International Emergency Nursing (2013) 21, 89 96

Available at www.sciencedirect.com

journal homepage: www.elsevierhealth.com/journals/aaen

Triage assessment of registered nurses in

the emergency department
Torunn Kitty Vatny RN, MSc a,*, Mariann Fossum RN, PhD
shild Sletteb RN, PhD a
Nina Smith RN, MSc c, A
a
b
c

a,b

Department of Health and Nursing Science, Faculty of Health and Sports Sciences, University of Agder, Grimstad, Norway
rebro University, O
rebro, Sweden
School of Health and Medical Sciences, O
Srlandet Hospital, Arendal, Norway

Received 22 February 2012; received in revised form 15 June 2012; accepted 18 June 2012

KEYWORDS
Emergency department;
Nursing assessment;
Triage;
Vital signs

Abstract
Standardised triage systems have been implemented in emergency departments (EDs) to
improve the efficacy of assessment strategies as performed by registered nurses (RNs). However, the exact effect the standardised triage systems have on the decision-making process
remains unclear.
Aim: To evaluate decision making in the triage setting before and after implementation of the
Medical Emergency Triage and Treatment System Adult in one hospitals ED.
Methods: A descriptive intervention design with a quantitative approach. A total of 655
patients before and 413 patients after the intervention were included. A questionnaire was
used to evaluate how the RNs assessed the patients before intervention while the emergency
patient records were used for data collection after intervention.
Results: Before the intervention, a majority of the assessments were founded on signs and
symptoms and medical diagnoses, whereas vital parameters were rarely used. After the intervention, nearly two thirds of the patients were assessed according to a triage system with vital
parameters and standardised algorithm for symptoms and signs included in the assessment procedure.
Conclusion: Implementing a standardised triage system, including vital parameters and standardised algorithms for signs and symptoms, increased the use of vital parameters and signs and
symptoms for decision making and acuity assignment.

2012 Elsevier Ltd. All rights reserved.

* Corresponding author. Address: Department of Health and Nursing Science, Faculty of Health and Sports Sciences, University of Agder,
P.O. Box 509, 4898 Grimstad, Norway. Tel.: +47 48129644/37233775.
E-mail address: torunn.vatnoy@uia.no (T.K. Vatny).
1755-599X/$ - see front matter 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ienj.2012.06.004

90

Introduction
The aim of triage assessment in the initial encounter between the nurse and the patient in emergency departments
(EDs) is to quickly determine and classify the patients in the
order of urgency based on the need for treatment (Brabrand
et al., 2010; Gilboy et al., 1999; Huryk, 2006). Because
accuracy in triage is critical, acuity assignment affects the
prioritisation of limited medical resources among patients
in acute need of medical care. Triage assessment constitutes a challenge and responsibility for nurses in EDs. Because patients have unknown and potentially very serious
illnesses, there is a high degree of uncertainty and acuity
that complicates the assessment process (Go
ransson
et al., 2008; Hale and Tippett, 2009; Wolf, 2010a,b). In
developed countries several triage protocols and scoring
systems are available to support patient quality and safety
(Brabrand et al., 2010; Forsgren et al., 2009; Go
ransson
et al., 2008; Odell et al., 2009). Despite different findings
on the validity and reliability of triage protocols and scoring
systems, the literature supports the use of standardised
methods to identify patients at risk for developing critical
illnesses (Considine and McGillivray, 2010; Odell et al.,
2009; Twomey et al., 2007).
A national review of Norwegian EDs conducted by the
Norwegian Board of Health Supervision (NBHS) in 2007 reported a lack of established guidelines in several EDs to secure the reception and priority of the patients as they
arrive. Based on these findings, the NBHS concluded that a
standardised method for triage to support patient safety
and quality care was recommended in all EDs (Norwegian
Board of Health Supervision, 2008). This intervention study
was based on the implementation of a triage protocol and
scoring system called the Medical Emergency Triage and
Treatment System Adult (METTS-A) in an ED in a regional
hospital in Southern Norway.

