Clinical decision-making: Cognitive biases and heuristics in triage decisions in the emergency department

In emergency medicine, triage decisions are critical for ensuring patient safety and optimizing resource usage. Such decisions involve a complex interplay of rational and analytical thinking, combined with an intuitive and humanistic approach. However, the influence of cognitive biases on triage decisions remains poorly understood.

Between February 20 and June 27, 2023, we conducted an online scenario-based survey with 78 triage-competent Registered Nurses in the emergency department at Princess Alexandra Hospital in Australia. Co-designed with nurse educators and nursing academics, the survey included domains covering demographic information, tailored diagnostic tests to capture the presence of cognitive biases and risk-taking behavior, and six vignettes requiring triage using the Australasian Triage Scale. Logistic mixed-effects and multivariate Poisson regression models were performed to identify the influence of cognitive biases and risk-taking behavior on triage decision accuracy.

We identified negative framing bias (82.5 %), anchoring bias (82 %), and availability bias (62.8 %) as the most prevalent cognitive biases among triage nurses. After adjusting for age, sex, education, and triage work experience, no statistically significant associations were observed between cognitive biases or risk-taking behavior and triage accuracy. This indicates that cognitive biases may have a limited influence on well-trained nurses. However, age, sex, and triage work experience were found to be significant predictors of inaccurate triaged decisions.

Our study provides preliminary evidence that cognitive biases and risk-taking behavior are not associated with triage accuracy among well-experienced and trained emergency triage nurses. Further research is required to fully understand the impact of cognitive biases on emergency triage decisions.