International Emergency Nursing (2013) 21, 103 112

Available at www.sciencedirect.com

journal homepage: www.elsevierhealth.com/journals/aaen

Comparing triage evaluation of adult

dyspneic patients between emergency nurses
and doctors using simulated scenarios
Lim Beng Leong MBBS (UNSW), MRCS (A&E), FAMS (Consultant)*,
Eunice Tay Zhi Rui BNurs, MHsc Ed (Nurse Clinician),
Alicia Vasu BSc (Biomedical Sciences), MPH (Senior Research Executive),
Kenneth Heng Wei Jian MBBS (Singapore), FRCS (A&E),
FAMS (Senior Consultant)
Tan Tock Seng, Emergency Department, Singapore
Received 4 March 2012; received in revised form 6 June 2012; accepted 11 June 2012

KEYWORDS
Simulator;
Triage nurses;
Emergency department

Abstract
Objective: Although registered nurses frequently perform triaging in many emergency
departments (EDs), little is known regarding the agreement between nurses and doctors in
triaging dyspneic patients. The aim of our study was to compare the effectiveness of trained
ED nurses with doctors in the evaluation of dyspneic patients at triage using the SimMan 3G
simulator.
Methods: We compared eight nurses who underwent a structured training/accreditation program with eight doctors. Two assessors evaluated them through seven common and/or important cardiorespiratory simulated scenarios. Each scenario had an evaluation instrument that
scored participants on triage assessment and management. Each nurse was also surveyed over
a six-point Likert scale (05) on their confidence in triaging dyspneic patients after the study.
Data was analyzed using descriptive statistics with statistical significance set at p < 0.05.
Data/results: There were no statistically significant differences between the mean assessment
or management scores across all scenarios between doctors versus nurses (p ranging from 0.070
to 0.798). Six nurses felt they could evaluate ED dyspneic patients alone (score of 4) and the
remainder with supervision (score of 23).

* Corresponding author. Address: Tan Tock Seng, Emergency Department, 11, Jalan Tan Tock Seng, Singapore 308433, Singapore. Tel.: +65
63578777; fax: +65 62543772.
E-mail address: Beng_Leong_Lim@ttsh.com.sg (B.L. Lim).
1755-599X/$ - see front matter 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ienj.2012.06.003

104

B.L. Lim et al.

Conclusion: Trained ED nurses; when compared to doctors; could triage and evaluate dyspneic
patients effectively on a simulator.

2012 Elsevier Ltd. All rights reserved.

Introduction
Triage is an essential function in the emergency department
(ED) where many patients present with undifferentiated
complaints. Dyspnea is a common presenting complaint
and common causes include decompensated heart failure,
pneumonia, chronic obstructive pulmonary disease (COPD)
and asthma (Ray et al., 2006). Patients also present with
varying severities of these illnesses. The principle of ED triage is to identify patients who need emergent or urgent
interventions from those who do not need such care and
can safely wait.

Background
ED triage of the dyspneic patient requires a rapid decision
making process using limited clinical information and targeted physical examination including vital signs and pulmonary auscultation. This process informs decision making
about urgency of care, Patient Acuity Category (PAC) assignment and triage initiated treatments and investigations like
the electrocardiogram or chest radiograph. The study ED
uses a four point PAC system to categorize all patients
according to the guidelines established by the Singapore
Society of Emergency Medicine (Society for Emergency
Medicine in Singapore, 2010). The criteria for the various
PAC categories are shown in Table 1.
The roles of emergency nurses (ENs), especially emergency nurse practitioners (ENPs), have been expanding
and in many centres, they are not confined to manage minor
illnesses or injuries and follow up reviews (Lowe, 2011;
Steiner et al., 2008). In this study, we attempted to explore
the ED nursing role in triaging the dyspneic patient in our
centres which requires critical decision making skills.

Setting
Triaging is commonly performed by nurses in many EDs.
However, little is known regarding the agreement between
nurses and doctors in triaging dyspneic patients. Our ED triage system of the dyspneic patient uses a combined assessment by doctors and nurses in contrast to other EDs. The
reason for this combined approach is that there has not
been a formal training and accreditation process for triaging

Table 1

complex complaints like dyspnea for our nurses in a busy ED.

Our existing workflow requires the adult dyspneic patient to
be auscultated by an emergency doctor (specialist or nonspecialist) who will relate the findings and any necessary
treatment or investigations (including the need for emergent or urgent treatment) to the triage nurse. The nurse will
subsequently assign a PAC category to the patient and executes the triage treatment and investigations.
Our department has trained a group of eight triage nurses
through a structured clinical evaluation, pulmonary auscultation training and accreditation program in order to reduce
or eliminate the requirements for doctors to contribute to
this triage process. The teaching and accreditation program
has been vetted by our emergency physicians (EPs) in our
department.
We designed this exploratory pilot study to compare the
effectiveness and safety of these trained triage nurses and
ED doctors in evaluating dyspneic patients at triage using
a simulation model.

Methods
Overview
Our hospital is a 1000 bed acute adult tertiary hospital. Its
ED receives patients from all regions of the country and
had an annual census of 161,719 patient visits in 2010.
Triage nurses who had undergone a structured training
and accreditation program to evaluate dyspneic patients
were asked to participate in this study. The study was performed in strict accordance with the institutional review
board guidelines and was approved by the National Healthcare Group ethics committee.

Participants
Before the study, eight triage nurses from our ED were
trained from September to December 2009 to perform a
competent evaluation of dyspneic patients at triage. These
nurses had 610 years of experience in emergency patient
care. They underwent a structured program that included
a series of lectures, bedside teaching sessions and accreditation. The lectures were conducted by experienced EPs
who taught on basic sciences of the respiratory system, clinical evaluation and management of common respiratory

Patient Acuity Category (PAC) system as recommended by Society of Emergency Medicine of Singapore.

PAC

Criteria

1
2
3
4

In or with imminent cardiorespiratory arrest requiring immediate attention

Not in imminent cardiorespiratory arrest but require early attention (within 80 min); failing which deterioration is likely
Ambulatory patients with mild to moderate symptoms
Non-emergency patients who can be managed in the primary care setting

Comparing triage evaluation of adult

105

conditions like asthma, COPD, pneumonia, decompensated

heart failure, pneumothorax and upper airway obstruction.
Separate bedside teaching was also conducted by the EPs on
real ED dyspneic patients. This teaching concentrated on
pulmonary auscultation as well as the assimilation of auscultatory findings with limited clinical information (general patient appearance and vital signs) to make rapid triage
decisions on patient management. The nurses were taught
to identify normal breath sounds and common adventitial
sounds like rhonchi, crepitations and stridor.
Following these teaching sessions, the nurses were required to verify their pulmonary auscultatory and clinical
decision making on 10 real-time ED dyspneic patients with
emergency doctors as a means of accreditation. All eight
nurses had successfully completed this accreditation
process.
Eight doctors were selected from our ED pool of doctors
and asked to participate in the study. They form a group
with two members each from the pools of rotating non-specialists, resident non-specialists, emergency medicine (EM)
specialists in training and nationally accredited EPs. They
had between 2 to 23 years of clinical experience among
them.
Two EPs (Lim, B.L., and Kenneth Heng, W.J.) were the
assessors in the study and they were not selected from
the cohort of participating doctors. They are the core faculty member and program director respectively of our emergency medicine (EM) residency program. They have vast
experience in teaching and mentoring EM trainees and
nurses as well as involved as examiners in the College of
EM (United Kingdom) membership and local specialist exit
examinations. One EP (Lim, B.L.) was involved in the teaching sessions of the participating nurses.

The simulator and study scenarios

We used the SimMan 3G simulator to conduct the study. The
manikin is a portable and advanced patient simulator that
can reproduce normal and common abnormal breath sounds
including stridor, rhonchi and crepitations (SimMan 3G,
2007).
Prior to the study, we conducted a separate session each
for our participating nurses and doctors to orientate and
familiarize themselves on the features of the SimMan 3G
simulator.
The two assessors designed the scenarios before the
study. They developed a pool of common and/or important
cardiorespiratory conditions that would present to the ED
with dyspnea together with their spectrum of severities.
This pool was derived from personal practitioner experience, surveying the collective opinion of specialist (n = 19)
and non-specialist doctors (n = 50) in the department and
review of a reference guide on common respiratory emergencies written for EPs (Wolfson et al., 2010). The conditions included asthma, decompensated heart failure,
COPD, pneumonia, pneumothorax and upper airway
obstruction.
Each scenario included a short history, pertinent vital
signs and brief description of the overall clinical appearance
of the patient. Participants would then evaluate the simulated patient by auscultation.
Each scenario was accompanied by an evaluation instrument that separately scored participants on triage assessment and management. The assessment portion in each
scenario included pulmonary auscultation of the simulator
aiming to test the participants competency to identify
the abnormal pulmonary findings. The management portion

