This paper aims at analyzing a clinical practice guideline regarding triaging at the emergency room. The problem at hand regards the delays that patients experience at the emergency room, coupled with extended wait times, which is likely to lead to increased mortality. The related guideline developed by the National Guideline Clearinghouse will be analyzed using the AGREE II instrument developed by the AGREE Research Trust (Brouwers et al., 2010). The paper will also enumerate the development of a theoretical/conceptual framework regarding the chosen concept. A theoretical creation of the newly developed framework will also be provided.

Part 1:

The problem identified for discussion in the paper is: “Delays in emergency room triage area with extended wait times.” The rationale for the choice of the problem regards the realization that a majority of trauma patients spends quite a lot of time in the emergency room before they are attended. Due to the hitches in the triaging of patients, some well-up patients may be attended before more severe cases are attended. Such a scenario leads to the loss of lives that could have been, otherwise, prevented. The concept, in this case, is to: “Apply the field triage principle to the advanced nurse practitioner role in the triage area of the emergency room.”

The guideline under analysis in this case is: “Guidelines for field triage: recommendations of the expert panel on field triage, 2011” (Agency for Healthcare research and Quality, 2011)

The AGREE II instrument ratings for the guideline will be discussed under this section. AGREE II Instrument was developed with a view to addressing the aspect of variability in the quality of guidelines. The instrument has six domains, and all the domains will be used in the current appraisal. Under each domain, there are various aspects that the appraiser considers. They are called ‘items.’ The items are rated between 1 to 7, depending on their reliability. The score ratings range from ‘1? to ‘7? as shown below:

1Strongly Disagree

2

3

4

5

6

7Strongly Agree

Explanation of the Formula:

Before going to the tables showing the calculations, it is important to understand how the calculations have been done. In this case, there is one appraiser. The maximum possible score for on item 7. The maximum possible score for 2 items would be 7 x2, which is 14, and so on. The minimum score for one item would be 1 since the appraiser is one. The minimum score for 2 items will be 2, and so on.

The percentages will be calculated using the formula:

Obtained Score-Minimum possible score, divide by Maximum possible score – minimum possible score, and then multiply by one hundred. If, for example, three items of domain one are rated 4, 5, and 6, respectively, the total score would be 15. The maximum possible score would be 21; minimum possible score would be 21-3=18. The percentage would be 13/18, multiplied by 100, which is 72%.

Below are the ratings, rationale, total scores and percentages for each of the six domains for the chosen guideline

Domain 1: Scope and Purpose

	Item 1	Item 2	Item 3	Total	Percentage
Rating	7	5	5	17	77
Rationale	Guidelines are well written, specific and with easy content	Target population not very specific	Does not give the specifics of the target population

Domain 2: Stakeholder Involvement

	Item 4	Item 5	Item 6	Total	Percentage
Rating	6	5	7	18	83%
Rationale	Some stakeholders do not have all aspects considered	A good search for views, but some groups not consulted	The users are clearly identified

Domain 3: Rigour of Development

	Item 7	Item 8	Item 9	Item 10	Item 11	Item 12	Item 13	Item 14	Total score	Percentage
Rating	5	7	4	7	6	6	7	7	52	92
Rationale	No record of information from clinical evidence	Clear docu-mentation of criteria	No clear explanation of limitations	Clearly stated	Lacks deeper explanations	Explicit link evident	Yes. It is even an updated review	Was reviewed thoroughly

Domain 4: Clarity of Presentation

	Item 15	Item 16	Item 17	Total score	Percentage
Rating	5	4	7	16	72
Rationale	Most are specific; a few are ambiguous	Has not majored on the different options	Meets all requirements

Domain 5: Applicability

	Item 18	Item 19	Item 20	Item 21	Total score	Percentage
Rating	6	7	4	7	24	84
Rationale	Yes, but not very specific	Tools provided, though not in totality	No much consideration of resource implications	Yes, and has provided the specifics

Domain 6: Editorial Independence       

	Item 22	Item 23	Total score	Percentage
Rating	7	7	17	100
Rationale	A clear statement of financial disclosures	A clear statement of conflict of interests

 

My overall recommendation regarding the use of the guideline, as evidenced by the AGREE II scores, is that the guideline is suitable for application to curb the identified problem. In the application of the guideline, any recommendations for improvement can be done by following the recommended criteria for making improvements into the guideline. The experience of using the AGREE II analysis for this analysis has been good. I have learnt a lot regarding the reliability of a guideline. I will apply the knowledge I have gained from this exercise in the evaluation of other guidelines before using or recommending them for use.

Part II: Theoretical and Conceptual Framework

In relation to the guideline, the chosen related concept is: “The benefits of using a provider (advanced nurse practitioner) in the triage area of an emergency room.” It is assumed that such a policy will lead to reduced wait times. A conceptual framework model is drawn to guide the process at hand. In truth, a conceptual framework model enables the learner/researcher/implementer to know the factors/concepts that one needs to focus on (Ilot, Gerrish, Laker, & Bray, 2013, P.1). In a case like the one under discussion in this paper, a conceptual framework guides the implementation of the concept through clinical evidence. The clinical evidence will be monitored using the factors identified in the conceptual framework model. The Knowledge to Action (K2A) process is one such model that was developed in Canada by Graham et al. (2006). The model focuses on easing the concepts in regard to understanding knowledge, translating it and applying it.

Assumptions:

The conceptual framework derived from the chosen concept leads to the following assumptions:

I). The use of an advanced practice nurse in the triage area will result in reduced wait time.

II). Reduced wait time will result in casualties being attended on time, leading to a reduction in mortality in the casualty department

III). Intermediate outcomes for on-time attendance to casualties will be desirable, enabling time for a comprehensive management.

The model is very applicable in the clinical area since all the necessary factors have been considered. Additionally, the guidelines from which the concept was drawn was analyzed using the AGREED II Instrument, and the results were excellent.

Diagram of the New Framework:                                        (1)

Priority Casualties(2)

Early detection of priority cases

Screening (3)                                                            Association (6)

Intervention (4)

(5)

(8)

(7)

References

Agency for Healthcare research and Quality.(2011). Guidelines for field triage of injured patients.Recommendations for the National Expert Panel on Field Triage, 2011. Rockville, MD: Author. Retrieved from http://www.guideline.gov/content.aspx?id=38452&search=field+triage

Brouwers, M., Kho, M.E., Browman, P.G., Cluzeau, F., Feder, G., Fervers, B., Hanna, S., Makarski, J., on behalf of the AGREE Next Steps Consortium. (2010). AGREE II: Advancing guideline, development, reporting and evaluation in healthcare. Canadian Medical Association Journal, 182, 839-842.

Graham, D.I., Logan, J., Harrison, B.M., Straus, E.S., Tetroe, J., Caswel, W., & Robinson, N. (2006). Lost in knowledge translation: Time for a map? Journal of Continuing Education in the Health Professions, 26, 13-24.

Ilot, I., Gerrish, K., Laker, S., & Bray, K. (2013). Naming and framing the problem: Using theories, models and conceptual frameworks. Bridging the Gap Between Knowledge and Practice, Your Starter, 10(12), 1-4.