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My name is Kelli Bryla, and I'm completing my preceptorship in the ED at SLH. I will not be working there after graduation, but I intend on going back to the ED in the future. Triage is crucial in the ED to prioritize care based on patient severity. However, inefficiencies cause delays, increased morbidity, and overcrowding, putting strain on nurses and resources. This presentation explores current triage challenges and evidence-based strategies to improve efficiency, optimize patient flow, and enhance care.

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Emergency departments (EDs) across the United States are increasingly overwhelmed, resulting in prolonged triage times and delays in care. Patients presenting with potentially life-threatening conditions may experience delays in EKGs, vital sign assessments, and treatment. The lack of standardized triage tools such as the Emergency Severity Index (ESI), understaffing, and inefficient workflow systems are all contributing factors. This affects patient outcomes, particularly in high-risk populations like those with chest pain or respiratory distress. Nurses are directly involved in the triage process and play a crucial role in timely assessment and care prioritization.

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Electronic Kiosks for Triage Efficiency (Nature Digital Medicine, 2023)

This literature review explored how electronic triage kiosks can help reduce emergency department overcrowding and improve pre-triage wait times. The review looked at nine different studies, six of which showed positive results. These studies found that kiosks could reduce wait times, improve triage documentation, and make patient flow smoother. However, three studies identified challenges like low patient engagement or technical issues. Despite these barriers, the overall evidence supported using kiosks as a helpful addition to nurse-led triage.

Kiosks allow patients to enter their symptoms and demographic information, which gives triage nurses a head start on making decisions. This helps speed up the triage process, especially during busy times, and ensures better use of hospital resources. While kiosks are not meant to replace the judgment of healthcare professionals, they can improve the speed, accuracy, and quality of triage documentation. This, in turn, allows nurses to spend more time on direct patient care and more critical assessments.

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The Flex Track Model and Bed Allocation Efficiency (PMC, 2014)

This study examined how flexible bed allocation can improve patient flow in an emergency department, using a discrete-event simulation to model patient movement in a 50-bed ED that handles around 85,000 visits annually. Traditionally, the ED reserved 10 beds for a Fast Track unit for low-acuity patients, but this rigid system led to inefficiencies. The researchers proposed a Flex Track policy, where up to five beds could be assigned to either low- or high-acuity patients based on demand.

Results showed that a three-bed Flex Track configuration reduced average wait times from 40.6 minutes with the traditional system to 30.9 minutes, a 31% improvement. A fully flexible model also showed improvement, but was less efficient than the hybrid approach.

The study demonstrates that dynamic bed allocation, especially with tools like ESI scoring, can improve patient flow, efficiency, and satisfaction in the ED. By adapting bed use to demand, hospitals can reduce delays, ensure timely care, and enhance overall patient safety.

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The Flex Track: Flexible Partitioning between Low- and High-Acuity Areas of an Emergency Department

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EDs with both low- and high-acuity treatment areas often have fixed allocation of resources, regardless of demand. We demonstrate the utility of discrete-event simulation to evaluate flexible partitioning between low- and high-acuity ED areas to…

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Influence of Door-to-ECG Time on ACS Outcomes (PMC, 2023)

This retrospective study reviewed 903 patients diagnosed with acute coronary syndrome (ACS) to examine how the timing of ECG (electrocardiogram) acquisition affects in-hospital mortality. The researchers found that a median ECG time of 5 minutes significantly improved patient care. Although ECGs performed after 10 minutes were associated with higher mortality rates, multivariable analysis showed no statistically significant correlation after adjusting for other factors.

The study emphasizes the importance of a protocol-driven approach to early ECG acquisition, guided by triage processes and acuity tools such as the heart-broken index. This approach contributed to earlier percutaneous coronary intervention (PCI) and better patient outcomes.

This study is particularly insightful, as it reinforces the importance of timely diagnostics and structured protocols in enhancing patient care. It further supports the need for triage nurses to initiate ECGs promptly, improving overall patient outcomes and reducing the risk of delays in critical care.

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Influence of the Door-to-ECG Time on the Prognosis of Patients with Acute Coronary Syndrome

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The rapid acquisition of an electrocardiogram (ECG) plays a crucial role in the diagnosis and management decisions in patients with acute coronary syndrome (ACS). We determined the time-to-ECG acquisition, identified factors associated with timely…

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Nurses are essential in triage, responsible for tasks such as taking vital signs, gathering patient history, performing EKGs, and applying ESI scoring to assess patient acuity. However, inconsistencies in the thoroughness of triage often arise due to staffing shortages, time constraints, and limited resources. These challenges can lead to delays in care and missed diagnoses. When nurses are able to perform comprehensive triage, including full assessments, timely diagnostics, and appropriate patient assignment (such as directing patients to fast track or main treatment areas), it results in reduced wait times, earlier diagnoses, and improved patient flow.