Mrs C is a 65 year old lady with past medical history of ischemic heart disease and
hypertension. She presents with one day history of dyspnea and cough.
Current vitals: T: 37 degrees Celsius, BP 230/100 mmHg, PR 120/min, RR 25/min, SaO2
90% on room air.
Assessment: Alert but diaphoretic.
Dyspneic at rest; cannot speak short sentences
Lungs: Bibasal crepitations; widespread rhonchi

Should do
Assessment
Ask for vitals
Ask for general appearance
Auscultation
Identify bibasal crepitations
Identify widespread rhonchi
Sum Assessment Score

ASSESSMENT
Scoring
Shouldnt do

Scoring

25
25
25
25

MANAGEMENT
Should do
Scoring
Shouldnt do
Escalate to resuscitation
50
Put in P2 or P3 area
room
Administer oxygen
15
Perform ECG at triage
State will ask doctor to see
15
Failure to administer
patient
oxygen
State will perform ECG in
10
resuscitation room
Administer bronchodilators
10
Sum Management Score

Scoring
- 50
-10
-10

T: temperature; BP: blood pressure; mmHg: millimetre mercury; PR: pulse rate; RR: respiratory rate; SaO2: oxygen
saturation; %: percent; ECG: electrocardiogram; P2: Patient Acuity Category 2; P3: Patient Acuity Category 3

Fig. 1

Scoring instrument for dyspnea from Acute Pulmonary Oedema (APO) with bilateral crepitations and rhonchi.

106

B.L. Lim et al.

Mr G is a 20 year old gentleman, previously healthy, complains of 2 hours history of chest
pain worse on inspiration and dyspnea.
Current vitals: T: 37 degrees Celsius, BP 80/50 mmHg, PR 110/min, RR 20/min, SaO2
94% on room air
Assessment: Alert and communicative.
Dyspneic when speaking
Lungs: Reduced air entry of the left lung.

Should do
Assessment
Ask for vitals
Ask for general appearance
Auscultation
Identify (L) reduced air entry
Sum Assessment Score

Should do
Escalate to resuscitation
room
Administer oxygen
State will ask doctor to see
in resuscitation room
Sum Management Score

ASSESSMENT
Scoring
Shouldnt do

Scoring

25
25
50

MANAGEMENT
Scoring
Shouldnt do
50
Put in P2/P3 area
30
20

Failure to administer
oxygen
Failure to perform CR
at resuscitation room

Scoring
- 50
- 10
- 10

T: temperature; BP: blood pressure; mmHg: millimetre mercury; PR: pulse rate; RR: respiratory rate; SaO2: oxygen
saturation; %: percent; (L): left; P2: Patient Acuity Category 2; P3: Patient Acuity Category 3; CR: chest radiograph

Fig. 2

Scoring instrument for dyspnea from tension pneumothorax with unilateral reduction in air entry.

tested the participants on their ability to assimilate the

auscultatory findings, vital signs and general patient appearance to formulate a safe management plan at triage.
The maximum points attainable for the assessment or
management portion for each scenario were 100. The scoring methodology allowed for differential weighting of various aspects of patient assessment and management to
simulate the study scenarios as close to reality as possible.
For example, a critical maneuver of escalation to the resuscitation room in a dyspneic patient with stridor would be
weighted at 50 (out of 100) points, whereas a less critical
intervention (providing oxygen supplement) would only be
weighted at 25 points. Furthermore, if a dangerous management decision like assigning a PAC of >1 in the same patient,
50 points would be deducted. The scenarios and scoring
sheets were vetted by the EPs of our department. The
scoring charts for two of the scenarios are shown in Figs.
1 and 2.
Immediately after the study, the participating nurses
were asked to rate their confidence in performing triage
evaluation and critical decision making of ED dyspneic patients. These confidence ratings were ranked on the following six-point Likert scale adapted from a previous study on
the use of simulated pages to prepare medical students
for internship (Schwind et al., 2011). The various ratings
within the Likert scale were shown as follows.
I can perform a competent evaluation and make safe
decisions of the ED dyspneic patient at triage:
 0 = Not at all.
 1 = Maybe with complete supervision walking me through
it step by step.
 2 = I still need someone right at my side.
 3 = I think I could do it with someone nearby.