Literature
Validating triage protocols and scoring systems has been an
important goal for research (Brabrand et al., 2010; Twomey
et al., 2007; van Veen and Moll, 2009), even though uncertainty exists regarding the assessment strategies that registered nurses (RNs) use to assign acuity in EDs (Wolf,
2010a,b). RNs use a wide range of thinking strategies in
detecting deterioration (Odell et al., 2009) or preforming
triage (Go
ransson et al., 2008). Studies have shown that
nursing strategies and decision-making in triage settings
are complex and not only a result of an assessment based
on professional, well-considered foundations (Edwards and
Sines, 2008; Wolf, 2010a,b) or data relevant for the acuity
assignment (Jessica, 2011). Brannon and Carson (2003) suggest that contextual information can incur biases in a way
that might lead nurses not to properly explore the physical
conditions of their patients. In diagnostic decision-making
processes nurses tend to dismiss the physical symptoms of
the patient in favour of less serious conditions that may
be present. Some studies report that vital parameters are
ignored or disregarded as the basis for decision making in
nursing practice (Cooper et al., 2002; Day and Oldroyd,

T.K. Vatny et al.

2010; Odell et al., 2009). According to other studies conducted in EDs, the inclusion of vital parameters in the triage
assessment allows outcomes to be more predictive (Cooper
et al., 2002; Domagala, 2009; Sklar et al., 2007). Measuring
vital signs contributes to low inter-rater variability among
RNs, supporting validity by predicting mortality and identifying patients that are either at high risk or low risk of deterioration during their stay in the EDs (Thompson et al., 2009;
Widgren and Jourak, 2011).
Other studies have underscored the pitfalls that affect
the assessment process in a way that can lead to distortions
in the RN decision-making process (Edwards and Sines, 2008;
Wolf, 2010a,b). Wolf (2010a,b), for instance, found that the
process of acuity assignment in the ED is influenced by irrelevant factors, such as the interplay of elements among the
individual nurses, the immediate unit environment, and the
general care environment. From their findings, Edwards and
Sines (2008) conclude that nurses tend to perform triage
processes that include judging clinical data based on the
way that the patient behaves. They found that nurses in triage settings determined credibility by the way patients depicted the problem: outward clinical signs were not viewed
as a neutral manifestation on pathology but as a representation of the physical discomfort of the patient. Some studies
have noted the potential impact health care providers
emotions may have on decision making in clinical practice
(Croskerry et al., 2010). Croskerry et al. (2010) examined
the literature across multiple disciplines to review the interrelationships between emotion, decision making, and
behaviour to assess their potential impact on patient safety.
The authors found that the emotional state of the health
care provider leads to an affective bias in decision making.
This may be influenced by many factors, including the characteristics of the patient, ambient conditions in the health
care setting, (diurnal, circadian, infradian, and seasonal
variables), and the endogenous disorders of the individual
provider (Croskerry et al., 2010). Hence, emotions may also
influence the assessment process in a way that can impact
triage assignment. Croskerry et al. (2010) emphasise the
need for strategies to prevent emotional influences that
may impact care.
Some literature and studies have focused on the working
conditions of RNs in EDs as factors that may have a negative
impact on validity and reliability in RNs decision making in
triage settings (Adriaenssens et al., 2011; Forsgren et al.,
2009; Gail and Nora, 2007; Go
ransson et al., 2008). Adriaenssens et al. (2011) found that in most EDs nurses work under adverse conditions compared with nurses working in
other settings (Adriaenssens et al., 2011). The perception
of RNs regarding overcrowded EDs and the constant flow
of patients (Gail and Nora, 2007), time pressure, the lack
of adequate work procedures, and the complexity of the triage role (Go
ransson et al., 2008) may cause psychosomatic
distress and a lack of job satisfaction among RNs (Forsgren
et al., 2009). Adriaenssens et al. (2011) found that using
guidelines and adequate work procedures have a positive effect on job satisfaction, work engagement, and turnover for
RNs, in addition to contributing to clarity and reduced
stress. Working within protocols and clinical guidelines are
viewed as important for providing trust and assurance
among nurses working in EDs (Melby et al., 2011).

