After investing in a triage education program, some emergency department (ED) managers and educators become frustrated due to gaps in the application of that education. Implementing practice change does not always come easily, especially for those who have operated according to certain protocols for several years.
The following are some of the common barriers that can interfere with the application of updated triage practices:
- Practicing with providers/peers who lack knowledge of triage standards. ED staff members who are unaware of the implementation of new triage criteria by their organization might prevent nurses from following or adopting the new scoring system. Nurse leaders and medical directors should communicate with their staff about the new triage criteria; they should also provide the collaborative position of both ENA and ACEP on triage standards along with the organizational policy outlining the triage scoring system selected. In addition, triage criteria reference tools such as laminated posters should be available in staff work areas.
- Prioritizing task-directed care rather than critical thinking. Triage decision-making is based on critical thinking skills. However, when there is a backup in triage due to a volume surge, for example, the triage nurse needs to accomplish more in less time; this can result in a task-directed focus toward triaging patients. Take the patient who is using accessory muscles to breathe as an example. The nurse using critical thinking will notice this as a red flag, whereas the nurse who is task-directed might miss the red flag because they are focusing only on completing the mandatory assessment elements (e.g., vital signs, weight, etc.). Leadership must train staff to be aware of the barriers to critical thinking at triage.
- Refusing to accept new evidence. This is typically motivated by the mentality of, “That’s the way we always triaged around here and it worked for us.” In this situation, leadership should step up to enforce current and acceptable triage practices to ensure the safety of patients and engagement of staff.
- Concentrating on vital signs rather than identifying red flags for demise. When a patient presents with cyanotic lips and delayed capillary refill, the nurse should not wait for vital sign results before making a triage decision; for example, in the presence of these red flags, waiting for this patient’s oxygen saturation level to see if it’s low would cause a delay in rapid identification of a patient at great risk of demise.
Another gap is created when staff focus on the completion of a training requirement rather than the learning experience to improve patient care. Although this is typically not the majority of staff, it is imperative to implement a process that retrospectively reviews triage records because quality care depends heavily on triage nurse decisions in high-risk situations.
Triage accuracy record reviews should be coordinated to determine the level of compliance with established standards. As an example, an organization might pull ten records quarterly for each nurse and review for accuracy. For one quarter, the organization might look at the following:
- 2 pediatric charts, checking for the collection of weights and triage level accuracy
- 2 adult chest pain charts, checking for documentation of pain location and triage level accuracy
- 2 respiratory complaint charts, checking for perfusion elements and triage level accuracy
- 2 pediatric trauma charts, checking for perfusion and triage level accuracy
- 2 sepsis charts, checking for SIRS criteria and triage level accuracy
Within our RSQ® Solutions Triage Assessment, triage nurses retrospectively enter their own data into a system that offers critical thinking tips. While moving through a past encounter, each nurse can select the correct level to triage each patient. This provides an opportunity for individuals to identify areas of improvement in competency and care moving forward.
Nurse managers and educators can also use the results of chart reviews to assess how individual nurses align with department policy and to guide efforts to improve performance in the triage arena.