Determining Emergency Severity Index Acuity: Key Triage Elements Identified by Emergency Nurses

The conflation of mandated screening question data collection with patient assessment at the initial triage encounter challenges the ability of the emergency nurse to identify patients at risk for deterioration rapidly and accurately. Further, inexperienced triage nurses are generally challenged in differentiating between questions that establish stability and questions that meet other requirements. The aims of the study included exploration of how triage nurses identified critical data elements to facilitate more rapid and accurate patient triage and Emergency Severity Index acuity assignment, perceptions of appropriate location of assessment elements, and identifying common triage processes.

A quantitative descriptive exploratory study using survey data was used to address study aims.

Participants identified the following elements appropriate to triage as chief complaint, vital signs, allergies (and latex allergy), pain/pain description, weight, history of present illness, suicide risk, preferred language, Glasgow Coma Scale, pregnancy status/last menstrual period, travel history, infectious diseases, arrival method, height, and use of blood thinners. All other screenings were identified as "belonging" during provision of care, at discharge, or never.

Emergency nurses identified critical triage data necessary to assign an Emergency Severity Index level. We recommend that future research focus on evaluation of a triage process that removes screening not directly related to the triage decision in terms of nursing accuracy in assigning an Emergency Severity Index level and patient outcomes.