Triage assessment of registered nurses in the emergency department

Aim
The study aimed to evaluate decision making in the triage
setting before and after implementation of the METTS-A in
an ED at a regional hospital.

Methods
Study design
This study had a descriptive intervention design with a quantitative approach. Data were collected before and after the
implementation of METTS-A in an ED. See Fig. 1 for design
and timeline.

Setting and sample

This study was conducted in an ED of a regional hospital in
Southern Norway between April 2008 and November 2009.
This hospital receives approximately 20,000 patients per
year with acute need of medical care. Patients with mental
health problems are in addition to these numbers and are
assessed in a separate ED. The half of these patients arrives
directly to the injury policlinic or the medical policlinic. The
rest 9700 are assessed in the ED and admitted to hospitalisation and those are the population of this study. The patients who arrive at the ED are referred from the hospitals
policlinics, a general practitioner, by emergency medical
service, or the emergency medical service communication
system. The ED is covered by six full-time employees, five
RNs and one licensed practical nurse (LPN) and 48 part-time
employees, 44 RNs and four LPNs. Eight of the RNs were
specialised as critical care RNs or RNs specialised in anaesthesia for work in the operating theatre. None of the nurses
was specialised as emergency RNs, but all new RNs underwent a training programme before working in the ED. There
were no turnovers in the nursing staff during the time of the
study. The participants in this study were RNs who received
patients as they arrive in the ED. During each shift, one RN
on duty was responsible for receiving and assessing patients
who arrive in the ED. The exception was incoming patients
with a known critical condition and where an accepting physician receives the patient upon arrival to the ED. Before the
intervention, there was no prioritisation system used to support the RNs decision-making process.

Ethical considerations
The aim of the study and the data collection methods were
presented to the head of the Regional Committee for
Before
intervention
2008

Information and
educational sessions

91

Medical Research Ethics (RCMRE) in Southern Norway in

2007. However, the study was deemed by the head of the
RCMRE, not necessary to be presented to the RCMRE. The
RNs were given written and oral information about the nature of the study and were encouraged to participate. After
the intervention, the basis for decision making was abstracted from the EDs patient records. The patients were
informed verbally and in writing about the study, including
that participation was voluntary and that they could withdraw without consequences on the care they received.
The patients gave their written informed consent to use
the ED patient record in the study.

Intervention
The METTS-A triage protocol involves assigning a colourcoded category of priority based on vital parameters and
symptoms and signs. METTS-A, a protocol for intra-hospital
triage of adult patients (Widgren et al., 2008), was developed in 2004 at Sahlgrenska University Hospital. This instrument provides the basis for sorting, prioritising and
identifying the risk of poor outcome of all adult patients
in EDs (Widgren and Jourak, 2011). The METTS-A triage protocol has demonstrated high inter-rater reliability and is a
sensitive tool for identifying those in need of immediate
medical attention and for the early detection of those
who deteriorate during their ED stay. The tool is also sensitive in predicting mortality in the ED as well as throughout
the hospitalisation period (Widgren and Jourak, 2011; Widgren et al., 2008).
Before implementation of the intervention, some adjustments were made to the original METTS-A. The original
METTS-A protocol was a five-level scale that included the
levels red, orange, yellow, green, and blue. The lowest level (blue) was given to patients who did not need emergency
care or hospital facilitation (Widgren and Jourak, 2011). The
blue level was excluded as a priority level and the Glasgow
coma scale (GCS) (Teasdale and Jennett, 1974) was used for
the assessment of consciousness, replacing the Reaction Level Scale (RLS85). These adjustments should not affect the
validity because the blue level implied no constraint observations or measurements. The rationale for these adjustments was that the blue priority included patients who did
not need emergency care or hospital facilitation. This category of patients would not normally come to the ED but
would instead be treated by the policlinic at the hospital referred from a general practitioner or treated in the primary
healthcare system in Norway. The GCS replaced the RLS85
because the GCS was the standard used for assessing consciousness in the study hospital. The authors of METTS-A
were informed about the adjustments.

Implementation of an
emergency patient record form

Implementation of the
triage system METTS-A,
establish use and follow up

Participants:
n=655

After
intenvention
2009
Participants:
n= 413

Timeline
April - May
2008

Fig. 1

May - December
2008

July - December

January - April

October

2008

2009

2009

Overview of the study design and timeline for the intervention.

92

T.K. Vatny et al.

Method

Red

Orange

Yellow

Green

A: Airway

Inspection

Airway
compromised

Not used

Not used

Not used

B: Respiration

RR/min

Stridor
>30 or <8

>25

< 25

9- 25

SpO2 < 90 with

SpO2 < 90

SpO2 90-95

SpO2 > 95

with O2

without O2

without O2

without O2

inhalation therapy

inhalation therapy

inhalation therapy

inhalation therapy

HR > 130, HR ir

HR> 120 or < 40

HR > 110 or < 50

HR 51-109

Unconscious

Somnolent

Acute confused

Alert (GCS 15)

(GCS 3-9) or on-

(GCS: 10-12)

(GCS: 13-14)

> 41 or < 35

> 38.5

POX %

C: Circulation

HR

> 150
BP
SBP < 90 mmHg

D: Disability

GCS

going seizure

E: Exposure

Body temp

Not used

35 - 38.5

RR=respiratory rate, POX=pulse oximetry, O 2= medical oxygen, HR= heart rate, HR ir=irregular heart rate, BP=blood
pressure, SBP=systolic blood pressure, GCS= Glasgow coma scale

Fig. 2 The METTS-A vital parameters limits referring to each priority (Widgren and Jourak, 2011), including the adjustments for
implementation in the ED.

The triage method of METTS-A includes two steps assessed simultaneously: step one by algorithm for vital
parameters shown in Fig. 2 and step two by one of 96 algorithms (emergency symptoms and signs, ESS). An example of
one of the ESS algorithms is shown in Fig. 3.
ESS outcomes are determined on the basis of the patients chief complaints, symptoms, and signs, as assessed
according to the METTS-A protocol. The combined outcome
of both these algorithms is given the final priority level. The
ESS gives a higher priority in cases of deterioration when the
physiological vital parameters are within normal limits. Priority, according to the METTS-A, determines the time that
patients could wait for a medical examination by a physician
and the level of monitoring received. The priority levels and
interventions for triage priority are shown in Fig. 4 (Widgren
and Jourak, 2011).
During the nurse-patient encounter, the RNs measured
physiological vital signs and decided the categories regarding the METTS-A vital parameter limits. While in dialogue
with the patient the RNs made observations to determine
the ESS algorithm that best described the problem. Fig. 5
depicts the assessment process according to the METTS-A
protocol.
The ED patient records and a triage protocol adapted to
the formal triage system were used to support the triage
process and for documentation. The physician was informed
about the patients triage priority and prioritised examination according to the patients priority level (Fig. 4). The

ESS algorithm no. 5 METTS-A

Chest pain
ST elevation in ECG in ambulance or in ED
(Red ESS)

Pathological ECG and chest pain

-or history of chest pain during the last 24 h
combined with vegetative (autonomous)
symptoms
-or chest pain + dyspnea
-or symptoms of unstable angina
(Orange ESS)

Moderate chest pain with no signs of

unstable angina but with one or more risk
factors of cardiovascular disease
(Yellow ESS)

None of the above

(Green ESS)

Fig. 3 Example of an emergency symptoms and signs (ESS)

algorithm (Widgren and Jourak, 2011).

