RESEARCH

AN EXAMINATION OF ESI TRIAGE SCORING

ACCURACY IN RELATIONSHIP TO ED NURSING
ATTITUDES AND EXPERIENCE
Authors: Andrew Martin, MSN, RN, PHRN, CEN, Carolyn L. Davidson, PhD, RN, CCRN, FNP-BC, CPHQ, Anne Panik, MS, BSN, RN, NEA-BC,
Charlotte Buckenmyer, MS, RN, CEN, Paul Delpais, MSN, RN, CEN, and Michele Ortiz, BSN, RN, CEN, Allentown, PA

Earn Up to 9.0 CE Hours. See page 521.

Introduction: This research was designed to examine if there is a
difference in nurse attitudes and experience for those who assign
Emergency Severity Index (ESI) scores accurately and those who do
not assign ESI scores accurately. Studies that have used ESI scoring
discussed the role of experience, but have not specically addressed
how the amount of experience and attitude towards patients in
triage affect the triage nurse's decision-making capabilities.
Methods: A descriptive, exploratory study design was used.

Data from 64 nurses and 1,644 triage events at 3 emergency

departments was collected. Participants completed demographic data, attitude (Caring Nurse Patient Interaction, CNPI-23)
survey, and triage data collection tools during the continuous 8hour triage shift. Clinical nurse expert raters retrospectively
reviewed the charts and assigned an ESI score to be compared
with the nurse. Descriptive statistics were used to describe the
nurse and Pearson's correlation was used to examine the
relationship between experience and attitude.
Results: In this study of 64 nurse participants, the ESI score
assigned by nurse participants did not differ signicantly based on
Andrew Martin, Member, Berks County Chapter, is Director, Emergency
Services, Lehigh Valley Health Network, Allentown, PA.
Carolyn L. Davidson is Administrator, Quality and Evidence-Based Practice,
Lehigh Valley Health Network, Allentown, PA.
Anne Panik is Sr. VP, Patient Care Services and Clinical Excellence, Lehigh
Valley Health Network, Allentown, PA.
Charlotte Buckenmyer is former Director, Emergency Services, Lehigh Valley
Health Network, Allentown, PA.
Paul Delpais is Director, Emergency Services, Lehigh Valley Health Network,
Allentown, PA.
Michele Ortiz is Emergency Department Patient Care Coordinator, Lehigh
Valley Health Network, Allentown, PA.
For correspondence, write: Andrew Martin, MSN, RN, PHRN, CEN, Lehigh
Valley Health Network, 1637 Chew St, Allentown, PA 18102; E-mail:
Andrew_S.Martin@lvhn.org.
J Emerg Nurs 2014;40:461-8.
Available online 26 November 2013
0099-1767
Copyright 2014 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.jen.2013.09.009

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VOLUME 40 ISSUE 5

years of experience or CNPI mean score. The Kappa statistic

ranged from a high of 0.63 in the nurse participant with 1.00 to
1.99 years of experience to a low of 0.51 in the nurse participant
with 15 to 19 years of experience. The nurse participants with an
overall mean CNPI-23 score of 106 to 115 achieved the highest
agreement compared with a single participant with a CNPI-23
overall mean score of less than 77 who had a Kappa agreement of
0.50. The nurse participants with a CNPI-23 overall mean score
between 81 and 92 demonstrated agreement of 0.54 to 0.60.
Discussion: Based on the high level of liability the triage area

presents, special consideration needs to be made when deciding

which nurse should be assigned to that area. The evidence
produced from this study should provide some reassurance to ED
managers and nurses alike that nurses with minimal ED
experience and a working understanding of the ESI 5-level triage
algorithm possess the knowledge and the capacity to safely and
appropriately triage patients in the emergency department.
Key words: Emergency department; Triage nurse; Nurse

attitude; Nurse experience; ESI

he triage area of the emergency department has

been identied by many professional organizations
as a location that leaves the hospital vulnerable to
liability. Further compounding the vulnerability of the
triage area is ED crowding, a problem projected as only
worsening by the American College of Emergency
Physicians. 1 Further, in the landmark report, The Future
of Emergency Care in the United States, the Institute of
Medicine described the worsening crisis of crowding that
occurs daily in most emergency departments. 2 Predictions
like this highlight the importance of taking all available
precautions to manage triage area liability.
Given the described crowding crisis, the role of the ED
triage nurse in the initial assessment may be the most crucial
to ensure that the right patient is in the right place at the
right time and that no one is overlooked. 3 These initial
decisions made by the triage nurse affect the entire
department. In spite of the current nationwide nursing

