Root out under-triage in the ED

Train nurses to think beyond triage tools

Under-triage, or assessing patients as being less ill than they actually are, can lead to treatment delays and adverse outcomes, including serious injury and even death. Despite such dire consequences, however, Lisa Wolf, PhD, RN, CEN, FAEN, a clinical assistant professor nursing at the University of Massachusetts in Amherst, MA, believes that under-triage is occurring in ED environments across the country. Why? Wolf believes that part of the problem is that triage decisions are not always based strictly on a patient's condition.

"A lot of clinical decision-making is affected by the people around you — the nurses, the volume, the lengths of time that patients wait in the waiting room, and the presentation of the patient," she says. Further, Wolf suggests that the people charged with making triage decisions are not always equipped with the high-level capabilities needed to be able to differentiate between Emergency Severity Index (ESI) level 2 patients, who are typically seen right away, and ESI level 3 patients, who are deemed stable enough to wait.

An under-triage problem is not always obvious, but routine chart reviews can give ED leaders clues as to whether their triage process is working effectively and whether the right clinicians are handling triage. Then it is up to ED leaders to devise appropriate corrective steps to improve triage accuracy.

Consider implications of triage designation

Wolf has been observing clinical decision-making in EDs across different regions for years, but recently participated in a study to identify what factors most impact transfer times between the ED and the intensive care unit (ICU.)1 In the study, which was conducted at a 142-bed community hospital, data was collected on 75 patients who were transferred from the ED to the ICU. The researchers found that more than half of these patients (58.7%) spent more than four hours in the ED before being transferred, and that the strongest factor impacting transfer times in these cases was the initial ESI triage assignment.

Perhaps not surprisingly, patients designated as ESI 3 were well-represented in the delayed group. In fact, 19 of the 25 patients designated as ESI 3 had delayed transfers, making up more than 40% of all the patients who had delayed transfers. This highlights the difficulty many triage nurses can face, trying to discern whether a patient is potentially unstable, which would match the ESI 2 assignment, or urgent but stable, which is in line with ESI 3. However, Wolf stresses that the difference between these two triage designations has important implications for how these patients will be cared for in the ED.

"The triage designation sets the tone and the trajectory for the entire visit. When a patient is triaged as urgent but stable, the nurse is less likely to go to that patient first if she is busy because the patient is stable. That is what ESI 3 tells you. This patient can wait a half hour," she explains. "However, when somebody gets triaged as potentially unstable or unstable, the nurse will go to see that patient first, so things will be picked up faster with a higher triage."

In Wolf's study, cases of sepsis were the most likely to be under-triaged, but she observes that there are many conditions that require higher-level skills to assign accurately. "There is a whole category of well-appearing ill people out there who get ignored, and their treatment gets delayed. It is really problematic," says Wolf.

Further, in a tricky case, a triage nurse may be reluctant to follow her instincts in an environment that she senses will not be supportive of her decision. "We ignore the fact that clinical decision-making takes place within a social context rather than on a piece of paper," says Wolf. "It is really hard for people to put forward their clinical decisions in the face of resistance."

Given the stakes involved with an incorrect triage assignment, Wolf is concerned about attempts to speed up or simplify the triage process in the interest of faster throughput. "The whole point of triage is to get people the resources they need as quickly as they need them rather than just to put bodies in chairs or in beds," she says. "It is an assessment decision, not a task."

Assign the right nurses to triage,

More than anything else, getting triage right boils down to making sure that the right people are doing the job, according to Jeff Solheim, RN, BRE, CEN, CFRN, a triage expert, consultant, and frequent speaker at emergency care conferences around the world. "There are a lot of ED leaders who look at triage as just another assignment, but it isn't. It is a very unique place that needs to be staffed by the right people," he says. "Not everybody is going to be a good charge nurse or manager, and if they don't have the skills they shouldn't be there. I think triage is the same. It requires a certain subset of skills that I am not convinced every emergency nurse has."

