Who is Competent to Triage?

How do you determine who is actually competent to triage? If you do have a competency assessment plan, is it documented in writing? How do you know it is effective? Is it up to date?

These and many other questions arise when exploring the development and documentation of a triage competency validation process. Answers to these questions are imperative, as they not only impact litigation that may arise, but are also essential for ensuring the highest quality patient care.

Considerations for Triage Competency Requirements

When determining triage competency, consider the following elements for your requirements.

• Experience as an Emergency/Urgent Care Nurse - Does the nurse have current experience in this specialty? If so, how many years? If not, how long should a nurse work in this area prior to being able to function independently at triage? If you are hiring new graduate nurses, you may elect a different level of experience prior to triage.
• Successful Completion of a Triage Course/Training - How do you determine if someone has successfully completed a course? There are people who re-certify their ACLS/PALS, yet still cannot demonstrate proficiency in a real code. If attendance alone in a course is not sufficient, then what is? The use of case scenarios, written exams, and observation of practices along with retrospective chart reviews are all methods to assist in determining successful completion of training.
• Completion of Particular Certifications (ACLS, PALS, ENPC, TNCC) - Setting the standard for triage competency sends a message to the community you serve that these are your minimal performance requirements for triage staff. Many certification programs serve as excellent foundation knowledge to support triage decisions; e.g., the Emergency Nurse Association Trauma Nursing Core Curriculum.
• Ability to Demonstrate Application of Knowledge - Triage skills include far more than the selection of a triage level number for the patient; they are also about the choice and provision of interim care measures such as providing a wheelchair or applying ice to an injured extremity. Direct observations during the actual triage process prove very helpful in validating triage competencies. The retrospective chart review, in addition to tracking triage nurses' performance, also provides an opportunity to review triage policies and procedures.
• Ability to Apply Positive Customer Service Skills with Multiple Patients and Families - Triage competency is about so much more than how good a nurse is at starting an IV or performing tasks on a checklist. The ability to calm and reassure those presenting to triage is as important as the skill of determining a correct triage level. Some describe the ED as organized chaos; no one knows this better than the triage nurse who is trying to sort through multiple patients and their caregivers. The challenge is doing this with empathy, reassurance, and of course, a smile!

As with other recommendations related to guidelines and policies, it is important to select competency criteria that are realistic for your work setting and patient demographic.

• An environment that is 100% pediatric clients should require competencies specific to that age population.
• If part of your demographic presents with complaints related to changes in behavior, then staff should demonstrate triage knowledge in that area.

Design a Triage Training Program that results in measurable change. Read our free playbook for implementation best practices.

Most Common Gap in Triage Competency

Triage competency should be evaluated at the point of hire and on an ongoing basis. This is the most common gap in triage competency assessment – assessment that is only performed at the point of hire. There is no guarantee that a nurse who demonstrated triage proficiency upon hiring will maintain the same level of practice five years into employment.

I have seen many organizations assume that once the orientation for triage box is "checked off," no additional requirements remain. Not only is this untrue, but The Joint Commission actually requires that competency be re-validated a minimum of every three years.

Practice standards change; evidence-based principles intertwine with our standing triage orders; and even the classification for immunocompromised patients changes. These are just a few examples that reinforce the need for ongoing education and current knowledge base maintenance to ensure excellence in triage practice.

It is necessary to develop a process to ensure that staff maintain the defined minimal competency level of triage. For example, compassion fatigue can develop over time; unacceptable work practices might creep in as time passes since their training; there is also the potential for lack of policy compliance and a disregard for attentive customer service. All of these can wreak havoc on the risk associated with your department.

You may identify some staff who excel and exceed competency expectations, while others may no longer be able to meet your minimum criteria. Remediation processes can be effective when tied to performance expectations and nursing job descriptions.

The bottom line regarding triage competency is this: What is the minimal level of skill your community deserves when they present at triage?

Case: Competency in Question

Consider the facts of this malpractice case against an ED nurse. Sandra triaged an 87-year-old female who presented with abdominal pain. Sandra had assigned the patient a triage level of 3, despite the fact that her documentation reflected a patient who was pale and diaphoretic with a blood pressure of 102/50 and a heart rate of 112.

The patient's appendix ruptured; she suffered an MI during surgery and died the following day. The family hired a legal firm and is seeking a claim against the hospital, the triage nurse, the nurse manager, and the ED physician.

During the deposition, the plaintiff's attorney claimed that there was no record of competency for triage in Sandra's employment file and asked about her qualifications to triage in 2008.

• When asked for proof that she was qualified to triage this patient in 2008, Sandra referred to her years of experience as an ED nurse.
• The ED Nurse Manager was also deposed. He was asked how he validates triage competency for the nursing staff; he responded that he refers to a lack of bad outcomes as validation. 

Clinical experience, in and of itself, does not prove or validate competency; it simply tells someone how many years you have worked in a particular field. 

Don't wait for a deposition to address your organization's triage competency assessment. Document your requirements and validate them on an ongoing basis to best serve your patients and avoid litigation.