first medical examination and treatment of the patient in

the ED were administered by a junior physician who had

Triage assessment of registered nurses in the emergency department

93

Red = Life-threatening condition that requires full monitoring (telemetry if necessary, ischemia supervision, BP,
SpO2, respiratory rate, consciousness), and the nurses remain bedside until the doctor responsible for treating the
patient has down-graded the patient to orange or lower. Time to Doctor (TTD) = 0 minutes

Orange = Condition that require full monitoring (same as red), but with intervals of 20 minutes, and supervision by
the patient charge nurse until the TTD. Time to Doctor (TTD) = <20 minutes

Yellow = Standard process controls and further controls when necessary, selective monitoring and control of the
parameters with a marked impact on triage, upgrading TTD. Time to Doctor (TTD) = <120 minutes

Green = No monitoring, but regular supervision by the RN. Time to Doctor (TTD) = <240 minutes

Fig. 4

Interventions regarding triage priority.

Patient arrives to ED
Admittance to hospital by a general
practitioner, the emergency medical
service, or the acute medical
emergency communication central.

Triage area
The RN follows the METTS-A
protocol by step 1, and step 2,
assessed simultaneously.

Step 1
The RNs measuring all vital
parameter according to A, B, C, D
and E (figure 2).The RNs assesses
acuity level. i.e.: all parameters
within normal limits hens acuity
level: GREEN.

Step 2

RNs assess priority level

Highest level of step 1 and step
2 gives the finale priority level.
i.e: This patients final acuity
level and priority is ORANGE.

The RN assesses which ESS

algorithms to follow on basis of the
patients chief complain, symptoms
and signs; i.e. patient complaint are
chest pain (figure 3). I addition the
patient has a history of chest pain
during the last 24 h combined with
vegetative (autonomous) symptoms
like pail an unwell. This gives the
acuity level: ORANGE.

Fig. 5

Triage decision-making process in accordance to the METTS-A protocol including an example.

the opportunity to consult with a senior physician if unsure

of the situation.
The METTS-A was implemented after informing and
educating the employees about the ED. The information

included a review of the METTS-A, how the implementation

would change the workflow, and impact tasks and responsibilities. A 4-h seminar consisting of lectures and casework in
smaller groups followed by a plenary discussion was offered

94

T.K. Vatny et al.

to the RNs who would be performing the triage according to

the METTS-A. These RNs were also offered 2 days in the
clinic to perform triages while being closely followed and
guided by an experienced user of the METTS-A. The RNs frequently received feedback regarding their performance of
the triage process based on documentation in the ED patient
records to improve the assessments preformed with the
METTS-A. Follow-up and feedback were provided by one of
the authors (TKV).

Data collection and procedures

A questionnaire was used to collect data before the intervention. The RNs select whether they assessed the medical
condition of the patient as urgent or not urgent based on
the patients need for a medical check and treatment. Furthermore, the RNs should provide an explanation of their
reasons for these assessments.
Data collection after the intervention was performed
9 months after the implementation of the METTS-A. Data
were collected from ED patient records to document such
vital parameters as respiratory rate, oxygen saturation,
heart rate, blood pressure, and disability score according
to the Glasgow coma scale (Teasdale and Jennett, 1974)
(Fig. 2). The ESS algorithm number and urgency are given
in Fig. 3.

Results
The data collected before the intervention were analysed
using descriptive and comparative statistics. Frequency tables and cross tables were used to present the distribution
Table 1 The registered nurses basis for decision making in
initial patient encounter before intervention N = 655.

Used
Not used

Vital parameters

Emergency symptoms
and signs

24 (4%)
631 (96%)

267 (41%)
198 (30%)

Table 2 The registered nurses basis for decision-making in

initial patient encounter 2009, N = 413.

Used
Not used

Vital parameters

Emergency symptoms
and signs

361 (87%)
52 (13%)

318 (77%)
95 (23%)

of the data. A vertical bar chart presents the variance.

The software Statistical Package for the Social Sciences
v.15.0 for Windows was used for data management and
analyses.
Data collection was conducted on 655 adult patients who
arrived at the ED over a period of 6 weeks before the intervention (table 1) and 413 adult patients over a period of
4 weeks after the intervention (Table 2). Before the intervention, 4% of the patients were assessed on the basis of vital parameters. In 96% of the triage assessments, vital
parameters were not mentioned (Table 1).
Before the intervention, 41% of the patients were assessed based on symptoms and signs, whereas vital parameters were rarely used when no standardised system for
triage was available. Medical diagnoses according to the
International Classification of Diseases (ICD 10) were used
as a basis of assessment in 29% of the patients (Table 3).
After the intervention, the use of vital parameters for decision making increased from 4% to 87% (Tables 1 and 2). The
use of vital parameters and symptoms and signs as a basis
for decision making increased from 1% to 69% (Tables 3
and 4). Medical diagnoses were not used as basis for decision
making and acuity assignment after the implementation of
the METTS-A (Tables 3 and 4). Table 2 shows that after
the intervention 87% of the patients were assessed based
on vital parameters according to the METTS-A and 77% were
assessed based on emergency symptoms and signs (ESS)
according to the METTS-A protocol. Vital parameters were
not completely documented in 13% of the assessments
(Table 4).
A difference in acuity assignation before and after intervention is illustrated in Fig. 6. After the intervention, there
was a decrease in the number of patients assessed as urgent. The mean time of initial assessment by a doctor was
less than 20 min.

Discussion
Implementing a standardised triage protocol and scoring
system, including validated ESS algorithms and vital parameters, increased the use of vital parameters and symptoms
and signs for decision making and acuity assignment. Our results from the intervention show that, to a small extent, the
RNs decision making and acuity assignment were based on
the patients vital parameters. This result corresponds to
those from other studies that describe vital parameters to
be ignored or disregarded as the basis for decision making
in nursing practice (Cooper et al., 2002; Day and Oldroyd,
2010; Odell et al., 2009). Not using vital parameters as basis
for decision making may occur in low inter-rater variability
among RNs in the triage decision-making process (Widgren
and Jourak, 2011) and may have a negative effect on patient

Table 3 Registered nurse basis for decision-making in acuity assignment in the initial patient nurse encounter before (2008) the
implementation of the METTS-A, N = 655.
Basis for decision-making in acuity assignment

Used emergency
symptoms and signs

Did not use the emergency

symptoms and signs

Used medical
diagnoses

Vital parameters assessed

Vital parameters not assessed

6 (1%)
261 (40%)

13 (2%)
185 (28%)

5 (1%)
185 (28%)

Triage assessment of registered nurses in the emergency department

95

Table 4 Registered nurse basis for decision-making in acuity assignment in the initial patient nurse encounter after (2009) the
implementation of the METTS-A, N = 413.
Basis for decision-making in acuity assignment

Used emergency
symptoms and signs

Did not use emergency

symptoms and signs

Vital parameters assessed

Vital parameters not assessed

286 (69%)
32 (8%)

75 (18%)
20 (5%)

In our study, the RNs adopted the METTS-A such that

changed the basis of their decision-making process.
Whether the implementation of a standardised triage system improves patient safety in the ED requires additional
research. Further studies should focus on whether motivation influences changes in practice.