 4 = I think I can do it myself.

 5 = I can do it myself and can teach others.

Study procedure
The study was conducted first on the participating doctors
in April 2011 followed by the nurses in June 2011. The two
sessions were 6 weeks apart to minimize impacts on manpower issues and service delivery in our ED. We briefed
the participants before the study not to communicate with
each other regarding study complements in order to ensure
blinding. The two assessors decided on a 6 week lapse between the two sessions to ensure a sufficient washout
period for any small but unavoidable risk of inadvertent
communication between the two groups of participants.
For each session, each participant was exposed to the
SimMan 3G simulator, program engineer and two assessors
in an isolated room. The engineer and assessors had rehearsed through the series of auscultatory sounds before
the session. No communication occurred between the two
assessors and the engineer during the conduct of each scenario. One assessor would introduce each scenario to the
participant with only information of the presenting complaints. The following was an example of the opening presentation of a scenario: Mr. A is a 40 year old gentleman
who complained of one day history of dyspnea, sore throat,
hoarse voice and fever.
The participant would then be asked regarding what other
information he/she would wish to know (i.e. general appearance and vital signs) before proceeding to perform the pulmonary auscultation. Following auscultation, he/she would
be questioned regarding the triage management. No feedback was given to the participants throughout the session.

Nurses scores for assessment and management of each of seven scenarios (n = 8).

Scenario

Domain

Assessor

Mean

SD

Median

Min

Max

IQR

1. Epiglottitis with stridor

Assessment

1
2
1
2

82.5
83.1
100.0
98.8

13.9
17.7
0.0
3.5

80.0
82.5
100.0
100.0

60
50
100
90

100
100
100
100

23
25
0
0

0.723

0.043

1
2
1
2

87.5
81.3
100.0
100.0

18.9
17.7
0.0
0.0

100.0
75.0
100.0
100.0

50
50
100
100

100
100
100
100

25
25
0
0

0.738

0.037

1
2
1
2

68.8
68.8
93.8
90.0

11.6
17.7
5.2
10.4

75.0
75.0
90.0
90.0

50
50
90
75

75
100
100
100

19
25
10
21

0.69

0.058

0.894

0.003

1
2
1
2

75.0
81.3
85.0
79.4

0.0
17.7
34.6
34.3

75.0
75.0
100.0
95.0

75
50
0
0

75
100
100
100

0
25
10
29

0.718

0.045

1
2
1
2

90.6
90.6
81.3
80.0

18.6
18.6
42.2
41.7

100.0
100.0
100.0
97.5

50
50
20
20

100
100
100
100

19
19
23
24

1
0.819

0.013

1
2
1
2

78.1
81.3
100.0
97.5

16.0
11.6
0.0
7.1

75.0
75.0
100.0
100.0

50
75
100
80

100
100
100
100

19
19
0
0

0.873

0.005

1
2
1
2

87.5
87.5
100.0
100.0

18.9
18.9
0.0
0.0

100.0
100.0
100.0
100.0

50
50
100
100

100
100
100
100

25
25
0
0

0.611

0.107

Management
2. Stable CCF with bilateral crepitations

Assessment
Management

3. APO with bilateral crepitations and rhonchi

Assessment
Management

4. COPD with CO2 retention and bilateral rhonchi

Assessment
Management

5. Stable asthma with bilateral rhonchi

Assessment
Management

6. Stable pneumonia with unilateral crepitations

Assessment
Management

7. Tension pneumothorax with unilateral reduction in air entry

Assessment
Management

p Value

Comparing triage evaluation of adult

Table 2

<0.001

The maximum score for the assessment or management portion is 100. SD: Standard Deviation; Min: Minimum; Max: Maximum; IQR: Interquartile range; r: Spearmans rho correlation
coefficient; : The correlation coefficient cannot be calculated because at least one of the variables is constant; p value: measures the statistical significance of r; CCF: Congestive Cardiac
Failure; APO: Acute Pulmonary Oedema; COPD: Chronic Obstructive Pulmonary Disease; CO2: Carbon Dioxide.

