EXPLORING BEST PRACTICE FOR TRIAGE

Author: Paula Funderburke, RN, MS, CEN, Atlanta, GaSection Editors: Andi L. Foley, RN, BSN, CEN, and Patricia Kunz Howard, RN, PhD, CEN

Triage is a French word meaning to “sort” or “choose.”It means a nursing judgment is made within a groupof patients to choose the sickest ones for earliest

treatment. The practice, beginning with the military inWorld War I, led to the best use of resources and improvedoutcomes.1 In the United States, there are many differentacuity level systems, ranging from 3- or 4-level systems to5-level systems. With increasing numbers of patients seek-ing emergency care, correct sorting allows the proper re-sources to be provided for each level of patient acuity.

Recent trends in emergency services in the UnitedStates have made the triage process very important. ED vis-its have increased steadily to 114 million reported in 2003,with the number of emergency departments and hospitalsdecreasing by 14% since 1993.2 Increasing numbers of in-digent, undocumented, and uninsured patients are seekingcare. The number of inpatient beds has decreased, andthere is a shortage of nurses, especially in critical care areas.All these factors have contributed to overcrowding in emer-gency departments. Crowded emergency departments neces-sitate the need to properly sort and identify the patientspresenting to triage.

Strong evidence exists to indicate 4 distinct areas ofbest practice and improvements for triage in the emergencydepartment: standardized 5-level acuity system understoodby nursing staff, physicians, and paramedics; a shortenedtriage process with standing orders initiated by the emer-gency nurse or physician; electronic systems that aid indecision making and provide reminders; and specific edu-cation and competency for this specialized area. These4 areas are supported by research and will lead to the bestpatient outcomes and improved patient satisfaction.

Five-Level Triage System

The first area of best practice is the adoption of a 5-level acuitysystem. The Emergency Nurses Association (ENA) and

American College of Emergency Physicians (ACEP) havepublished a joint position statement on the use of 5-level acu-ity systems: “ACEP and ENA believe that quality of patientcare would benefit from implementing a standardized EDtriage scale and acuity categorization process. Based on expertconsensus of currently available evidence, ACEP and ENAsupport the adoption of a reliable, valid 5-level triage scale.”3

The 2 best-known systems are the Canadian Triageand Acuity Scale (CTAS) and the Emergency Severity In-dex (ESI).4 In 1995, with support from the ENA, a groupof physicians and nurses met to develop a new triage acuitysystem with the goal of developing a standardized systemthat could be widely used across the United States. Theend result of this meeting was the ESI.5 During the sametime, Canadians were developing a system based on theAustralian National Triage System.6 The CTAS is well de-veloped and used throughout Canada as the standard fortriage in the emergency department.7

The ESI and CTAS are very similar. The ESI assessespatient presentation for higher-acuity patients and alsoconsiders the use of resources for lower-acuity patients. Re-search has indicated that the ESI is reliable and valid forpatients throughout the life span.4,5 The CTAS defines“door-to-physician” time and other objective measures asfactors in the decision-making process regarding acuitylevels.7 Although some may argue that the CTAS “door-to-physician” guideline increases litigious possibilities,especially in the United States, the CTAS is used widely,both in Canada and in the United States, as a reliableand valid triage acuity system.

In addition to the 5-tier standardized levels in the ESIand CTAS, any ED acuity system needs agreement and un-derstanding among paramedics, physicians, and nurses.Early triage studies indicate that the use of 3-level or non-standard systems could cause disagreement among healthcare professionals.8 Other studies recommended physicianand emergency medical technician knowledge and agree-ment, in addition to nursing.9 Thus the triage system actsas a means of communication.

Focused Triage with Standing Orders

Another area of triage best practice is an abbreviated orfocused triage, with initiation of standing orders. Manyemergency departments use a 2-tier system, starting withan initial assessment by nurses as the patient arrives, with

Paula Funderburke,Metro Atlanta Chapter, is Clinical Nurse Specialist, Emer-gency Services, Emory University Hospital, Atlanta, Ga.