Some facilities use a staffing process that insures that everyone gets rotated through triage, but Solheim believes that ED leaders should put a lot more thought and effort into determining which personnel can do the job well. "Some EDs have clinical ladders, and one of the levels that a nurse can reach is triage," he says. "I think that is a very powerful way of making sure the right people — people who have met the requirements — climb the ladder."

It's an objective process, although it still allows for an educator or ED leadership to have some input on who handles triage and who doesn't, says Solheim. This is important because the best triage nurses can pick up on things that triage tools cannot.

"This is one of the reasons why I like the Emergency Severity Index. It allows the nurse a little bit more subjectivity in decision-making than some of the other triage systems that are out there," says Solheim. "Some of the tools are great. They make people think, but ultimately the tool always has to allow for nurse subjectivity, and that is why you want the right nurse out there."

Solheim adds that some people just have those great decision-making skills where they can think outside the box or outside the tool, and that is what makes a good triage nurse. "Those who don't have that same critical thinking process may stick too close to the tool," he says. "Tools can be good and bad, but if the right person is out there they can use a tool to reinforce their triage, and ultimately know that they are making the right decision."

Make nurse training a priority

In addition to selecting the right people to handle triage, Solheim says ED leaders should prioritize training so that personnel fully understand the basics of triage as well as the particular process that is being used in the facility. Too often, ED leaders will tell someone that it is their day to triage, and then they will take 10 minutes to show them how to do it, he says. "That does not establish a good triage nurse," adds Solheim.

Further, to reinforce training, Solheim advises nursing leaders to establish procedures for good quality control, where a certain percentage of each nurse's charts are regularly audited to determine whether she or he is triaging to the correct level, or under- or over-triaging. "When thresholds of a certain percentage fall out, then the nurse needs to be retrained or reevaluated to determine whether [this individual] should even be doing triage," he says, noting that a triage nurse should be making accurate assessments about 95% of the time. "If this isn't happening, then it is a good opportunity to help the nurse go back and look at what she is doing."

"Sometimes we get into bad habits, even as triage nurses. Sometimes people forget the initial training. Quality control audits can help to keep the training in mind and keep triage at the right level," says Solheim.

There are different ways to conduct chart audits. Staff nurses can even conduct some of these audits themselves if department leaders want to increase the number of charts reviewed, says Solheim. However, he says an ED leader or an educator should complete some of these audits, or at least review them to bring some objectivity to the process.

Monitor nurse triage assignment

One other issue that ED leaders should consider is how the initial triage decision is being used. Why? Because like Wolf, Solheim has seen instances in which the triage assignment is used inappropriately throughout a patient's stay in the ED. "Whatever is initially assigned should be there, but you can assign a new level if the patient's condition changes," says Solheim. "A lot of times EDs are surprised to hear that."

Further, Solheim emphasizes that once a patient is in a bed, there should be no need to reassign a triage level. "Triage is all about who comes into the treatment area first, but once a patient is in the treatment area, the triage assignment should be put away," he says. "It really shouldn't be used in any further decision-making. Once a patient gets to the back, other tools should be used to determine urgency."

Solheim says that EDs that continue to rely on the triage priority as their assessment in the back are perverting what triage is meant to do. "It is not meant to continue throughout a patient's stay," he says. "Once a patient is in the back, there should be a new system defined for how urgent a patient is viewed."


  1. Yurkova I, Wolf L. Under-triage as a significant factor affecting transfer time between the emergency department and the intensive care unit. Journal of Emergency Nursing 2011; 37:491-496.


  • Jeff Solheim, RN, BRE, CEN, CFRN, Solheim Enterprises, Keizer, OR. E-mail:
  • Lisa Wolf, PhD, RN, CEN, FAEN, Clinical Assistant Professor of Nursing, University of Massachusetts, Amherst, MA. E-mail: