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CLINICAL DECISION MAKING IN TRIAGE: AN INTEGRATIVE REVIEW Author: Laura M. Stanfield, MSN, RN, CEN, Burlington, NC
mergency department overcrowding stems from fewer emergency departments being available for a greater number of patients seeking care. The American College of Emergency Physicians (ACEP) reports that there were closures of more than 1,000 emergency departments in the United States from 1991 to 2006 despite a steady increase in patient volume from 119.2 million visits in 2006 to 136 million in 2009. 1 From 1997 to 2007, the rate of ED visits surpassed the US population growth rate by 2-fold. 2 According to the Centers for Disease Control and Prevention’s 2010 National Ambulatory Medical Care Survey, there were 129.8 million visits to emergency departments. 3 The average wait time for patients to see a provider in the emergency department has also increased, with Hing and Bhuiya 4 noting a 25% increase from 2003 to 2009, from 46.5 to 58.1 minutes on average. With a limit to the resources available, accurate sorting of patients must occur to appropriately provide care for those who seek it. Patients in the emergency department are triaged on arrival to determine the acuity of their complaint. This triage determination is meant to decide the order of priority in which patients are to be seen and the amount of time patients can safely wait to see a provider. The Emergency Nurses Association (ENA) and ACEP have published multiple position statements since the movement to standardization of triage in the US began in 2000. Most recently, in 2010, both the ENA and ACEP recommended use of a 5-level triage system such as the Emergency Severity Index (ESI). 5 The 5 levels are as follows: level 1, immediate (life-saving intervention is required); level 2, emergent (patient should not wait for treatment); level 3, urgent (patient is stable to wait, and ≥ 2 resources are required);
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Laura M. Stanfield, Member, ENA North Carolina Piedmont Chapter, is Assistant Director, Emergency Department, Cone Health Alamance Regional, Burlington, NC. For correspondence, write: Laura M. Stanfield, MSN, RN, CEN, Cone Health Alamance Regional, 1240 Huffman Mill Rd, Burlington, NC 27216; E-mail: Laura.Stanfi[email protected]. J Emerg Nurs ■. 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.02.003
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level 4, less urgent (1 resource is required); and level 5, non-urgent (no resources are required). 5 A resource is described as laboratory work, radiographs, and procedures such as laceration repair among others. 5 Patient care begins with triage at the front door of the emergency department, and this affects the entire visit, including wait time for treatment; attention to how this process occurs is needed. Training on use of the 5-level ESI system is imperative for a triage nurse. However, research has shown that other factors play into the assignation of acuity. The purpose of this integrative review of the literature is to determine the clinical decision-making skills or other factors used by emergency nurses in triage as determined through previous studies. The information gathered can then be included in triage training, for veteran and new triage nurses, to review these factors for how they are incorporated into each nurse’s practice. Methods
Clinical decision-making skills used by nurses in ED triage have an impact on the entire patient experience. This can include the patient’s health outcomes, time to treatment, and overall length of stay, as well as patient satisfaction. The literature was reviewed to determine research recently conducted to better understand these clinical decision-making skills. The literature review covered a 12-year period from 2002 to 2014. The search included the use of 3 electronic databases—CINAHL (Cumulative Index to Nursing and Allied Health Literature), PubMed, and PsycINFO—with special attention paid to the Journal of Emergency Nursing and the Advanced Emergency Nursing Journal. Research articles from the US conducted with nurses either in an emergency setting or using triage case scenarios were included. Key words included emergency nurse or nursing, triage, and clinical decision making. Studies not relating to the decision-making process or factors that influenced triage acuity designation were excluded. In addition, studies with the specific intent of testing ESI reliability were excluded to focus on the other factors that affect triage. Multiple searches resulted in 126 studies (with duplication between databases), of which 11 were included in the review. Articles were examined using the matrix method as described by Garrard. 6 Each article was evaluated and organized in matrix format, using ascending chronologic order, regarding 8 specific topics. These topics varied among
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articles due to their nature, being either qualitative or quantitative research studies. The topics comprised journal identification, purpose, design, sample, variables, results, limitations, and implications for further studies. Detailed notes were taken while each article was read intently; the results of the researchers were then categorized, based on my notes, into common themes by grouping together the article findings. A summary of each article reviewed is included in the Table.
Results
After review of the current literature, common themes emerged from the research as factors relating to the clinical decision-making process of triage. These themes were (1) clinical information; (2) education and experience; (3) characteristics, attitudes, and beliefs of triage nurses; and (4) environment of care. CLINICAL INFORMATION
The triage process begins when the nurse first lays eyes on the patient, and researchers sought to find what specific clinical information nurses use and how it relates to patient acuity. Common threads of clinical information gathered included (1) chief complaint, 7,13 (2) vital signs including pain, 10,12–14 (3) symptoms, 7,8 and (4) medical history. 8,10 Chief Complaint Arslanian-Engoren 7 sought to determine what cues triage nurses use when interviewing male and female patients with possible acute coronary syndrome and whether these cues varied by patients’ sexes or the nurses’ demographic information. Questionnaires presented information to study participants from 2 patient vignettes, randomly generated by computer program, the first with classic symptoms of acute coronary syndrome and the second with symptoms that were more atypical. The study found that triage decisions were based on the chief complaint and did not vary by patient sex. Similar results were found by Garbez et al 13 in a study comparing patients assigned to either level 2 or level 3 acuity based on patient characteristics, as well as the time to initial intervention and utilization of resources in the emergency department. After assigning acuity, nurses filled out questionnaires about their triage assessment. Data were also collected from the patient chart regarding time to intervention and utilization of resources. The results of the study showed that acuity assignation was more likely to be based on chief complaint than on medical history or current medications.
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Vital Signs Cooper et al 12 used an observational study to determine whether knowing the vital signs of patients in triage changed the assigned triage designation and whether age and ability to communicate modified this change. The results showed that 92.1% of triage decisions were not affected by knowing the patient’s vital signs. In the other 7.9%, most changes occurred in young patients (b 2 years), elderly patients (N 75 years), and patients with a communication barrier. Triage acuity level was downgraded in 2.4% and upgraded in 5.5% after vital signs were obtained. In 2011 Castner 10 sought to determine what data were being collected in triage. Data were categorized as being either important to the nurse for triage or required of the nurse to collect during triage. Vital signs, pain score, medical history, and allergies were noted to be the most important, as well as the most required, information collected for triage. In the study by Garbez et al 13 mentioned earlier, if vital signs were outside of normal limits, patients were more likely to be assigned a higher acuity level. However, 13% of patients assigned to level 3 had abnormal vital signs, showing that some other factor played into the triage nurses’ decision making, suggesting that vital signs are used in addition to clinical judgment when applying the ESI algorithm 5 that vital signs are used in addition to clinical judgment. Using data gathered for the previous study, Garbez et al 14 sought to identify what factors triage nurses used when assigning either level 2 or level 3 acuity. This examination of data showed that patient age, vital signs, and the need for timely intervention were the most significant factors when assigning a patient to ESI level 2. The study also noted a difference in the explanation of acuity designation between experienced and beginning triage nurses: Experienced nurses reported using symptoms in addition to the chief complaint and the patient’s clinical presentation to influence decision making. Symptoms Results from the study by Arslanian-Engoren, 7 seeking to determine what cues triage nurses use when interviewing possible acute coronary syndrome patients, found that the triage decisions were also based on a patient’s presenting symptoms. The author noted limitations of the study using hypothetical clinical vignettes and reported that the sample of ENA members might not have been representative of all emergency nurses. In 2009 Arslanian-Engoren 8 used a qualitative approach to explain the triage decision-making processes for men and women presenting with myocardial infarction symptoms. The study reviewed conversations after hypothetical case presentations of patients with symptoms suggestive of myocardial infarction in triage.
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The sessions yielded similar results to the author’s previous study: Participants relied on the clinical presentation of the patient, such as his or her general appearance, transportation mode, and presence of pain, to determine triage acuity. Medical History In the 2009 study by Arslanian-Engoren, 8 session participants also reported relying on medical history to assign triage acuity. In the same manner, a survey of New York ENA members by Castner 10 showed that medical history was one of the most important pieces of information collected in triage, as well as one of the most required. EDUCATION AND EXPERIENCE
In 2002 Cone and Murray 11 sought to describe the traits, thought processes, and acts of decision making by expert emergency nurses in triage through a qualitative study. They used group forums with focused questions regarding characteristics of emergency nurses, decision-making experience, most important decision-making components, experience required for a triage nurse, and education required for triage. Common themes emerged, including the need for at least 1 year of experience before being placed in the triage role and a need for formal triage education (although none of the participants had this). Both of the studies by ArslanianEngoren 7,8 resulted in education and experience being required of triage nurses. In the 2005 study using hypothetical patients, the nurse’s experience level was found to have a small statistical significance toward increased accuracy when triaging. 7 A common theme from the qualitative 2009 study of self-volunteered nurses’ conversations related their feelings that nursing knowledge and ED experience are necessary to make triage decisions. 8 In 2010 Wolf 16 researched the decision-making strategies used to assign acuity to patients in triage, including particular cues and processes. The researcher focused on observations of triage interactions and findings on patient presentation (complaint, duration of symptoms, and body habitus), patient volume, and environment of care (unit leadership, communication with patient and providers, and length of time in triage). The results were interpreted to show that acuity was assigned based on factors of the individual nurses versus institutional protocol or rating scale. Factors of the individual nurses included use of intuition, ED experience, and the description of a “gut feeling.” Martin et al 15 studied whether a relationship existed between triage accuracy using the ESI and nurses’ attitudes and experience. ED triage experience was gathered through a demographic survey, the Nurse Characteristic Collection Tool, and attitude toward patients was measured using the
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Caring Nursing Patient Interactions scale (CNPI-23). ESI triage accuracy was confirmed by comparing assigned ESI scores from participants in triage with expert ESI assignation by clinical nurse experts from review of the patients’ charts. The study showed no statistical support that attitude or experience contributed to accuracy in ESI scoring. It did, however, support the reliability of the ESI triage tool, after appropriate training, for nurses with different experience levels. CHARACTERISTICS, ATTITUDES, AND BELIEFS
The study by Cone and Murray 11 seeking to describe the traits, thought processes, and acts of decision making by expert emergency nurses in triage produced themes of good communication skills, the ability to work at a fast pace, and flexibility in the role as characteristics of the triage nurse. The next year, Brannon and Carson 9 researched what cognitive aids (heuristics) influenced the process of decision making of triage nurses. The study used 2 case descriptions for participant review; each case presented classic symptoms of either a myocardial infarction or stroke, and some of the descriptions contained contextual information that could be the cause of symptoms (eg, experiencing a stressor like job loss or having the smell of alcohol on the breath). The results showed no variation between the decisions of nurses and those of nursing students. When contextual information was presented in the case description, participants were more likely to alter the decision process to choose the potentially less serious diagnosis: stress over myocardial infarction and intoxication over stroke. The study by Arslanian-Engoren 8 produced results indicating that personal attitudes, beliefs, and biases influenced triage decisions. This included distrusting reports of complaints for patients who continually talked on their cell phones, ate snacks, or were wearing full makeup, as well as patients from certain cultures (Asian/Hispanic) that study participants reported to be very demonstrative in their presentation. Wolf 16 also described the cultural bias of Hispanic presentation, with description of the triage nurse as being burdened by a patient’s demonstrative display of pain. This study also showed a similar bias to that noted by Brannon and Carson. 9 A particular description was given of a patient encounter in which the physician offering antianxiety treatment, despite the cardiac arrhythmia present on monitoring, lessened the perception of patient acuity. ENVIRONMENT OF CARE
The 2010 study by Wolf 16 showed that acuity was assigned based on environmental factors of the particular unit/facility
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TABLE
Integrative review article summary Study
Purpose
ArslanianEngoren 7 (2005)
Determine patient cues Quantitative Patient sex Patient sex did not play Clinical information used to triage patients Descriptive Patient cues a role in triage re- Education and exwith complaints sug- 3,000 ENA members Nurse demographic sponse perience gestive of acute cor- randomly selected to characteristics Experience played a onary syndromes and receive questionnaire; small role determine if cues var- 840 questionnaires Triage decision based ied by patient sex or completed on CC and symptoms nurses’ demographic characteristics Explain triage pro- Qualitative Determine underlying Reliance on PMH, Clinical information cesses of emergency Descriptive cause of chief demographic Education and exnurses when tria- 12 nurses in 3 ques- complaint characteristics, clini- perience ging both sexes for tion-answer group Identify important/ cal presentation, gen- Characteristics, attiMI sessions using hy- relevant patient cues eral appearance, tudes, and beliefs pothetical situations Ultimate goal in transportation mode, triage decision for vital signs, and prepossible MI sence of chest pain Reliance on own attitudes, perceptions, beliefs, nursing knowledge, and ED experience Reliance on ESI scale for urgency Determine if repre- Quantitative Medical training No variation whether Characteristics, attisentativeness heuris- Descriptive (nurse vs student nurse or student tudes, and beliefs tic (using mental 182 nurses and nur- nurse) nurse map to guide search sing students; 2 case Presence of contex- Contextual informafor additional infor- descriptions tual information in tion altered decisionmation) influences patient profiles making process; decision making in more likely to choose nurse triage potentially less serious diagnosis through representativeness heuristic Describe data ob- Quantitative Important to RN vs Vital signs, allergy, Clinical information tained in triage Descriptive required of RN pain, and medical 1,600 surveys sent Length of triage history ranked most to New York ENA Protocols in triage important members; 430 surVascular access, oral veys completed intake, height, and skin/wound screening ranked least important Average triage time, 9.03 min 54% indicated using nurse-initiated protocols continued
ArslanianEngoren 8 (2009)
Brannon and Carson 9 (2003)
Castner 10 (2011)
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Design/sample
Variables
Findings
Themes identified
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Table Continued Study
Purpose
Cone and Murray 11 (2002)
Describe characteris- Qualitative Characteristics All expressed need for Education and extics, insights, and Descriptive Experience at least 1 y of experi- perience decision making in 10 nurses from 2 Decision-making ence and some formal Characteristics, attitriage hospitals component triage education tudes, and beliefs Time to become (participants had not triage RN received formal triage Triage education training) Good communication, fast pace, and flexible Determine whether Quantitative Outcome: triage des- Triage decision down- Clinical information vital signs changed Prospective observa- ignation graded in 2.4% and nurse triage designa- tional Independent: vital upgraded in 5.5% tions and whether 14,285 patients; signs, age, and abil- after vitals known; age/ability to com- 625 triage nurses; ity to communicate changes more likely municate modified 24 emergency deto occur in young effect of vital signs partments across patients (b 2 y), country elderly patients (N 75 y), and patients with communication barrier In general, 92.1% of triage decisions were not affected by vital signs Compare assignment Quantitative Triage acuity Acuity assignation Clinical information to level 2 or level 3 Prospective, cross- Patient characteris- more likely to be acuity specific to sectional design tics based on chief compatient characteris- 18 nurses; 2 emergency Time to first inter- plaint than PMH or tics, time to first departments; 334 vention medications intervention, and nurse-patient triage in- Resources used If vital signs outside resource utilization teractions; questionof normal limits, naire after assignment then assign level 2 of level 2 or 3 (13% had abnormal vital signs but assigned level 3—possibly clinical judgment by RN) Time to physician and time to first intervention less for level 2 Admission more likely for level 2 No statistically significant difference in pain level for acuity level 2 or 3 Level 2 used more resources continued
Cooper et al 12 (2002)
Garbez et al 13 (2011)
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Design/sample
Variables
Findings
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Themes identified
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Table Continued Study
Purpose
Garbez et al 14 (2011)
Identify specific fac- Quantitative Triage acuity Patient age, vital signs tors used by triage Prospective correla- Patient characteris- and need for timely nurse to differenti- tional design tics intervention signifiate level 2 patients 18 nurses; 2 emer- Time to first inter- cant factors for level 2 from level 3 patients gency departments; vention Number of resources 334 nurse-patient Resources used required by patient triage interactions; influenced level 3 dequestionnaire after cision assignment of level 2 or 3 Determine if there Quantitative Outcome: accuracy of No statistically signifwas a difference in Descriptive ESI scoring icant support that nurse attitude and Convenience sam- Predictor: ED triage attitude or experiexperience related ple in 3 emergency experience and atti- ence contributed to to assigning acuity departments; 64 tude toward pa- accurate ESI score accurately RNs; 1,644 triage tients in triage Confirmed reliabilevents using CNPI-23 ity of ESI scoring tool between nurses with varying levels of experience Explore processes and Qualitative Patient presentation Triage acuity assigned cues for patient dis- Descriptive Complaint based on elements position from triage 1 2 e m e r g e n c y Duration of symp- particular to indivinurses; 120 patient toms dual nurse, immediencounters Body habitus ate environment of Patient volume unit, and general Environment of environment of care care (unit leadership, communication with patient and providers, and length of time in triage) Explore relationship Quantitative Accuracy in clinical Positive correlation of knowledge base, Descriptive decision making between post-concritical application, Purposive sample of Moral reasoning ventional moral reamoral agency, unit 2 0 0 e m e r g e n c y Perceived care en- soning and accuracy culture, nurse-pro- nurses through net- vironment in decision making vider relationship, working; survey Demographic char- Positive correlation and institutional through question- acteristics between environand general health naire format mental factors and care environments accuracy with accurate decision Positive correlation making of higher education to triage accuracy Lower acuity setting related to lower accuracy
Martin et al 15 (2014)
Wolf 16 (2010)
Wolf 17 (2013)
Design/sample
Variables
Findings
Themes identified
Clinical information
Education and experience
Education and experience Characteristics, attitudes, and beliefs Environment of care
Education and experience Environment of care
CC, chief complaint; CNPI-23, Caring Nursing Patient Interactions scale; ENA, Emergency Nurses Association; ESI, Emergency Severity Index; PMH, past medical history; RN, registered nurse.
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where triage occurred and the environment of care including physician relationships and nurse autonomy. In 2013 Wolf 17 studied the relationship between knowledge base, critical application, moral agency, unit culture, nurseprovider relationship, and institutional/health care environment and accuracy in triage decision making. The study’s purpose was to give initial support to Wolf’s model of clinical decision making in the emergency setting. The results showed a positive relationship between higher levels of moral reasoning and triage accuracy. The study also showed a relationship of environments of care that fostered teamwork, increased control over practice, good communication about patients, and increased leadership and autonomy with increased accuracy in triage. Furthermore, there was also a positive relationship between accuracy and educational level and a negative relationship for institutions with lesser complexity (ie, free-standing emergency departments).
Discussion
It is clear, after examining the recent research on this topic, how complex a process triaging a patient is. As previously stated, it is also apparent that the triage nurse must incorporate multiple pieces of information to accurately assign acuity. The purpose of this review was to determine what clinical decision-making skills or other factors were used in triage. The results from the literature indicate that to triage a patient, nurses must integrate clinical information presented to them while relying on their education and experience, avoiding personal bias, in conjunction with the environment of care in which they are practicing. All triage nurses must critically analyze clinical information presented to them by the patient and through their brief examination. This includes determining the chief complaint and interpreting vital signs in light of that complaint, as well as integrating symptoms and medical history findings into the whole patient picture. Triage nurses must also use their education and past experience to make inferences as to what could be happening with the patient based on his or her clinical presentation. Although Martin et al 15 cited evidence that ESI acuity rating could be accurate even without experience, the study did not provide concrete proof that a nurse’s prior experiences did not play a role in triage. The characteristics, attitudes, and beliefs of the individual nurse need to be internally evaluated to improve the relationship with the patient and prevent bias from obstructing the triage process. The environment in which the triage nurse practices must also foster a healthy atmosphere for the nurse-patient interaction to be best facilitated.
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Limitations of the research examined include several similar issues among studies. Many of the researchers used hypothetical case scenarios to mimic the triage setting, which can lead to results that are not explicitly replicable in the actual practice environment. 7–9,17 Subject sample was also mentioned to be a limitation, including the use of a convenience sample that may not be generalizable on a broad scale, the use of ENA members that might not represent all emergency nurses, and small sample sizes. 7,10,11,13,15,16 Another common limitation of the studies reviewed was the research methodology of using self-reports of data and the nurses’ awareness that they were being studied. 7,12,14,17 Gaps in the recent literature center around the studies not being performed in an actual triage setting, where the true interaction between the nurse and patient could be observed and measured. Several researchers concluded that more research was needed on the triage process 8,11,12 and focuses should include demographic data of triage nurses, 9 a real-life prospective, 7 and the context for additional data required for triage and what data these are. 10,14,16 Cooper et al 12 noted a change in patient acuity after vital signs were known, especially if there was a communication barrier. However, a limitation of their study was that the communication barrier was not separated into categories of language barrier versus patients’ inability to communicate for themselves (because of pain, chief complaint such as altered mental status, or mental disability). Further research could address the effect of communication barriers on the triage process and how the family or caregiver is involved. Wolf 17 noted the need to delve further into the environment of care, as well its role in the triage process, and the need to test the model of clinical decision making presented in her study. Martin et al 15 noted that future research of a qualitative nature might provide insight into the role that attitude plays in triage decision making. This type of study may also give insight into the cultural bias noted by Arslanian-Engoren 8 and Wolf 16 with broad expansion not limited to the Hispanic and Asian cultures.
Implications for Practice
The research surrounding clinical decision-making factors involved in the triage process lends insight into the implications for current ED practice. Nursing leadership and emergency nurses should focus on implementing specific triage education practices into their orientation to triage, as well as training on ESI acuity rating. Discussion during triage education should involve introspectively examining bias and preconceived thoughts about patient
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presentation and complaint reports to avoid hindering an accurate triage assessment. Although the experience of the emergency nurse varies by individual assessment, it is imperative that the triage nurse integrate gained clinical knowledge into the triage interview. ED leadership should continually assess and ensure triage accuracy through chart audits for resources used by the patient and severity of illness compared with the triage acuity level, as well as reviews of patient charts reported as having an incorrect acuity level assigned. Leadership can also maintain the competency of practicing triage nurses through yearly skill evaluations with review of the triage process. Leadership, the emergency nurse, and future research should focus on ensuring efficiency and safety in the triage setting, given the complexity entailed in the triage process and continual changes in the emergency environment. REFERENCES 1. American College of Emergency Physicians. Emergency department wait times, crowding and access fact sheet. http://newsroom.acep.org/ index.php?s=20301&item=29937. Accessed April 18, 2014. 2. Tang N, Stein J, Hsia R, Maselli J, Gonzales R. Trends and characteristics of US emergency department visits, 1997–2007. J Am Med Assoc. 2010;304(6):664–670. 3. National hospital ambulatory medical care survey: 2010 emergency department summary tables. Centers for Disease Control and Prevention. Web site http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/ 2010_ed_web_tables.pdf. Published 2010. Accessed April 18, 2014. 4. Hing E, Bhuiya F. Wait time for treatment in hospital emergency departments: 2009. Centers for Disease Control and Prevention. Web site http://www.cdc.gov/nchs/data/databriefs/db102.htm. Published 2012. Accessed April 18, 2014. 5. Gilboy N, Tanabe P, Travers D, Rosenau A. Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care; Version
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4Implementation Handbook, Rockville, MD: Agency for Healthcare Research and Quality; 2011. http://www.ahrq.gov/professionals/ systems/hospital/esi/esihandbk.pdf. Accessed April 18, 2014. 6. Garrard J. Health Sciences Literature Review Made Easy: The Matrix Method. 4th ed., Burlington, MA: Jones and Bartlett Learning; 2014. 7. Arslanian-Engoren C. Patient cues that predict nurses’ triage decisions for acute coronary syndromes. Appl Nurs Res. 2005;18(2):82–89. 8. Garbez RO, Carrieri-Kohlman V, Stotts N, Chan G. Level 2 and level 3 patient in emergency severity index triage system comparison of characteristics and resource utilization. Adv Emerg Nurs J. 2011;33(4):322–335. 9. Cooper RJ, Schriger DL, Flaherty HL, Lin EJ, Hubbell KA. Effect of vital signs on triage decisions. Ann Emerg Med. 2002;30(3):223–232. 10. Castner J. Emergency department triage: what data are nurses collecting?. J Emerg Nurs. 2011;37(4):417–422. 11. Garbez R, Carrieri-Kohlman V, Stotts N, Chan G, Neighbor M. Factors influencing patient assignment to level 2 and level 3 within the 5-level ESI triage system. J Emerg Nurs. 2011;37(6):526–532. 12. Arslanian-Engoren C. Explicating nurses’ cardiac triage decisions. J Cardiovasc Nurs. 2009;24(1):50–57. 13. Cone KJ, Murray R. Characteristics, insights, decision making, and preparation of ED triage nurses. J Emerg Nurs. 2002;28(5):401–406. 14. Wolf L. Acuity assignation an ethnographic exploration of clinical decision making by emergency nurses at initial patient presentation. Adv Emerg Nurs J. 2010;32(3):234–246. 15. Martin A, Davidson CL, Panik A, Buckenmyer C, Delpais P, Ortiz M. An examination of ESI triage scoring accuracy in relationship to ED nursing attitudes and experience. J Emerg Nurs. 2014;40(5):461–468. 16. Brannon LA, Carson KL. The representativeness heuristic: influence on nurses’ decision making. Appl Nurs Res. 2003;16(3):201–204. 17. Wolf L. An integrated, ethically driven environmental model of clinical decision making in emergency settings. Int J Nurs Knowl. 2013;24(1):49–53.
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CLINICAL DECISION MAKING IN TRIAGE: AN INTEGRATIVE REVIEW Author: Laura M. Stanfield, MSN, RN, CEN, Burlington, NC
mergency department overcrowding stems from fewer emergency departments being available for a greater number of patients seeking care. The American College of Emergency Physicians (ACEP) reports that there were closures of more than 1,000 emergency departments in the United States from 1991 to 2006 despite a steady increase in patient volume from 119.2 million visits in 2006 to 136 million in 2009. 1 From 1997 to 2007, the rate of ED visits surpassed the US population growth rate by 2-fold. 2 According to the Centers for Disease Control and Prevention’s 2010 National Ambulatory Medical Care Survey, there were 129.8 million visits to emergency departments. 3 The average wait time for patients to see a provider in the emergency department has also increased, with Hing and Bhuiya 4 noting a 25% increase from 2003 to 2009, from 46.5 to 58.1 minutes on average. With a limit to the resources available, accurate sorting of patients must occur to appropriately provide care for those who seek it. Patients in the emergency department are triaged on arrival to determine the acuity of their complaint. This triage determination is meant to decide the order of priority in which patients are to be seen and the amount of time patients can safely wait to see a provider. The Emergency Nurses Association (ENA) and ACEP have published multiple position statements since the movement to standardization of triage in the US began in 2000. Most recently, in 2010, both the ENA and ACEP recommended use of a 5-level triage system such as the Emergency Severity Index (ESI). 5 The 5 levels are as follows: level 1, immediate (life-saving intervention is required); level 2, emergent (patient should not wait for treatment); level 3, urgent (patient is stable to wait, and ≥ 2 resources are required);
E
Laura M. Stanfield, Member, ENA North Carolina Piedmont Chapter, is Assistant Director, Emergency Department, Cone Health Alamance Regional, Burlington, NC. For correspondence, write: Laura M. Stanfield, MSN, RN, CEN, Cone Health Alamance Regional, 1240 Huffman Mill Rd, Burlington, NC 27216; E-mail: Laura.Stanfi[email protected]. J Emerg Nurs ■. 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.02.003
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level 4, less urgent (1 resource is required); and level 5, non-urgent (no resources are required). 5 A resource is described as laboratory work, radiographs, and procedures such as laceration repair among others. 5 Patient care begins with triage at the front door of the emergency department, and this affects the entire visit, including wait time for treatment; attention to how this process occurs is needed. Training on use of the 5-level ESI system is imperative for a triage nurse. However, research has shown that other factors play into the assignation of acuity. The purpose of this integrative review of the literature is to determine the clinical decision-making skills or other factors used by emergency nurses in triage as determined through previous studies. The information gathered can then be included in triage training, for veteran and new triage nurses, to review these factors for how they are incorporated into each nurse’s practice. Methods
Clinical decision-making skills used by nurses in ED triage have an impact on the entire patient experience. This can include the patient’s health outcomes, time to treatment, and overall length of stay, as well as patient satisfaction. The literature was reviewed to determine research recently conducted to better understand these clinical decision-making skills. The literature review covered a 12-year period from 2002 to 2014. The search included the use of 3 electronic databases—CINAHL (Cumulative Index to Nursing and Allied Health Literature), PubMed, and PsycINFO—with special attention paid to the Journal of Emergency Nursing and the Advanced Emergency Nursing Journal. Research articles from the US conducted with nurses either in an emergency setting or using triage case scenarios were included. Key words included emergency nurse or nursing, triage, and clinical decision making. Studies not relating to the decision-making process or factors that influenced triage acuity designation were excluded. In addition, studies with the specific intent of testing ESI reliability were excluded to focus on the other factors that affect triage. Multiple searches resulted in 126 studies (with duplication between databases), of which 11 were included in the review. Articles were examined using the matrix method as described by Garrard. 6 Each article was evaluated and organized in matrix format, using ascending chronologic order, regarding 8 specific topics. These topics varied among
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articles due to their nature, being either qualitative or quantitative research studies. The topics comprised journal identification, purpose, design, sample, variables, results, limitations, and implications for further studies. Detailed notes were taken while each article was read intently; the results of the researchers were then categorized, based on my notes, into common themes by grouping together the article findings. A summary of each article reviewed is included in the Table.
Results
After review of the current literature, common themes emerged from the research as factors relating to the clinical decision-making process of triage. These themes were (1) clinical information; (2) education and experience; (3) characteristics, attitudes, and beliefs of triage nurses; and (4) environment of care. CLINICAL INFORMATION
The triage process begins when the nurse first lays eyes on the patient, and researchers sought to find what specific clinical information nurses use and how it relates to patient acuity. Common threads of clinical information gathered included (1) chief complaint, 7,13 (2) vital signs including pain, 10,12–14 (3) symptoms, 7,8 and (4) medical history. 8,10 Chief Complaint Arslanian-Engoren 7 sought to determine what cues triage nurses use when interviewing male and female patients with possible acute coronary syndrome and whether these cues varied by patients’ sexes or the nurses’ demographic information. Questionnaires presented information to study participants from 2 patient vignettes, randomly generated by computer program, the first with classic symptoms of acute coronary syndrome and the second with symptoms that were more atypical. The study found that triage decisions were based on the chief complaint and did not vary by patient sex. Similar results were found by Garbez et al 13 in a study comparing patients assigned to either level 2 or level 3 acuity based on patient characteristics, as well as the time to initial intervention and utilization of resources in the emergency department. After assigning acuity, nurses filled out questionnaires about their triage assessment. Data were also collected from the patient chart regarding time to intervention and utilization of resources. The results of the study showed that acuity assignation was more likely to be based on chief complaint than on medical history or current medications.
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Vital Signs Cooper et al 12 used an observational study to determine whether knowing the vital signs of patients in triage changed the assigned triage designation and whether age and ability to communicate modified this change. The results showed that 92.1% of triage decisions were not affected by knowing the patient’s vital signs. In the other 7.9%, most changes occurred in young patients (b 2 years), elderly patients (N 75 years), and patients with a communication barrier. Triage acuity level was downgraded in 2.4% and upgraded in 5.5% after vital signs were obtained. In 2011 Castner 10 sought to determine what data were being collected in triage. Data were categorized as being either important to the nurse for triage or required of the nurse to collect during triage. Vital signs, pain score, medical history, and allergies were noted to be the most important, as well as the most required, information collected for triage. In the study by Garbez et al 13 mentioned earlier, if vital signs were outside of normal limits, patients were more likely to be assigned a higher acuity level. However, 13% of patients assigned to level 3 had abnormal vital signs, showing that some other factor played into the triage nurses’ decision making, suggesting that vital signs are used in addition to clinical judgment when applying the ESI algorithm 5 that vital signs are used in addition to clinical judgment. Using data gathered for the previous study, Garbez et al 14 sought to identify what factors triage nurses used when assigning either level 2 or level 3 acuity. This examination of data showed that patient age, vital signs, and the need for timely intervention were the most significant factors when assigning a patient to ESI level 2. The study also noted a difference in the explanation of acuity designation between experienced and beginning triage nurses: Experienced nurses reported using symptoms in addition to the chief complaint and the patient’s clinical presentation to influence decision making. Symptoms Results from the study by Arslanian-Engoren, 7 seeking to determine what cues triage nurses use when interviewing possible acute coronary syndrome patients, found that the triage decisions were also based on a patient’s presenting symptoms. The author noted limitations of the study using hypothetical clinical vignettes and reported that the sample of ENA members might not have been representative of all emergency nurses. In 2009 Arslanian-Engoren 8 used a qualitative approach to explain the triage decision-making processes for men and women presenting with myocardial infarction symptoms. The study reviewed conversations after hypothetical case presentations of patients with symptoms suggestive of myocardial infarction in triage.
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The sessions yielded similar results to the author’s previous study: Participants relied on the clinical presentation of the patient, such as his or her general appearance, transportation mode, and presence of pain, to determine triage acuity. Medical History In the 2009 study by Arslanian-Engoren, 8 session participants also reported relying on medical history to assign triage acuity. In the same manner, a survey of New York ENA members by Castner 10 showed that medical history was one of the most important pieces of information collected in triage, as well as one of the most required. EDUCATION AND EXPERIENCE
In 2002 Cone and Murray 11 sought to describe the traits, thought processes, and acts of decision making by expert emergency nurses in triage through a qualitative study. They used group forums with focused questions regarding characteristics of emergency nurses, decision-making experience, most important decision-making components, experience required for a triage nurse, and education required for triage. Common themes emerged, including the need for at least 1 year of experience before being placed in the triage role and a need for formal triage education (although none of the participants had this). Both of the studies by ArslanianEngoren 7,8 resulted in education and experience being required of triage nurses. In the 2005 study using hypothetical patients, the nurse’s experience level was found to have a small statistical significance toward increased accuracy when triaging. 7 A common theme from the qualitative 2009 study of self-volunteered nurses’ conversations related their feelings that nursing knowledge and ED experience are necessary to make triage decisions. 8 In 2010 Wolf 16 researched the decision-making strategies used to assign acuity to patients in triage, including particular cues and processes. The researcher focused on observations of triage interactions and findings on patient presentation (complaint, duration of symptoms, and body habitus), patient volume, and environment of care (unit leadership, communication with patient and providers, and length of time in triage). The results were interpreted to show that acuity was assigned based on factors of the individual nurses versus institutional protocol or rating scale. Factors of the individual nurses included use of intuition, ED experience, and the description of a “gut feeling.” Martin et al 15 studied whether a relationship existed between triage accuracy using the ESI and nurses’ attitudes and experience. ED triage experience was gathered through a demographic survey, the Nurse Characteristic Collection Tool, and attitude toward patients was measured using the
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Caring Nursing Patient Interactions scale (CNPI-23). ESI triage accuracy was confirmed by comparing assigned ESI scores from participants in triage with expert ESI assignation by clinical nurse experts from review of the patients’ charts. The study showed no statistical support that attitude or experience contributed to accuracy in ESI scoring. It did, however, support the reliability of the ESI triage tool, after appropriate training, for nurses with different experience levels. CHARACTERISTICS, ATTITUDES, AND BELIEFS
The study by Cone and Murray 11 seeking to describe the traits, thought processes, and acts of decision making by expert emergency nurses in triage produced themes of good communication skills, the ability to work at a fast pace, and flexibility in the role as characteristics of the triage nurse. The next year, Brannon and Carson 9 researched what cognitive aids (heuristics) influenced the process of decision making of triage nurses. The study used 2 case descriptions for participant review; each case presented classic symptoms of either a myocardial infarction or stroke, and some of the descriptions contained contextual information that could be the cause of symptoms (eg, experiencing a stressor like job loss or having the smell of alcohol on the breath). The results showed no variation between the decisions of nurses and those of nursing students. When contextual information was presented in the case description, participants were more likely to alter the decision process to choose the potentially less serious diagnosis: stress over myocardial infarction and intoxication over stroke. The study by Arslanian-Engoren 8 produced results indicating that personal attitudes, beliefs, and biases influenced triage decisions. This included distrusting reports of complaints for patients who continually talked on their cell phones, ate snacks, or were wearing full makeup, as well as patients from certain cultures (Asian/Hispanic) that study participants reported to be very demonstrative in their presentation. Wolf 16 also described the cultural bias of Hispanic presentation, with description of the triage nurse as being burdened by a patient’s demonstrative display of pain. This study also showed a similar bias to that noted by Brannon and Carson. 9 A particular description was given of a patient encounter in which the physician offering antianxiety treatment, despite the cardiac arrhythmia present on monitoring, lessened the perception of patient acuity. ENVIRONMENT OF CARE
The 2010 study by Wolf 16 showed that acuity was assigned based on environmental factors of the particular unit/facility
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TABLE
Integrative review article summary Study
Purpose
ArslanianEngoren 7 (2005)
Determine patient cues Quantitative Patient sex Patient sex did not play Clinical information used to triage patients Descriptive Patient cues a role in triage re- Education and exwith complaints sug- 3,000 ENA members Nurse demographic sponse perience gestive of acute cor- randomly selected to characteristics Experience played a onary syndromes and receive questionnaire; small role determine if cues var- 840 questionnaires Triage decision based ied by patient sex or completed on CC and symptoms nurses’ demographic characteristics Explain triage pro- Qualitative Determine underlying Reliance on PMH, Clinical information cesses of emergency Descriptive cause of chief demographic Education and exnurses when tria- 12 nurses in 3 ques- complaint characteristics, clini- perience ging both sexes for tion-answer group Identify important/ cal presentation, gen- Characteristics, attiMI sessions using hy- relevant patient cues eral appearance, tudes, and beliefs pothetical situations Ultimate goal in transportation mode, triage decision for vital signs, and prepossible MI sence of chest pain Reliance on own attitudes, perceptions, beliefs, nursing knowledge, and ED experience Reliance on ESI scale for urgency Determine if repre- Quantitative Medical training No variation whether Characteristics, attisentativeness heuris- Descriptive (nurse vs student nurse or student tudes, and beliefs tic (using mental 182 nurses and nur- nurse) nurse map to guide search sing students; 2 case Presence of contex- Contextual informafor additional infor- descriptions tual information in tion altered decisionmation) influences patient profiles making process; decision making in more likely to choose nurse triage potentially less serious diagnosis through representativeness heuristic Describe data ob- Quantitative Important to RN vs Vital signs, allergy, Clinical information tained in triage Descriptive required of RN pain, and medical 1,600 surveys sent Length of triage history ranked most to New York ENA Protocols in triage important members; 430 surVascular access, oral veys completed intake, height, and skin/wound screening ranked least important Average triage time, 9.03 min 54% indicated using nurse-initiated protocols continued
ArslanianEngoren 8 (2009)
Brannon and Carson 9 (2003)
Castner 10 (2011)
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Design/sample
Variables
Findings
Themes identified
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Table Continued Study
Purpose
Cone and Murray 11 (2002)
Describe characteris- Qualitative Characteristics All expressed need for Education and extics, insights, and Descriptive Experience at least 1 y of experi- perience decision making in 10 nurses from 2 Decision-making ence and some formal Characteristics, attitriage hospitals component triage education tudes, and beliefs Time to become (participants had not triage RN received formal triage Triage education training) Good communication, fast pace, and flexible Determine whether Quantitative Outcome: triage des- Triage decision down- Clinical information vital signs changed Prospective observa- ignation graded in 2.4% and nurse triage designa- tional Independent: vital upgraded in 5.5% tions and whether 14,285 patients; signs, age, and abil- after vitals known; age/ability to com- 625 triage nurses; ity to communicate changes more likely municate modified 24 emergency deto occur in young effect of vital signs partments across patients (b 2 y), country elderly patients (N 75 y), and patients with communication barrier In general, 92.1% of triage decisions were not affected by vital signs Compare assignment Quantitative Triage acuity Acuity assignation Clinical information to level 2 or level 3 Prospective, cross- Patient characteris- more likely to be acuity specific to sectional design tics based on chief compatient characteris- 18 nurses; 2 emergency Time to first inter- plaint than PMH or tics, time to first departments; 334 vention medications intervention, and nurse-patient triage in- Resources used If vital signs outside resource utilization teractions; questionof normal limits, naire after assignment then assign level 2 of level 2 or 3 (13% had abnormal vital signs but assigned level 3—possibly clinical judgment by RN) Time to physician and time to first intervention less for level 2 Admission more likely for level 2 No statistically significant difference in pain level for acuity level 2 or 3 Level 2 used more resources continued
Cooper et al 12 (2002)
Garbez et al 13 (2011)
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Design/sample
Variables
Findings
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Themes identified
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Table Continued Study
Purpose
Garbez et al 14 (2011)
Identify specific fac- Quantitative Triage acuity Patient age, vital signs tors used by triage Prospective correla- Patient characteris- and need for timely nurse to differenti- tional design tics intervention signifiate level 2 patients 18 nurses; 2 emer- Time to first inter- cant factors for level 2 from level 3 patients gency departments; vention Number of resources 334 nurse-patient Resources used required by patient triage interactions; influenced level 3 dequestionnaire after cision assignment of level 2 or 3 Determine if there Quantitative Outcome: accuracy of No statistically signifwas a difference in Descriptive ESI scoring icant support that nurse attitude and Convenience sam- Predictor: ED triage attitude or experiexperience related ple in 3 emergency experience and atti- ence contributed to to assigning acuity departments; 64 tude toward pa- accurate ESI score accurately RNs; 1,644 triage tients in triage Confirmed reliabilevents using CNPI-23 ity of ESI scoring tool between nurses with varying levels of experience Explore processes and Qualitative Patient presentation Triage acuity assigned cues for patient dis- Descriptive Complaint based on elements position from triage 1 2 e m e r g e n c y Duration of symp- particular to indivinurses; 120 patient toms dual nurse, immediencounters Body habitus ate environment of Patient volume unit, and general Environment of environment of care care (unit leadership, communication with patient and providers, and length of time in triage) Explore relationship Quantitative Accuracy in clinical Positive correlation of knowledge base, Descriptive decision making between post-concritical application, Purposive sample of Moral reasoning ventional moral reamoral agency, unit 2 0 0 e m e r g e n c y Perceived care en- soning and accuracy culture, nurse-pro- nurses through net- vironment in decision making vider relationship, working; survey Demographic char- Positive correlation and institutional through question- acteristics between environand general health naire format mental factors and care environments accuracy with accurate decision Positive correlation making of higher education to triage accuracy Lower acuity setting related to lower accuracy
Martin et al 15 (2014)
Wolf 16 (2010)
Wolf 17 (2013)
Design/sample
Variables
Findings
Themes identified
Clinical information
Education and experience
Education and experience Characteristics, attitudes, and beliefs Environment of care
Education and experience Environment of care
CC, chief complaint; CNPI-23, Caring Nursing Patient Interactions scale; ENA, Emergency Nurses Association; ESI, Emergency Severity Index; PMH, past medical history; RN, registered nurse.
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where triage occurred and the environment of care including physician relationships and nurse autonomy. In 2013 Wolf 17 studied the relationship between knowledge base, critical application, moral agency, unit culture, nurseprovider relationship, and institutional/health care environment and accuracy in triage decision making. The study’s purpose was to give initial support to Wolf’s model of clinical decision making in the emergency setting. The results showed a positive relationship between higher levels of moral reasoning and triage accuracy. The study also showed a relationship of environments of care that fostered teamwork, increased control over practice, good communication about patients, and increased leadership and autonomy with increased accuracy in triage. Furthermore, there was also a positive relationship between accuracy and educational level and a negative relationship for institutions with lesser complexity (ie, free-standing emergency departments).