For correspondence, write: Paula Funderburke, RN, MS, CEN, 1364 CliftonRd, NE, Atlanta, GA 30322; E-mail: paula.funderburke@emoryhealthcare.org.

J Emerg Nurs 2008;34:180-2.

0099-1767/$34.00

Copyright © 2008 by the Emergency Nurses Association.

doi: 10.1016/j.jen.2007.11.013

T R I A G E D E C I S I O N S

180 JOURNAL OF EMERGENCY NURSING 34:2 April 2008

the second step involving a more comprehensive assessment,history, and initiation of standing orders.10 The initial eval-uation by nurses allows the sickest patients to be rapidlymoved to an acute care area for treatment. Rapidly initiat-ing treatments decreases length of stay. Another aspect ofthis process is the use of a physician or nurse practitionerat triage.11 The physician can order needed testing and pain-medications and discharge lower-acuity patients. Studiesdocument that this process decreases “door-to-physician”times and also decreases length of stay while increasingpatient satisfaction.

Standardized Electronic Systems with Enhanced

Decision Making

The third method of triage best practice is the use of elec-tronic systems, especially those that enhance decision mak-ing. An example is eTRIAGE (TEC Edmonton, Edmonton,Alberta, Canada).12 Developed at the University of Alberta(Edmonton, Alberta, Canada), in cooperation with thenurses and physicians practicing at a multi-hospital systemin Edmonton, eTRIAGE is electronic software. It is aCTAS-compliant Web-based triage tool, maintained byDavid Meurer, for the Alberta hospitals using this system.It is user-friendly and allows the nurse to enter the patient’sage, chief complaint, and vital signs and to quickly answera few key questions. It provides prompted questions depend-ing on the chief complaint and other data. For example, ifyou enter “fever, respiratory rate >36/minute,” the eTRIAGEsystemmight ask, “Have you considered respiratory isolationor chest x-ray?” It has also been used by pre-hospital EMSproviders, leading to seamless care.13,14

There are a number of computer software companiesin the United States with programs for ED documentationsystems, but none provide decision-making prompts atthis time.13,14 As more emergency departments adopt elec-tronic documentation, standardization in the triage processacross the United States will be possible. Standardized sys-tems could also aid in real-time syndrome surveillance forbioterrorism and public health.

Education and Competency

The last area important to the area of triage best practice isthat of nursing education and competency. The ENA rec-ommends that a registered nurse with at least 6 monthsof ED experience perform triage.15 One study, in whichnurses were trained in pediatric mass casualty triage, foundthat “structured training results in triage performance im-provement.”16 In this study nurses were given a pre-test,training, and a post-test. The researchers used a staged sce-nario for performance. Although the study had a small

sample size, it did prove effective in retention of triageknowledge and its application to specific patient scenarios.

A very exciting finding was a study describing an online6-week course for the CTAS.9 The course was developed byCentennial College in Toronto, Ontario, Canada. Offeredonline, this teaching method decreased travel time and othereducational costs. The nurse completed a module using in-teractive case studies and photographs to enhance scenariosimulations and participated online to discuss case studies.The course concluded with an examination based on casestudy scenarios. Post-course chart audits of the nurses whocompleted the course indicated 99% reliability between thetriage levels of the students and expert reviewers.9 Hospitalscould enhance the course learning by providing didactic andclinical competency evaluation as well as an ongoing perfor-mance improvement program for feedback to nurses.

Measuring Best Practice at Triage

Improvement in any system could be measured by specificquality characteristics. Acuity levels (decisions made bynurses) before and after implementation of a new systemcould be measured against expert reviewers for reliability.Other quality indicator measures to examine could includethe rate of discharges against medical advice, customer ser-vice scores, “door-to-physician” time, length of stay, andappropriate use of standing orders.

In summary, there are many best practice standards as-sociated with ED nursing triage. The current environmentwith overcrowding and limited resources makes triage de-cisions and processes increasingly important. Improvingthe processes nurses are currently using can positively affectpatient outcomes and patient satisfaction. Although addi-tional costs and resources may be required to implementthese triage best practices, focused 5-level triage, early im-plementation of standing orders, electronic documentation,training and competency evaluations of triage staff, andcontinued quality and process improvement measures willbe in the future of emergency nursing.