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shortages, it is important to ensure that emergency

departments are staffed not only with adequate nursing
support but with high-quality, well-trained nurses capable
of accurately triaging ED patients. 4
The characteristics of the triage nurse that exemplify
prociency have not been well elucidated in the literature.
Reports conict regarding the adequate amount of experience
and the attitude a nurse requires to be considered competent
in the skill of triaging. 58 The inability to formulate consistent
conclusions is further compounded by the study methods
chosen to evaluate nurses in triage, because all the studies used
simulation scenarios.
The accurate triage of patients is leveraged by the
Emergency Severity Index (ESI). The ESI is a 5-level
triage system guided by algorithms for clinical decision
making and is a tool that allows the nurse to rapidly
assess the patient, initiate decision making for resources,
and assign a score that is familiar to the health care team.
The algorithm is simple to use, reduces the subjectivity of
the triage decision, and is more accurate than other triage
systems, therefore contributing to a common language
among ED caregivers. 9
Although the validity and reliability of the ESI have
been established, questions remain about the characteristics
that contribute to a procient ED triage nurse. To better
evaluate attitude, the denition a mental position with
regard to a fact or state, or a feeling or emotion toward a fact
or state was used for the purposes of this study. 10
The lack of available literature conclusively addressing
(1) the effect of attitude toward patients and (2) the amount
of experience on the prociency of the ED triage nurse
supports this descriptive, exploratory study. The following
research questions were examined:
1. Does the number of years of experience differ
between ED nurses who do and do not accurately
assign (ESI) triage scores?
2. Does the attitude toward patients in triage differ
between ED nurses who do and do not accurately
assign ESI triage scores?

Setting

The study was conducted in a 988-bed tertiary Magnet

health network with emergency departments at 3 sites in
northeast Pennsylvania. The 3 distinct sitesa level I
trauma center in a suburban location, a center city location,
and a community campuscollectively exceed 130,000
ED patient visits on an annual basis.

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JOURNAL OF EMERGENCY NURSING

Sample

A convenience sample was recruited from registered nurses

in the 3 emergency departments. Inclusion criteria for the
nurse participants were:

A current full-time, part-time, or ED specialty oat pool

employee in any one of the 3 emergency departments

Possession of a current nursing license in the

commonwealth of Pennsylvania

Completion of the Lehigh Valley Health Network

(LVHN) required critical care course, or equivalent

Completion of the ESI training course within the

2 months preceding study enrollment

Completion of an 8-hour triage shift

All patients who entered the emergency department via

the designated triage area and were assigned an ESI score by
enrolled nurse participants during the 8-hour shift were
identied as eligible for the study. Triaged patients with one
of the criteria deemed a protected/vulnerable population (ie,
domestic violence, sexual assault, behavioral health, and
pediatric patients) dened by LVHN organization policy
were excluded from the study. Patients arriving by
ambulance were excluded because they bypass the nurse
triage area.

Study variables

Accuracy of ESI scoring by nurses was the outcome variable

in this study. The ESI score was obtained by nurse
participants who triaged patients in live situations and
assigned a score based on the established valid and reliable
ESI algorithm. 11 Secondarily, an ESI score was assigned by
ESI-validated clinical nurse expert raters who retrospectively
reviewed the presenting information on the ED patients
chart. The two predictor variables in the study were ED
triage experience and attitude toward patients in triage as
measured by the Caring Nursing Patient Interactions Scale
(CNPI-23), a psychometrically valid tool with 4 subscales
(clinical care, relational care, humanistic care, and comfort
care) designed to assess nurse attitudes and behaviors based
on Watsons 10 carative factors. 12 The interaction at
point of triage is linked to many of the caring factors, such
as trust, altruism, humanism, sensitivity, supportive,
problem-solving, and protective.
Instruments

