Structure, process, and recommendations of emergency department triage in the U.S.

The purpose of this study was to explore and describe (1) to what extent emergency departments (EDs) in the United States (U.S.) are assuring the quality and reliability of triage acuity decisions and triage systems implementation according to recommendations in the Emergency Severity Index Handbook and (2) if relationships existed between triage structure and processes in EDs that promoted accuracy of triage decisions. The study was guided by Donabedian’s Structure, Process, Outcome model that allows for the assessment of operations in EDs that organize and influence the quality of triage decision accuracy. The sample of 152 ED nurses with an average of 18 years of emergency nursing experience completed the online survey. The participants represented all four geographic regions of the United States, multiple levels of trauma center designation, annual patient visits from less than 25,000 to greater than 100,000, and 3, 4, and 5-level triage acuity systems. The majority of EDs (94%) used the Emergency Severity Index triage system. In 43% of EDs, nurses with less than one year of nursing experience met the qualification to triage. Triage nurse experience, triage education and quality monitoring of triage accuracy in EDs in the U.S. are not consistent with the recommendations outlined in the Emergency Severity Index guidelines. Procedures (processes) for triage education and quality monitoring were reported more often than having a policy (structure) to guide either of the processes. Significant positive relationships were found between EDs with a policy for triage education and those that required triage system training and between EDs with a policy for quality monitoring and those that monitored the accuracy of triage decisions. The findings add to the body of knowledge that relationships exist between structure (triage policies) and process (triage procedures) in the ED. The relationship needed to be established before quality assessment of emergency department triage can begin. This study is a foundation for examining triage accuracy and improvements in meeting the Emergency Severity Index recommendations