107

108

Table 3

Doctors scores for assessment and management of each of seven scenarios (n = 8).

Scenario

Domain

Assessor

1. Epiglottitis with stridor

Assessment

1
2
1
2

Management
2. Stable CCF with bilateral crepitations

Assessment
Management

3. APO with bilateral crepitations and rhonchi

Assessment
Management

4. COPD with CO2 retention and bilateral rhonchi

Assessment
Management

5. Stable asthma with bilateral rhonchi

Assessment
Management

6. Stable pneumonia with unilateral crepitations

Assessment
Management

7. Tension pneumothorax with unilateral reduction in air entry

Assessment
Management

Mean

SD

Median

Min

Max

IQR

92.5
92.5
87.5
90.6

11.3
11.3
18.9
18.6

1
2
1
2

84.4
81.3
98.8
95.6

1
2
1
2

p Value

100.0
100.0
100.0
100.0

75
75
50
50

100
100
100
100

21
21
25
19

1
0.378

0.356

12.9
17.7
3.6
9.0

75.0
75.0
100.0
100.0

75
50
90
75

100
100
100
100

25
25
0
8

0.25

0.556

0.54

0.167

68.8
71.9
86.9
88.8

25.9
28.2
5.9
3.5

75.0
75.0
90.0
90.0

25
25
75
80

100
100
90
90

44
50
8
0

0.936

0.001

0.54

0.167

1
2
1
2

78.1
87.5
76.8
78.7

8.8
13.4
33.4
33.5

75.0
87.5
82.5
90.0

75
75
1
0

100
100
100
100

0
25
25
25

0.378

0.356

0.701

0.053

1
2
1
2

93.8
90.6
34.9
34.9

11.6
12.9
48.8
48.8

100.0
100.0
0.0
0.0

75
75
0
0

100
100
100
100

19
25
95
95

0.745

0.034

0.744

0.034

1
2
1
2

87.5
81.3
100.0
100.0

13.4
25.9
0.0
0.0

87.5
87.5
100
100.0

75
25
100
100

100
100
100
100

25
25
0
0

0.956

<0.001

1
2
1
2

96.9
93.8
96.3
100.0

8.9
11.6
10.6
0.0

100.0
100.0
100.0
100.0

75
75
70
100

100
100
100
100

0
19
0
0

<0.001

0.655

0.078

B.L. Lim et al.

The maximum score for the assessment or management portion is 100. SD: Standard Deviation; Min: Minimum; Max: Maximum; IQR: Interquartile range; r: Spearmans rho correlation
coefficient; : The correlation coefficient cannot be calculated because at least one of the variables is constant; p value: measures the statistical significance of r; CCF: Congestive
Cardiac Failure; APO: Acute Pulmonary Oedema; COPD: Chronic Obstructive Pulmonary Disease; CO2: Carbon Dioxide.

Comparing triage evaluation of adult

The scoring was performed in real time by each of the
two assessors on printed copies of the score sheets; blinded
to each others scores. The assessors would also debrief
each participant and summarize the recommended diagnostic and therapeutic manoeuvres after the study for maximal
educational benefits. Upon completion of all scenarios,
each nurse was also asked to fill in the survey using a sixpoint Likert scale of their confidence in evaluating and making safe decisions at triage of the adult ED dyspneic patient.
The participant would then be ushered out of the room with
no chance of meeting the next participant.
The hard copies of the scoring sheets were maintained in
folders and the data transferred to an electronic SPSS 13.0
database (SPSS Inc., Illinosis, USA) spreadsheet after the
study.

Data analysis and statistical methods

We collected data on each participants scores on assessment and management for all seven scenarios as evaluated
by both assessors. Post study self report measures of confidence levels on triaging ED dyspneic patients were also collected from all eight nurses.
Data was analyzed using descriptive statistics. For each
scenario, we reported mean, median, minimum and maximum assessment and management scores with their Standard Deviations (SDs) and interquartile ranges (IQRs) for
the two groups of nurses and doctors. Spearmans rho correlation coefficients (r) were computed to assess interrater
reliability between the assessors on their evaluation of the
participants assessment and management of each simulated scenario as scores might not follow a normal distribution. We used the Mann Whitney U test to investigate the
differences in scores between the groups for each of the

Table 4

109
scenarios. All tests were two tailed and results were considered statistically significant if p < 0.05.