The Nurse Characteristic Collection Tool (NCCT) was

developed from the relevant literature to collect

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Martin et al/RESEARCH

demographic data and characteristics about the nurse

participant: age, sex, educational level, certications,
employment status, shift status, years of nursing experience,
years of ED nursing experience, years of ED triage nursing
experience, and triage hours worked per week. Additionally,
each nurse was asked to rate their perceived competence
of triage ability: novice, beginner, intermediate, advanced,
or expert.
The CNPI-23, a 23-item instrument used to measure
caring attitudes and behaviors, was used in this study to
reect attitudes of nurses. The authors permission was
obtained to use this instrument. The CNPI-23 requires a
forced choice response on a 5-point Likert scale (1 = not at
all to 5 = extremely). The instrument was scaled down from
the original 70-item, 10-subscale instrument and produces
subscale scores in 4 distinct caring domains (clinical,
relational, humanistic, and comfort care). The total CNPI23 score range is 23115. The instrument has been
factor analyzed and tested and found to be reliable (clinical,
r = 0.82 to 0.93; relational, r = 0.89 to 0.91; humanistic,
r = 0.64 to 0.73; and comfort care, r = 0.61 to 0.74).
Attitude is dened as a mental position with regard
to a fact or state, or a feeling or emotion toward a fact or
state, 10 whereas caring is dened as to be concerned
about, to feel interest or concern. 13 The CNPI-23 and the
subscales address Watsons original theory of carative factors
that embody both attitude and caring. These factors provide
clear guidelines for the nurse-patient interaction. The
subscales are interdependent and reect an individual
nurses value system. Decision making in triage is guided
primarily by a categorized patient acuity algorithm but also
may be a factor of intrapersonal characteristics. 14 The
linkage of patient outcomes with intrapersonal behaviors is
reected in the CNPI-23. Items within the subscale of
humanistic care refer to a nurses attitude and behaviors as
they relate to the patients own capacities and abilities.
Relational care addresses the nurses respect of patient
perceptions, and the clinical care subscale addresses the
clinical expertise. The comforting care subscale is most
representative of the hidden work associated with nursing.
The ESI is 5-tier algorithm used to categorize patient
acuity based on key patient factors: presence of a condition
that is life threatening or high risk; vital signs; and how
many resources the patient will need. The utilization of the
validated and reliable ESI 5-tier triage scoring tool is best
used in combination with patient presentation including
age, history, pain, current medications, and patient severity
of complaint to support an overall ESI score assignment.
The ESI has evolved during the past 14 years, and with use
of the Kappa statistic it has most recently demonstrated
interrater reliability ranging from .70 to .80 when nurses

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make triage decisions based on case studies and 0.69 to 0.87

when nurses make triage decisions for actual patients. 9

Procedures

The study was approved by the Institutional Review Board.

Exemption to full Institutional Review Board review was
granted because the study met all criteria for posing a low
risk to participants. The study data were collected in 3
phases. In phase I, ED nurses were briefed about the study
and invited to participate by the principal investigator (PI)
at education days. Nurse participants signed an informed
consent at enrollment and were given the NCCT and
CNPI-23 to complete.
In phase II, enrolled nurse participants worked one
continuous 8-hour shift in the triage area. During this time
they continued to use standard triage procedures to prioritize
patients and documented their triage assessments in the ED
electronic medical record. In addition, the participants
completed the Triage Case Tracking (TCT) form that
contained the patient medical record numbers, nurseassigned ESI scores, and the number of resources the nurse
predicted the patient would require. Completed TCT forms
were placed in a locked box located in each study sites triage
room. To thank them for their participation, the participants
received a $25 gift card after completion of all requirements:
NCCT, CNPI-23, and an 8-hour shift in triage.
In phase III, the completed TCT forms were collected
by 1 of the 6 ESI-validated clinical expert nurse reviewers to
obtain patient medical record numbers. Using the
emergency departments electronic medical record, the
nurse experts carefully reviewed each patients medical
record to determine if an accurate ESI score was assigned.
The clinical experts reviewed medical records on an
ongoing basis throughout the study implementation period
and recorded their ndings on the triage research
retrospective review forms.
The ESI-validated clinical expert nurse reviewers were
identied by ED clinical leadership as procient in ESI
scoring. The expert reviewers were educated on the
procedures for retrieving completed TCT forms, accessing
the closed medical record, and completing triage research
retrospective review forms and were briefed on the study
intent by the PI. Additionally, they completed a refresher
ESI training module consisting of video case scenarios and a
written test after completion. Using the posttest, the expert
triage nurses interrater reliability was established by
independent scoring on a minimum of 20 case scenarios
and achieved 0.80 using Fleiss-Kappa statistics.

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Enrollment
Assessed for Eligibility (n = 185)
ESI Trained within past 2 months
LVHN required Critical Care Course
Completed 8-hour triage shift

Declined to
participate
(n = 57)

Completed Initial Tools (n = 125)

Informed Consent
Nurse Characteristic Collection Tool
CNPI (Caring Nurse Patient Interaction Scale-23) (n = 125)

Attrition (n = 48)
Inability to complete 8-hour triage
assignment
Changed intent to participate
Voluntary Resignation

Completed 8-hour triage

assignment (n = 80)

Analysis

Analyzed (n = 64)
Excluded from analysis due to missing > 10%
CNPI-23 data
No prior ED triage experience

ED Triage Experience

0.20-.99
years

1.00-1.99
years

2.0-4.99
years

5.0-9.99
years

10.0-14.99
years

> 15 years

FIGURE 1
ED triage study participation. CNPI-23, Caring Nursing Patient Interactions-23 item; ED, emergency department; ESI, Emergency Severity Index; LVHN, Lehigh Valley
Health Network.

Data Analysis

SPSS software (version 17.0; SPSS Inc, Chicago, IL) was

used to analyze the data. The data were conrmed to ensure
its correctness before data analysis. The researcher did not
nd any patterns for missing data. Unanswered demographic data questions were left blank in the data le. In the
CNPI-23 instrument measuring attitude, 16 data points
were replaced with the group mean, and 3 participants with
more than 10% (2 questions) left unanswered were

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JOURNAL OF EMERGENCY NURSING

eliminated from the nal data analyses. The data points

replaced were varied, and no one subscale had more than
one data point missing across a single participant.
Simple descriptive statistics were used to analyze the
demographic characteristics of the nurse participants. The
Kappa statistic was used to determine interobserver agreement between nurse participant ESI score assignment and
validated, clinical nurse expert ESI score assignment. The
Kappa statistic was used to examine the interobserver
agreement by category of experience and by site of triage.
Pearsons correlation was used to examine the relationship

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TABLE 1

Results

Demographic characteristics of registered nurses

Characteristic

No. of RNs at site

Site A: 36
Site B: 7
Site C: 21
Gender
Male
Female
Age (y)
b 25
26-35
36-45
N 45
No response
Years of RN ED triage experience
.25-.99
1.00-1.99
2-4.99
5-9.99
10-14.99
N 15
Education
ADN
Diploma
BSN
No response
Employment status
N 36 h/wk
20-35 h/wk
b 20 h/wk
Weekend
No response
Triage ability (self-rate)
Novice
Beginner
Intermediate
Advanced
Expert

Frequency
triage cases

979
121
544

59.5
7.4
33.1

10
54

15.7
84.3

3
19
13
16
13

4.7
30.0
20.3
.25
20.3

6
5
15
14
11
13

9.4
7.8
23.4
22.0
17.2
20.3

28
12
22
2

44.0
19.0
34.4
3.1

49
4
3
3
5

76.5
6.3
4.7
4.7
7.8

5
5
19
32
3

7.8
7.8
30.0
50.0
4.7

ADN, Associates degree in nursing; BSN, bachelor of science in nursing; ED, emergency
department; RN, registered nurse.

between experience and attitude. Additionally, one-way

analysis of variance was used to test for differences of attitude
across sites, gender, ESI agreement, and triage experience.

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The data from this study represent 64 nurse participants

