Introduction
In the fast-paced, high-stakes environment of emergency departments (EDs), the role of triage nurses is crucial [1]. Triage, the process of determining the priority of patients’ treatments based on the severity of their condition, requires quick decision-making and accuracy [2]. The outcomes of triage can significantly impact patient care, influencing everything from treatment efficacy to resource allocation and overall ED efficiency [3]. Despite its importance, there is considerable variability in triage outcomes [4, 5], which are largely influenced by the competencies and characteristics of the triage nurses conducting these assessments. Triage nurses must continually improve the accuracy of their classifications through ongoing retraining [6]. They must be able to make quick decisions [7], possess a broad knowledge of various medical conditions [8], and have excellent communication and customer service skills [9]. The variability in triage outcomes can be attributed to differences in these skills and the proficiency levels of nurses in managing complex triage situations.
The patients in the ED were categorized according to the severity of their conditions using the Korean Triage and Acuity Scale (KTAS), a five-level triage tool. Level 1 instances that require immediate resuscitation are indicated by the KTAS, whereas Level 5 cases are considered non-emergency conditions and are the least urgent. Triage accuracy is pivotal to the operational effectiveness of EDs. Accurate triage ensures that patients receive care that is appropriately timed and suited to their medical needs, preventing overcrowding and underutilization of resources [10]. Moreover, the accuracy of triage affects patient safety [1], trust in the healthcare system, and overall health outcomes [11]. Studies have indicated that discrepancies in triage decision-making can lead to variations in patient outcomes, underscoring the need for precise and consistent triage practices [2].
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The factors influencing triage accuracy range from individual nurse characteristics to broader systemic issues. On a personal level, the clinical and triage experience, education, and training of nurses play crucial roles. A study aimed at identifying the operational factors affecting the perception of the triage system among 90 nurses found that clinical experience was one of the significant variables [1]. Another preceding study reported a substantial improvement in triage accuracy, from about 75–90%, after conducting education and training sessions for emergency room triage nurses [6]. Additionally, the personal dimensions of a nurse’s education, experience, and training play a vital role. A systematic review study attempting to identify factors contributing to patient safety during triage in EDs found that psychological factors such as nurses’ fatigue, work environment, and cognitive biases may also influence decision-making [1]. Thus, professional dynamics, including nurses’ communication with other healthcare staff and access to ongoing professional development, may further influence triage outcomes.
As such, accurate severity classification in emergency rooms directly impacts patient safety and outcomes [5, 12]. Understanding the characteristics that contribute to accurate triage can lead to better staffing decisions and training programs, and optimize both workflow and resource allocation within the emergency room. Additionally, identifying the most influential characteristics of triage nurses can aid in customizing professional development programs to enhance these traits among nursing staff. However, previous studies mainly explored whether patient characteristics [13, 14] or nurse characteristics [5, 15] affected the accuracy of triage, and it was difficult to find studies examining whether the time required for a triage nurse to triage patients affects classification accuracy. Efficient triage processes reduce wait times and congestion in ED [16]. Moreover, by examining how the time allocated to each triage decision impacts accuracy, this research could lead to more effective time management strategies in triage training and protocols, ultimately optimizing the throughput of patients in emergency settings.
This study will systematically examine how triage nurses’ characteristics, including time spent triaging, educational background, years of emergency care experience, and continuing education, are related to their ability to accurately triage the urgency of patient cases. Ultimately, this study attempted to bridge the gap between triage theory and practice and provide actionable insights that can be used to improve patient care.
Methods
Study design
In this descriptive study, we retrospectively reviewed and analyzed the electronic medical records (EMRs) of patients who visited the ED of a general hospital located in Seoul. Additionally, we investigated the general characteristics of the triage nurses who participated in the patient classification at that time, the time required for classification, and the accuracy of the classifications.
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Data collection
Data for this study were collected between November 1 and November 30, 2023. The collection process involved the electronic medical records (EMR) data manager at the affiliated medical institution, who was responsible for extracting and transferring the relevant patient and triage nurse information that met the selection criteria into an Excel file. The data were divided into two categories: patient data and triage nurse data.
