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Improving Traumatic Brain Injury Care and Research : A Report From the National Academies of Sciences, Engineering, and Medicine

• 1 National Academies of Sciences, Engineering, and Medicine, Washington, DC
• 2 Institute for Healthcare Improvement, Boston, Massachusetts
• JAMA Insights Mild Traumatic Brain Injury in 2019-2020 Noah D. Silverberg, PhD; Ann-Christine Duhaime, MD; Mary Alexis Iaccarino, MD JAMA
• Special Communication CDC Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children Angela Lumba-Brown, MD; Keith Owen Yeates, PhD; Kelly Sarmiento, MPH; Matthew J. Breiding, PhD; Tamara M. Haegerich, PhD; Gerard A. Gioia, PhD; Michael Turner, MD; Edward C. Benzel, MD; Stacy J. Suskauer, MD; Christopher C. Giza, MD; Madeline Joseph, MD; Catherine Broomand, PhD; Barbara Weissman, MD; Wayne Gordon, PhD; David W. Wright, MD; Rosemarie Scolaro Moser, PhD; Karen McAvoy, PhD; Linda Ewing-Cobbs, PhD; Ann-Christine Duhaime, MD; Margot Putukian, MD; Barbara Holshouser, PhD; David Paulk, EdD; Shari L. Wade, PhD; Stanley A. Herring, MD; Mark Halstead, MD; Heather T. Keenan, MD, PhD; Meeryo Choe, MD; Cindy W. Christian, MD; Kevin Guskiewicz, PhD, ATC; P. B. Raksin, MD; Andrew Gregory, MD; Anne Mucha, PT, DPT; H. Gerry Taylor, PhD; James M. Callahan, MD; John DeWitt, PT, DPT, ATC; Michael W. Collins, PhD; Michael W. Kirkwood, PhD; John Ragheb, MD; Richard G. Ellenbogen, MD; Theodore J. Spinks, MD; Theodore G. Ganiats, MD; Linda J. Sabelhaus, MLS; Katrina Altenhofen, MPH; Rosanne Hoffman, MPH; Tom Getchius, BA; Gary Gronseth, MD; Zoe Donnell, MA; Robert E. O’Connor, MD, MPH; Shelly D. Timmons, MD, PhD JAMA Pediatrics
• Review Pharmacological Interventions and Symptom Reduction for Mild Traumatic Brain Injury Charles Feinberg, BA; Catherine Carr, MLIS; Roger Zemek, MD; Keith Owen Yeates, PhD; Christina Master, PhD; Kathryn Schneider, PT, PhD; Michael J. Bell, MD; Stephen Wisniewski, PhD; Rebekah Mannix, MD, MPH JAMA Neurology

Traumatic brain injury (TBI) takes a substantial toll on health and health care costs in the US. Yet TBI is often unrecognized, misclassified, undertreated (especially in its longer-term manifestations), and, in proportion to its public health consequences, underresearched. Despite the dedication of an increasing number of professionals, disciplines, and organizations devoted to TBI care and research, including innovative programs for military service members and veterans, care often fails to meet the needs of affected individuals, families, and communities. The US lacks consolidated leadership for achieving improvements in TBI care and outcomes, and, partly as a result, it lacks a strategic plan for fostering change and overseeing progress. With stronger leadership and proper redesign, the health care system could reduce the morbidity and disability associated with TBI, while enhancing the effectiveness of TBI care.

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Bowman K , Matney C , Berwick DM. Improving Traumatic Brain Injury Care and Research : A Report From the National Academies of Sciences, Engineering, and Medicine . JAMA. 2022;327(5):419–420. doi:10.1001/jama.2022.0089

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Trauma nursing 3: assessing and managing head injury

19 December, 2022 By Nuala Oughton and Peachiammal Subramanian

This third article in our trauma series explores causes, types and treatment of traumatic brain injuries

Head injury is a major cause of hospital admission for trauma patients. This third article in our series on trauma nursing explores causes and types of head injuries, and the assessment and management of traumatic brain injury. As well as a focus on acute care, topics also discussed are rehabilitation and long-term support.

Citation: Oughton N, Subramanian P (2023) Trauma nursing 3: assessing and managing head injury. Nursing Times [online]; 119: 1.

Authors: Nuala Oughton and Peachiammal Subramanian are both senior sisters in practice development, Adult Critical Care Unit, Barts Health NHS Trust, and honorary lecturers, City, University of London.

• This article has been double-blind peer reviewed
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Introduction

Head injury (HI) is defined by the National Institute for Health and Care Excellence (NICE) (2014) as “any trauma to the head other than superficial injuries to the face”; this may or may not involve brain injury. Although the overall incidence of death from HI is low at six to ten people per 100,000 annually, HI is the most common cause of death or disability in people aged 1 year to 40 years in the UK (NICE, 2014).

In the UK, around 20% of people with HI require hospital admission, but only 2% of people attending the emergency department with HI die (NICE, 2014). Most fatal outcomes involve people who have sustained moderate-to-severe HIs.

This article, the third in a series about trauma, explores how HIs are assessed and managed, including how to identify the few patients who will go on to develop serious acute intracranial complications.

“A blunt brain injury is usually caused by a fall, blunt assault or road traffic collision”

Traumatic brain injury

Traumatic brain injury (TBI) is defined as injury to brain function, or the indication of brain pathology, caused by an external force (Khellaf et al 2019). The worldwide yearly incidence of TBI is estimated at 50 million; severe TBI can cause significant physical, psychosocial and social deficits and, in up to 60% of cases, has mortality rates of 30–40% (Khellaf et al, 2019).

TBI is the largest contributor to the global burden of disability and costs the international economy around US$400bn annually, amounting to approximately 0.5% of the entire annual global economic output (Maas et al, 2017).

Timely intervention and structured follow-up for this patient cohort could, therefore, reduce this burden (Maas et al, 2017). TBI might also be a major risk factor for late neurodegenerative disorders, such as dementia and Parkinson’s disease , contributing to the view that TBI can evolve into a progressive, lifelong illness (Maas et al, 2017).

The epidemiology of TBI is changing. In high-income countries, the number of older people sustaining TBIs is increasing, primarily due to falls; in lower-income countries, the number of TBIs caused by road traffic collisions is increasing (Maas et al, 2017).

Small regional studies reported a decrease in TBI during Covid-19 lockdowns, reflecting decreased mobility, sports and recreational activity, and possibly a reluctance to seek medical help for milder injuries (Mass et al, 2022).

Primary and secondary brain injury

Primary brain injury occurs at the moment of impact and is irreversible. Primary brain injuries can be:

• Penetrating;

A penetrating brain injury involves an open wound to the head from a foreign object, for example, during a shooting or stabbing. It is typically evident due to focal damage occurring along the route through which the object has travelled in the brain; this includes fractured skull, torn meninges (layers that protect the brain), and damage to the brain tissue.

A blunt brain injury is usually caused by a fall, blunt assault or road traffic collision (American College of Surgeons (ACS), 2018).

Secondary brain injuries can:

• Evolve from primary damage;
• Be a result of insult from highly preventable and treatable causes, such as hypotension and hypoxia.

Intracranial injuries can be further classified according to the location of damage (Table 1).

Assessing HI

All trauma patients and clinical emergencies must receive a thorough and systematic ABCDE assessment, which checks:

• Circulation;
• Disability;
• Exposure (ACS, 2018).

Additionally, TBI severity is assessed by the Glasgow Coma Scale (GCS) and further determined by the duration of post-traumatic amnesia (Tenovuo et al, 2021).

The GCS is a practical, structured assessment method that determines impaired consciousness in response to defined stimuli. It supports, but does not replace, clinical decision making (Royal College of Physicians and Surgeons of Glasgow, nd).

The GCS scores a patient’s best motor, verbal and eye-opening responses (Table 2). This information is used to classify a TBI’s clinical severity as mild (concussion), moderate or severe. However, the GCS is limited due to there being other causes for a reduced score in trauma , such as alcohol consumption, sedation or seizure.

