Which emergency severity index level should be considered a high priority for the nurse?

Triage is derived from the French “trier” (to sort) and is a crucial component of proper acuity assignation and resource allotment in the emergency care setting. Triage nurses generally perform initial assessment and a focused physical examination and may order initial diagnostic studies according to standing orders or protocols. The process of triage and acuity assignment is dynamic and should involve multiple reassessments focused on identifying the patient who is decompensating.1 In practice, however, the criteria used to assign patient acuity levels at the initial patient encounter in the emergency department (triage) vary among emergency nurses and their respective emergency departments. Patient acuity decisions are sometimes made in the absence of physiological data and are dependent on nursing knowledge and skills and the social context in which the decision occurs.2, 3, 4, 5 The correctness of the initial triage decision has been reported to drive the clinical trajectory for ED patients,6 and therefore this step in patient care is critical to patient safety. The Emergency Severity Index (ESI)—a 5-point score assigned by a triage nurse and based on disease acuity, patient potential for decompensation, and anticipated resource use7—is used both in the United States and internationally. In the US, the ESI is used by up to 94% of the academic medical center emergency departments.8 Originally, a group of emergency physicians and nurses devised the ESI concept; later, the Agency for Healthcare Research and Quality funded the initial research on the application of the ESI in emergency care settings. In recent years, the Agency for Healthcare Research and Quality has maintained and supported this evidence-based system, now in its fourth edition; in 2020, the Emergency Nurses Association acquired the intellectual property rights to the ESI and is responsible for the index’s maintenance and improvement. The ESI classification implicitly allows for variation and relies heavily on individual triage judgment by emergency nurses and other clinicians, and thus the triage decision is reliant on the nurse’s education, experience, and expertise in identifying patients classified as high risk. The ambiguities in the ESI algorithm9, 10, 11, 12 make it particularly susceptible to variability in clinician training and experience as well as to other human and institutional biases, ultimately leading to under-triage (risk to patients) and over-triage (inappropriate use of resources). In reliability studies, the highest agreement measured between triage nurse and expert nurse was at sites that reported initial ESI training, ongoing ESI training, and quality monitoring of triage decisions,8 suggesting that a consistent approach to training and quality follow-up is important to safe and accurate triage processes.

Errors in triage can challenge safe patient care; specifically, under-triage (assignment of an inappropriately low acuity score) can result in dangerous delay of necessary medical care, and over-triage (when patients who are less critical are assigned a higher priority) can lead to resource overuse and delays in providing care for those with more urgent needs. Research findings11, 12, 13, 14 suggest that not only do emergency triage nurses demonstrate high error rates on average, but that the nurses’ errors are also clustered around specific presentations, including those that would be high risk. More research needs to be conducted on both the process and application of the ESI when making a triage assignation to improve the use of the ESI.

The purpose of this study was to develop a research agenda for the improvement of individual and institutional understanding of, and use of, the ESI.

Methods

We used a modified Delphi process with 3 rounds of data. The Delphi technique has 4 main characteristics: anonymity, iteration with controlled feedback of group opinion, statistical aggregation of group response, and expert input.15 The Delphi method is recommended for use in the health care setting as a reliable means of determining consensus for a defined clinical problem.16, 17, 18, 19 Before the first round of the Delphi process, a literature review was circulated to a work group of

Results

Round 1 (N = 13) yielded a total of 112 issues (Q1 = 34; Q2 = 39; Q3 = 24; and Q4 = 15). These 112 issues were examined by the research team for repetition and similarity and ultimately collapsed by consensus into 18 potential research questions in 4 general categories: education and training (6 questions), workplace environment (3 questions), emergency care services (7 questions), and special populations (2 questions). In round 2 (N = 14), the participants reported their agreement with the

Discussion

The purpose of this study was to develop a research agenda for the improvement of individual and institutional understanding and use of the ESI.

Using a modified Delphi process, we were able to develop a rank-ordered list of priorities. The focus of the list is on education and training, ranked as the highest priority category (1.38/4), which aligns with much of the extant literature.

Studies of triage education are well represented in the literature. Delnavaz et al20 report in their review of

Limitations

The participants in this study were a self-selecting group who applied to be part of a work team focused on how the Emergency Nurses Association can best maintain and improve the ESI scale. The participants had varying levels of nursing expertise and experience in triage. However, some of the limits imposed by the variety of expertise and triage experience may be mitigated by the fact that they work in different areas of the US and in different hospital settings, thus bringing a broad range of

Implications for Emergency Clinical Care Nurses

Establishing priorities for research into the use of the ESI delineates a necessary knowledge base for clinical nurses using the ESI as they perform triage functions.

Conclusions

The research priorities as set through the use of this modified Delphi process align well with current gaps in the literature. Research in these areas should be encouraged to improve the understanding of educational, environmental, and process challenges to emergency nurses’ triage decisions and accuracy of ESI assignments.

Author Disclosures

Both authors are employees of the Emergency Nurses Association.

Lisa A. Wolf is Director, Emergency Nursing Research, Emergency Nurses Association, Schaumburg, IL and is Member, Pioneer Chapter (MA). ORCID identifier: https://orcid.org/0000-0002-7065-470X.

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