1. 1Emergency Department, University Hospitals Leuven, Belgium
Training nurses in categorisation for evacuation in a large university hospital: an ongoing challenge
Hendrickx C1, Sabbe MB1
1Emergency Department, University Hospitals Leuven, Belgium
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Discussion
The limitation of the study is that not all departments have performed their exercise. An important bias is that first the most motivated headnurses participated with their entire department. Important confounders are the rather limited knowledge about the HIMS. In our Belgian Healthcare system a nurse does not take care of all patients on a ward. However, the end result was a collaborative effort of different nurses in each group. During the study, there was also the working pressure of getting a prestigious accreditation.
We evaluated the classification of the patients in the various mobility categories, based on an assessment of the nursing professionals of the department. Although they have a good view on how different patients function, however, they may have different opinions on the categories. Some could classify a patient as mobile and self-reliant, whereas others might label the same patient as mobile with the assistance of one person. The reliability of this classfication needs further fine tuning.
Background
In hospital disaster preparedness, knowledge on and skills in evacuation and more specific on categorisation of patients is an essential competence that nurses are not trained in during a normal education curriculum.
The purpose of this study is to set up and to evaluate a categorisation exercise on the patient population. Meanwhile an effective and easy to perform training method for all types of departments in a large university hospital is searched for.
The aims of the study are: training nurses to improve the knowledge and skills about the Hospital Incident Management System, obtaining staff satisfaction, feasibility of the exercise and pursuing validity of patient categorisation.
The dimension of the university hospitals is composed of 1950 authorised beds and consists of the following staff: 1385 physicians, 2985 nurses and 4516 others. The emergency department (ED) receives visits per year.
An adjustment of the exercise was made depending on the type of department: depending on patient characteristics (mobility of patients):
Type 1: Information on alert procedures - evacuation routes - safety zones
No variation in mobility of patients
Type 2: Type 1 plus exercise on categorisation of patients
Variation in mobility of patients
Comparing two groups
Type 3: Table top exercise with department specific scenario
Categorisation using duration
Critical Care Units (CCU)
Results
More than 93 wards, functional units, operating rooms, the ED and critical care units participated in the study. Type 1 exercises: 34/54, type 2 exercises: 38/48 and type 3 exercises: 21/26 (OR 39/45 and CCU 8/12).
The exercise was highly appreciated by the participating nurses. And the feasibility of the exercise was realistic: done within 30 to 40 minutes. In type 2 exercises the equal scores were 82,11%. The comparison resulted in a high correlation (r2 > 0.78) between both groups and with the control categorisation group.
Differences between groups in type 2 exercises are presented in the table:
Conclusion
Categorisation has another purpose and executer than triage. Namely: prioritising for evacuation done by nurses.
A short and practical exercise on categorisation for evacuation was highly appreciated by the majority of all participating nurses and units. Although categorisation for evacuation is not a routine skill for nurses, surprisingly high correlation factors were observed. This indicates that the categorisation system is easy to apply and has practical implications. This categorisation was declared valid and there was an acceptance of the patient classification made in advance within the hospital: subclasses were added for the fifth category (CCU).
Looking at the above categories in function of evacuation, the speed with which the procedures are conducted, is an important determinant. Along with the mobility features, the data on a possible postponement of medical and nursing care are relevant to assessing the staff and logistic resources required. This system will certainly be useful for departments that have to evacuate a major part of the department. Within hospitals, nursing professionals represent a large group and the nature of their activities means that they will play an important executive part in the evacuation of a department or hospital.
However, organizing such exercises in a large university hospital with other priorities, remains an ongoing challenge.
Methods
Categorising depends on mobility of the patient and duration of the intervention.
3 types of categorisation according to type of department:
Transportation - Logistics (normal wards, function units, …)
Transportation - Logistics + 1 additional categorisation/class
(critical care units, ED, …)
Duration of intervention (operating room, delivery room, …)
Patients immediately endangered will be evacuated first, followed by patients assigned to categories I to V. The first category of patients are mobile and self-reliant. The second category are mobile, but require assistance of one person. The third category are mobile, but require assistance of at least two persons. The fourth category are not mobile at all. For critical services, a fifth category was added for patients who are not mobile and depend on external vital equipment.
After an introduction of the existing categorisation system and a categorisation made in advance, the group of nurses was divided in two groups. In a table top setting, both groups of nurses were asked to categorise the patients present at the time of the exercise and to place them in evacuation order.
An evaluation of the exercise and a description of the different categories was made. Finally, a comparison between groups was calculated.
Number
N = 682
Total number of patients
C = 560
Total number of correct categorisation
M = 122
Total number of incorrect categorisation
Variation X
X/C - X/M in %
1  2 62
9, ,82
1  3 4
0,59 - 3,28
1  4
2  3 16
2, ,11
2  4
3  4 20
2, ,39