Acknowledgments

The author wishes to greatly thank Andi Foley for her assistance in

this article.

REFERENCES1. Bracken J. Triage. In: Newberry L, editor. Sheehy’s emergency

nursing principles and practice. 5th ed. St. Louis: Mosby; 2003.p. 75-83.

2. Fox News. Snyder D. In U.S. hospitals, emergency care in criti-cal condition. Available at: http://www.foxnews.com/story/0,2933,193883,00.html. Accessed September 13, 2007.

TRIAGE DECISIONS/Funderburke

April 2008 34:2 JOURNAL OF EMERGENCY NURSING 181

3. Emergency Nurses Association. Emergency Nurses Association(ENA) and American College of Emergency Physicians (ACEP)Joint Five-Level Triage Task Force. Standardized ED triagescale and acuity categorization: joint ENA/ACEP statement.Available at: http://www.ena.org/about/position/ACEP/Joint5-LevelTriageTask.asp. Accessed November 10, 2007.

4. Wuerz RC, Travers D, Gilboy N, Eitel DR, Rosenau A, YazhariR. Implementation and refinement of the Emergency SeverityIndex. Acad Emerg Med 2001;8:170-6.

5. Eitel DR, Travers DA, Rosenau AM, Gilboy N, Wuerz RC.The Emergency Severity Index Triage Algorithm version 2 isreliable and valid. Acad Emerg Med 2003;10:1070-80.

6. Thompson JM, Graham D. Ruralizing the Canadian triage andacuity scale. CJEM 2000;2:267-9.

7. Canadian Association of Emergency Physicians. CanadianTriage and Acuity Scale (CTAS). Available at: http://caep.ca/template.asp?id=B795164082374289BBD9C1C2BF4B8D32.Accessed September 30, 2007.

8. Gill JM, Reese CLIV, Diamond JJ. Disagreement among healthcare professionals about the urgent care needs of emergency de-partment patients. Ann Emerg Med 1996;28:474-9.

9. Atack L, Rankin JA, Then KL. Effectiveness of a 6-week onlinecourse in the Canadian Triage and Acuity Scale for emergencynurses. J Emerg Nurs 2005;31:436-41.

10. Fisher L, Whalen KC. A look at a two-step triage system: “howone high volume, level I trauma center decreased long triagewaits”. J Emerg Nurs 2004;30:584-5.

11. Subash F, Dunn F, McNicholl B, Marlow J. Team triageimproves emergency department efficiency. Emerg Med J2004; 21:542-4.

12. Dong SL, Bullard MJ, Meurer DP, Colman I, Blitz S, Holroyd BR,Rowe BH. Emergency triage: comparing a novel computer triageprogram with standard triage. Acad Emerg Med 2005;12: 502-7.

13. Dong SL, Bullard MJ, Rowe BH, Hauswald M. The need forreliable and valid triage … [comment on Acad Emerg Med2005;12:533-5] [letter]. Acad Emerg Med 2005;12:1013.

14. Dong SL, Bullard MJ, Meurer DP, Blitz S, Holroyd BR, RoweBH. The effect of training on nurse agreement using an elec-tronic triage system. CJEM 2007;9:260-6.

15. Killian M, editor. Standards of emergency nursing practice.4th ed. Park Ridge (IL): Emergency Nurses Association; 1999.

16. Sanddal TL, Loyacono T, Sanddal ND. Effect of JumpSTARTtraining on immediate and short-term pediatric triage perfor-mance. Pediatr Emerg Care 2004;20:749-53.

Submissions to this column are welcomed and encouraged. Sub-missions may be sent to:Andi L. Foley, RN, BSN, CENandii42@yahoo.comorPatricia Kunz Howard, RN, PhD, CENPKHoward@uky.edu

TRIAGE DECISIONS/Funderburke

182 JOURNAL OF EMERGENCY NURSING 34:2 April 2008