The patient data extracted from the EMRs included the following variables: age, gender, time of arrival, mode of arrival at the emergency department, type of medical condition (disease or injury), medication status, and patient status indicators such as Glasgow Coma Scale (GCS), vital signs (V/S), body temperature, pain level, bleeding status, and any known allergies. Additionally, the triage details were captured, including the initial KTAS level assigned, the final KTAS level after reassessment if applicable, and the outcomes of the KTAS assessment, specifically whether the patient was admitted to the hospital or discharged.
The triage nurse data included the following variables: the specific nurse who performed the initial triage classification for each patient, the nurse’s years of experience in emergency care, particularly in triage roles, the time the nurse had spent specifically using the KTAS tool for patient classification, and the time required for KTAS classification for each patient.
Triage accuracy was retrospectively evaluated by a senior nurse with over 20 years of emergency department experience, working in conjunction with an emergency physician. This evaluation was based on the initial triage assessments performed by the triage nurses. Accuracy was assessed by comparing the initial triage results with the subsequent diagnostic and treatment outcomes recorded in the electronic medical records. Out of the 1,033 patients whose data were provided by the EMR data manager, 787 patients who met the selection criteria were analyzed after a thorough review by the researcher.
Study sample
The participants of this study were adult patients aged 19 years and older who visited the ED of a general hospital in Seoul between May 1 and May 12, 2023. Additionally, the study targeted triage nurses who were responsible for patient classification during the same period. Participants were selected based on the following criteria: (1) adult patients aged 19 years and older; (2) cases where the triage nurse conducted the initial patient classification without a physician; (3) Patients with no missing information in the EMR. Furthermore, the definition of an experienced triage nurse was as follows: (1) Emergency nurses accredited as KTAS providers; (2) Emergency nurses with at least five years of experience in KTAS classification. The inclusion criteria fir triage nurses is crucial in improving the accuracy of triage in ED.
Ethical considerations
This study was conducted after obtaining approval from the Institutional Review Board (IRB NO: 20-2023-48) affiliated with the researcher’s institution. Written consent was obtained to collect the general characteristics of the triage nurses. The collected information is used solely for research purposes and is managed and disposed of in accordance with management standards and relevant laws and regulations.
Statistical analysis
The statistical analysis for this study was performed using SPSS for Windows (version 29.0). Descriptive statistics were used to present categorical variables as frequencies and percentages, while continuous variables were presented as means and standard deviations. To compare groups, categorical variables were analyzed using the chi-square test, and continuous variables were analyzed using the independent samples Student’s t-test. Binary logistic regression analysis was employed to identify factors influencing classification accuracy. The statistical significance level was set at p < .05.
Results
General characteristics of study subjects
The gender distribution of the triage nurses showed that 10 (76.9%) were female, with an average age of 34.19 years (SD = 3.547). The average clinical experience of the triage nurses was 78.14 months (SD = 22.518), and their average experience with KTAS classification was 37.27 months (SD = 14.944). The average time taken to classify patients was 6.03 min (SD = 2.127), and the classification accuracy was 84.9%. Among the 787 patients, the distribution of KTAS levels was as follows: level 1 (1.1%), 111 patients (14.1%) at level 2, and 230 patients (29.2%) at level 3. Levels 4 and 5 had 366 patients (46.5%) and 71 patients (9.0%), respectively. Regarding the patients’ gender, 368 (46.8%) were female, with an average age of 58.53 years (SD = 20.737). The number of patients visiting the ED during the daytime was 344 (43.7%). The means of arrival at the ED showed that 229 patients (29.1%) used an ambulance, and 641 patients (81.4%) visited the ED due to disease (Table 1).
