Trina's Notes

Triage in the Emergency Department (ED) is one of the most high-pressure jobs in healthcare. ED nurses have to make fast but accurate decisions to ensure patients get the care they need while managing limited resources and a never-ending flow of new cases.

Getting triage right is crucial—lives depend on it. But what actually affects how accurate triage decisions are? Research points to three major factors:

1. The triage nurse’s experience and mental state
2. The patient’s presentation and characteristics
3. The chaos of the ED work environment

Let’s break these down and see why they matter.

1. Triage Nurse Experience & Mental Load

Not all nurses are the same when it comes to triage. Experience in the ED makes a huge difference. More experienced nurses tend to make more accurate triage decisions because they’ve seen it all before. They can quickly spot red flags—subtle signs that something serious is happening.

Fast vs. Slow Thinking in Triage

Psychologist Daniel Kahneman, in his book, “Thinking, Fast and Slow,” describes two types of thinking:

• System 1 Thinking – Fast, instinctive, and automatic. Great for quick decisions, but prone to bias and mistakes.
• System 2 Thinking – Slow, logical, and analytical. Takes more effort but leads to better accuracy.

Triage nurses mostly rely on System 1 because they have only a few minutes per patient. Their brains automatically connect the dots based on experience, but this can sometimes lead to snap judgments and errors—especially when they’re tired, stressed, or burnt out.

That’s why ongoing training and mental breaks are so important. Nurses need refresher courses to sharpen their decision-making skills and proper breaks to avoid exhaustion.

2. Patient Presentation & Characteristics

When triage nurses only have a few minutes to assess a patient, implicit biases can sneak in.

For example:

• A young, visibly distressed person with a bloody towel may get seen faster than an older patient sitting quietly in pain—even if the older patient has a serious issue like a heart attack.
• Trauma cases (e.g., cuts, fractures) are often over-triaged, while non-traumatic conditions (like internal pain or infections) can be underestimated.
• Race and ethnicity also play a role—some studies have shown that minority patients may experience longer wait times or under-triage.

This isn’t about bad intentions—it’s just how the brain works under pressure. The best way to fix this? Awareness and training. Nurses need to recognise these unconscious biases so they can step back and reassess when needed.

3. The Chaotic ED Environment

Let’s be real—the emergency department can at times be a madhouse. Overcrowding, constant noise, flashing monitors, alarms, and a stream of new patients make it really tough for triage nurses to focus.

More patients = more pressure = more mistakes. Studies show that:

• Night shifts (when things are quieter) have the highest triage accuracy (~62%).
• Day and evening shifts (when EDs are slammed) have lower accuracy (~57-59%).
• However, some nurses actually perform better under mild stress—but there’s a fine line between being sharp under pressure and completely burnt out.

What can we do?

• Redesign triage spaces to reduce noise and crowding.
• Let nurses take proper breaks (even a quick mental reset can make a difference).
• Use better digital tools to assist with triage decisions.

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How Can We Improve Triage Accuracy?

We can’t magically give every triage nurse 10 years of experience, but we can make things better by:
✅ Providing ongoing education & refresher courses to sharpen decision-making.
✅ Recognizing biases so nurses can make more objective decisions.
✅ Improving triage spaces to reduce distractions and cognitive overload.
✅ Letting nurses take mental breaks to stay sharp and avoid burnout.

Triage is fast, high-pressure, and sometimes messy—but by focusing on these three key factors, we can make it more accurate, fair, and effective for everyone. What strategies do you take in your ED to improve triage accuracy?

References:

Butler, K., Anderson, N., Jull, A. (2023) Evaluating the effects of triage education on triage accuracy within the emergency department: An integrative review. International Emergency Nursing. https://doi.org/10.1016/j.ienj.2023.101322

Suamchaiyaphum, K., Jones, A., Markaki, A. (2024). Triage accuracy of emergency nurses: An evidence-based review. Journal of Emergency Nursing, 50(1): 44-54.