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Staffing Shortages Limit Triage Time and Reduce Thoroughness
Staffing shortages in EDs limit the time nurses can dedicate to each patient during triage. With fewer nurses available, critical steps like obtaining full vital signs or evaluating patient histories may be rushed or incomplete, leading to missed diagnoses and delayed care.

Workflow Inefficiencies Prevent Prompt Diagnostics
Inefficient workflows can delay diagnostic tests such as EKGs or lab work, especially if tests are not ordered promptly during triage. These delays are particularly dangerous when trying to rule out critical conditions like cardiac events or sepsis.

Lack of Training or Standardization in ESI Scoring Across All Nurses
Inconsistent training and lack of standardization in ESI scoring can lead to discrepancies in triage. Nurses may use different methods to assess acuity, potentially misclassifying patients and misallocating resources, which can result in delayed or improper care.

Financial Constraints in Adopting Electronic Triage Systems
Financial constraints often prevent EDs from adopting electronic triage systems, which require significant investment in hardware, software, and training. Without these systems, nurses rely on outdated, paper-based methods, leading to inefficiency and higher chances of error.

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Mandate ESI Scoring System Training

All triage nurses should receive formal training and certification in the Emergency Severity Index (ESI) system. This ensures that nurses are consistently applying the same criteria when assessing patient acuity, which leads to more reliable triage decisions. Ongoing education is essential to keep nurses updated on any changes or improvements in the ESI system, ensuring they maintain accuracy in their assessments. By standardizing how acuity is determined, this training helps prevent errors and improves overall patient care. A well-trained nursing staff will be able to prioritize cases more effectively, making sure that high-acuity patients are seen quickly and low-acuity patients are not over-prioritized.

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Implement Electronic Triage Tools

The use of electronic triage tools powered by artificial intelligence could significantly improve the speed and accuracy of the triage process. These tools can assist nurses by offering real-time decision-making support, helping them prioritize patients based on symptoms and medical history. AI systems can guide nurses to take immediate actions, such as ordering an EKG for a patient presenting with chest pain, or flagging potentially urgent cases that may need rapid attention. These systems can also reduce human bias by providing objective, data-driven recommendations. Integrating electronic tools can ultimately streamline the triage process, allowing nurses to spend more time providing care rather than sorting through paperwork or relying on memory alone.

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Develop a Fast Track Care Pathway

A Fast Track Care Pathway would involve creating a designated area in the emergency department specifically for low-acuity patients, such as those with minor injuries or non-urgent conditions. This would allow nurses to quickly assess and treat these patients, freeing up critical resources in the main ED area for more urgent cases. By directing low-acuity patients to the fast track, the ED can improve patient flow and reduce overall wait times. Nurses should play a key role in managing this pathway by accurately determining which patients belong in the fast track and ensuring they are directed there immediately. This approach not only makes the triage process more efficient but also enhances patient satisfaction, as low-acuity patients receive quicker treatment and more severe cases get the attention they need without unnecessary delays.

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Emergency department triage plays a vital role in patient outcomes, flow, and overall efficiency. During my education and ER preceptorship, I’ve seen how tools such as ESI scoring, full vital sign assessments, early ECGs, electronic check-ins, and fast-track bed use can improve care. However, these tools are only effective when supported by strong nurse leadership and adequate staffing.

Prioritization
In the emergency setting, prioritization is essential. Nurses must be able to assess patients quickly and determine who requires immediate attention. Through clinical experiences and coursework, I’ve developed the ability to make these decisions efficiently and accurately. Understanding patient acuity and available resources has helped me practice effective time management.

Critical Thinking
Critical thinking has been just as important in shaping my readiness for practice. Triage is often complex, requiring more than adherence to set protocols. It involves recognizing subtle changes in condition, anticipating potential complications, and adjusting the plan of care in real time. My education has strengthened my ability to analyze situations, ask the right questions, and apply evidence-based reasoning to clinical decisions.

Improving ED triage involves more than adding new technology. It requires building systems that empower nurses and support clinical judgment. With a strong foundation in prioritization and critical thinking, I feel prepared to take on a leadership role and contribute to a more responsive, efficient, and patient-centered emergency department.