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Table 1
General characteristics of study subjects
Variables | Characteristics | n (%) or mean (SD) | |
|---|---|---|---|
Triage nurses (n = 13) | Sex | female sex | 10 (76.9) |
Age | years | 34.19 (3.547) | |
Clinical experiences | months | 78.14 (22.518) | |
KTAS classification experience | months | 37.27 (14.944) | |
Time required for KTAS classification | minutes | 6.03 (2.127) | |
Accuracy of patient triage | accurate | 668 (84.9) | |
Patients (n = 787) | Initial KTAS | Level 1 | 9 (1.1) |
Level 2 | 111 (14.1) | ||
Level 3 | 230 (29.2) | ||
Level 4 | 366 (46.5) | ||
Level 5 | 71 (9.0) | ||
Sex | female sex | 368 (46.8) | |
Age | yrs | 58.53 (20.737) | |
Visiting time | daytime | 344 (43.7) | |
Mode of arrival | ambulance | 229 (29.1) | |
direct | 558 (70.9) | ||
Disease or injury | disease | 641 (81.4) |
Characteristics of triage nurses between accurately and inaccurately classified patients
When comparing the characteristics of triage nurses between accurately and inaccurately classified patients, it was found that nurses who accurately classified patients had longer overall clinical experience compared to those who inaccurately classified patients (79.15 ± 22.722 months vs. 72.46 ± 20.513 months, t=-2.999, p = 0.001). Additionally, nurses who accurately classified patients had longer KTAS classification experience than those who inaccurately classified patients (37.89 ± 15.010 months vs. 33.79 ± 14.129 months, t=-2.767, p = .003). Furthermore, the time taken to classify patients was longer for nurses who accurately classified patients compared to those who inaccurately classified patients (6.10 ± 2.185 min vs. 5.62 ± 1.717 min, t = -2.661, p = .004) (Table 2).
Table 2
Characteristics of triage nurses between accurately and inaccurately classified patients
Variables | Accurate (n = 668) mean (SD) | Inaccurate (n = 119) mean (SD) | t | p |
|---|---|---|---|---|
Clinical experiences | 79.15 (22.722) | 72.46 (20.513) | -2.999 | 0.001 |
KTAS classification experience | 37.89 (15.010) | 33.79 (14.129) | -2.767 | 0.003 |
Time required for classification | 6.10 (2.185) | 5.62 (1.717) | -2.661 | 0.004 |
Triage nurses’ factors affecting accurate patient classification
Table 3 presents the factors influencing accurate patient classification by triage nurses. Longer clinical experience (p = .001, CI = 1.094–2.052), longer KTAS classification experience (p = .003, CI = 1.094–1.605), and longer time taken to classify patients (p = .002, CI = 1.338–2.916) were found to have significant impacts on classification accuracy. In contrast, the age (p = .19, CI = 0.0889-1.313) and gender (p = .481, CI = 0.702-1.221) of the triage nurses were found to have no significant impact (Nagelkerke R2 = 31.0, Hosmer and Lemeshow test: X2 = 6.058, p = .641) (Table 3).
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Table 3
Factors influencing accurate patient classification by triage nurses
Variable | β | p | OR | 95% CI for OR | |
|---|---|---|---|---|---|
Lower | Upper | ||||
Age | 0.012 | 0.19 | 0.985 | 0.889 | 1.313 |
Sex | -0.245 | 0.481 | 0.684 | 0.702 | 1.222 |
Clinical experiences | 0.121 | 0.011 | 1.119 | 1.094 | 2.052 |
KTAS classification experience | 0.145 | 0.003 | 1.312 | 1.148 | 1.605 |
Time required for classification | 0.235 | 0.002 | 1.096 | 1.338 | 2.916 |
Discussion
The findings of our study indicate an 84.9% classification accuracy among triage nurses in EDs, which aligns with the expected standards in emergency care but suggests room for improvement. The significant positive correlation between classification accuracy and both triage experience and classification time suggests that more seasoned nurses with sufficient time to evaluate patients tend to perform better in triage accuracy. The binary logistic regression analysis further confirmed that the time taken for classification and the nurse’s triage experience are significant predictors of triage accuracy. This reinforces the idea that ensuring adequate time for assessment and valuing triage experience are critical factors in enhancing triage outcomes. Through this discussion, we would like to identify and present what is needed to improve the classification accuracy of nurses.
Classification time
A study that explored the correlation between classification accuracy and the duration required for triage among 7,705 adult patients visiting the ED of a tertiary hospital over roughly one month discovered that nurses required a longer average time to make precise classification decisions [17]. Additionally, there was a study where they looked at how accurately patients with chest pain were categorized when they came into the ED. According to Sammons [18] the longer the nurses had worked in the ED, the more time they took to classify the patients. for instance, chest pain can be difficult to diagnose and rule out other potential causes. Thus, nurses having more clinical experience may actually take more time to get the accurate triage, particularly in cases as complicated as chest pain. However, in a multicenter prospective study conducted across 11 EDs in Tuscany, Italy, it was observed that the more seasoned the triage nurse, the shorter the time needed for triage, reflecting the characteristics of the nurses performing triage [19]. These findings align closely with our own. The direct relationship between extended classification times and heightened accuracy highlights the intricate nature of triage decision-making, suggesting that when nurses are afforded sufficient time, they are more likely to render accurate assessments. This insight poses a challenge to prevailing ED protocols, where rapid response is frequently prioritized due to the high volume of patients and the urgent demands of the setting. It advocates for a potential reevaluation of existing workflows and processes to provide triage nurses with more time per patient, which could ultimately lead to improved patient outcomes.