The minimum required neurological observations for patients admitted to hospital with HI are:

• Pupil size and reactivity;
• Limb movements;
• Respiratory rate ;
• Heart rate ;
• Blood pressure;
• Temperature;
• Blood–oxygen saturation (NICE, 2014).

These should be documented.

NICE (2014) guidelines state that all patients with HI taking anticoagulants must receive a CT scan. CT is a fast and precise method of imaging in acute craniocerebral trauma, allowing quick diagnosis of TBI (Kumar et al, 2019). The patterns of damage that a CT scan detects can be:

• Focal (localised);
• Diffuse (widespread).

However, the two types often coexist (Haydel and Lauro, 2021). Table 3 lists features of each type.

CT assessment of primary brain injuries, combined with clinical assessment using the GCS, helps determine HI severity and helps in the planning of treatment (Kumar et al, 2019). Fractures occur in 5% of patients with mild TBI and in up to 50% of those with severe TBI (Haydel and Lauro, 2021).

Intracranial pressure (ICP) can increase quickly in the limited space of the skull and if the brain’s blood supply is interrupted for just a few minutes, brain tissue dies; TBI is, therefore, a time-critical injury (Fairley, 2017).

Pre-hospital management

Pre-hospital management of patients includes initial resuscitation and interventions to stabilise them at the scene of injury and when they are on the way to hospital. This assessment and management should focus on preventing secondary brain injury and follow the Advanced Trauma Life Support course (NICE, 2014).

To avoid hypoxia, patients should be intubated, and ventilation should be started if they have:

• Severe HI and a GCS score of ≤8;
• Facial fractures;
• Injuries that compromise oxygenation and ventilation (ACS, 2018).

Hypotension (systolic blood pressure of <90mmHg) has the highest correlation with increased morbidity and mortality (Vella et al, 2017). The Brain Trauma Foundation (BTF) (2016) guidelines recommend maintaining a mean arterial pressure (MAP) of around 90mmHg.

Intravenous access should be established, and volume resuscitation with isotonic fluids is recommended (McNair, 2019). Cervical spine immobilisation must be maintained until full clinical assessment and imaging are completed.

Effective pain management is important to reduce the ICP, and GCS and pupil response should be continuously assessed for any abnormalities. Immediate transport to the nearest trauma centre to further evaluate and manage the HI is essential.

Hospital management

The goals of the intensive care unit (ICU) care are to:

• Maintain adequate cerebral oxygen delivery;
• Manage and treat intracranial hypertension;
• Prevent secondary brain injury;
• Prevent or manage potential complications.

On arrival at the emergency department, the patient’s history, mechanism of injury and previous treatment must be clarified. When that has been done, health professionals should:

• Attach the patient to continuous monitoring equipment;
• Establish adequate vascular access;
• Insert an indwelling urinary catheter;
• Continue resuscitation and stabilisation;
• Conduct relevant diagnostic tests (NICE, 2014).

CT scanning without contrast will help to diagnose most intracranial injuries, such as depressed skull fracture, extradural haematoma, subdural haematoma, intracerebral haemorrhage and contusion (Table 1). Cerebral angiograms are needed to exclude any vascular injury that is secondary to trauma (McNair, 2019).

Management in the emergency department is directed at resuscitation, stabilisation and diagnosis. When these steps have been completed, surgical intervention for life-threatening injuries can be carried out, or the patient can be transferred to the ICU or ward for medical management.

Patient monitoring should be tailored to the clinical presentation. As a minimum, it is essential to monitor:

• Electrocardiography;
• Oxygen saturation;
• Central venous pressure;
• Arterial pressure;
• Urine output.

Cardiac-output monitoring should be used to guide fluid and inotrope requirements (Khellaf et al, 2019).

ICP monitoring is essential if the therapy is targeted to maintain cerebral perfusion pressure (CPP). CPP refers to the blood-pressure gradient across the brain and is calculated as follows:

MAP-ICP = CPP

Raised ICP reduces cerebral perfusion, which results in cerebral ischaemia (Khellaf et al, 2019). The BTF’s (2016) guidelines recommend maintaining ICP at 20-25mmHg and CPP at >60mmHg. Criteria for patients who need ICP monitoring are outlined in Table 1.

Maintaining a CPP of >60mmHg is achieved by increasing the MAP and decreasing the ICP. Hypotension and prolonged increases in ICP of >20mmHg are associated with poorer patient outcomes (Rosner et al, 1995).

Patients with HI require ICP monitoring if they have a GCS score of ≤8 and either an abnormal CT scan or a normal CT scan and two or more of the following:

• Aged >40 years;
• Motor posturing;
• Systolic blood pressure of <90mmHg (BTF, 2016).

Respiratory management

Tracheal intubation remains the gold standard for airway management for patients with a GCS of ≤8. Careful preparation and pre-oxygenation are mandatory. Adequate sedation and muscle relaxation reduce cerebral metabolic oxygen requirements and optimise ventilation (Dinsmore, 2013).

Hypoxia is defined as a lack of oxygen supply or excessive oxygen consumption resulting in insufficient oxygen levels to maintain normal cellular function (Bhutta et al 2022). Oxygenation should be monitored, and hypoxia or oxygen saturation of <90% avoided.

Blood–oxygen content regulates the cerebral blood flow; Nathanson et al (2020) have recommended maintaining the partial pressure of oxygen (PaO2) at >13kPa. Hypoxia causes vasodilation and impairs cerebral autoregulation, resulting in increased ICP.

Maintaining the normal partial pressure of carbon dioxide (PaCO2) value of 4.5-5kPa in a patient with TBI is fundamental. Hypercapnia or too much carbon dioxide in the blood (PaCO2 of >6kPa) is a potent vasodilator, which increases cerebral blood flow and results in increased ICP (Dinsmore, 2013).

Endotracheal suctioning increases the ICP and so health practitioners should hyper oxygenate patients with 100% oxygen for 60 seconds, before suctioning for less than 15 minutes (Mestecky, 2007). Mild-to-moderate hyperventilation is recommended when other medical interventions fail to reduce the ICP: BTF (2016) guidelines suggest using hyperventilation to achieve a PaCO2 of 4-4.5kPa as a temporary measure to reduce the ICP.

“Enteral feeding must be started as soon as possible to meet patients’ nutritional requirements”

Nursing activities

Nursing interventions – such as positioning, personal care, linen changing and endotracheal suctioning – can increase ICP if carried out in sequence, so clustering nursing activities should be avoided (Mestecky, 2007). If the patient is receiving ICP monitoring, the nurse must assess their individual response to these interventions and adjust their care accordingly.

Noxious stimuli must be avoided, and nursing interventions that reduce the patient’s ICP must be used. Ensure everything is ready before repositioning the patient to avoid a prolonged period of increased ICP.

The optimal head position for a patient with HI is 30 degrees because it promotes venous drainage; the neck should be kept in alignment to avoid interrupting venous drainage.

Endotracheal ties around the neck should fit properly and care should be taken to avoid obstructing venous return. Extreme hip flexion should also be avoided as it increases the intra-abdominal pressure, resulting in increased ICP (McNair, 2019).

Adequate sedation is essential to help ventilation and prevent coughing and gagging on the endotracheal tube. Coughing increases intrathoracic pressure and impairs cerebral venous drainage. Sedation reduces cerebral metabolic rate and demand, cerebral blood flow and the ICP (Dinsmore, 2013).

Flower and Hellings (2012) recommended using the sedative propofol, due to its neuroprotective properties and short duration of action, which allows the patients to be formally neurologically assessed. However, a common side-effect of propofol is hypotension, which is important to avoid. Fluids and inotropes should be administered to minimise the effect on the MAP and CPP.

Analgesics such as morphine and fentanyl are often used to manage pain and reduce anaesthetic requirements. Fentanyl is commonly used in neurosurgical units due to its reduced half-life and accumulation properties when compared with other opioids (Flower and Hellings, 2012). Barbiturates are recommended over other medical and surgical treatments when the ICP remains high (Mestecky, 2007).

