Triage in Australian emergency departments: Results of a New South Wales survey

Australasian Emergency Care 22 (2019) 81–86

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Australasian Emergency Care journal homepage: www.elsevier.com/locate/auec

Research paper

Triage in Australian emergency departments: Results of a New South Wales survey Wayne Varndell a,b,∗ , Alister Hodge c,d , Margaret Fry b a

Prince of Wales Hospital Emergency Department, Barker Street, Sydney, Australia University of Technology Sydney, Faculty of Health, Sydney, Australia Sutherland Hospital Emergency Department, Caringbah, Australia d The University of Sydney, School of Nursing, Sydney, Australia b c

a r t i c l e

i n f o

Article history: Received 30 June 2018 Received in revised form 14 January 2019 Accepted 15 January 2019 Keywords: Triage Emergency nursing Accuracy Triage quality Triage education

a b s t r a c t Aim: To describe current models of triage, the preparation and education of triage nurses, and methods of auditing triage practice in New South Wales emergency departments. Background: Triage is a critical component of emergency department practice; affecting patient safety and access to emergency care. Within Australia, triage is an autonomous role predominantly conducted by trained emergency nurses. Patient safety and timely access to emergency care relies upon the experience, education and training of emergency triage nurses. To date, little is known about triage models of care, the preparation and education of triage nurses, and assessment of triage practice and decision accuracy. Method: Descriptive, exploratory study design employing a self-reporting cross-sectional survey of clinical nurse consultants and educators in New South Wales. Results: The survey results reveal variability in models of triage, and the eligibility, preparation and education requirements of triage nurses; that appear geographically related. Auditing of triage practice was commonly undertaken retrospectively; feedback to triage nurses was infrequent. The survey found evidence of locally developed guidelines directing triage category allocation for specific conditions or symptoms. Conclusion: The purpose of triage is to ensure that the level of emergency care provided is commensurate with clinical urgency. Variability in the preparation, education and evaluation of triage nurses may in and of itself, contribute to poor patient outcomes. Further, workforce size and geography may impede auditing and the provision of feedback, which are critical to improving triage practice and triage nurse performance. It is imperative that the Emergency Triage Education Kit be revised and maintained in tandem with future revisions of the Australasian Triage Scale. © 2019 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.

1. Introduction To ensure patients receive time-critical intervention, all patients are assessed and prioritised against their clinical urgency using the Australasian Triage Scale (ATS) [1]. Triage is a critical component of emergency department practice; affecting patient safety and access to emergency care. Within Australia, triage is an autonomous role conducted by trained emergency nurses. It is a highly complex process; for each patient seeking emergency care, the triage nurse must assess the information gained during a clinical assessment, to determine an appropriate urgency category and disposition

within the department [2]. Triage decisions regarding urgency categorisation determine the order in which patients receive medical attention. The triage role requires highly refined clinical assessment skills, and a relevant knowledge base to differentiate non-urgent complaints from life-threatening conditions in an environment that can be hectic and stressful [3]. Patient safety and timely access to emergency care relies upon the experience, education and training of emergency triage nurses. To date, little is known about triage models of care, the preparation and education of triage nurses, and triage quality assurance processes. 2. Background

∗ Corresponding author at: Clinical Nurse Consultant, Prince of Wales Hospital Emergency Department, Barker Street, Randwick, NSW 2031, Australia. E-mail address: [email protected] (W. Varndell).

Triage is the process of identifying and prioritising persons or resources, and is used in three distinct situations: military situations, disaster conditions and emergency departments. When

https://doi.org/10.1016/j.auec.2019.01.003 2588-994X/© 2019 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.

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W. Varndell, A. Hodge and M. Fry / Australasian Emergency Care 22 (2019) 81–86

performed in the emergency department (ED), the aim of triage is to determine the priority of patients based on the urgency of their presenting condition, and to ensure that ED resources (staff, equipment and management area) are optimally utilised [4]. To prioritise patients, a triage assessment has to be made, and consists of interpretation of the clinical history and physiological assessment, allocation of an urgency code, and disposition to an appropriate treatment area within the ED [5]. The triage assessment is generally expected to take no more than five minutes; balancing speed and thoroughness to ensure the triage assessment itself does not impede access to necessary clinical intervention. The ATS consists of five categories of urgency ranging from 1 (immediately lifethreatening) to 5 (less urgent) [1]. Each triage category is associated with clinical history and assessment findings, high-risk features and physiological signs. Accurate assessment of patient urgency is critical to ensuing patient safety [6–8]. If the urgency is classified too low (undertriage), it can have serious clinical consequences [9]. If urgency is classified too high (over-triage), patients with more urgent conditions may be delayed from accessing timely emergency care, and scarce resources are wasted [10]. During triage, additional activities may be undertaken to improve patient comfort or time to diagnosis. Activities performed at triage can be divided into two distinct groups: primary and secondary. Primary activities consist of the triage assessment and categorisation of patient urgency. Secondary triage activities can include: administration of medication, ordering radiographic (e.g. X-ray) or pathology investigations collected by the same person performing triage. In some EDs, the Clinical Initiatives Nurse, an extended practice role, assists with or undertakes secondary activities; however, this role is not always available on each shift or across all EDs [11,12]. Triage in Australia is predominantly undertaken by a Registered Nurse with experience in emergency care, who has completed additional specialised training [13]. The accuracy of triage decisions has major implications for patient safety and outcomes [9,10,14,15]. Triage nurse training, experience and skill have been cited as influential factors in triage decision-making [16,17]. For triage decisions to be accurate and consistent, several factors are important: the education of emergency nurses; ongoing professional development of triage nurses; regular revision of the ATS and a quality framework to audit triage processes and outcomes [2]. In New South Wales (NSW), clinical nurse consultants and educators are responsible for training and mentoring triage nurses, and evaluating and reviewing the quality and safety of triage practice [18]. While definitions vary across Australia, clinical nurse consultants are senior experienced Registered Nurses with highly advanced specialist knowledge and skills that contribute to the development and direction of clinical practice; service design, delivery and quality; research; and, specialist clinical education [19]. In NSW, there are two levels of educator: nurse educator and clinical nurse educator. While both roles deliver training, evaluate education outcomes and provide mentorship, the nurse educator is responsible for the development of nursing education programmes [20]. For the purpose of this paper, the term clinical educator will be used hereafter. Thus, the aim of this study was to survey clinical nurse consultants and clinical educators to: (i) describe triage models; (ii) examine the preparation and education of triage nurses; and (iii) explore approaches to assessing and monitoring triage practice and decision accuracy in New South Wales EDs.

3. Method 3.1. Design The study utilised a descriptive, exploratory design employing a self-reporting cross-sectional survey administered via an online survey platform. 3.2. Setting and sample Of the states and territories of Australia, NSW has the highest population (n = 7,480,228) [21]. Of the 186 public EDs in NSW, 25 (13.4%) are situated within major referral hospitals with capabilities to manage a wide range of highly complex emergency and critical care; 10 (18.6%) of which are designated trauma centres [22]. In 2017, there were 2.7 million ED presentations in NSW, of which 21.9% (n = 592,805) were aged 14 years and under [23]. An email was distributed to clinical nurse consultants and clinical educators (n = 33) identified from the Emergency Care Institute New South Wales ED mailing list. The email contained information about the study, including an anonymous link to the online survey. A follow-up email was sent at two and four weeks. 3.2.1. Data collection tool Data was collected via an online survey consisting of 46 questions and five triage vignettes. The survey collected participant demographics, information on the model of triage used, preparation and education of triage nurses, application of the ATS, use of national and local guidelines to guide triage assessment, examined secondary triage practices, and auditing of triage practice and decision accuracy. As part of assessing triage decision accuracy of emergency nurses transitioning into the triage nurse role, written triage scenarios are used that are then evaluated by the either the clinical nurse consultant or clinical educator. To gauge triage decision accuracy of participants, five triage vignettes (n = 4 adult, n = 1 paediatric) were designed by members (WV and AH) of the research team based on previous methods [24,25]. Vignettes were reviewed by six senior emergency nurses with five or more years of experience in teaching triage who were not associated with the study. Comments were invited using an online survey. Minor alterations were made following feedback until there was complete agreement regarding triage information and expected triage category (Table 1). The survey was then pilot tested for acceptability and content validity by 12 emergency triage nurses. Pilot testing reported an Individual Content Validity Index of 0.96 which is greater than the recommended ≥0.78, and a Content Validity Index of 0.95 which is also consistent with the recommended Individual Content Validity Index (≥0.90) [26]. No changes were required to be made to the survey. Average completion time of the questionnaire was 17 min (SD 3 min). 3.2.2. Data analysis Data was analysed using IBM SPSS version 25 [27]. Categorical data was summarised using frequency counts (n) and proportions (%). Continuous data were summarised using measures of central tendency, with mean and standard deviation (SD) if normally distributed, and median and inter-quartile range if abnormally distributed. Fleiss kappa () was used to measure agreement between participants’ and the expected vignette triage category with the following values:  < 0.20 slight agreement, 0.21–0.40 fair agreement,

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Table 1 Triage vignettes and expected triage category. Vignette

Scenario description

Expected category

1

10 year old female, fell off swing onto grass. Hit back of head. Unresponsive for few seconds (witnessed by father, present). Complaining of headache. No vision changes or neck pain. Child alert, orientated, well perfused, pain 2/10. 30 year old male, presents following inversion injury of left ankle sustained two days ago. Requesting X-ray – concerned about possible fracture. Fully weight-bearing, limb neurovascular intact. Pain reproducible on inversion. Nil pain at distal tibia/fibular region, navicular or base of fifth metatarsal. Pain 2/10. 69 year old female, presents with abdominal pain and nausea for three days, reduced appetite. Mobile. Denies vomiting or diarrhoea. Bowels not open today. RR 18/min, HR 71/min, BP 146/88 mmHg, Temp 36.2 ◦ C, SaO2 95%, pain 3/10. 47 year old male, presents with worsening sleeplessness for past two weeks, states ‘brain doesn’t stop running’. Agitated and pacing at triage with poor eye-contact. Discharged from ED this morning. RR 18/min, HR 76/min, BP 126/88 mmHg, Temp 37.2 ◦ C, SaO2 95%, pain 0/10. 31 year old male, presents complaining of severe abdominal pain commencing less than 1 h ago. Nil nausea or vomiting, nil diarrhoea or dysuria reported. Ambulant. Abdomen rigid. RR 18/min, HR 100/min, Temp 36.9 ◦ C, BP 120/80 mmHg, pain 10/10.

3

2

3 4

5

4

3 3

2

Keys: RR, respiratory rate; HR, heart rate; BP, blood pressure; Temp, temperature; SaO2 , peripheral oxygen saturation.

0.41–0.60 moderate agreement, 0.61–0.80 good agreement and 0.81–1.00 very good agreement [28]. Data from free-text commentary were examined using content analysis with word frequency (f) and percentages reported [29–31]. 3.2.3. Ethics The study design adhered to the National Statement on the Conduct of Human Research by the Australian National Health and Medical Research Council [32], and was approved by the South Eastern Sydney Local Health District Human Research and Ethics Committee (HREC 17/234). Anonymity was maintained as data was non-identifiable, and no tracking of internet protocol address occurred. Consent was implied through completion of the online survey. 4. Findings

Table 2 Respondent characteristics. N (%) Gender Female Male Age (mean, SD) Nursing years (mean, SD) ED years (mean, SD) Role Clinical Nurse Consultant Nurse Educator Clinical Nurse Educator Level of ED Major tertiary referral hospital Major regional hospital Regional base hospital Urban district hospital Rural hospital Multi-purpose service

19 (65.5) 10 (34.5) 42.6 (10.4) 17.8 (9.5) 15.4 (8.5) 17 (58.6) 7 (24.1) 3 (10.3) 11 (37.9) 6 (20.7) 6 (20.7) 3 (10.3) 1 (3.4) 2 (6.9)

4.1. Response rate Of a total of 33 surveys, 29 (87.9%) were completed representing 122 EDs across NSW. Surveys were completed on average within thirteen minutes (12.7 min, SD 5.3 min). The majority of participants were female (n = 19, 65.5%), aged 42.6 (SD 10.4) years old with 17.8 (SD 9.5) year’s nursing experience, with an average of 15.4 (SD 8.5) year’s emergency nursing experience, and worked in a mixed adult and paediatric department (n = 26; 89.7%) based in a metropolitan hospital (n = 11, 37.9%) with an average (median) weekly presentation rate of 1000 (IQR 542). Most (n = 20, 69.0%) participants were responsible for one ED facility, however nine (31.0%) reported overseeing multiple ED facilities (median 7, IQR 12, range 2–37) (Table 2). 4.2. Models of triage All participants reported triage was conducted by emergency nurses using the ATS, although the number emergency nurses allocated to triage varied by shift and level of ED. Major tertiary and regional hospitals had the highest number of triage nurses across morning, evening and night shifts (Table 3). While the majority (n = 20; 69.0%) of participants indicated that the ATS was relevant in prioritising patients, nearly half (n = 13; 44.8%) of participants reported the use of local triage guidelines. Guidelines were more frequently (n = 8; 61.5%) used at major tertiary and region hospital ED sites. Of 32 local triage guidelines described by participants, most (n = 28; 87.5%) recommended a minimum triage category of 2 (imminently life-threatening) (Table 4). Secondary processes were conducted during the initial triage period (n = 25; 86.2%), which included nurse-initiated analgesia

Table 3 Average triage staffing by level of ED. Shift, number of triage nurses (mean, SD)

Level of ED

Weekly presentations (median, IQR)

Morning

Afternoon

Night

Major tertiary referral hospital Major regional hospital Regional base hospital Urban district hospital Rural hospital Multi-purpose service

1393 (1050)

1.8 (0.6)

2.0 (0.5)

1.1 (0.3)

680 (500)

1.3 (0.6)

1.3 (0.6)

1.3 (0.6)

45 (24.5)

1.0 (0.0)

1.0 (0.0)

1.0 (0.0)

(n = 24; 96%) or other symptom control medications (e.g. salbutamol) (n = 19; 76%), radiology investigations (n = 18, 72%), pathology collection (n = 17, 68%), and referrals to on-call medical specialists or consulting with aeromedical services (n = 3; 12%). 4.3. Preparation, education and training of triage nurses In preparation for the triage nurse role, emergency nurses were required to meet certain eligibility criteria, which differed across ED facilities. Of the returned surveys, eligibility criteria included being a Registered Nurse (n = 22; 75.9%) with an average of two or more years (2.3 y; SD 1.0 y) of emergency nursing experience. The length of experience varied depending on the level of ED. In metropolitan tertiary and regional hospital ED setting, emergency nurses were

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Table 4 Local triage guidelines developed for specific symptom criteria, frequency (f) and recommended triage category. Condition

f (%)

Criteria

Recommended urgency category

Febrile post chemotherapy

6 (18.8)

New neurological complaint Trauma

6 (18.8) 6 (18.8)

Unwell child

4 (12.5)

Sepsis Staff health

3 (9.4) 3 (9.4)

Pregnancy

2 (6.3)

Febrile post chemotherapy in last 12 days Febrile within 21 days of chemotherapy New neurological signs or symptoms <5 h New neurological signs <6 h Major trauma Elderly (>70 y) fall from standing height Motor vehicle combined speed >60 km//h Crushed by large animal Unwell neonate (<28 days old) Sick newborn (<3 months old) Possible sepsis Needles-stick injury at work Possible exposure to HIV Pregnancy related issue of less than 2 weeks Onset of labour/imminent birth Hypertension (SBP >140 mmHg or DBP >90 mmHg) in pregnancy or up 12-weeks post-partum

Sexual assault Representation

1 (3.1) 1 (3.1)

2 3 2 2 1 2 2 2 2 2 2 2 2 2 2 2 2 “Up-triage”

Alleged sexual assault Represents to ED within 48 h

Keys: km/h, kilometres per hour; HIV, human immunodeficiency virus; SBP, systolic blood pressure; DBP, diastolic blood pressure.

required to have two or more years (2.5 y, SD 1.0 y and 2.3 y, 1.0 y respectively) of emergency nursing experience, compared to rural and multi-purpose services (1.3 y, SD 0.6 y). Participants (n = 14; 48.3%) reported that in preparation for transitioning into the triage nurse role, emergency nurses were required to be competent in all clinical areas of ED such as the resuscitation area (n = 7; 50%), have advanced life support skills (n = 7; 50.0%), able to nurse-initiate medications (n = 6; 42.9%) and hold a postgraduate qualification in emergency nursing (n = 6; 42.9%). The training of emergency nurses for the role of triage typically consisted of attending a face-to-face education programme (n = 22; 75.9%). The average duration of face-to-face training was 10 h (SD 8 h), and was guided by the Emergency Triage Education Kit [33] (n = 23; 79.3%). In addition to a formal education programme, emergency nurses transitioning into the role of triage (n = 26; 89.7%) underwent a period of clinical supervision of at least two clinical shifts (2.4, SD 0.9). 4.4. Auditing of triage practice Of the 29 completed surveys, 22 (75.9%) participants provided information regarding assessing and monitoring of triage practice and decision accuracy. Participants (n = 18; 81.8%) assessed and monitored triage practice and decision accuracy by retrospectively auditing triage documentation, compared to direct observation (n = 2; 9.1%). Auditing of triage practice and decision accuracy was frequently (n = 19; 86.4%) undertaken by the clinical nurse consultant (n = 19; 86.4%), clinical educator (n = 13; 59.1%) or nurse manager (n = 7; 31.8%). Few (n = 2; 9.1%) sites included an emergency physician or novice triage nurse (n = 2; 9.1%). Auditing of triage practice and decision accuracy occurred one to three times per year (n = 12; 54.5%). The average (median) number of triage records audited was 5 (IQR 1.8). Retrospective auditing of triage documentation was reported to take an average of 10 h (IQR 6 h), and included reviewing the documented patient history, assessment findings and the assigned triage category. Review of triage documentation was not blinded (n = 17; 77.3%). Acceptable rate of triage decision accuracy reported by participants was 63.4% (SD 11.1%), with half (50.6%; SD 48.7%) of urgency ratings to be within one triage category of the expected category. Triage audit findings were reported at ED leadership team meetings (n = 15; 68.2%), education sessions (n = 13; 59.1%), advertised on noticeboards (n = 3; 13.6%) or communicated to nursing staff

Table 5 Participant triage accuracy per vignette. Vignette Expected category

Overall accuracy (%)

Under-triage (%)

Over-triage Agreement (%) (k)

1 2 3 4 5

75 35 20 40 70

10 45 55 0 30

15 20 25 60 0

3 4 3 3 2

0.471 0.118 0.048 0.210 0.483

by email (n = 1; 4.5%). Feedback to individual triage nurses (n = 18; 81.8%) was also provide, which typically (n = 7; 31.8%) occurred as part of their annual performance appraisal. As part of the survey, participants were asked to assign a triage category to five vignettes. Of the 29 participants, 20 (69.0%) rated the triage vignettes. Overall accuracy was 48%, with fair agreement demonstrated ( = .341). Higher levels of agreement were seen in vignette 1 ( = .471) and 5 ( = .483). Nearly half (49%) of the triage codes assigned were within one triage category; 28% were overtriage and 24% were under-triaged (Table 5). 5. Discussion The findings of this study demonstrate that models of triage, preparation and education of emergency nurses are highly variable, and auditing of triage practice occurs infrequently. Access to emergency care across Australia is provided through a wide range of facilities. With rising demand for access to emergency care, and increasing acuity of patients presenting to EDs across the world [14,34,35], accurate identification of critically ill patients at triage is vital to ensure effective distribution of ED resources and patient outcomes. Variability in triage decision-making is associated with increased patient morbidity and mortality [10,14,15]. The number of triage nurses scheduled per shift appears aligned to the number of patient presentations. Similar to an earlier study by Kelly and Richardson in 2001 [36], the duration of emergency nursing experience required before undertaking triage varied. In this study, nurses were required to have on average two or more years of emergency nursing experience prior to transitioning into the triage role. However, in rural and remote ED settings, duration of emergency nursing experience was far less. The reasons for this are unclear, possible explanations include lower levels of ED activity [37], and challenges with recruitment and retention of

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nursing staff in geographically isolated areas [38,39]. While patient presentations (n = 253,501; 3.3%) to rural and remote facilities are low, emergency care is largely nurse-driven with up to 52% of patients managed independently by nurses without medical review [40]. In a recent study by Ekins and Morphet [41] examining rural, remote and outpost nurse triage, experienced emergency nurses were more accurate and consistent in their triage decisionmaking. Prompt, accurate triage is vital to identifying critically ill or injured patients requiring urgent stabilisation, management and/or retrieval to other higher-level care facilities [41]. Compared to previous findings [36,42], the training and supervision of emergency nurses transitioning into the role of triage is more consistent with current professional guidelines [2,13,43]. A possible explanation for this is the introduction of Emergency Triage Education Kit (ETEK) to guide training in the application of the ATS [44]. In this study, it was identified that many ED facilities used locally developed triage guidelines. One potential reason for this may be to guide novice triage nurses in categorising presenting complaints or symptoms not clearly defined within the ATS. Emergency care is complex with a wide range of potential conditions, injuries and illness. However, while the last revision of the ATS was in 2016 [1], ETEK [44] was last revised in 2007. In line with previous recommendations within the literature [4,45–48], ETEK should be revised with broad consultation and maintained in tandem with the ATS to ensure clarity and consistency. Within NSW, clinical nurse consultants and clinical educators lead training and evaluation of triage in which written triage scenarios are used to assess education outcomes and competency. In this study, five written scenarios were used to assess triage accuracy and consistency of participants. Participant accuracy (48%) and consistency ( = .341) fell within the lower ranges published in the literature (40.7–78.3% and  = 0.21–0.75 respectively), and had an over-triage rate of 28% [49–51]. One possible explanation for this may be reduced shifts at triage and skill decay. Results presented in this study are incongruent with previous research findings that increased frequency of triage shifts is associated with higher levels of over-triage, with senior nurses less likely to overtriage [41]. Clinical nurse consultants and clinical educators are largely supernumerary, and would therefore be infrequently scheduled to staff triage; potentially increasing the risk of clinical skill decay [52]. Within other triage systems, refresher training has been shown to successfully increase triage accuracy and decease risk of poor patient outcomes regardless of years of triaging and emergency nursing experience [53]. While there are recommendations regarding auditing and ongoing education of triage nurses [15], there are presently no national recommendations regarding triage instructor/trainer competency or revalidation framework. In addition, there is presently no nationally agreed measure or threshold for triage consistency. A Fleiss kappa value of 0.75 or greater has been initially suggested [41], but further research is needed. To date, there has been no evaluation of national triage accuracy and consistency since the implementation of ETEK. Auditing and providing feedback are critical components of successfully improving triage practice and patient safety [2]. In this study, auditing occurred infrequently, and relied upon manually examining triage documentation retrospectively. This process is often time consuming [54], and may be increasingly more difficult to sustain for clinical nurse consultants or clinical educators supporting multiple facilities. Despite recent advancements in electronic health record systems and data science, there remains an increasing reliance upon manual processes to identify gaps in clinical practice and patient safety [4] due to a lack of integrated analytics built into healthcare software systems [55]. A new online software system has recently been designed to assist in assessing triage accuracy and consistency [48]. While preliminary testing appears favourable, further research is required.

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Other alternative methods to assessing triage competency and identifying areas for improvement include collaborative observational assessment [56–58] such as real-time feedback by a preceptor or peer, the use of mobile applications or online case studies [59–61]. To date, there is no evidence as to which approach or combination of approaches best prepares emergency nurses for the role of triage. Further research is needed to explore and examine education modalities, including feasibility and impact on patient outcomes across a range of ED settings. 5.1. Strengths and limitations The sample obtained represents a large cross-section of ED clinical nurse consultants and educators with the lead responsibility of overseeing triage education and practice in EDs in NSW. The majority of participants completed the questionnaire in its entirety with a return rate exceeding 80%, which suggests an appropriately designed and timed survey. However, generalisability of findings may be limited, due to potential bias inherent in the nature of convenience sampling. The triage scenarios used were designed to test respondent knowledge, and cannot be assumed to be a true measurement of triage accuracy occurring in the clinical environment. However, the use of written scenarios to assess triage decision making is no less accurate when compared to direct observation of decisions made in the clinical environment [25]. Despite these limitations this work provides evidence on current triage models, the preparation and training of emergency nurses for the role of triage, and approaches taken to monitor triage quality and accuracy. 6. Conclusion This study examined current models of triage, the preparation and education of triage nurses and examined approaches to auditing triage practices in NSW EDs. Triage is a critical component of emergency department practice, and affects patient safety and delivery of emergency care. The ATS aims to standardise and thereby increase the appropriateness and reliability of nurses’ urgency assessments. However, variability in the preparation, education and evaluation of triage nurses may in and of itself, contribute to poor patient outcomes. The current study identified variation in the preparation and education of triage nurses, including the use of local triage guidelines to direct urgency categorisation in addition to those stated in the ATS. There is urgent need to update the ETEK that is currently used to guide course content, education and evaluation of triage nurses. Further, it is vital that both the ETEK and ATS are maintained in tandem and regularly revised with broad consultation. Funding This study was not funded or commissioned. Conflict of interest WV and MF are Editors for Australasian Emergency Care, but had no role to play in the editorial review and decision-making processes of this manuscript whatsoever. There are no other conflicts of interest declared. This paper was not commissioned. References [1] Australasian College for Emergency Medicine. Guidelines for the implementation of the Australasian Triage Scale in emergency departments. ACEM; 2016. [2] College of Emergency Nursing Australasia. Triage and the Australasian Triage Scale. CENA; 2015. Available from: http://cena.org.au/wp-content/uploads/

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