Implementing an Emergency Severity Index (ESI) Triage Refresher Training to Decrease

the Under-Triage Rate in the Emergency Department (ED)

A DNP Project Submitted to the

Graduate Faculty
of Jacksonville State University
in Partial Fulfillment of the
Requirements for the Degree of
Doctor of Nursing Practice

By
Monique V. Wallace

Jacksonville, Alabama

August 4, 2023
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copyright 2023
All Rights Reserved

________________________________________________
Monique V. Wallace August 4, 2023
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Abstract

Background: The Emergency Severity Index (ESI) is a triage tool used in most emergency

departments in the United States (U.S.) that assesses acuity and resource allocation for

emergency care patients. Registered nurses (RNs) must assign the appropriate triage category to

ensure patients are seen in a proper time frame, have ideal patient outcomes, and have efficient

patient throughput.

Purpose: This quality improvement project aims to decrease the under-triage rate of patients in

the emergency department (ED) by implementing an Emergency Severity Index (ESI) triage

refresher training.

Methods: This project used an A3 methodology. The triage specialist completed retrospective

chart reviews to assess triage accuracy pre-and post-implementation. All ED and under-triage

patients’ lengths of stay were compared pre-and post-implementation. In addition, pre-and post-

education test results were compared.

Results: The results did not show any statistical significance in pre-and post-education tests and

under-triage rates. However, there was a slight improvement in the under-triage rate from

20.59% to 16.44% and the average length of stay for ED patients of 235 to 218 minutes and

323.67 to 236 minutes for under-triage patients.

Conclusion: Triage accuracy is vital in improving patient outcomes and patient flow. It is crucial

for EDs to evaluate nurses' triage accuracy and implement policies and procedures for annual

triage education.

Keywords: emergency department nurses, emergency severity index (ESI) refresher

training, triage training, mistriage, under-triage

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Acknowledgments

First and foremost, I would like to praise and thank God. He has given me strength

through this process; this would not be possible without him. Secondly, I am incredibly grateful

for the support and encouragement from my family, friends, and Summer 2023 DNP cohort.

Lastly, I want to express my gratitude for the support and guidance from Dr. Theadoshia Hines,

Dr. Amanda Bullard, Dr. Cheryl Emich, Dr. Lori McGrath, and Dr. Douglas Stephens.

The views expressed herein are those of the author and do not reflect the official policy of the US

Army Medical Department, Department of the Army, Defense Health Agency, Department of

Defense, or the U.S. Government.

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Table of Contents

Abstract...............................................................................................................................................

Background.........................................................................................................................................

Needs Analysis..................................................................................................................................10

Strengths, Weaknesses, Opportunities, Threats (SWOT) Analysis...................................10

Problem Statement............................................................................................................................11

Aims and Objectives.........................................................................................................................11

Review of Literature.........................................................................................................................12

Triage Accuracy.................................................................................................................12

Under-Triage Impact.........................................................................................................13

Factors Associated with Under-Triage..............................................................................13

Strategies to Improve Triage Accuracy.............................................................................14

Theoretical Model.............................................................................................................................15

Methodology.....................................................................................................................................16

Setting................................................................................................................................18

Population..........................................................................................................................18

Inclusion/Exclusion Criteria for the Population................................................................19

Recruitment........................................................................................................................19

Consent..............................................................................................................................19

Design................................................................................................................................19

Data Review Process.........................................................................................................20

Risks and Benefits.............................................................................................................21

Compensation....................................................................................................................22
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Timeline.............................................................................................................................22

Budget and Resources........................................................................................................23

Evaluation Plan.................................................................................................................................23

Statistical Considerations...................................................................................................23

Data Maintenance and Security.........................................................................................23

Results...............................................................................................................................................24

Discussion.........................................................................................................................................25

Implications for Clinical Practice......................................................................................26

Implications for Quality/Safety.........................................................................................26

Implications for Education................................................................................................26

Limitations........................................................................................................................................26

Dissemination....................................................................................................................................27

Sustainability.....................................................................................................................................27

Plans for Future Scholarship.............................................................................................................28

Conclusion........................................................................................................................................28

References.........................................................................................................................................29

Tables................................................................................................................................................35

Table 1 Patient Demographic Information............................................................................35

Figures...............................................................................................................................................36

Figure 1 Pre-and Post-Test Results.......................................................................................36

Figure 2 Pre-and Post-Test Means........................................................................................37

Figure 3 Retrospective Chart Reviews..................................................................................38

Figure 4 Average Length of Stay..........................................................................................39

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Appendices........................................................................................................................................40

Appendix A-SWOT Analysis...............................................................................................40

Appendix B-Theoretical Model............................................................................................41

Appendix C-DNP Project Recruitment Flyer.......................................................................42

Appendix D-Participant Consent Form.................................................................................43

Appendix E-CITI Training Certificate..................................................................................46

Appendix F-JSU IRB Approval Letter.................................................................................47

Appendix G-Agency Letter of Support.................................................................................48

Appendix H-Agency IRB Approval Letter...........................................................................49

Appendix I -ESI Implementation Handbook Permissions....................................................51

Appendix J-Timeline.............................................................................................................53

Appendix K-Budget and Resources......................................................................................55

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Implementing an Emergency Severity Index (ESI) Triage Refresher Training to Decrease

the Under-Triage Rate in the Emergency Department

Prioritizing care for people seeking emergency medical attention is known as triage.