and 1644 patients triaged during the study period within
the 3 emergency departments. The rate of nurse
participation (Figure 1) was 34.5% (64 of 185 eligible).
The continuous 8-hour ED triage shift deterred some
nurses from initially participating; 48 nurses dropped
out after completing the required questionnaires because
they were unable to fulll the triage requirement, and 13
nurses were excluded because they did not have the
ESI training course. Demographic data are shown in
(Table 1).
Participants were primarily women (84%) and ranged
in age from older than 25 years to 65 years (n = 61, with 3
nonrespondents); the 26 to 35 years and 36 to 45 years age
groups together represented 42% of the nurses. A majority
of the participants had an associate degree in nursing
(44.0%). The ED experience ranged from 3 months to
35 years (M = 6.44, SD = 7.80), with the majority reporting
2 to 10 years experience (51.8%). Nurses who indicated
they had not completed the ESI training course were
eliminated from the primary study sample. The wide range
of experience contributed to the large standard deviations.
Nurse participants in the 3 emergency departments selfrated their triage ability on a scale of 1 to 5 (novice,
beginner, intermediate, advanced, and expert), with 80%
identifying as intermediate or advanced.
The attitude scores for the study sample measured
by the CNPI-23 indicated an overall mean of 92.88 (SD =
14.17). The CNPI-23 score stratied by experience
(Table 2) ranged from a low mean of 93.10 (N 20 years)
to a high mean of 97.59 (1 to 2 years). The CNPI-23 overall
mean score by site was lowest at site B (Table 3) (M = 91.37,
SD = 6.59).
In phase II of the study, 1644 ED patients were
triaged by nurses and assigned an ESI score. Overall, the
agreement between the ESI-validated, clinical expert nurse
raters and the nurse participants ESI score assignment
using the weighted Kappa statistic was 0.65 (95%
condence interval [CI], 0.63 to 0.68). Four participants
had an interobserver agreement less than 0.20; of these, 2
had more than 15 years of experience, one had 7 to 10
years of experience, and one had less than 2 years
of experience.
The assignment of ESI scores by experience level of the
nurse participants and ESI validated raters is described in
Table 4. The Kappa statistic ranged from a high of 0.63
(95% CI 0.58 to 0.64, P b .001) in the nurse participant
with 1.00 to 1.99 years of experience to a low of 0.51 (95%

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TABLE 2

Experience (Caring Nursing Patient Interactions-23 item scale and Kappa scores)
Years of experience

CNPI-23 total mean (SD)

Kappa by experience
CI

1-2

2.1-4.99

5-9.99

10-14.99

15-19.99

N 20

97.59 (10.5)
0.630
0.60, 0.66

93.37 (10.9)
0.59
0.49, 0.67

93.53 (10.4)
0.632
0.61, 0.66

96.79 (9.3)
0.61
0.47, 0.69

95.06 (10.2)
0.51
0.39, 0.63

93.10 (4.0)
0.631
0.62, 0.64

CI, Condence interval; CNPI-23, Caring Nursing Patient Interactions-23 item scale; SD, standard deviation.

TABLE 3

Site (Caring Nursing Patient Interactions-23 item scale and Kappa scores)
CNPI-23 total mean (SD)
Kappa by site
CI

Site A

Site B

Site C

94.97 (9.8)
0.56
0.51, 0.67

91.37 (6.6)
0.45
0.42, 0.66

96.95(10.7)
0.60
0.46, 0.75

CI, Condence interval; CNPI-23, Caring Nursing Patient Interactions-23 item scale; SD, standard deviation.

TABLE 4

Years of ED triage experience and Emergency Severity Index score agreement with expert rater
RN ED triage experience (y)

No. total cases

Kappa (mean)

CI

0.25-0.99
1.00-1.99
2-4.99
5-9.99
10-14.99
N 15

224
321
315
261
161
314

0.56
0.63
0.59
0.63
0.61
0.51

0.35,
0.60,
0.49,
0.61,
0.47,
0.39,

0.67
0.66
0.67
0.66
0.69
0.63

CI, Condence interval; ED, emergency department; RN, registered nurse.

CI 0.39 to 0.63, P = .03) in the nurse participant with 15 to

19 years of experience. Substantial agreement (0.61 to 0.80,
P b .001) was noted in 705 triaged patients, and 3.4%
(n = 56) were noted to have slight agreement (0.01 to 0.20).
Overall, 1260 cases (77%) had a range of 0.41 to 0.80,
indicating moderate to substantial Kappa agreement
between participants and the expert raters. Only 56 cases
(3.4%) had slight agreement (less than 0.20). Site B
agreement was lowest, with 121 triaged patients (Kappa =
0.45, 95% CI 0.38 to 0.52, P b .001).
The nurse participants (n = 9) with an overall
mean CNPI-23 score of 106 to 115 achieved the
highest agreement (Kappa = 0.71, P b .001) compared
with a single participant with a CNPI 23 overall mean