Discussion
It is clear, after examining the recent research on this topic, how complex a process triaging a patient is. As previously stated, it is also apparent that the triage nurse must incorporate multiple pieces of information to accurately assign acuity. The purpose of this review was to determine what clinical decision-making skills or other factors were used in triage. The results from the literature indicate that to triage a patient, nurses must integrate clinical information presented to them while relying on their education and experience, avoiding personal bias, in conjunction with the environment of care in which they are practicing. All triage nurses must critically analyze clinical information presented to them by the patient and through their brief examination. This includes determining the chief complaint and interpreting vital signs in light of that complaint, as well as integrating symptoms and medical history findings into the whole patient picture. Triage nurses must also use their education and past experience to make inferences as to what could be happening with the patient based on his or her clinical presentation. Although Martin et al 15 cited evidence that ESI acuity rating could be accurate even without experience, the study did not provide concrete proof that a nurse’s prior experiences did not play a role in triage. The characteristics, attitudes, and beliefs of the individual nurse need to be internally evaluated to improve the relationship with the patient and prevent bias from obstructing the triage process. The environment in which the triage nurse practices must also foster a healthy atmosphere for the nurse-patient interaction to be best facilitated.
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Limitations of the research examined include several similar issues among studies. Many of the researchers used hypothetical case scenarios to mimic the triage setting, which can lead to results that are not explicitly replicable in the actual practice environment. 7–9,17 Subject sample was also mentioned to be a limitation, including the use of a convenience sample that may not be generalizable on a broad scale, the use of ENA members that might not represent all emergency nurses, and small sample sizes. 7,10,11,13,15,16 Another common limitation of the studies reviewed was the research methodology of using self-reports of data and the nurses’ awareness that they were being studied. 7,12,14,17 Gaps in the recent literature center around the studies not being performed in an actual triage setting, where the true interaction between the nurse and patient could be observed and measured. Several researchers concluded that more research was needed on the triage process 8,11,12 and focuses should include demographic data of triage nurses, 9 a real-life prospective, 7 and the context for additional data required for triage and what data these are. 10,14,16 Cooper et al 12 noted a change in patient acuity after vital signs were known, especially if there was a communication barrier. However, a limitation of their study was that the communication barrier was not separated into categories of language barrier versus patients’ inability to communicate for themselves (because of pain, chief complaint such as altered mental status, or mental disability). Further research could address the effect of communication barriers on the triage process and how the family or caregiver is involved. Wolf 17 noted the need to delve further into the environment of care, as well its role in the triage process, and the need to test the model of clinical decision making presented in her study. Martin et al 15 noted that future research of a qualitative nature might provide insight into the role that attitude plays in triage decision making. This type of study may also give insight into the cultural bias noted by Arslanian-Engoren 8 and Wolf 16 with broad expansion not limited to the Hispanic and Asian cultures.
Implications for Practice
The research surrounding clinical decision-making factors involved in the triage process lends insight into the implications for current ED practice. Nursing leadership and emergency nurses should focus on implementing specific triage education practices into their orientation to triage, as well as training on ESI acuity rating. Discussion during triage education should involve introspectively examining bias and preconceived thoughts about patient
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presentation and complaint reports to avoid hindering an accurate triage assessment. Although the experience of the emergency nurse varies by individual assessment, it is imperative that the triage nurse integrate gained clinical knowledge into the triage interview. ED leadership should continually assess and ensure triage accuracy through chart audits for resources used by the patient and severity of illness compared with the triage acuity level, as well as reviews of patient charts reported as having an incorrect acuity level assigned. Leadership can also maintain the competency of practicing triage nurses through yearly skill evaluations with review of the triage process. Leadership, the emergency nurse, and future research should focus on ensuring efficiency and safety in the triage setting, given the complexity entailed in the triage process and continual changes in the emergency environment. REFERENCES 1. American College of Emergency Physicians. Emergency department wait times, crowding and access fact sheet. http://newsroom.acep.org/ index.php?s=20301&item=29937. Accessed April 18, 2014. 2. Tang N, Stein J, Hsia R, Maselli J, Gonzales R. Trends and characteristics of US emergency department visits, 1997–2007. J Am Med Assoc. 2010;304(6):664–670. 3. National hospital ambulatory medical care survey: 2010 emergency department summary tables. Centers for Disease Control and Prevention. Web site http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/ 2010_ed_web_tables.pdf. Published 2010. Accessed April 18, 2014. 4. Hing E, Bhuiya F. Wait time for treatment in hospital emergency departments: 2009. Centers for Disease Control and Prevention. Web site http://www.cdc.gov/nchs/data/databriefs/db102.htm. Published 2012. Accessed April 18, 2014. 5. Gilboy N, Tanabe P, Travers D, Rosenau A. Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care; Version
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4Implementation Handbook, Rockville, MD: Agency for Healthcare Research and Quality; 2011. http://www.ahrq.gov/professionals/ systems/hospital/esi/esihandbk.pdf. Accessed April 18, 2014. 6. Garrard J. Health Sciences Literature Review Made Easy: The Matrix Method. 4th ed., Burlington, MA: Jones and Bartlett Learning; 2014. 7. Arslanian-Engoren C. Patient cues that predict nurses’ triage decisions for acute coronary syndromes. Appl Nurs Res. 2005;18(2):82–89. 8. Garbez RO, Carrieri-Kohlman V, Stotts N, Chan G. Level 2 and level 3 patient in emergency severity index triage system comparison of characteristics and resource utilization. Adv Emerg Nurs J. 2011;33(4):322–335. 9. Cooper RJ, Schriger DL, Flaherty HL, Lin EJ, Hubbell KA. Effect of vital signs on triage decisions. Ann Emerg Med. 2002;30(3):223–232. 10. Castner J. Emergency department triage: what data are nurses collecting?. J Emerg Nurs. 2011;37(4):417–422. 11. Garbez R, Carrieri-Kohlman V, Stotts N, Chan G, Neighbor M. Factors influencing patient assignment to level 2 and level 3 within the 5-level ESI triage system. J Emerg Nurs. 2011;37(6):526–532. 12. Arslanian-Engoren C. Explicating nurses’ cardiac triage decisions. J Cardiovasc Nurs. 2009;24(1):50–57. 13. Cone KJ, Murray R. Characteristics, insights, decision making, and preparation of ED triage nurses. J Emerg Nurs. 2002;28(5):401–406. 14. Wolf L. Acuity assignation an ethnographic exploration of clinical decision making by emergency nurses at initial patient presentation. Adv Emerg Nurs J. 2010;32(3):234–246. 15. Martin A, Davidson CL, Panik A, Buckenmyer C, Delpais P, Ortiz M. An examination of ESI triage scoring accuracy in relationship to ED nursing attitudes and experience. J Emerg Nurs. 2014;40(5):461–468. 16. Brannon LA, Carson KL. The representativeness heuristic: influence on nurses’ decision making. Appl Nurs Res. 2003;16(3):201–204. 17. Wolf L. An integrated, ethically driven environmental model of clinical decision making in emergency settings. Int J Nurs Knowl. 2013;24(1):49–53.
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