Triage practices vary widely among emergency nurses and within EDs, according to the authors of a recent study.1
“We were interested in the clinical implications of the prevalence of ‘pull-to-full’ triage strategies,” says Lisa A. Wolf, PhD, RN, CEN, FAEN, director of the Emergency Nurses Association’s Institute for Emerging Nursing Research. This refers to an approach used at many EDs whereby less information is collected at triage and patients are put in treatment areas as such locations become available without prior screening.
Researchers conducted focus group interviews with 26 ED nurses. ED nurses reported a pervasiveness of “quick look” triage techniques, which do not rely on physiologic data, to make acuity decisions. Participants described processes that were manipulations of the triage system to “fix” problems in ED flow rather than a standard application of a triage system. “Essentially, they triaged the emergency department to facilitate flow rather than assigning an accurate triage level based on the patient presentation,” Wolf explains.
A 2010 observational study of triage revealed nurses were assigned acuity based on two things: patient volume in the ED and which providers happened to be working that shift.2 The authors of the 2018 study confirmed that these findings reflected what nurses themselves said about their triage practices. “The triage acuity sets the trajectory for the patient visit,” Wolf says. One important factor in delay in getting critical patients to the ICU from the ED is undertriage.3
“An inadequately staffed ED means nurses cannot focus fully on the patient in front of them,” Wolf says. “[Nurses] may miss critical cues that guide acuity assessment.”
Malpractice claims commonly allege that the ED nurse undertriaged a patient who clearly met criteria for a higher acuity level. The patient waits a long time and experiences a poor outcome.
“You could make the case that the driving factor in the delay in care was the lower triage level,” Wolf offers.
Triage nurse experience is another focus area in litigation. “Certainly, if a hospital puts a new nurse, a float, or one who has inadequate training in triage, you could make a case that the hospital neglected its duty to provide safe care,” Wolf says.
The Emergency Nurses Association recommends that triage nurses work a minimum one to two years in the ED, obtain emergency nursing certification, and undergo training in trauma care and critical care management. “In EDs where you have the charge nurse also doing triage, or the newer nurses doing triage, it becomes potentially problematic,” Wolf cautions.
- Wolf LA, Delao AM, Perhats C, et al. Triaging the emergency department, not the patient: United States emergency nurses’ experience of the triage process. J Emerg Nurs 2018;44:258-266.
- Wolf LA. Acuity assignation: An ethnographic exploration of clinical decision making by emergency nurses at initial patient presentation. Adv Emerg Nurs J 2010;32:234-246.
- Yurkova I, Wolf L. Under-triage as a significant factor affecting transfer time between the emergency department and the intensive care unit. J Emerg Nurs 2011;37:491-496.