Patients with HI have high energy and protein requirements due to hypermetabolic and hypercatabolic responses to HI. Enteral feeding must be started as soon as possible to meet the patient’s nutritional requirements (Kurtz and Rocha, 2020). Carney et al (2017) highlighted the importance of avoiding hypoglycaemia (<80mg/dL or ≤4.4mmol/L) and hyperglycaemia (>180mg/dL or ≥10mmol/L).

Hyperglycaemia increases the cerebral metabolism and hypoglycaemia causes cerebral ischemia. Dextrose-containing solutions should be avoided because they reduce the plasma osmolality, which, in turn, increases the water content in the brain (McNair, 2019).

Surgical interventions

Surgical evacuation should be considered for patients with acute subdural haematoma, extradural haematoma or compound fractures with associated mass effect (Vella et al, 2017).

Decompressive craniectomy is a surgical procedure in which a large area of the skull is removed to make additional space for the swollen brain. This procedure is used for patients with refractory ICP that is not responding to medical management. However, the practice remains controversial and evidence of its benefits is insufficient to make it a level 1 BTF recommendation (BTF, 2016).

Supporting psychological issues and personality changes

HI can result in a vast array of psychological effects. Common issues include:

• Depression;
• Cognitive issues;
• Problems regulating behaviour.

These develop due to damage to the areas of the brain responsible for managing emotions, or the patient’s inability to do the activities they previously did. Some patients may experience post-traumatic stress disorder.

This is a severe psychological reaction to trauma, involving persistent re-experiencing of the event, avoidance of stimuli triggering memories of it and a numbing of emotional response (Vasterling et al, 2018). The emotional problems associated with brain injury depend on an individual’s personality, coping skills and the personal and professional support available to them.

HI is also a source of acute stress for a patient’s close family members, due to:

• The shock of the initial injury;
• The recovery;
• Adjusting to the patient’s personality changes (Barman et al, 2016).

Psychological services help patients with HI and their families throughout the course of recovery, including through acute care, rehabilitation and long-term support. Most regional neurosurgical centres and neurorehabilitation services have access to specialist neuropsychological services. Services that are available at these centres are:

• Early cognitive assessment;
• Cognitive rehabilitation;
• Behavioural management;
• Social skills training;
• Psychological counselling;
• Psychotherapy;
• Family therapy (Barman et al, 2016).

The recovery period is varied and patients can show marked improvement and make successful adjustments to disabilities that remain. Headway (headway.org.uk) is a UK-wide charity that aims to improve life after HI by providing support and information services.

It has a range of factsheets on all aspects of brain injury, books and publications about the effects of injury, emergency funds for patients and a directory of approved residential homes and rehabilitation units specialising in HI.

Clinical management of patients with HI starts with an ABCDE assessment, and interventions depend on the degree of patient risk according to the intracranial injury symptoms.

Prompt treatment can prevent secondary brain injury and improve patient outcomes. Acute care management based on best-evidence guidelines and recommendations should be provided from the initial injury onwards.

This requires a sound knowledge of pathophysiology and best practice for the effective management of HI.

• Traumatic brain injury is a significant cause of morbidity and mortality worldwide
• Head injuries should be assessed using the ABCDE (airway, breathing, circulation, disability, exposure) assessment and the Glasgow Coma Scale
• Initial management should focus on preventing secondary brain injury
• Intracranial pressure can increase quickly, so head injuries are time critical
• Head injuries can cause psychological problems in patients and their families

Also in this series

Trauma nursing 1: an overview of major trauma and the care pathway, trauma nursing 2: management of patients with rib fractures.

• Trauma nursing 4: recognising and managing haemorrhage in trauma
• Trauma nursing 5: identifying and assessing patients who self-harm

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Trauma-informed care: recognizing and resisting re-traumatization in health care

Samara grossman.

1 Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA

Zara Cooper

2 Department of Trauma, Burn and Surgical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA

Heather Buxton

3 Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA

Sarah Hendrickson

4 The Institute for H.O.P.E™, The MetroHealth System, Cleveland, Ohio, USA

Annie Lewis-O'Connor

5 Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA

Jane Stevens

6 Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA

Lye-Yeng Wong

Stephanie bonne.

7 Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA

Trauma is often viewed as an individual or interpersonal issue. This paper expands the definition of trauma to include the impact collective and structural elements on health and well-being. The need for a trauma-informed response is demonstrated, with instruction as to how to implement this type of care in order to resist re-traumatization. Three examples from healthcare settings across the nation are provided, to demonstrate the ways in which organizations are bringing forward this patient-centered, trauma-informed approach to care.

Introduction

Trauma, whether physical or psychosocial, has profound effects on health, and influences how people engage with their healthcare services. Healthcare providers and anchor systems are beginning to explore trauma through a more inclusive lens. However, traditional definitions of trauma as a purely physical phenomenon are still prevalent, such as in the case of the Coalition for National Trauma Research website that defines trauma as: “traumatic injury includes that from vehicular collisions, falls from heights, gunshot wounds and burns…”. 1 If healthcare providers and healthcare systems are to break down the structural barriers that negatively impact and promote the under-resourcing and marginalization of populations and communities, trauma must be considered in a broader, more multi-layered definition. To account for this, “trauma” in this manuscript is defined as both individual and interpersonal as well as collective and structural (See figure 1 ). A glossary of definitions of trauma is shown in box 1 .

Glossary of definitions of trauma

Individual trauma— an event, series of events, or set of circumstances, that is experienced by an individual as physically or emotionally harmful or life threatening and has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being. 10

Interpersonal trauma— adverse childhood events, child maltreatment, domestic and sexual violence, human trafficking, elder abuse, etc.

Collective trauma— cultural, historical, social, political, and structural traumas (ie, racism, bias, stigma, oppression, genocide) that impact individuals and communities across generations.

This image describes the many levels on which trauma is experienced. Traumatic experiences can occur on individual, interpersonal, and/or collective levels; these levels do not necessarily occur in isolation, but rather as intersectional and dynamic layers.

Individual and interpersonal trauma

Negative experiences in childhood are highly prevalent, including abuse and neglect, witnessing domestic abuse, parental mental illness, and parental imprisonment yet continue to be considered taboo subjects in society, and often, in medical encounters during a trauma evaluation. Seminal work by Felitti et al demonstrated the impact of adverse childhood experiences (ACEs) in adult health outcomes, in which more than half of 17,000 adult patients surveyed reported having an experience in childhood of at least one ACE, with one-fourth reporting two or more ACEs. 2 The greater the number of ACES reported, the more prevalent were adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. 2 Further large-scale replication, including a CDC review of Behavioral Risk Factor Surveillance System data from 2011 to 2014, shows the same prevalence and dose response effect. 3 4

Collective/structural trauma

Healthcare services themselves can unintentionally traumatize or re-traumatize people. This is especially true in communities that have been hurt by histories of, as well as current medical institutional practices that propagate and maintain collective traumas. In order to respond effectively to trauma of all types, healthcare providers need to understand trauma as beyond the personal and include community and societal trauma. As pointed out by Kelly-Irving and Delpierre, when one makes ACES/trauma an individual problem, there is risk of placing the onus of responsibility on individuals solely to act to rectify their trauma, instead of on the cause or source of the trauma. 5 Collective trauma is, therefore, a collective responsibility. The collective impacts of trauma can be traced in ACEs data as well: Merrick et al found that women, Native American and Black people, and the category “other racial/ethnic group” were more likely to experience four or more ACEs than males and whites. Higher ACE scores were reported by Black, Latinx, and LGBTQIA+ communities, with the highest ACEs in multiracial (2.5) and bisexual respondents (3.1). 3

A collective approach to understanding trauma gives the ability to look upstream at the root causes of ACEs, to see trauma as embedded in collective and structural elements of history, systemic oppressions, and racism. The Philadelphia Urban ACE Study, the first to address the intersection of ACEs and social determinants of health, attended to this by including the addition of collective traumas such as seeing or hearing someone being beaten, stabbed, or shot; bullying; and racism and discrimination, finding that 40.5% of Philadelphia adult respondents, coming from diverse race and class backgrounds, reported these types of ACEs. 6 Ellis and Dietz also called for examining the root causes of toxic stress and childhood adversity and sought to address this by creating a model for building community resilience. 7

In the patient care setting, particularly in trauma or other disciplines that care for individuals from oppressed populations, it is common to encounter patients who carry histories of individual, interpersonal, and/or collective trauma. These experiences impact both patient health and the ways in which they engage with their healthcare. Given that there is neither time nor precedent to understand ACE and trauma history before trauma evaluation, it is imperative that care providers recognize the impact of the unspoken traumas that are brought to the clinical encounter. Box 2 shows a short exemplary list of experiences patients may find difficult due to ACE or trauma histories:

Patient experiences as related to ACE/trauma histories

Individual: Lack of privacy, removal of clothing, overall vulnerability including physical positions, fear of waking during surgery, loss of control inherent in surgical procedure/s.

Interpersonal : Physical touch, procedures of all kinds are not routine for patients, being unsure what is said about them or done to them during surgery, fear of surgical mistakes, confirmation of a poor diagnosis or outcome.

Collective: Care provider and/or institutional bias, discrimination or racism, stigma leading to worse outcomes, neglectful care.

Using trauma-informed care in a universal precaution method can address these concerns. One practical solution is to ask patients broad trauma inquiry such as “Have you had any life experiences that you feel have impacted your health and well-being?” 8 Questions like these allow surgical teams and providers to understand not only acute traumas present, the potential causal interpersonal aspects of this trauma, but also the effects of collective/structural trauma. 9 The Substance Abuse and Mental Health Administration (SAMHSA) summarizes this type of trauma-informed proactive approach as the “4 R’s” wherein providers seek to R ealize how trauma affects the individuals and communities they serve in their practice, R ecognize the symptoms of trauma in their patients, R espond to patients in a trauma-informed way, and R esist Re-traumatization of patients. 10 This stance allows care providers to move beyond the conception of “what’s wrong with you” when assessing patients, to the broader question “what happened to you and how has what happened affected you?” This advances providers’ ability to pro-actively address trauma histories by asking patients what would be helpful before healthcare encounters, and to collaborate with healthcare teams to offer referrals or resources as needed. 11 This universal trauma approach allows providers to address “hidden” traumas (undisclosed or unaccounted), as well as those that are rooted in collective and structural trauma. 12

Toxic stress, historical trauma, and epigenetics

Toxic stress can come from trauma at all levels, and stress can come from all levels of trauma. For example, a person can experience relative resiliency in their personal lives, while still experiencing intergenerational trauma due to historical occurrences such as slavery or genocide. The stress response is understood as both psychological and physiologic. When the body’s fight or flight, or adrenergic, response is activated, stress hormones like epinephrine and cortisol are released. Over time, when the stressful stimulus is removed, individuals return to homeostasis and the stress response subsides. However, for individuals who live in situations of chronic stress, it can become difficult to return to homeostasis. This experience of living with chronic stress and constant, low level activation of the adrenergic system creates changes in the brain, learning, and responses, and creates altered reactions to stress in the future. Known as toxic stress, this response has been linked to poor health outcomes, increased incidence of psychiatric and substance abuse disorders, and decreased immune responses. 13

It is relatively easy for physicians to imagine that toxic stress can lead to altered physiology later in life. It is less intuitive to understand how toxic stress, which is an experience, is passed through to the next generation. A relatively new field of study, epigenetics, seeks to identify how experiences and stress shape the way DNA is transcribed over generations. 14 The same stress hormones that cause individual toxic stress also affect DNA methylation and the formation of histones, so although the genetic code itself is not changed, its transcription is. 15 When an individual experiences toxic stress, these responses can be passed on through generations. 16 Although the specific genes affected and how stress affects gene transcription is still largely not understood, the downstream clinical effects of epigenetic changes are apparent in a number of clinical settings, particularly in behavioral health. 17

Trauma-informed practices in the provider–patient relationship

Traumatic stress happens when individuals are unable to recover or feel safe after the body’s autonomic system is activated. As described previously, patients may arrive with complaints related to the physiologic effects of toxic stress, and/or to traumas of individual, interpersonal, or communal origins. It is critical then, that provider–patient interactions do not re-traumatize individuals who have likely just had an autonomic response from their injury or illness. Providers should seek to understand what types of trauma are present—individual, interpersonal and/or communal. It is important that providers know the traumas that are prevalent in their patient’s community and the historical trauma that this community may have faced, such as a history of poverty and violence, or for populations, impacts of slavery, racism, genocide, or displacement.

As a provider continues to evolve in their understanding of the community they serve, they can learn to recognize trauma in the patients they care for. Trauma may come in the form of anxiety, lack of eye contact, or hesitancy to participate in the healthcare encounter. It can also come in less obvious ways, like poor compliance with the medical care plan or pain out of proportion to injury or examination. As trauma-informed providers, we understand that these reactions are the result of previous trauma. To reduce re-traumatization in the provider–patient relationship, one must build trust and mutual respect, responding to patients in a trauma-informed way. One can protect privacy in the physical examination, and in the medical record by asking consent throughout the process; asking or telling a patient when you need to touch them and why, remaining at eye level with the patient, and explaining and asking input on the plan of care. While much of this may seem intuitive, these practices have been shown to be lacking in many healthcare interactions. 18

Building a trauma-informed organization

Understanding trauma-informed principles and the effects of ACEs on the provider–patient relationship is not enough; it is critical to implement trauma-informed practices throughout the institution. Physicians are in a position within hospitals, educational institutions, and medical systems to build an entire system that is trauma-informed. 19 This can be accomplished through formal teaching and training, mentoring, and through the establishment of trauma-informed institutional structures. Nursing literature has informed the field on trauma-informed care for decades. 20–22 A synthesis of the nursing literature on TIC revealed the following themes: trauma screening and patient disclosure, provider–patient relationships, minimizing distress and maximizing autonomy, multidisciplinary collaboration and referrals, and advancement of TIC in diverse settings.

The Substance Abuse and Mental Health Administration (SAMHSHA) has outlined 10 domains of trauma-informed organizational leadership to assist with this. 10 It is critical when considering these domains that this is considered a process that organizations are constantly striving to improve, rather than a “one-and-done” checklist. In the next section, we highlight how three institutions have promoted trauma-informed care to improve and transform services at interpersonal and structural levels.

Example 1: The Center for Health Resilience of MetroHealth in Cleveland, Ohio

The Center for Health Resilience at MetroHealth in Cleveland, Ohio expands the understanding of how trauma intersects and impacts the health of communities, systems and people. The Center uses Resilience in Action, which promotes connection through an innovative and proprietary Recovery Coaching model.

This model comprised three main elements: needs assessment, resource navigation, and care coordination. Recovery Coaches are trained in building rapport, empowering and providing ongoing support, education, and resources to the patients and families they serve. Peer support has been shown to benefit the patient receiving support and also the peer supporter. 23

The Center’s training and education efforts have focused on embedding trauma-competent programming into multiple specialties. By focusing training and education on physicians, nursing, and administrative staff, they have successfully identified champions who believe in the intrinsic value of recovery services. The team identifies areas of importance and relevance to specific departments and has demonstrated impact on patient outcomes based on interaction with services. 24

Published findings have shown exposure to these recovery focused services is associated with higher overall patient-reported care ratings (modeled after the Hospital Consumer Assessment of Healthcare Providers and Systems survey), lower rates of emergency department misuse, higher rates of patient-perceived ability to recover, and higher rates of patient perception of physician competence and responsiveness. 25 26 These findings have earned recognition throughout this health system and nationally.

