jun;36-41.
  2. Black RE, Morris SS, Bayer J. Where and why are 10 million children dying every year? Lancet 2003;361:2226-34.
  3. Chaudhary N, Mohanty PN, Sharma M. integrated management of childhood illness (IMCI) Follow up basic health workers. Indian Journal of Paediatrics 2005 Sep;72:735-9.
  4. World Health Organization. Report of the division of child health and development 1996-1997. Geneva: WHO; 1998.
  5. Nolan T, Angos P, Cunha AJLA, Mahe L, Quazi S, Simoes EAF, et al. Quality of hospital care for seriously ill children in less developed countries. Lancet 2001;357:106-10.
  6. Underfive mortality rate in India. [online]. Available from: URL:
  7. Underfives with diarrhoea (2000-2007) in India. [online]. Available from: URL:
  8. Malaria related mortality rate in India. [online]. Available from: URL:
  9. Bergeron S, Goulin S, Bailey B, Patel H. Comparison of triage assessment among paediatrics registered nurses and paediatrics emergency physicians. Acad Emerg Med 2002 Dec 9(12):1397-401.
  10. Tamberline G, Di Mario S, Schindler-Maggi R, Vilarim JV, Gove S. Evaluation guidelines for emergency triage assessment and treatment in developing countries. Arch Dis Child 1999;81:478-82.

  1. Durojaiye L, O’Meara M. A study of triage paediatric patients in Australia. Emerg Med (Fremantte) 2002 Mar;14(1):67-74.
  2. Maldonado T, Avner JR. Triage of paediatric patients in the emergency department: are we all in agreement? Paediatrics 2004 Aug;114(2):356-60.
  3. Durani Y, Brecther D, Walmsely D, Attia MW, Loiselle JM. The emergency severity index version 4: reliability in paediatric patients. Paediatr Emerg Care 2009 Aug;25(8):504-7.
  4. Madati PJ, Bachur R. Development of an emergency department triage tool to predict acidosis among children with gastroenteritis. Paediatr Emerg Care 2008 Dec;24(12):822-30.
  5. Dong SL, Bullard MJ, Meurer DP, Blitz S, Brain R, et al. The effect of training on nurse agreement using an electronic triage system. JEM 2007;9(4):260-6.

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