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JOURNAL OF EMERGENCY NURSING

score of less than 77 who had a Kappa agreement of 0.50

(P b .001). The nurse participants with a CNPI-23 overall
mean score between 81 and 92 (n = 54, 84%) demonstrated
agreement of 0.54 to 0.60 (P b .001). CNPI-23 overall
mean scores and Kappa agreement by site are displayed in
Table 3.
A one-way between subjects analysis of variance was
conducted to compare the effect of ED triage experience
on attitude (CNPI-23) at the P .05 level (F = 0.897,
P = .49), the effect of gender on attitude (F = 0.017,
P = .90), or the effect of site of practice on attitude (F =
0.216, P = .81). The years of experience in the emergency
department and attitude scores were negatively correlated
(r = 0.78, P = .01).

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Discussion

The ndings in this study did not achieve statistical

signicance to support the notion that attitude or a specied
amount of experience contributed to accurate ESI score
assignment. The ndings did not support the current practice
at the study sites, which require at least 1 year of ED
experience before being assigned in the triage area. The range
of ED nurse experience was wide, although most were
clustered in the 2- to 10-year range. The lack of
representation from the group with less than 2 years
experience made it difcult to adequately explore experience
as a variable. The comprehensive number of nurses with an
overall CNPI-23 score exceeding 81 on a scale of 23 to 115
supports an overall attitude of caring in this sample of nurses.
The number of triage events examined in this study
contributes to the reliability of the ESI scoring tool with
acceptable Kappa scores between nurses with varying levels
of experience. The overall agreement between the nurse
participants and expert raters did achieve statistical
signicance. It is important to note that the overall rate of
agreement was less than the weighted kappa of 0.76
reported by Eitel et al, 9 whose study did not evaluate
experience as a factor, as we did in this study.
With the usage and demand for care in the emergency
department up 32% in the past 10 yearsupward of 124
million visits or 340,000 people every day 15organizations
are challenged to consider efcient, effective, and alternate
models for triage. In addition, the Patient Protection and
Affordable Care Act promises to provide affordable, quality
healthcare for all Americans. 16 ED leaders must be
condent that the right nurses are placed in the triage
area to ensure patient safety and decrease liability. Gilboy
et al 3 and Schriver et al 4 both concluded that ED nurses
skills are crucial to accurately triaging patients, and McNair
and Gurney 7 suggested that education, experience, and
empathy were important factors in triage. None of these 3
articles provided insight into years of experience that would
exemplify triage competence. A greater depth of exploration
and discovery through qualitative methods may contribute
to an expanded meaning of the selected constructs,
especially attitude in a cross-sectional examination of ED
nursing staff.
Limitations

This study had several limitations. First is the use of a

convenience sample of nurses who were self-selected for
participation and lacked equal representation in experience
and number of patients triaged at each site. The size
differences between the 3 departments contributed to the

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uneven distribution of participants from one site to another.

Additionally, although 6 ESI-validated clinical expert nurse
raters were used, one nurse expert rated a larger number of
participants than did other expert reviewers, exposing the
study to a possible bias. Further, the use of retrospective
chart review is contingent upon the accurate documentation
of patient presentation and may underestimate the live
patient presentation. The length of the data collection
period also must be considered, because the duration was
longer than one calendar year, leading to a higher rate of
attrition of nurse participants.

Implications for Emergency Nurses

An inexperienced nurse should not be condent that his or

her experience level alone warrants competence in the triage
area. However, the evidence discovered in this study should
provide some reassurance to nurses with minimal ED
experience and a working understanding of the ESI 5-level
triage algorithm that they possess the knowledge and the
capacity to safely and appropriately triage patients in the
emergency department. The results of this study should also
be considered during policy development for triage practices
in the emergency department.
Acknowledgments
The authors would like to thank the Dorothy Rider Pool Health Care Trust
for their monetary donations that enabled the completion of this study.
They also would like to extend a special thank you to Courtney Vose,
MSN, RN, MBA, APRN, NEA-BC, and Dr. Bryan Kane for lending both
their intellectual and clinical knowledge throughout the course of this
investigation. Finally they would like to extend their sincere gratitude to
the nurses who work in the emergency departments of the Lehigh Valley
Health Network for participating and helping to foster nursing research.

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VOLUME 40 ISSUE 5

September 2014