Data/results
Table 2 shows the details of the assessment and management scores across all seven scenarios for both assessors
in the group of nurses.
The mean scores on the assessment portion were lowest
for scenario three [Acute Pulmonary Oedema (APO) with
bilateral crepitations and rhonchi]. They were 68.8 11.6
and 68.8 17.7 for assessor one and two respectively. These
scores were highest for scenario five (stable asthma with
bilateral rhonchi) where both assessors assigned a score of
90.6 18.6.
The mean scores on the management portion were lowest for scenario five and they were 81.3 42.2 and
80.0 41.7 for assessor one and two respectively. Similarly,
these scores were highest for scenarios two [stable Congestive Cardiac Failure (CCF) with bilateral crepitations] and
seven (tension pneumothorax with unilateral reduction in
air entry) where both assessors assigned scores of
100.0 0.0. Both assessment and management scores were
more evenly distributed in this group with IQR ranging from
0 to 25. The correlation coefficients between the assessors
ranged from 0.611 to 1.000 and these values reached statistical significance for most scenarios except for the assessment portion in scenario three and seven.
Table 3 reveals the details of the assessment and management scores across all seven scenarios for both assessors
in the group of doctors.
There was a wider distribution of scores among the participating doctors with IQR ranging from 0 to 95. The mean

Comparison of average assessment scores by both assessors for doctors (n = 8) versus nurses (n = 8).

Scenario

Domain

Mean

SD

Median

Min

Max

IQR

p Value

1. Epiglottitis with stridor

Doctors
Nurses

92.5
82.8

11.3
15.0

100.0
83.8

75
55

100
100

21
23

0.167

2. Stable CCF with bilateral crepitations

Doctors
Nurses

82.8
84.4

9.3
17.4

81.3
87.5

75
50

100
100

13
25

0.544

3. APO with bilateral crepitations and rhonchi

Doctors
Nurses

70.3
68.8

26.7
13.4

75.0
75.0

25
50

100
88

47
22

0.703

4. COPD with CO2 retention and bilateral rhonchi

Doctors
Nurses

82.8
78.1

9.3
8.8

81.3
75.0

75
63

100
88

13
13

0.386

5. Stable asthma with bilateral rhonchi

Doctors
Nurses

92.2
90.6

11.5
18.6

100.0
100.0

75
50

100
100

22
19

0.798

6. Stable pneumonia with unilateral crepitations

Doctors
Nurses

84.4
79.7

18.6
13.3

87.5
75.0

50
62

100
100

25
19

0.452

7. Tension pneumothorax with unilateral reduction in air entry

Doctors
Nurses

95.3
87.5

9.3
17.7

100.0
93.8

75
50

100
100

9
22

0.303

Each of the mean, SD, median min, max, IQR scores was computed by averaging the respective scores assigned by assessor one and two.
SD: Standard Deviation; Min: Minimum; Max: Maximum; IQR: Interquartile range; p value: measures the statistical significance of the
comparison between the mean scores of the doctors versus nurses in each scenario using the Mann Whitney U test; CCF: Congestive
Cardiac Failure; APO: Acute Pulmonary Oedema; COPD: Chronic Obstructive Pulmonary Disease; CO2: Carbon Dioxide.

110
Table 5

B.L. Lim et al.

Comparison of average management scores by both assessors for doctors (n = 8) versus nurses (n = 8).

