An inaccurate Emergency Severity Index assignment at triage can have rippling consequences for patients. The realization that serious symptoms sometimes go unrecognized led the Veterans Health Administration, the health care arm of the U.S. Department of Veterans Affairs, to delve into the reasons why and implement sweeping changes.
The session “Emergency Severity Index Training and Competency: Working Toward Effective Triage Skills” discussed a push to create a nationwide formal framework for ESI training.
Patients with undifferentiated diagnoses at triage represent the riskiest population in an ED, said Ashley Lunkenheimer, DNP, CEN, NE-BC, national emergency medicine nurse executive at the Department of Veterans Affairs, speaking to attendees yesterday at the session “Emergency Severity Index Training and Competency: Working Toward Effective Triage Skills.” Because these patients haven’t yet seen a doctor, they may be unsure exactly what’s wrong with them. “We need to have experienced, competent nurses making those assessments,” Lunkenheimer stressed.
The problem is a lack of standardization when it comes to making ESI judgments. A 2024 study regarding triage training methods across the VHA system revealed a wide variety of educational techniques. Nine percent of respondents said their training was classroom based, 8 percent relied on online learning, 37 percent experienced precepted time in triage positions and 26 percent used ENA triage modules. Sixteen percent of respondents relied on other methods, such as outdated ESI handbooks, homemade online modules, and even YouTube videos.
This lack of uniform training within the VHA poses a risk to patient safety, quality of care and operational efficiency, according to Jennifer Noble, BSN, RN, CEN, TCRN, a staff nurse at Michael E. DeBakey VA Medical Center in Houston. But why is it happening?
One reason is a variation in individual triage nurse characteristics, with differing levels of knowledge and skills among them. Some nurses may have cultural knowledge deficits or face language barriers, while others may harbor personal biases that can impact their choices.
Patient characteristics also may influence nurses’ judgment. “Nontrauma patients are most likely undertriaged compared to trauma patients,” Noble said, adding that nurses need to balance what patients are saying with how they appear: “How do they look when they come to the ER? Are they walking?” The work environment matters, with heavy patient volume possibly leading to mistakes. Digital symptom checkers can be misleading as well, providing recommendations based on presenting symptoms and screening questions but failing to take into account a patient’s medical history.
Realizing ESI needed to be implemented more uniformly, a VHA facility in 2021 embarked on a study in which nurses conducted random audits of their peers, examining at least five charts per peer nurse each month. Triage accuracy increased from 80 percent to 86 percent during the study. Later the participants managed to sustain 100 percent accuracy. This led to a VHA study in 2023 in which 10 nurses of varying backgrounds and skill levels participated in pre- and post-test ESI exercises with an ENA instructor. This standardized triage education improved ESI accuracy by 38.5 percent, regardless of the nurses’ experience.
The VHA now is in the process of implementing standardized ESI training through ENA’s Emergency Nursing Triage Education Program, which it has determined offers the highest level of triage training possible. ENTEP offers independent study, live instruction, assessment and a four-year certification upon completion, plus annual refreshers to help maintain competency.