Example 2: Oregon Health Science University (OHSU) in Portland, Oregon

Oregon Health and Science University (OHSU), in Portland, Oregon recognizes the impact of trauma on patients and to surgical residents. Surgical residents are exposed to traumatic experiences and stressors throughout their residency. 27 One study of surgical residents found that 22% screened positive for PTSD and another 35% screened in the “at-risk” range suggesting that residents as well as patients may benefit from a systematic response to the high prevalence of trauma. 27 Despite evidence that trauma-informed care (TIC) can benefit patients and providers, the integration of TIC training into the residency curricula has been slow. 28

OHSU used a novel, interdisciplinary, peer-to-peer training model to address to the prevalence of these types of trauma in medicine. The objective of the training was to improve surgical resident physician understanding of the effects of trauma and introduce TIC principles and practices with the ultimate goal of improving patient care by increasing the awareness of the trauma that shows up in patients and providers. A cohort of four surgical and one psychiatry residents participated in a series of trainings addressing the principles of TIC and TIC curriculum development based on the text Training for Change: Transforming Systems to be Trauma-Informed, Culturally Responsive and Neuroscientifically Focused . 29 This group then developed a TIC curriculum for surgical interns using a peer-to-peer teaching model culminating in three 30 min sessions delivered during protected surgery didactic time. The surgery TIC curriculum uses case-based learning, reflection, and collaborative small group work to describe the neurobiology of trauma and fear, discuss provider experiences of vicarious trauma, and identify trauma-informed patient care practices.

Surgical residents’ learning was assessed with pre-training and post-training surveys. Results quantified by post-training assessments showed marked improvement in skills in TIC after the trainings. This training has impacted day-to-day care from a bottom-up approach, as the newly trained interns report feeling empowered to broach difficult situations and generate discussion with their seniors and team members using a TIC lens. The training is ongoing and the curriculum continues to adapt and improve since its inception 3 years ago.

Example 3: Rutgers New Jersey Medical School

At Rutgers New Jersey Medical School in New Jersey providers and residents were trained in depth in TIC, with follow-up provided for residents in the form of TIC-informed peer support. The TIC program was brought to this school as part of the launch of a hospital-based violence intervention program (HVIP). The trauma service elected to train physicians, advanced practice providers, and HVIP staff together in a trauma-informed care course. This three-part course was offered by a local TIC training program being employed in pediatric settings at regional medical centers as part of a SAMSHA-funded program to train providers in TIC principles.

Trauma-informed care principles, adverse childhood experiences, and the science of epigenetics and toxic stress were introduced via didactic teaching. Follow-up sessions focused on building provider team trust, sharing ideas for how to implement trauma-informed practices as a team, and discussing what trauma-informed patient interactions would look like in clinical settings. In the third session, a trainer accompanied the team on rounds, observed interactions with patients, and gave immediate feedback about how to make the interaction more trauma informed.

Providers feedback reported that training helped them better care for patients, better manage their own life stress and trauma, and practice better self-care. The main feedback was that training should be provided to all who manage trauma patients, most particularly the nursing and residency staff.

To implement this, ongoing trauma-informed care teaching was applied to the residency program. In this model, residents attend a department-wide grand rounds presentation on trauma-informed care at the beginning of the academic year. At the onset of their trauma rotation, the second interactive lecture is given as part of the curriculum. Finally, a trainer attends rounds with the trauma team and provides specific feedback to residents on their patient interactions in the week following the second didactic lecture.

The program implementation has been well received and was easy to integrate into the trauma rotations. The interactions observed by attending staff between patients and residents has been improved. As medical providers seek to further implement this programming hospital-wide, we are eager to understand if these programs can translate to improved patient outcomes.

As we constantly seek to improve the care of our patients, it is important to realize that trauma impacts all individuals, patients and providers alike, across the lifespan and across generations. Awareness of the breadth and depth of trauma and its impact on healthcare outcomes is critical to improving the health of all patients, as well as those providing care. Using the framework above, we can improve ourselves and our provider practices, and we can also advocate for and build organizations that account for trauma. As SAMHSA notes, “everyone has a role to play in a trauma-informed approach (p.15).” 10 This will improve outcomes and create healthier communities in which we and our patients will live, work, and play.

Acknowledgments

SG acknowledges Eve Rittenberg, MD for editorial assistance for this manuscript, as well as for collaboration in bringing trauma-informed care forward, along with AL-O'C, NP, and Nomi Levy-Carrick, MD, MPhil. She has no competing interests. SH acknowledges Dr. Heather Vallier, MD, founder of Trauma Recovery Services, at the MetroHealth System; as well as Katie Kurtz, LISW-S and Mary Breslin, MPH for support with organizational collaboration and research. She has no competing interests.

Contributors: SG assumed the primary writing responsibility for the manuscript content, references, tables and figures, final formatting and references and review overall and wrote the introduction, and individual/interpersonal and collective/structural trauma sections of the manuscript. SB wrote the sections on toxic stress, historical trauma, and epigenetics; trauma-informed practices in the provider–patient relationship; and building a trauma-informed organization and the section entitled: Rutgers New Jersey Medical School. SH wrote the section entitled: The Center for Health Resilience of MetroHealth in Cleveland, Ohio. HB, JS, and L-YW wrote the section entitled: Oregon Health Science University (OHSU) in Portland, Oregon. AL-O'C provided overall comments on the manuscript and relevant information on nursing literature. SB served as the senior author and advised SG throughout the entire process, contributing to the content in the manuscript. All authors reviewed and contributed to the final manuscript.

Funding: HB was awarded a $7000 educational mini grant through OHSU to fund projects related to trauma informed care. Grant award number: none.

Disclaimer: The study sponsor(s) had no role in the study design; in the collection, analysis, and interpretation of the data; in the writing of the report; and in the decision to submit the paper for publication.

Competing interests: The curriculum used in the OHSU study included text from the book Training for Change: Transforming Systems to be Trauma-Informed, Culturally Responsive, and Neuroscientifically Focused written by Dr Alisha Moreland. This is the only related disclosure.

Provenance and peer review: Not commissioned; externally peer reviewed.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study does not involve human participants.

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Peer-reviewed

Research Article

Korean Triage and Acuity Scale education using role-playing and its effects on triage competency: A quasi-experimental design

Roles Conceptualization, Formal analysis, Funding acquisition, Methodology, Writing – original draft, Writing – review & editing

Affiliation Department of Nursing Science, Andong National University Andong-si, Andong-si, Gyeongsangbuk-do, South Korea

Roles Conceptualization, Data curation, Investigation, Methodology, Writing – original draft

* E-mail: [email protected]

Affiliation Department of Nursing, Shinsung University, Dangjin-si, Chungcheongnam-do, South Korea

• Yon Hee Seo, 

• Published: October 14, 2024
• https://doi.org/10.1371/journal.pone.0311892
• Reader Comments

Triage is the process of prioritizing patients in the emergency department (ED). This has a pivotal role in ensuring patient safety and that the ED operates smoothly; therefore, triage training education is an important aspect of triage nurses’ preparedness in different emergency situations. This study employed a quasi-experimental research design using a non-equivalent control group pre–post-test design to verify the effect of the Korean Triage and Acuity Scale (KTAS) education using role-playing on the knowledge of triage, triage performance ability, and triage competency in nursing students. Participants were 78 fourth-year nursing students from Shinseong University in South Korea; 39 were assigned to the experimental group, and 39 to the control group. The intervention was conducted for three weeks, from January 31 to February 16, 2024. The experimental group received KTAS education through role-playing, whereas the control group received triage education through lectures. Triage knowledge (t = 2.94, p = .004) and triage performance ability (t = 3.11, p = .003) were significantly improved in the experimental group. However, there was no significant difference in triage competency between groups (t = 1.32, p = .192). The post-test score of triage record in the experimental group showed a significant improvement over time (t = 0.56, p < .001). This study demonstrated that KTAS education using role-playing was more effective in improving triage knowledge and performance ability than traditional lecture methods for nursing students. Triage education programs should be developed considering the effectiveness of various teaching methods.