Scenario

Domain

Mean

SD

Median

Min

Max

IQR

p Value

1. Epiglottitis with stridor

Doctors
Nurses

89.1
99.4

16.9
1.8

93.8
100.0

50
95

100
100

13
0

0.073

2. Stable CCF with bilateral crepitations

Doctors
Nurses

97.2
100.0

5.3
0.0

100.0
100.0

88
100

100
100

8
0

0.144

3. APO with bilateral crepitations and rhonchi

Doctors
Nurses

87.8
91.9

4.1
7.4

90.0
90.0

80
83

90
100

6
16

0.244

4. COPD with CO2 retention and bilateral rhonchi

Doctors
Nurses

77.8
82.2

33.1
34.0

88.8
95.0

0
0

100
100

24
17

0.418

5. Stable asthma with bilateral rhonchi

Doctors
Nurses

34.9
80.6

48.5
41.9

0.01
98.8

0
20

100
100

90
23

0.07

6. Stable pneumonia with unilateral crepitations

Doctors
Nurses

100.0
98.8

0.0
3.5

100.0
100.0

100
90

100
100

0
0

0.317

7. Tension pneumothorax with unilateral reduction in air entry

Doctors
Nurses

98.1
100.0

5.3
0.0

100.0
100.0

85
100

100
100

0
0

0.317

Each of the mean, SD, median min, max, IQR scores was computed by averaging the respective scores assigned by assessor one and two.
SD: Standard Deviation; Min: Minimum; Max: Maximum; IQR: Interquartile range; p value: measures the statistical significance of the
comparison between the mean scores of the doctors versus nurses in each scenario using the Mann Whitney U test; CCF: Congestive
Cardiac Failure; APO: Acute Pulmonary Oedema; COPD: Chronic Obstructive Pulmonary Disease; CO2: Carbon Dioxide.

scores on the assessment portion were lowest for scenario

three. They were 68.8 25.9 and 71.9 28.2 as assigned
by assessor one and two respectively. These scores were
highest for scenario seven. They were 96.9 8.9 and
93.8 11.6 for assessor one and two respectively. The mean
scores on the management portion were lowest for scenario
five. Both assessors assigned scores of 34.9 48.8. Five out
of eight doctors had 50 points deducted by both assessors
for inappropriate assignment of PAC status in a stable asthmatic patient who received bronchodilators (PAC 2 instead
of 1). The mean management scores were also highest in
scenario six (stable pneumonia with unilateral crepitations)
where both assessors assigned a score of 100 0.0. As compared to the nurses, the level of correlation of assessment
and management scores in this group of doctors was weaker
between the two assessors with r ranging from 0.247 to
1.000 and r not reaching statistical significance in half (7/
14) of these observations.
As demonstrated in Tables 2 and 3, we also observed consistently high management scores (P75) in both groups for
simulated scenarios that required classification as emergent. These scenarios were acute epiglottitis, APO, COPD
with Carbon Dioxide (CO2) retention and tension pneumothorax. With the exception of the scenario on APO, our participants also attained assessment scores P75 for these
emergent conditions.
We next reported the comparison of the assessment and
management scores between the nurses and doctors. Table 4
reveals the details of the comparison of the assessment
scores between the two groups. The averages of the mean
assessment scores assigned by both assessors were marginally higher for doctors compared to nurses in all scenarios
except scenario two (stable CCF with bilateral crepitations).
There were, however, no statistical significant differences
between these assessment scores of doctors versus nurses

across all scenarios. Table 5 reveals the comparison of the

management scores between doctors versus nurses. The
averages of the mean management scores assigned by both
assessors were higher for the nurses compared to the doctors in most scenarios except in scenario six. There were,
however, no statistical significant differences between
these management scores of doctors versus nurses across
all scenarios.
The median score of the nurses confidence level to triage and evaluate ED dyspneic patients after the study was
four on a Likert scale from 0 to 5. Six out of eight participating nurses felt they could perform this task by themselves
(score of 4). They had 68 years experience in EM nursing.
The remaining two; each with 10 years experience in EM
nursing; felt they could do it with supervision. One nurse
felt she could do it with someone nearby (score of 3) and
the other felt she could do it with someone right by her side
(score of 2).