Many emergency departments (EDs) in the United States (U.S.) use a five-level scale called the

Emergency Severity Index (ESI) as a triage tool. ESI classifies patients based on acuity and

resource needs. When a patient is assigned a triage category that does not match their acuity

and/or resource needs, this is known as a mistriage. The problem focus of this project is the

increasing number of mistriages, specifically under-triages. Inconsistencies in triage

categorization can lead to longer wait times, misuse of resources, and patient deterioration

(Ghazali et al., 2020). Tam et al. (2018) believe a correct triage category will ensure patients are

seen in the most suitable timeframe based on their acuity and needs.

Background

ESI is the most used triage tool in the U.S., assessing patients' needs based on acuity and

resources (Wolf & Delao, 2021). Acuity evaluates threats to life, limb, organs, and vital

functions (Gilboy et al., 2020). The number of interventions a patient is anticipated to need

before a disposition decision is referred to as a resource (Gilboy et al., 2020). The ED nurse uses

the ESI triage algorithm to determine a triage category. The algorithm helps guide patients into

one of the five triage levels using four decision points (A, B, C, and D) (Gilboy et al., 2020). An

ESI one is an urgent patient requiring immediate medical intervention, while an ESI five is the

least acute patient who requires no resources. The four decision points are (A) "Does this patient

require immediate lifesaving intervention?", (B) "Is this a patient who should not wait?", (C)

"How many resources will this patient need?", and (D) "What are the patient's vital signs?"

(Gilboy et al., 2020, p.7). A mistriage can lead to extended wait times and adverse patient
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outcomes. Mistriages include over-triage or under-triage. Over-triage patients are assigned a

higher triage category than their acuity and/or resource needs. Conversely, under-triage patients

are given a lower triage category than their acuity and/or resource needs. An over-triage patient

can misallocate resources to a less urgent patient, leading to longer wait times for other patients

(Gilboy et al., 2020). Longer wait times, a higher risk of patient deterioration, or a lack of

accessible resources are all consequences of under-triaging (Gilboy et al., 2020). An under-

triaged patient will wait longer because patients are seen by acuity; for example, an ESI two will

be seen before the ESI three. An ESI four or five can be seen in a non-urgent care area (Gilboy et

al., 2020). This area is utilized for patients who require one or no resources and can be seen and

discharged quickly. Under-triaging patients can delay treatment times (Chmielewski & Mortez,

2022).

The current practice at the southeastern military treatment facility (MTF) is that

emergency department registered nurses (RNs) receive an initial two-hour ESI course once in the

department for six months and annual triage audits. Despite the RN's length of time in the

department, further triage education is not offered. A recent chart review revealed that the lack of

adherence to the ESI algorithm and the knowledge level of nurses contribute to under-triaging.

According to the Emergency Nurses Association (ENA) (2018), seasoned nurses do not follow

formal rules while allocating triage categories, instead relying on their recollection and prior

experiences. Worth et al. (2019) noted in the descriptive correlation study that most EDs did not

adhere to the ESI triage system's minimal standards for triage qualifications, policies and

processes for education, and monitoring. Tam et al. (2018) expressed that triage refresher

training for ED nurses will improve triage accuracy. Brosinski et al. (2017) improved the under-

triage rate to 9.3% after implementing a triage refresher training. Delnavaz et al. (2018)
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discovered that triage education through scenario-based lectures and role-playing increased

triage knowledge. The continual triage competence validation process should include

observation, chart review, remediation, and more education as necessary (ENA, 2018). Although

there is no national standard for an acceptable mistriage rate, the ESI Implementation Handbook

states that a frequently used threshold for triage accuracy is 90% (Gilboy et al., 2020). This

project focused on implementing an ESI triage refresher training to improve the under-triage rate

to meet the threshold discussed by the ESI Implementation Handbook.

Needs Analysis

The growing ED overcrowding may threaten patient safety; thus, it is critical to correctly

classify seriously sick patients during ED triage and distribute the limited ED resources as

effectively as possible (Mistry et al., 2018). Mistry et al. (2018) found that in the U.S., the

overall triage accuracy was 61.3% and 59.2% in the United Arab Emirates (UAE), Brazil, and

the U.S. combined. A chart review from April to September 2022 at the southeastern MTF

revealed that 278 out of 1350 (20.59%) patients were under-triage. This chart review also noted

that the average length of stay for the under-triage patient was 323.67 minutes, while the average

length of stay in the ED was 235 mins.