Limitations

Fig. 6 Patients assessed to be urgent or not urgent, as stated

by the RNs, before and after the implementation.

safety in the ED (Cooper et al., 2002). An unexpected finding

was that the RNs used medical diagnoses in their decisionmaking process before the intervention. When using medical diagnosis as a foundation in triage decisions, the diagnosis is most likely tentative because it is not necessarily
verified by a physician but might be determined instead by
contextual information and conditions. Contextual information can be irrelevant in decision making regarding the
intention of the triage process in which the aim is to determine and classify the priority of patients according to their
need of urgent treatment in a resource-limited setting
(Brannon and Carson, 2003).
Without a standardised protocol, the nurses assessment
included symptoms and signs that were observed and interpreted based on the individual RNs competence (or lack
thereof). Studies concluding that the process of acuity
assignment were influenced by the nurses knowledge base,
critical cue recognition, and social context (Wolf,
2010a,b) where depended on intuition (Odell et al., 2009)
and interpreting patient behaviour (Edwards and Sines,
2008). The studies suggest that decision making under these
conditions might be performed on a misleading basis. Parttime working nurses and nurses without specialisation, as in
our study, are targets for competence improvement. Further assessments during the initial nurse-patient encounter
for the purpose of acuity assignment in the ED imply the
capacity to assess complicated medical conditions that
may exceed ordinary nursing competence. Such complicated assessments may require special qualifications, education, and skills (Gilboy et al., 1999). The METTS-A ESS
protocol represents support in RN assessment and may improve the RNs competence in acuity assignment.

This sample included all patients >15 years of age who visited the ED. Different data collection tools were used before and after the intervention. When analysing the data
collected before the intervention, any mention by a nurse
of a vital parameter was considered ample information to
register use of vital parameters (e.g., an explanation of
their reasons for these assessments in the free text space
was: blood pressure high; the registration was use of vital
parameters). Thus, the analysis of data before the intervention can only interpret whether RNs regarded the vital
parameters as important parameters in their decision-making process. The data source for the assessment after the
intervention was the EDs patient records. All of the vital
parameters recommended by the METTS-A had to be documented if the registration reported use of vital parameters in the data analyses (e.g., if the respiration rate was
not documented, the registration reported vital parameters not used). Adjustments were performed to the original
METTS-A. There is a risk that the adjustments preformed to
the original METTS-A has affected the validity of the protocol. This risk is considered to be low because the excluded
blue level did not imply any constraint observation or
measurements.

Conclusions
Because patients have unknown and potentially very serious
illnesses, there is a high degree of uncertainty and acuity
that complicate the triage decision process. Performing triage under these difficult conditions is a demanding process
and a challenge for the RNs working in an emergency medical service unit. Implementing a standardised triage system, including vital parameters and standardised
algorithms for signs and symptoms, was found to increase
the use of vital parameters and symptoms and signs for decision making and acuity assignment.

Acknowledgments
The authors wish to thank all of the RNs and patients who
participated in this study. We also express our gratitude

96
to all of the ED staff members who contributed to data collection and who photocopied records. We are grateful for
the implementation project members and the management
for their support. Finally, we are thankful for the financial
support of the hospital.

References
Adriaenssens, J., De Gucht, V., Van Der Doef, M., Maes, S., 2011.
Exploring the burden of emergency care: predictors of stresshealth outcomes in emergency nurses. J. Adv. Nurs. 67, 1317
1328.
Brabrand, M., Folkestad, L., Clausen, N., Knudsen, T., Hallas, J.,
2010. Risk scoring systems for adults admitted to the emergency
department: a systematic review. Scand. J. Trauma Resusc.
Emerg. Med. 18, 8.
Brannon, L.A., Carson, K.L., 2003. The representativeness heuristic: influence on nurses decision making. Appl. Nurs. Res. 16,
201204.
Considine, J., McGillivray, B., 2010. An evidence-based practice
approach to improving nursing care of acute stroke in an
Australian Emergency Department. J. Clin. Nurs. 19, 138144.
Cooper, R.J., Schriger, D.L., Flaherty, H.L., Lin, E.J., Hubbell,
K.A., 2002. Effect of vital signs on triage decisions. Ann. Emerg.
Med. 39, 223232.
Croskerry, P., Abbass, A., Wu, A.W., 2010. Emotional influences in
patient safety. J. Patient Saf. 6, 199205.
Day, A., Oldroyd, C., 2010. The use of early warning scores in the
emergency department. J. Emerg. Nurs. 36, 154155.
Domagala, S.E., 2009. Discharge vital signs: an enhancement to ED
quality and patient outcomes. J. Emerg. Nurs. 35, 138140.
Edwards, B., Sines, D., 2008. Passing the audition the appraisal of
client credibility and assessment by nurses at triage. J. Clin.
Nurs. 17, 24442451.
Forsgren, S., Forsman, B., Carlstrom, E.D., 2009. Working with
Manchester triage job satisfaction in nursing. Int. Emerg. Nurs.
17, 226232.
Gail, C., Nora, C., 2007. Safety in the emergency department: its
about time. Kansas Nurse 82, 3.
Gilboy, N., Travers, D., Wuerz, R., 1999. Re-evaluating triage in the
new millennium: a comprehensive look at the need for standardization and quality. J. Emerg. Nurs. 25, 468473.
Go
ransson, K.E., Ehnfors, M., Fonteyn, M.E., Ehrenberg, A., 2008.
Thinking strategies used by registered nurses during emergency
department triage. J. Adv. Nurs. 61, 163172.

T.K. Vatny et al.

Hale, N., Tippett, J., 2009. Safeguarding vulnerable adults in the
emergency department. Int. Emerg. Nurs. 17, 141142.
Huryk, L.B., 2006. Is it really an emergency? When nonurgent cases
overwhelm the ED. Am. J. Nurs. 106 (1), 6972.
Jessica, C., 2011. Emergency department triage: what data are
nurses collecting? J. Emerg. Nurs. 37, 417422.
Melby, V., Gillespie, M., Martin, S., 2011. Emergency nurse
practitioners: the views of patients and hospital staff at a major
acute trust in the UK. J. Clin. Nurs. 20, 236246.
Norwegian Board of Health Supervision, 2008. While we are
waiting. . .. do patients receive adequate treatment in
accident and emergency units? Report from the Norwegian
Board of Health, Supervision 2/2008.
Odell, M., Victor, C., Oliver, D., 2009. Nurses role in detecting
deterioration in ward patients: systematic literature review. J.
Adv. Nurs. 65, 19922006.
Sklar, D.P., Crandall, C.S., Loeliger, E., Edmunds, K., Paul, I.,
Helitzer, D.L., 2007. Unanticipated death after discharge home
from the emergency department. Ann. Emerg. Med. 49, 735
745.
Teasdale, G., Jennett, B., 1974. Assessment of coma and impaired
consciosness: a practical scale. Lancet 304, 8184.
Thompson, M., Coad, N., Harnden, A., Mayon-White, R., Perera, R.,
Mant, D., 2009. How well do vital signs identify children with
serious infections in paediatric emergency care? Arch. Dis. Child.
94, 888893.
Twomey, M., Wallis, L.A., Myers, J.E., 2007. Limitations in
validating emergency department triage scales. Emerg. Med.
J. 24, 477479.
van Veen, M., Moll, H., 2009. Reliability and validity of triage
systems in paediatric emergency care. Scand. J. Trauma Resusc.
Emerg. Med. 17, 38.
Widgren, B.R., Jourak, M., 2011. Medical emergency triage and
treatment system (METTS): a new protocol in primary triage and
secondary priority decision in emergency medicine. J. Emerg.
Med. 40, 623628.
Widgren, B.R., Jourak, M., Ann, M., 2008. Ny tra
ffsa
ker triagemetod. METTS-A ger underlag fo
r prioritering till ra
tt va
rdniva
.
Lakartidningen 105, 201204 (in Swedish).
Wolf, L., 2010a. Acuity assignation: an ethnographic exploration of
clinical decision making by emergency nurses at initial patient
presentation. Adv. Emerg. Nurs. J. 32, 234246.
Wolf, L., 2010b. Does your staff really get initial patient
assessment? Assessing competency in triage using simulated
patient encounters. J. Emerg. Nurs. 36, 370374.