Discussion
Our study suggested that appropriately trained ED nurses
could triage and evaluate dyspneic patients as effectively
as ED doctors on simulated patient scenarios. We have
shown that, at least on a simulator, ENs were able to perform more frontline patient evaluation and management
that involves accurate diagnostic and management skills.
This role progression of trained ENs and ENPs is important
to improve staff allocation with increasing ED workloads
and worsening overcrowding with aging populations in most
metropolitan cities (Hoot and Aronsky, 2008).
We also observed that our nurses attained consistently
high scores in both assessment and management of scenarios where timely escalation of the patients to emergent care

Comparing triage evaluation of adult

was required. These scenarios included acute epiglottitis,
APO, COPD with CO2 retention and tension pneumothorax.
These scores were comparable to ED doctors without statistical significant differences between the two groups. These
findings suggested that patient safety would not be compromised when triage was performed by appropriately trained
nurses. In addition, the scores of our nurses in these scenarios were not widely distributed with small IQRs, suggesting
that there was consistency in their performances in these
scenarios. Early and consistent recognition of emergent, life
threatening cardiorespiratory conditions is the most important goal in any triage system and guideline (Bullard et al.,
2008; Australasian College for Emergency Medicine, 2005;
Mackway, 1997) as failure to do so will compromise patient
safety.
In our study, the participating doctors showed a wider
distribution of assessment and management scores across
all scenarios. This was likely due to the wider variation of
clinical experience and grades among the doctors. In addition, doctors scored poorly in their management of the stable asthmatic patient with rhonchi. This poor performance
is likely a result of a major deduction of points resulting
from an inappropriate assignment of PAC status. Our ED assigns a PAC 1 status to asthmatic patients who require bronchodilators at triage and believe that such patients should
be assessed the soonest possible.
Correlation between assessors was observed to be better
in the nursing versus doctors group. We recognize that
weaknesses in the evaluation instrument could explain at
least, in part, the discrepancy between the two assessors
for both doctors and nurses. Although vetted by our EPs,
there would be parts of the evaluation instrument that involved varying degrees of subjectivity in assigning scores.
Besides this, we also postulated that the better correlation
between the two assessors in the nurses group was likely
due to the more uniform distribution of nursing experience
(610 years) within this group. For the doctors, we postulated that this discrepancy between the two assessors was
likely a reflection of their biases in perception of clinical
competency. There were greater variations in doctors
grades and clinical experience (223 years) and these differences could translate into varying styles of presentation
and confidence levels in delivering the assessment and management portions of each scenario.
Our study suggested that high fidelity simulated patient
scenarios using the SimMan 3G simulator constitute an
effective method to assess the competency of healthcare
providers in performing an integrated and complex task
especially in comparison with the existing gold standard
providers. Our findings concurred with previous studies
(Tubbs et al., 2009; Overly et al., 2007; Bryne et al.,
2002; Ali et al., 2000) that demonstrated the effectiveness
of high fidelity medical simulation to assess trainees in several stressful emergency situations like acute contrast reactions, pediatric intubations, anesthetic crises and traumatic
resuscitation. We used the SimMan 3G simulator which can
reproduce a wide variety of adventitial pulmonary sounds
and together with a spectrum of cardiorespiratory conditions and severities, we were able to assess our participants
in their abilities to incorporate clinical evaluation with their
experience to rapidly make critical decisions at the triage
point. This approach could assess competencies in patient

111
care, medical knowledge, practice-based learning and professionalism in accordance with the recommendations of
the Accreditation Council for Graduate Medical Education
(Lyss-Lerman et al., 2009).
We are currently validating our findings by comparing the
evaluation and critical decision making of our eight nurses
with ED doctors on real time dyspneic patients at triage in
a sufficiently powered prospective study. We also propose
to use and review the SimMan 3G patient simulated scenarios as a tool for assessment and accreditation of future
nurses in the triage evaluation and decision making of the
dyspneic patient.

Limitations
We recognize some important limitations of our study.
Although our scenarios were created from collective opinions of our entire staff cohort and recommended guidelines,
the weightings used in our scoring instruments were subjective. These could add biases to our study. Although we had
recruited every trained nurse, our study population was still
small and it remained possible that our results arise by
chance alone. We were also unable to simulate the busy
and often unexpected work schedule of ED staff that requires them to multi-task effectively amidst constant distractions. We understand that the triage nurse or doctor
can be faced with more than one dyspneic patient at a particular time and prioritising is a skill that we did not assess
in this study. Finally, we also did not investigate whether
our nurses structured training and simulated patient scenarios result in error reduction or decrease in adverse patient events.

Conclusions
Our findings suggested that trained ED nurses could effectively evaluate and make critical decisions on dyspneic patients at triage when compared to doctors, at least on
simulated patient scenarios. We propose to validate our
findings on real time ED dyspneic patients in a future study.

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