Citation: Seo YH, Lim S-O (2024) Korean Triage and Acuity Scale education using role-playing and its effects on triage competency: A quasi-experimental design. PLoS ONE 19(10): e0311892. https://doi.org/10.1371/journal.pone.0311892

Editor: Vanessa Carels, PLoS ONE, UNITED STATES OF AMERICA

Received: March 3, 2024; Accepted: September 25, 2024; Published: October 14, 2024

Copyright: © 2024 Seo, Lim. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: I have attached the data file as a supporting information .

Funding: This study was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (No. RS-2022-00166800).

Competing interests: The authors have declared that no competing interests exist.

Introduction

Globally, emergency departments (EDs) face the critical issue of overcrowding, which is largely attributed to an influx of non-emergency cases. Overcrowding in EDs strains resources, delays urgent treatment, and hampers service efficiency [ 1 ]. To ensure quick and accurate care for critical cases, a robust triage system and training for triage nurses based on the severity of the patient’s condition is vital.

The Korean Triage and Acuity Scale (KTAS), which is used in EDs, was developed based on the Canadian Triage and Acuity Scale and has been used in emergency medical centers in South Korea since 2016 [ 2 ]. Triage is a critical and challenging task performed by ED nurses [ 3 , 4 ]; however, systematic training programs that can improve the triage decision-making skills of triage nurses in South Korea are not available.

Currently, KTAS training primarily comprises theoretical explanations of the field applications of the KTAS algorithm. Education (lecture method) is mainly verbal-based or lecturer-centered and takes four to five hours per session using four triage cases. With this approach, learners may not be engaged, and the instructor is mostly in charge of creating educational activities. The current approach is insufficient for enhancing the decision-making skills of triage nurses in emergency settings [ 5 ], and lacks a process for objectively evaluating triage competency within the KTAS framework [ 2 , 6 ]. In addition, studies in several countries have shown that nurses often lack adequate education and preparation in triage areas, including Sweden [ 7 ], Iran [ 8 ], South Korea [ 9 ], and Australia [ 10 ]. The latter study revealed that 42% of nurses had not been trained for triage, and 14% were not adequately prepared, even after attending triage education classes [ 10 ]. Nurses are responsible for triage, and they must be equipped for and trained in this role [ 11 , 12 ]. Triage nurses will not employ triage correctly if they do not receive adequate and efficient education [ 8 ]. Nursing faculties need to expose nursing students to critical situations to prepare them for triage [ 13 ].

Various methods have been used in triage education, such as lectures, reading manuals (guidelines), simulations, workshops, and seminars; some of these could have advantages over others [ 13 ]. In parts of nursing education where there may be a lack of practical experience, it is important to utilize experiential learning methods, such as simulation and role-playing [ 14 – 17 ]. Role-playing in nursing education is a well-known teaching method in which learners acquire new roles or behaviors through training in a situation similar to real life by simulating actual patient situations for severity classification [ 18 ]. Introducing role-playing into KTAS education will significantly help nursing students understand and accurately identify real-life medical situations and patient problems. This method enhances their theoretical knowledge of triage and improves their decision-making and emergency treatment abilities, particularly for those lacking clinical experience.

We thus developed KTAS education using role-playing and tested its impact on the triage competency of nursing students before applying it to actual triage nurses in clinical settings. The objective of this study was to determine and compare the effectiveness of two methods, role-playing and lectures, on the triage knowledge, triage performance and triage competency of nursing’s students.

Materials and methods

Research design.

This study used a non-equivalent control group pre–post-test design to verify the effect of KTAS education using role-playing on nursing students’ knowledge of triage, triage performance ability, and triage competency.

Participants

Participants were recruited from the nursing departments of the universities of Shinseong, located in Dangjin-si, South Korea, after posting a recruitment notice on the nursing notice board and community explaining the study purpose and contents. All participants who agreed to participate were selected from among those who understood the study purpose, provided written consent, and met the study selection criteria: (1) completed the fundamentals of nursing and health assessment within the Department of Nursing Science, (2) had no previous experience with triage education, and (3) participated in adult nursing clinical practice as a fourth-year nursing student.

The experimental group was assigned to receive KTAS education using role-playing, whereas the control group was assigned to students who participated in triage education based on lectures ( Table 1 ). Participants were not provided with information regarding the group to which they belonged. The group assignment method involved using number cards labelled with two groups. Participants who drew ’0’ were assigned to the experimental group, and those who drew ’1’ were assigned to the control group.

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https://doi.org/10.1371/journal.pone.0311892.t001

The sample size was calculated with G*Power 3.1.9.4. According to a meta-analysis of virtual patient education n for health professionals, the effect size d was 0.8 [ 19 ]. In a two-tailed significance test with a power of 80% and an alpha level of .05, the sample size of each group was calculated to be 26. We recruited 78 participants (39 in the experimental group and 39 in the control group), considering a dropout rate.

Ethical considerations

This study was conducted after Institutional Review Board approval (1040191-202401-HR-002-01). Written informed consent was obtained from all participants. All methods were conducted in accordance with the relevant guidelines and regulations.

The KTAS is used as a nationwide triage tool to determine patients’ priority for treatment in EDs in South Korea. KTAS levels are categorized according to emergency symptoms, which are divided into grades 1–5 depending on severity ( Fig 1 ). When a patient arrives at the ED, a critical first look and a screening test for infectious diseases are performed, following which primary modifiers or special modifiers are selected to assign an appropriate score. The KTAS includes 155 main complaints of adults and 165 complaints of children. After the complaints are selected, the common and general characteristics of all complaints are the primary considerations, such as respiration status, vital signs, mental status, and pain. Secondary considerations include the specific characteristics of each complaint. These include blood sugar levels measured at the time of visit, symptoms of dehydration, high blood pressure, pregnancy, and mental health as judged by medical history and patients’ responses. The KTAS includes both severity and urgency [ 20 ]. Priority of care is determined based on the KTAS classification results.

Note. KTAS = Korea Triage Acuity Scale.

https://doi.org/10.1371/journal.pone.0311892.g001

Demographic characteristics.

Participants’ demographic characteristics included sex, age, grade point average (GPA), and major satisfaction. The scores on the major satisfaction tools ranged from 3 (“satisfied”) to 1 (“dissatisfied”). The higher the score, the higher the satisfaction with their major.

Triage knowledge measurement.

The triage knowledge measurement tool was developed with reference to the Education Guidelines of Emergency Patients’ Classification and KTAS committees [ 2 ]. The expert group in this study comprised two ED triage nurses and three nursing professors who evaluated the validity of the triage knowledge questionnaire using content validity indices (CVI). The overall CVI on the triage knowledge questionnaire was 0.9. This tool comprises 20 items, including 3 items on the role of triage nurses and triage records, 11 items on the triage classification process and triage level, and 6 items on the primary consideration in performing KTAS. For each item, a score of 1 point was given for a correct answer and 0 points for an incorrect answer, resulting in a score range of 0–20 points. Higher scores indicated higher triage knowledge.

Triage performance ability measurement.

Triage performance ability means that a triage/urgent triage role collects subjective and objective information and history about the patient to determine the severity/urgency of their condition, and then measures the severity/urgency score according to the KTAS algorithm. The triage performance ability measurement tool was developed with reference to the Education Guidelines of Emergency Patient Classification and KTAS Committees [ 2 ]. The researchers developed cases for four diseases—cardiovascular, respiratory, neurological, and gastrointestinal diseases—to assess triage performance ability. Each case component included age, gender, reason for visit, symptoms (including level of consciousness), and signs (vital signs and oxygen saturation). This tool comprises 10 items, with three items for KTAS Level 1, three items for KTAS Level 2, two items for KTAS Level 3, and two items for KTAS Level 4. The expert group in this study comprised two triage nurses in the ED and three nursing professors who evaluated the validity of the triage performance ability questionnaire using the CVI. The overall CVI score on the questionnaire was 0.90. The evaluation method required participants to read the case and write down the triage stage. For each item, a score of 1 point was given for a correct answer and 0 points for an incorrect answer, resulting in a score range of 0–10 points. A higher score indicated greater triage performance ability.

