Enhancing triage accuracy in the emergency department − a path to effective patient care

Authored by: Michael Zimmermann, MBA, RN, CEN, CRRN, CENP, NREMT-P, Consultant 
Margaret (Peggy) Grover MHA, BSN, RN, CPEN, Senior Consultant

In emergency departments (EDs) across the nation, the Emergency Severity Index (ESI) has become the standard for categorizing patients based on acuity and resource needs. However, challenges related to hiring and retaining experienced registered nurses (RNs) in the ED setting have led to suboptimal decisions regarding triage assignments. In some cases, less experienced or temporary nurses are assigned to triage without proper ESI education or training, potentially leading to delays in care and inaccurate patient assignments. These issues can have detrimental effects on patient outcomes and staff morale. This article aims to explore the components of an effective ESI education program and propose steps to improve triage accuracy in the ED.

“An effective triage program should include baseline staff requirements, clearly defined objectives and goals, and a robust education plan for initial and ongoing training.”

Call to action
There is an urgent need to improve ED throughput, flow, and patient outcomes. To achieve this, it is crucial to ensure that the right care is provided at the right time and in the right setting. Currently, the overall accuracy rate for ESI assignments in EDs is low, highlighting the importance of a proactive response from leaders and educators.

Triage, which originated in the late 18th century on battlefields, has evolved significantly over time. The demands placed on modern EDs necessitate a more sophisticated triage system that considers both resource needs and patients’ emergent or urgent medical requirements. The transition from a three-level to a five-level triage system allows for better stratification of patient needs upon arrival at the ED.

Accuracy of ESI triage
Accurate assignment of ESI levels is critical for providing timely, high-quality, and safe patient care in the ED. Failing to assign the appropriate ESI level can disrupt flow and efficiency, leading to unnecessary delays in care or inadequate resource allocation. Both scenarios can result in adverse patient outcomes.

Impact of nursing experience
The role of the triage nurse requires exceptional skills in rapid assessment, clinical acumen, visual assessment, and effective communication. Distinguishing between sick and non-sick patients is a skill that takes time, experience, and exposure to master. Experienced triage nurses play a vital role in setting the tone for the entire ED visit and ensuring patients are routed to the appropriate care pathway. However, the reliance on temporary nursing staff, including those with prior ED experience, may create a false sense of security regarding their competency in ESI triage. It is crucial to validate the competency of all temporary staff before assigning them to triage duties.

Pressure to change ESI acuity
Assigning an ESI level is based on a snapshot assessment that may not capture the full clinical picture. Patient conditions can change after triage due to additional history, laboratory values, or diagnostic imaging. It is essential to support the triage nurse’s initial assessment while acknowledging that subsequent information may warrant a change in the assigned ESI level. Documentation should clearly explain the reasoning behind the initial ESI assignment to avoid second-guessing and provide a basis for subsequent clinical decision-making.

Ongoing education
Given the workforce challenges in sustaining comprehensive triage education programs, special attention must be given to triage accuracy and effectiveness. An effective triage program should include baseline staff requirements, clearly defined objectives and goals, and a robust education plan for initial and ongoing training. In-person competency validation by qualified ED RNs/educators is crucial for immediate feedback and coaching. Annual ESI training and focused education on high-risk patient groups should be established to ensure ongoing proficiency.

Inter-rater reliability
To ensure evidence-based decisions, leaders must assess team performance and reliability through tools such as Inter-Rater Reliability (IRR). Establishing a baseline percentage of triage accuracy and conducting retrospective reviews using experienced raters can provide insights into team performance and identify areas for improvement. These metrics should be used to set team goals and monitor decision-making trends and potential biases.

Triage resources
Engaging experienced ED nurses or educators is paramount to enhance the accuracy of ESI triage. Their expertise and ability to identify subtle clues and exercise intuition can significantly impact the determination of appropriate ESI levels. Utilizing resources such as the Emergency Nurses Association’s Emergency Severity Handbook, 5th Edition can provide a solid foundation for developing comprehensive triage education programs.

ESI serves as an evidence-based tool used in the majority of EDs, yet the accuracy rate for ESI assignments remains suboptimal. To address this issue, it is essential to provide appropriate education, training, and validation for those performing ESI assignments. Relying solely on independent online learning modules is insufficient in today’s healthcare environment. By implementing a comprehensive triage education program and fostering ongoing competency, EDs can improve patient care and outcomes.