What strategies can improve triage accuracy in emergency departments?

Daily Audit-Feedback Cycles Significantly Improve Triage Accuracy in Emergency Departments

Daily triage auditing is a highly effective strategy to improve triage accuracy in emergency departments, reducing error rates by more than 50% and significantly improving inter-rater agreement between nurses and physicians. 1

Understanding Triage Accuracy and Its Importance

Accurate triage is fundamental to emergency department (ED) operations and directly impacts patient outcomes. The accuracy of field triage can be understood as the degree of match between the severity of injury and the level of care provided 2. Inaccurate triage decisions can lead to:

• Undertriage: When patients requiring higher-level care aren't identified correctly, potentially resulting in death or substantial morbidity
• Overtriage: When patients who don't require higher-level care are unnecessarily sent to specialized centers, consuming scarce resources

Trauma systems typically aim for undertriage rates of 0-5% and accept overtriage rates of 25-50% to ensure patient safety 2.

Evidence-Based Strategies to Improve Triage Accuracy

1. Daily Audit-Feedback Cycles

The most recent and compelling evidence comes from Zaboli et al. (2023), who demonstrated that implementing daily triage audits:

• Reduced triage error rates from 23.3% to 9.7%
• Improved concordance between physician and nurse assessments from moderate (Cohen's K of 0.447) to excellent (Cohen's K of 0.881) 1

This approach provides real-time feedback to nurses, reinforcing correct decision-making and promoting professional development in a structured manner.

2. Innovative Staffing Models

Several effective staffing approaches can improve triage accuracy:

• Physician-led team triage models have been associated with improved throughput and quality of care, decreased length of stay, reduced rates of patients leaving without treatment, decreased unscheduled return visits, and decreased mortality within 7 days 2
• Utilizing nurse practitioners or physician assistants at triage or in treatment areas can have positive effects on patient flow and satisfaction 2
• Dedicated second triage nurse during periods of high activity to support waiting room patients 3

3. Addressing Common Triage Error Factors

Research has identified several factors associated with higher triage error rates:

• High patient volume (>1 patient triaged every 15 minutes)
• Patient characteristics: older age, multiple chronic conditions, higher acuity cases
• Nurse factors: previous experience with different triage systems 4

Implementation Framework for Improving Triage Accuracy

1. Establish a daily audit system:

   • Review triage decisions systematically
   • Provide immediate feedback to triage nurses
   • Focus on both correct decisions and errors

2. Optimize staffing patterns:

   • Implement team-based triage during peak hours
   • Consider physician-led triage for complex cases
   • Ensure adequate staffing ratios to prevent rushed assessments

3. Standardize triage processes:

   • Avoid unit-dependent or nurse-dependent variations
   • Eliminate "quick look" approaches that don't incorporate physiologic data 5
   • Ensure consistent application of triage scales

4. Design effective feedback mechanisms:

   • Target errors of omission
   • Provide explicit, measurable instruction
   • Deliver feedback in the clinical setting
   • Use a combination of individual and group feedback 6

Pitfalls and Caveats

1. Avoid system manipulation: Emergency nurses often report manipulating triage systems to "fix" problems in ED flow rather than applying standard triage protocols 5. This undermines accuracy and patient safety.

2. Beware of bottlenecks: Triage bottlenecks during intake and long waiting times have been linked to higher rates of patients leaving without being seen 5.

3. Consider workload impact: High patient volume significantly increases error risk. When triage nurses assess more than one patient every 15 minutes, the odds of triage errors more than double (OR: 2.112) 4.

4. Address physical environment limitations: The physical triage environment can be a barrier to optimal adherence to evidence-based practice guidelines 3.

By implementing these evidence-based strategies, emergency departments can significantly improve triage accuracy, enhance patient safety, and optimize resource utilization while fostering a culture of continuous quality improvement.