Triage competency measurement.

Triage competency is the ability to allocate medical resources efficiently by determining care priorities according to patients’ health status [ 21 ]. This study used the triage competency measurement tool developed by Moon and Park [ 5 ]. This tool comprises 30 items divided into five sub-areas: clinical judgment (13 items), expert assessment (4 items), management of medical resources (4 items), timely decisions (4 items), and communication (5 items). Each item was measured on a Likert scale ranging from 0 (“not at all”) to 4 (“always”), with the total possible points ranging from 0 to 120. Higher scores indicate greater triage competency. The reliability at the time of development of this tool was Cronbach’s α .91 [ 5 ], and Cronbach’s α was .95 in this study, indicating excellent internal consistency.

Triage record measurement.

The triage record measurement tool was developed with reference to the educational guidelines of the emergency patient classification and KTAS committees [ 2 ]. The expert group in this study comprised two triage nurses in the ED and three nursing professors who evaluated the validity of the triage record sheets using the CVI. The overall CVI score on the triage sheet was 0.91. This tool comprises 12 items, including 3 items on patient information; 7 items on patient assessment; and 2 items on the accuracy of the KTAS level, including the rationale for the triage level decision. For each item, a score of 2 points was given for an accurate record, 1 point for an average record, and 0 points for a poor or no record (score range = 0–24 points). A higher score indicated greater accuracy of the triage record.

Data collection and experimental treatment

The intervention was conducted for three weeks, from January 31 to February 16, 2024. The experimental group received KTAS education through role-playing, whereas the control group received triage education through lectures. As shown in Table 1 , the experimental and control groups received the same learning content and instructor guidance time for each session.

In the first week, an orientation was conducted, and training methods for role-playing were explained in terms of the KTAS learning process and procedures. In the second week, theoretical learning for KTAS was conducted. The training lasted 120 min and covered learning objectives, basics of severity classification, application of KTAS in adults, and the levels and methods of using KTAS. In the third week, training was conducted using emergency patient cases developed with reference to the education guidelines of the emergency patient classification and KTAS committees. Eight cases were chosen from the 17 disease categories, focusing on 4 categories with a high number of severe cases: cardiovascular, respiratory, digestive, and neurological. The cases included essential information for emergency classification, such as age, gender, reason for visit, symptoms (including consciousness level), and signs (vital signs and oxygen saturation), and they were structured to allow the triage level to be selected from 1 to 5.

For the experimental group that received KTAS education using role-playing, the teams comprised four members each. Each team member took turns playing the roles of patient, triage nurse, ER administrator, and triage facilitator so that everyone could experience all roles. The patient’s role was to become familiar with the relevant clinical case and express the motivation for admission and symptoms in a realistic manner, as if the patient had actually visited the ED. The role of the triage nurse was to directly perform a critical first look and select the primary modifiers examined when a patient arrives at the ED, then decide the triage level based on the results of the assessment and write the details of the triage level classification on the triage record. The role of the ED administrator was to help the triage nurses input the triage progress stages into the computer. The triage facilitator checked the triage monitoring record sheet to ensure that the triage nurse classified the patient using the correct method and KTAS algorithm and played a role in coordinating the overall work within the ED. When the role-playing learning for one case was completed, the triage record sheet submitted by each team was checked, and peer feedback was provided to determine whether the triage level was accurately classified. Every participant in this discussion was given the opportunity to share their thoughts, feelings, observations, and recommendations. Finally, each participant was asked to write a reflection journal about their role-playing and then move on to the next clinical case.

The control group received KTAS education using traditional lecture-style. In the first week, a 60-minute orientation covered training methods and program procedures. The second week featured a 120-minute lecture on KTAS concepts and algorithms for the control group. Subsequently, in the third week, the control group received case-based KTAS education via traditional lectures, and were trained to independently assess patient cases and determine triage levels. The control group received eight cases from four categories with a high number of severe cases: cardiovascular, respiratory, digestive, and neurological, which were the same as the experimental group. Following individual KTAS learning using the eight cases, the instructor provided feedback to each student regarding the accuracy of their triage level determination.

To minimize participant contamination, the control group received KTAS education in the morning in a conventional classroom setting for theory lectures. In contrast, the experimental group received KTAS training in the afternoon in a problem-based learning environment conducive to team-based learning. To minimize the diffusion of the educational intervention, the classrooms of the control and experimental groups were housed in different buildings. The program schedule ensured that the control group received KTAS training via traditional lectures first, followed by role-playing sessions for the experimental group.

Data analysis

Collected data were analyzed using SPSS 25.0 (IBM, Chicago, IL, USA). Participants’ general characteristics were analyzed as numbers, percentages, means, and standard deviations. To verify the homogeneity of the experimental group and the control group, χ 2 -tests and t-tests were performed. To verify the differences in triage knowledge, performance, and competency, we calculated the difference between the pre-post means within each group and then compared the differences between the two groups using an independent t-test. As the pre-test result presented a difference in baseline triage knowledge, an analysis of covariance was applied to verify the difference in post-knowledge between the two groups using pre-knowledge as a covariate.

Homogeneity test for general characteristics and dependent variables

The general characteristics of the experimental and control groups and homogeneity tests are presented in Table 2 . There were no significant differences in gender, GPA, or satisfaction with nursing major between groups ( p > .05). Among the dependent variables, triage knowledge, performance ability, and competency showed homogeneity between groups ( p > .05).

https://doi.org/10.1371/journal.pone.0311892.t002

Pre- and post-comparison of triage knowledge and triage performance ability between the groups

The first hypothesis in this study posited that the experimental group would show higher triage knowledge than those in the control group. The experimental group’s pre-post triage knowledge score showed significant improvement compared with that of the control group (t = 2.944, p = .004).

The second hypothesis was that the experimental group would show higher triage performance ability than the control group. When the pre-post triage performance ability of the two groups was verified, the experimental group showed significant improvement (t = 3.106, p = .003). Specifically, the results of analyzing the performance ability in KTAS level showed that there was a significant difference in the KTAS Level 2 “emergency” between groups (t = 2.363, p = .021; Table 3 ).

https://doi.org/10.1371/journal.pone.0311892.t003

Pre- and post-comparison of triage competency between the groups

The hypothesis in this study posited that the experimental group would show higher triage competency than the control group. There was no significant difference between the two groups regarding triage competency when the pre- and post-test values were compared (t = 1.316, p = .192). Specifically, after examining the sub-factors of the pre-post triage competency, the experimental group demonstrated significant improvement in expert assessment (t = 2.163, p = .034) and communication (t = 2.056, p = .043) compared to the control group ( Table 4 ).

https://doi.org/10.1371/journal.pone.0311892.t004

Comparison of triage record score in the only experimental group over time

The comparison of the triage record scores of the experimental group over time showed a significant difference, with the average score increasing from 17.08 ± 2.45 at the first recording to 19.26 ± 2.06 at the second recording (t = 0.561, p < .01). Post examining the sub-factors of the triage record score over time, significant differences were observed in the patient assessment (t = 4.257, p < .01), main symptom (t = 2,512, p = .014), vital signs/SpO 2 (t = 6.183, p < .01), pain assessment (t = 3.411, p = .002), accident mechanism (t = 2.695, p = .010), and the accuracy of triage records (t = 5.707, p < .001; Table 5 ).

https://doi.org/10.1371/journal.pone.0311892.t005

This study was conducted to verify the effects of KTAS education using role-playing on knowledge of triage, triage performance ability, and triage competency, and to provide evidence for establishing a foundation for emergency patient classification education in future nursing education.

The experimental group that received KTAS education using role-playing showed significantly higher triage knowledge than the lecture group. Role-play may be more effective for triage training than lecture methods [ 14 , 18 , 22 , 23 ], which coincides with our results. Considering that students have not been using role-playing teaching methods thus far, Heidarzadeh et al. [ 23 ] observed nursing students’ learning motivation and the collaborative environment in a role-play group, which might contribute to their willingness to learn triage knowledge. Conversely, traditional lecture methods place learners in a passive role, limiting their opportunities for collaboration [ 22 ]. This study showed that triage knowledge improved when KTAS education using role-playing was applied to nursing students.

The experimental group showed a significantly higher triage performance ability than the control group. This result coincides with those of previous studies on triage among nursing students [ 13 , 23 ]. In addition, analysis of the triage performance ability sub-area revealed a significant difference in KTAS Level 2 between the groups in this study. If the KTAS education using role-playing can help the nursing students in identifying life-threatening cases better like “severe emergency patients” (KTAS Level 2), they will be more beneficial. Role play is recognized as a good way to boost performance because it provides a stress-free, safe atmosphere and repeated assessment practice for gaining expertise in clinical situations [ 18 , 24 ]. Nursing students performed a 20-minute role-play several times based on each role that incorporated the concepts of the KTAS algorithm. In particular, the first impression of an emergency patient and a vivid expression of chief complaints, like a realistic patient, seem to make it easy to follow the process of the KTAS algorithm step-by-step. Nursing students also had the opportunity to share their opinions or be rationally related to KTAS-level decision-making and the error of KTAS algorithm application in the reflection phase. Through such feedback and debriefing, the difficulties in matching patients’ main complaints and the triage algorithm [ 4 ] have been improved. From this, it can be inferred that the triage performance ability of nursing students was enhanced.

This study confirmed the effect of applying KTAS education using role-playing on the triage competency of nursing students, and there was no difference from the control group that received lecture education. However, sub-factors such as “communication” and “expert assessment” significantly improved. Direct comparison is impossible because there are no similar studies on nursing students; however, our results contradict those of a previous study that measured the effect of nurses’ triage competency based on a competency-based triage education application [ 25 ]. Important factors to consider in relation to triage nurses’ triage competency are not only knowledge [ 4 ] and triage training [ 26 ], but also critical thinking disposition, problem-solving ability, and clinical judgment ability [ 5 , 27 ]. However, the current KTAS education comprises a four-hour training program that includes lectures and cases covering the concept of KTAS, the application of KTAS in adult and pediatric patients, and the selection of relevant items from the first and second considerations to determine KTAS level. This section focuses on applying the KTAS algorithm to the presented cases. The content of education to improve critical thinking disposition, problem-solving ability, and clinical judgment ability, which are key factors in improving trial competency, was not considered. Given that these factors cannot be improved by short-term theoretical education, it appears that it was somewhat difficult to improve triage competency after KTAS training was conducted for nursing students without clinical experience by applying role-playing for a short period of three weeks. Therefore, to enhance the triage competency of nursing students, it is necessary to improve the current one-time education focusing on triage knowledge and the KTAS algorithm, and implement KTAS education from an undergraduate course that can comprehensively enhance the key elements suggested in a previous study [ 5 , 26 , 27 ]. According to Delnavaz et al. [ 13 ], combining the interactive educational methods can improve the learning of nursing students.

As expert assessments identify patients’ problems through physical examinations and interviews, physical assessment and communication require direct interaction between patients and nurses. Therefore, KTAS education using role-playing was more effective in those sub-areas (physical assessment and communication) compared to mobile-based non-face-to-face study [ 25 ] or the control group with lecture methods. Therefore, to improve nursing students’ triage competency, it is necessary to develop a program that combines various educational methods such as simulation, role-play, workshops, and seminars. These methods improve not only screening knowledge but also communication, physical assessment, and clinical reasoning.

In view of the rising importance of nursing records in legal disputes [ 28 ] and because nurse triage outcomes in South Korea are closely related to the cost of emergency medical care [ 29 ], evidence for triage decisions should be carefully documented. However, studies on nursing records in triage education are limited. Therefore, we analyzed the effect of triage records on nursing students receiving KTAS education through role-playing over time. KTAS education using role-playing improved the ability to write nursing records over time. Unlike traditional lecture-style KTAS education, the KTAS education method allows students to experience not only the understanding of triage algorithms but also the roles of ED colleagues, such as the ED administrator and the triage facilitator, through role-play. This may be helpful in writing accurate nursing records, even in tense situations in the ED, owing to feedback from colleagues. This greatly contributes to nursing students learning more accurate and effective ways to write ED nursing records through KTAS education. Future research should compare the effects of the two educational methods on the improvement of nursing records between the control and experimental groups.

This study has a few limitations. First, it should be noted that the majority of the nursing students (37 out of 39) who participated were female, indicating a gender distribution limitation. We measured the effectiveness of KTAS education through role-playing immediately after its use. Therefore, it was impossible to estimate the continuation of the educational effect on nursing students or the interval requiring repeated education. Further research is required to determine the sustainability of the effects of this program. This study was conducted in only one nursing school in South Korea; therefore, the generalizability of the results is limited.

KTAS education using role-playing was more effective than lecture-style education in improving triage knowledge and performance ability. Although this was insufficient to improve the triage competency of nursing students, it can be concluded that education utilizing role-play is more effective in improving communication and expert assessment capabilities. In addition, this study is meaningful in that it utilized basic data on emergency nursing among nursing students, as it is the first study to conduct KTAS professional education for domestic nursing students.

Supporting information

S1 data set..

https://doi.org/10.1371/journal.pone.0311892.s001

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• 3. Dello Stritto RA. The experiences of the emergency triage nurse: a phenomenological study [dissertation]. Denton (TX): Texas Woman’s University; 2005.
• 4. Yu KH. Practice and knowledge and performance of triage nurses in an emergency department [master’s thesis]. Gwangju: Chonnam National University; 2012.

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Clinical Guideline for Nursing Care of Children with Head Trauma (HT): Study Protocol for a Sequential Exploratory Mixed-Method Study

Affiliations.

• 1 School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran.
• 2 Critical Care Nursing Department, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran.
• 3 Children Care Nursing Department, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran.
• 4 Department of Neurosurgery, Isfahan University of Medical Sciences, Isfahan, Iran, Department of Pediatric Neurosurgery, Isfahan University of Medical Sciences, Isfahan, Iran.
• 5 Department of Neurosurgery, Dezful University of Medical Sciences, Dezful, Iran.
• PMID: 32848495
• PMCID: PMC7429226
• DOI: 10.2147/PHMT.S260720

Background: Head trauma is a major health problem. Its primary complications happen at the time of trauma and are inevitable; thus, head trauma management is focused on the prevention and management of secondary complications. A clear clinical guideline for head trauma care can help nurses effectively prevent and manage secondary complications. This study aims to develop the clinical guideline for nursing care of children under 18 years with head trauma hospitalized in emergency departments, critical care units, and neurosurgery wards.

Methods: This sequential exploratory mixed-method study will be conducted in three main phases as follows: qualitative, systematic review, and integration phases. In the qualitative phase, semi-structured interviews will be conducted to determine the care-related needs of children with head trauma. In the systematic review phase, a systematic review will be performed to find and then to review the most relevant articles, books, and the appropriate clinical guidelines. The quality of the retrieved guidelines will be assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. In the integration phase, the findings of the qualitative and systematic review phases were integrated, the draft of the guideline will be prepared, which will then be revised and validated through a nationwide Delphi survey.

Discussion: The guideline for nursing care of children with head trauma can help to more effectively prevent, reduce, and manage the secondary complications of head trauma. Moreover, it reduces disability and mortality rates, improves nursing care quality, decreases healthcare costs, shortens hospital stay, and makes more rational clinical decisions.

Keywords: children; clinical guideline; head trauma; nursing care.

© 2020 Kord et al.

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Conflict of interest statement

Authors have declared that there are no competing interests.

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