Triage experience
The positive impact of triage experience on classification accuracy emphasizes the value of experience and tacit knowledge gained over time in emergency care settings [20]. Our study results showed that the more experienced nurses were, the more accurate they were in classifying patients. These results are similar to the results of several studies. In a comprehensive systematic review of studies published from January 2011 to December 2021, researchers investigated factors influencing classification accuracy within emergency room settings. The findings revealed that classification accuracy significantly improved when nurses possessed greater clinical experience or had more extensive experience in patient classification [21]. In addition, in a comprehensive study aimed at identifying various factors that influence the classification accuracy among adult patients visiting the ED of a tertiary hospital, it was conclusively determined that the accuracy of classification was notably higher when the nurses involved had amassed a greater amount of clinical experience or had been engaged in patient classification activities for a longer duration [17]. This observation highlights the pivotal importance of both clinical expertise and specific classification experience in enhancing the precision and reliability of patient triage in high-pressure emergency care settings. This correlation underscores the critical role that hands-on experience plays in enhancing decision-making abilities and the overall effectiveness of triage processes in emergency care environments. Experienced nurses can draw from a vast array of past interactions and outcomes to make more informed and nuanced decisions [22]. This finding suggests that departments might benefit from strategies that leverage the experience of veteran nurses, such as paired work shifts or mentorship programs, where less experienced nurses can learn from their more experienced colleagues.
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The implications of these findings are significant for the management of EDs. Policies that focus on optimizing nurse scheduling to align with peak demand times, enhancing triage training programs to equip nurses with advanced skills, and possibly integrating sophisticated decision-support systems to aid in real-time clinical decision-making could prove to be extremely beneficial. Additionally, considering effective workload management strategies to prevent decision fatigue, which can compromise decision-making quality and reduce classification accuracy, could be vital in maintaining high standards of care and ensuring the reliability of patient triage in these high-pressure environments.
The results of our study indicate that both experience and the time allocated for triage significantly impact classification accuracy. However, it is also essential to consider the specific profiles of the triage nurses involved, including their educational background, specialized training, and certification levels. Research has shown that nurses with specialized training in emergency care, such as certifications in Advanced Cardiovascular Life Support (ACLS) or Emergency Nursing Pediatric Course (ENPC), tend to perform better in high-pressure situations, including triage [23]. Additionally, triage nurses who undergo continuous professional development and are familiar with the latest triage protocols, such as the Emergency Severity Index (ESI) or the Korean Triage and Acuity Scale (KTAS), may achieve higher accuracy in patient classification [24].
Limitations
While our study provides valuable insights, it is not without limitations. The retrospective nature of the analysis and the specific setting limit the generalizability of the findings. Future research should explore these factors in varied healthcare settings and include prospective studies to validate and extend these findings. Additionally, examining other variables such as patient outcomes and satisfaction could provide a more comprehensive understanding of the implications of triage accuracy.
Conclusion
In conclusion, this study has highlighted the importance of nurses’ triage experience and adequate classification time in enhancing the accuracy of triage decisions in EDs. By fostering an environment that supports ongoing professional development and allows sufficient time for patient assessment, EDs can improve the efficacy of their triage processes. Ultimately, the goal is to ensure that all patients receive timely and appropriate care, optimizing outcomes and maximizing the efficiency of emergency medical services.
Acknowledgements
Not applicable.
Declarations
Ethics approval and consent to participate
This study was approved by the Boramae Medical Center Institutional Review Board (IRB approval number: 20-2023-48). Written consent was obtained to collect the general characteristics of the triage nurses. The collected information is used solely for research purposes and is managed and disposed of in accordance with management standards and relevant laws and regulations.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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