Reduce risks of switch to 5-level triage system

Nurses may be over- or undertriaging patients

A growing number of EDs are switching to the Emergency Severity Index (ESI) five-level triage system, but many emergency nurses are struggling to find effective ways to determine competency.

After the ESI was implemented at NorthEast Medical Center in Concord, NC, ED nursing competencies were determined before and after the new system went live. First, nurses took an online post-test after attending a mandatory three-hour training course, says T.M. (Pat) Patrick, RN, staff development coordinator for the emergency care center.

Patrick created the course using a workbook from the Agency for Healthcare Research and Quality (AHRQ) and various other texts on ESI triage, after taking a two-day triage course held by Fairview, NC-based TriageFirst. "Their courses would run approximately $14,000 to run all 200 of my staff through, so the decision was made to home grow a course to cover the material," he explains. The post-test came from the AHRQ material, which was from the government (not copyrighted) and free of charge, says Patrick. He used Macromedia's Breeze product, a web communications system from Adobe Systems, to turn it into an online test.

If a nurse got an answer wrong, the rationale for the correct answer was given, and nurses were required to achieve a minimum score of 90%, says Patrick. "Those who did not were required to remediate with one of the trainers," says Patrick. "After the test was completed, the nurse saw their score, entered their name and employee number, and e-mailed the test results to me."

After ESI went live, a second validation was done by having emergency nurses audit random charts of other nurses, says Patrick. The nurse then would indicate whether the triage nurse had appropriately triaged, overtriaged, or undertriaged the patient based on the documentation, he explains.

"For the most part, we found that we were overtriaging. This was a drastic swing from the under triage that routinely occurred with our previous system," says Patrick. "Now that we have been live for some time, we need to do another round of peer review to validate that everyone is triaging in the same fashion."

Spreadsheet assesses accuracy

At Community Medical Center Healthcare System in Scranton, PA, accuracy of triage levels is assessed with a spreadsheet listing the date, medical record number, chief complaint, age, and triage level assigned, says Debbie Clark, RN, ED nurse manager. "I talk with the nurse involved to get their take on it. I plan to use scenarios that are in question as teaching moments," she adds.

Annie Carter, MS, CNS, RN, CEN, former ED clinical trainer at Upstate Medical Center in Syracuse, NY, realized that no audit tool was available after the ED switched to ESI. As a result, no audit of charts was done, she says, so Carter had to create her own tool. "When I audited some charts for scenarios for the class, I could see that everyone was not consistent. Nurses continued to use their own opinions to assign an ESI level instead of the criteria presented in the algorithm," says Carter, who is a clinical nurse specialist in the ED at Riverview Medical Center in Red Bank, NJ.

She first looked to see if nurses were choosing the correct resources and counting them correctly. "I had them audit four of their charts, then had their preceptor also audit the same four charts, to compare how they assigned levels," says Carter. "I then pulled an additional eight charts, to see how consistent they were."

Interestingly, the preceptors did not always assign the correct triage level, Carter reports. "However, I was surprised at how many the students did get correct. Out of four students, one got 100% correct, and one only got one wrong," she says. "To my delight, one of the four came to me for clarification of when to assign someone to ESI Level 1 [requiring immediate lifesaving intervention.]"

Since nurses were not being consistent, Carter developed an online program using a poorly assigned triage as an example, such as abnormal vital signs in pediatric patients. "I was able review the abnormal vital sign criteria for up-triaging to Level 2 [a high-risk situation], which was an issue," she says.

There was some disagreement about when a patient may have a life-threatening condition that requires intravenous fluids, Carter recalls. "These discussions not only allowed me to evaluate what people consider to be life-threatening interventions, but to re-educate the students and preceptors about the type of patients who should have an ESI Level 1 assigned to them," she says.


For more information on triage competencies, contact:

  • Annie Carter, MS, CNS, RN, CEN, Emergency Department, Riverview Medical Center, One Riverview Plaza, Red Bank, NJ 07701. E-mail:
  • Debbie Clark, RN, Emergency Department, Community Medical Center Healthcare System, 1800 Mulberry St., Scranton, PA 18510. Phone: (570) 969-8000. E-mail:
  • T.M. (Pat) Patrick, RN, Staff Development Coordinator, Emergency Care Center, NorthEast Medical Center, 920 Church St. N., Concord, NC 28025. Phone: (704) 783-1670. E-mail:
  • Up to three free copies of The Emergency Severity Index, Version 4 Implementation Handbook (Publication No. 05-0046-2) and The Emergency Severity Index, Version 4: Everything You Need To Know DVD set (Publication number 05-0046-DVD) are available at no charge or shipping costs. To order, contact the Agency for Healthcare Research and Quality Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907-8547. Phone: (800) 358-9295. E-mail: A free copy of the handbook can be downloaded at
  • A Comprehensive ED Triage Course is offered by TriageFirst, consisting of an online pretest, a two-day workshop, an Emergency Severity Index (ESI) training module and online clinical expertise modules, and online post-test. The cost of the course is $499 per person. A Triage Acuity Audit Guide is a web-based chart auditing tool for retrospectively reviewing triage levels assigned by ED nurses. The cost ranges from $500 to $2,000 a year, depending on the extent of use. For more information, contact TriageFirst, P.O. Box 1924, Fairview, NC 28730. Phone: (828) 628-8022. Fax: (828) 628-8025. E-mail: Web: