PRACTICE IMPROVEMENT

IMPROVING THE PROMPT IDENTIFICATION OF THE

EMERGENCY SEVERITY INDEX LEVEL 2 PATIENT IN
TRIAGE: RAPID TRIAGE AND THE REGISTERED
NURSE GREETER
Authors: Alan Howard, MSN, RN, MDiv, CEN, Gerald D. Brenner, RN, PHRN, CEN, Jessica Drexler, BSN, RN, CEN,
CPEN, SANE, Patti Ann DaSilva, RN, CEN, Brigitte Schaefer, BSN, RN, Joanne Elischer, RN, PHRN, CEN, and
Scott Bogust, RN, Reading, PA
Introduction: High triage volumes can delay rapid

identication of walk in ESI level 2 patients. This concern

coupled with persistently increasing volumes prompted the
Reading Hospital Emergency Department to move from
single-tiered triage to duel-tiered rapid triage in 2008, then
brought the addition of the RN Greeter in 2011. The purpose
of this study was to assess how rapid triage then the RN
Greeter impacted the ability to quickly identify the walk-in
ESI 2 patient.
Methods: A retrospective analysis of mini-registration to
triage time was conducted on ESI level 2 patients entering the
ED by means other than ambulance. Data was collected from
three separate time frames: The rst representing single-tiered

triage, the second duel-tiered rapid triage, and the third dueltiered triage with the RN Greeter.
Results: Data demonstrated despite increasing volumes both
rapid triage and the RN Greeter improved the prompt
identication of ESI 2 patients.
Discussion: While moving from single to duel-tiered triage met
little resistance from staff, the RN Greeter role was initially not as
well received. However, as empirical data demonstrated the
efcacy of the RN Greeter to quickly identify the potential ESI 2
patient, the role ultimately became an integral part of triage.
Key words: Rapid triage; Duel-tiered triage; RN Greeter; ESI 2

he Reading Health Systems Reading Hospital is a

735-bed acute care Level II Trauma Center located
in West Reading, Pennsylvania. The Reading
Hospital Emergency Department is an 80-bed state-ofthe-art facility with over 133,500 visits annually. Signicant growth in ED volumes has led to process and
quality-improvement initiatives designed to increase patient
throughput, decrease wait times, and coordinate the
movement of patients within the emergency department,
from the emergency department to other departments such

as radiology, as well as from the emergency department to

inpatient beds. Examples of such ED initiatives within the
Reading Hospital include the use of ED protocol
physicians in the triage area during the peak hours of 10
AM to 10 PM, over 57 registered nurse (RN) order protocols
developed collaboratively between emergency RNs and
physicians, a dedicated front-end triage RN facilitator to
coordinate and improve patient ow from triage to
examination room placement and physician evaluation,
and the use of immediate bedding when examination

Alan Howard, Member, Berks County ENA Chapter, is RN V, Reading

Hospital Emergency Department, Reading, PA.
Gerald D. Brenner, Member, Berks County ENA Chapter, is RN IV, Reading
Hospital Emergency Department, Reading, PA.

Scott Bogust, Member, Berks County ENA Chapter, is RN II, Reading Hospital
Emergency Department, Reading, PA.
Funding for this project was provided entirely by the Reading Hospital.

Jessica Drexler, Member, Berks County ENA Chapter, is RN III, Reading

Hospital Emergency Department, Reading, PA.

For correspondence, write: Alan Howard, MSN, RN, MDiv, CEN, 61

Wellington Blvd, Wyomissing, PA 19610; E-mail: howardsfour@yahoo.com.
J Emerg Nurs .

Patti Ann DaSilva, Member, Berks County ENA Chapter, is RN IV, Reading
Hospital Emergency Department, Reading, PA.
Brigitte Schaefer, Member, Berks County ENA Chapter, is RN II, Reading
Hospital Emergency Department, Reading, PA.
Joanne Elischer, Member, Berks County ENA Chapter, is RN III, Reading
Hospital Emergency Department, Reading, PA.

0099-1767/$36.00
Copyright 2014 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.jen.2014.01.009

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PRACTICE IMPROVEMENT/Howard et al

rooms are available. However, regardless of such initiatives

designed to improve metrics such as door-to-physician
time, patient satisfaction, or total time in the department,
the prompt identication of the critical or potentially
critical patient arriving in the emergency department
through the triage area has been of particular focus.
The purpose of this study was to evaluate how moving
from a single-tiered comprehensive triage to a dual-tiered
rapid triage in 2008, and then the addition of the RN
greeter in 2011, might improve the ability to promptly
identify the critical or potentially critical patient arriving in
the emergency department through the triage area.
Methods
PROBLEM

The Reading Hospital Emergency Department uses the

Emergency Severity Index (ESI) version 4 system to classify
patient acuity. The ESI level ranges from level 1 (most ill) to
level 5 (least resource intensive). 1 The ESI algorithm starts
with an assessment of patient acuity to immediately identify
the most ill patients, and resources are only considered for
less acute patients. The nurse starts at the top of the
algorithm and considers whether the patient needs
immediate, life-saving interventions. If so, the patient is
considered an ESI level 1 patient. If not, then the nurse
considers whether the patient is high risk, confused,
lethargic, disoriented, or in severe pain or distress. If so,
the patient is assigned ESI level 2. Therefore, for ESI levels 1
and 2, the nurse considers only the patients acuity in
making an ESI assignment. 2 Patients who are assigned ESI
level 1 include those who are intubated, apneic, pulseless, or
unresponsive, and such patients typically arrive by
ambulance. ESI level 1 patients who arrive through the
triage area are usually immediately identied and cared for.
Examples of ESI level 2 patients include those in high-risk
situations such as chest pain, shortness of breath, brain
attack, or sepsis; who have suicidal or homicidal ideation;
who are confused, lethargic, or disoriented; or who are in
severe pain or distress. 1 At times, ESI level 2 patients
arriving through triage may not be quickly identied,
particularly if seen rst by nonmedical personnel such as a
registration clerk. The presence of numerous patients
waiting to be triaged may also cause delays in the prompt
recognition of the ESI level 2 patient. High volumes and
ED overcrowding have been linked to delays in identication and treatment of time-sensitive critical conditions such
as acute coronary syndrome, brain attack, surgical emergencies, and septic shock, whereas the rapid recognition of
the critical patient can positively affect his or her outcome. 3

JOURNAL OF EMERGENCY NURSING

To address possible delays in the prompt recognition of the

ESI level 2 patient in triage, the Reading Hospital
Emergency Department implemented 2 quality-improvement initiatives: a dual-tiered rapid triage system in 2008
and an RN greeter in 2011.
LITERATURE REVIEW

Crowding in the emergency department has been one of the

major problems in the health care system nationwide for a
number of years. 4 Crowding dynamics strain overtaxed ED
resources, diminish patient throughput, and are associated
with patient safety issues. 5,6 One initiative to improve
patient throughput, ED efciency, and patient safety has
been rapid triage. A dual-tiered triage process combining
rapid and comprehensive triage is suggested as being a
necessary component for a successful triage program, 7 with
focused rapid assessment of the chief complaint, history,
vital signs, and subsequent ESI level considered an ideal
triage experience. 8 In practice, the use of a rapid triage
system within a pediatric emergency department showed
diminished arrival-to-triage times and improved throughput
of the nonurgent patient. 9 In addition, rapid-assessment
triage has been associated with diminished patient wait
times and a reduced number of patients who leave without
being seen. 10 The role of a greeter in triage has also been
associated with improved patient care. Although the type of
greeter or level of training was not identied, it has been
shown that placing a trained greeter in triage who screened
patients for signs of acute coronary syndrome improved
door-to-electrocardiography times. 11 The use of an RN
greeter in conjunction with reallocated stafng and
space was also found to increase ED capacity and improve
patient access. 12
PROCESS

In 2008 the Reading Hospital Emergency Department had

a monthly patient census of over 8,000 patients and a yearend census of almost 100,000 patients. A single-tiered
triage process was used, comprising 2 or 3 triage nurses
depending on volume and a nursing assistant, referred to as
a patient care assistant (PCA). According to Reading
Hospital Emergency Department policy, all triage RNs
completed formal triage training and were observed by a
preceptor while performing triage functions. At that time,
non-ambulance patients who accessed the emergency
department through the walk-in entrance provided their
chief complaint to a clerk, underwent mini-registration,
and were then directed to sit in the waiting area until called
by the triage nurse. No medical professionals were stationed

Howard et al/PRACTICE IMPROVEMENT

in the waiting area, and triage assessment occurred in

adjacent rooms.
On the basis of the chief complaint, the triage nurse
determined which patient would be assessed next. Patients
with specic complaints such as chest pain or shortness of
breath received priority. Once called by the triage nurse, the
patient received a comprehensive triage assessment, ESI
designation, and appropriate protocol-driven diagnostic
assessments and interventions. This process could take 10
minutes or more per patient. If patient volumes were low,
ESI level 2 patients could be identied and triaged quickly,
but when volumes were high or multiple patients presented
with similar complaints, triage and subsequent care could be
delayed. Furthermore, patients who were actually critical
but provided vague or inaccurate chief complaints to the
clerk might not have been rapidly identied, and again,
care could have been delayed. These concerns led to the
creation of a 2-tiered triage process with the addition of
rapid triage in 2008.
Whereas the comprehensive triage area remained and
functioned as before, a rapid triage area was placed in the
patient waiting room. To maintain privacy and condentiality, booths were constructed next to the registration area.
Depending on volume, 1 or 2 booths were staffed by a rapid
triage nurse(s) who received additional training in the rapid
triage process and a PCA. As before, walk-in patients would
still provide a chief complaint to a clerk and be miniregistered, but now, after registration, the rapid triage nurse
would evaluate the patient. The rapid triage process
consisted of the PCA obtaining initial vital signs while the
rapid triage nurse conrmed the chief complaint, elicited a
history regarding the present illness or injury, and assigned
an ESI level. If immediate bedding was available, the patient
was then placed in an examination room. If examination
rooms were not available, patients in need of diagnostic
assessments, interventions, or more in-depth assessment
were referred to the comprehensive triage area, where
nursing protocols could be started or an ED protocol
physician stationed in triage during the hours of 10 AM to 10
PM could initiate further care and order more specic
diagnostic assessments. The initial rapid triage process
would take 2 to 3 minutes per patient and would quickly
identify and expedite the care of the ESI level 2 patient. The
patients comprehensive triage would be completed later by
the comprehensive triage nurse or by the patients nurse
once placed in an examination room. Between 2008 and
2011, this process was occasionally modied because annual
volumes increased to over 127,000 patients, and ultimately,
patients waited again for extended periods for triage. The
growing concern that critical patients might not be quickly
identied led to the addition of the RN greeter role in 2011.

The RN greeter is an experienced ED triagetrained

nurse who received further department-specic in-service
training on the RN greeter role. The RN greeter is located at
a podium immediately inside the emergency departments
walk-in entrance. The RN greeter meets each walk-in
patient on arrival, determines the patients chief complaint,
assigns an initial ESI level, and expedites the triage and care
of patients who are identied as critical or potentially
critical. If the RN greeter determines that the patient is a
possible ESI level 1 or 2 patient, the front-end RN
facilitator is immediately notied by a communication
device, consent for treatment is obtained, and a triage nurse
collects the patient for evaluation and treatment. If
immediate bedding is available, the patient is brought to
an examination room. If not, the patient is placed in the
comprehensive triage area and care is quickly started.
Patients determined to be ESI level 3 to 5 by the RN greeter
are given a short form with their chief complaint and
tentative ESI level and are then directed to the registration
clerk as usual.
DATA COLLECTION

To determine whether the addition of rapid triage and an

RN greeter improved the prompt identication and
subsequent treatment of the ESI level 2 patient, a
retrospective analysis of mini-registrationtotriage time
was conducted, with triage time dened as either
comprehensive triage or rapid triage. This collection of
data did not meet Reading Hospital Institutional Review
Board criteria necessitating institutional review board
review and approval. For the purpose of this study, no
interventions or interactions with individuals were elicited
and all data were deidentied through deselecting any eld
containing an individuals name, medical record number,
patient account number, or birth date. Data were collected
from 3 separate time frames: the rst representing singletiered triage in 2008, the second representing dual-tiered
triage in 2011, and the third representing triage with the
RN greeter in 2012. For consistency, the data were from
between June and September of each year, and a minimum
of 1,000 patients meeting the criteria were included in each
dataset. Criteria for inclusion were all ESI level 2 patients
arriving through the walk-in emergency entrance by means
other than ambulance. Any ESI level 2 patient arriving by
ambulance was excluded. Mini-registrationtotriage time
was divided into 10-minute increments ranging from 0 to
60 minutes, and a single category listed as greater than 60
minutes was included. All patients were placed into their
appropriate time increment, and data were analyzed.

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PRACTICE IMPROVEMENT/Howard et al

FIGURE
Mini-registration (Mini Reg)totriage time.

Results

Data for June through September 2008 showed that a total

of 1,026 patients meeting the criteria were included
(Figure). Of these, 59% were identied and triaged within
0 to 10 minutes and 84% within 0 to 20 minutes. One
percent, or 15 patients, were triaged after more than 60
minutes. The total ED census during this period was 32,574
patients. Data for June through September 2011 showed
that 1,161 patients meeting the criteria were evaluated. Of
these, 72% were triaged within 0 to 10 minutes and 92%
within 0 to 20 minutes. Fewer than 1% were triaged at
beyond 60 minutes. The total ED census for this time frame
was 42,605 patients. Data for June through September 2012
showed that 2,255 patients meeting the criteria were
evaluated. Of these, 75% were triaged within 0 to 10
minutes, 94% were triaged within 0 to 20 minutes, and
fewer than 1% were triaged at beyond 40 minutes. The total
ED census for this time frame was 44,844 patients. The data
showed that despite increasing ED volumes, the addition of
rapid triage and then the RN greeter greatly improved the
ability to promptly identify and treat the ESI level 2 patient.

impetus to rene and improve the prompt identication of

the critical or potentially critical patient. The rst addition
the rapid triage processmet with little resistance from
nursing or physician staff, particularly once rapid triage nurses
became comfortable with the process. It also became evident
that the previous backlog of patients waiting to be triaged had
greatly diminished, which furthered the support of rapid
triage. The addition of the RN greeter role, however, did not
receive as much support and enthusiasm among triage staff. It
was viewed as a less-than-optimal use of an experienced triage
nurse. The RN greeter role was championed by the ED
Quality Improvement Coordinator and strongly supported
by department administration. Both viewed the RN greeter
role as imperative to the prompt identication of the critical
patient, and within this context, they sought staff buy-in by
selecting triage nurses who were willing to trial the role rst.
Those nurses realized that, indeed, ESI level 2 patients could
be swiftly identied, and on that merit, the RN greeter role
became accepted and eventually encultured into the triage
process. It is now agreed, especially in light of data from this
study, that the addition of both rapid triage and the RN
greeter role has provided a higher level of patient care to a very
busy emergency department.

Discussion

Conclusions

The ability to recognize a high-risk situation is a critical

element of the triage decision-making process, regardless of
the particular triage system used. 1 This concept provided an

Dramatic increases in patient volumes can cause emergency

departments to consider new and innovative methods to
promptly identify and treat the critically ill or potentially

JOURNAL OF EMERGENCY NURSING

Howard et al/PRACTICE IMPROVEMENT

critically ill patient. Rapid identication of such patients

could be imperative to their outcome. In response to this
challenge, the Reading Hospital Emergency Department
moved from a single-tiered triage process to a dual-tiered
triage with the addition of rapid triage in 2008. Data
showed improved door-to-triage times of walk-in ESI level 2
patients. Continued volume increases led to the addition of
the RN greeter role in 2011. Data showed that the addition
of the RN greeter further improved the ability to promptly
identify and treat ESI level 2 patients. These data served to
validate the addition of rapid triage and the RN greeter, as
well as to show that despite increasing ED volumes, the ESI
level 2 patient can be promptly identied and treated,
thereby improving the quality and timeliness of care.
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