Strengths, Weaknesses, Opportunities, Threats (SWOT) Analysis

A SWOT analysis was performed to identify this project's strengths, weaknesses,

opportunities, and threats (see Appendix A). Strengths noted in the ED at the southeastern MTF

include initial training and yearly chart audits. Many other surrounding local EDs do not offer

their nurses triage training. Another strength includes having a triage specialist in the ED and

department of emergency medicine (DEM) leadership support. Drawbacks include no policies

regarding refresher training in the organization or accrediting bodies. The ENA offers triage

training for a fee; however, there are no recommendations on how often staff should utilize the
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training. Utilizing the triage specialist is a chance to create a triage training program that includes

initial, annual, as-needed training, and department-specific policies. Gilboy et al. (2020) suggest

that facilities develop educational programs using the ESI Implementation Handbook. Threats

include staff buy-in for training, staff shortages, and no formal policies regarding triage training

established by any credentialing agencies. According to the ESI Implementation Handbook, each

ED will incorporate triage policies and procedures governed by their organization (Gilboy et al.,

2020).

Problem Statement

The problem focus for this project is the increasing number of under-triaged patients

identified by the DEM leadership. As stated previously, the under-triage rate is 20.59%, which

means this MTF is at 79.41% for triage accuracy. This triage accuracy is 10.59% below the

suggested benchmark. Improving triage accuracy is vital in preventing delayed care and

interventions (Tam et al., 2018), improving ED throughput (Hoffman et al., 2022), and

improving the length of stay (Al Hasni et al., 2019). Hosseini et al. (2022) found that triage

training improved the performance accuracy of triage. The PICOT statement for this project is:

For emergency department (ED) Registered Nurses (RNs) (P), does an Emergency Severity

Index (ESI) triage refresher training (I) compared to only an initial ESI triage training (C)

decrease the under-triage rate (O) in two months (T)?

Aims and Objectives

The overarching aims of this project were to:

1. Decrease the under-triage rate to 10% or less.

2. Decrease the average patient’s length of stay.

3. Improve RN's knowledge and utilization of the ESI algorithm.

Review of Literature
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Under-triages can have detrimental outcomes for patients and the flow of the ED. The

RN must correctly grasp and implement the ESI algorithm to ensure triage accuracy.

Understanding the under-triage rate in the ED requires a literature review focusing on triage

accuracy, under-triage impact, factors associated with under-triage, and strategies to improve

triage accuracy. This writer completed a literature review using PubMed, CINAHL, Google

Scholar, PsychINFO, and the Journal of Emergency Nursing with articles published in the last

five years. Keywords used included emergency department nurses, emergency severity index

(ESI) refresher training, triage training, under-triage, and mistriage. A total of 126,367 potential

articles were found by using different Boolean combinations. Articles were narrowed using full

texts, scholarly journals, and limiters within the last five years. This yielded approximately 57

potential findings. In addition, this writer reviewed the Emergency Nurses Association's (ENA)

position statement on Triage Qualifications and Competency.

Triage Accuracy

Tam et al. (2018) found that retrospective chart reviews and written scenarios were

frequently used to determine triage accuracy. The Emergency Nurses Association (ENA) (2022)

reported triage accuracy is roughly 60% in the United States (U.S.), while Mistry et al. (2018)

stated 61.3%. In the study by Mistry et al. (2018), the overall triage accuracy in the United Arab

Emirates (UAE), Brazil, and the U.S. was 59.2%. Oh and Kim (2021) concluded that 31% of

patients with abdominal pain were under-triaged. Hinson et al. (2018) noted that 24.2% of the

moderate and low acuity patients were under-triaged, and Brosinski et al. (2017) noted an under-

triage rate of 26.3%. In the retrospective observational study by Ausserhofer et al. (2021), 16.3%

of the patients had triage errors.

Under-Triage Impact
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Under-triaging patients can affect both patients and the workflow of the ED. Under-triage

patients tend to have longer wait times (Al Hasni et al., 2019; Ausserhofer et al., 2021; Brosinski

et al., 2017; Tam et al., 2018), deterioration in the waiting room (Hoffman et al., 2022) and delay

in interventions which can lead to poor patient outcomes (Brosinski et al., 2017; Chmielewski &

Mortez, 2022; Hinson et al., 2018; Rashid et al., 2021; Wolf & Delao, 2021). An under-triage

patient is at an increased risk for morbidity and mortality (Al Hasni et al., 2019; Ausserhofer et

al., 2021; Hinson et al., 2018; Rashid et al., 2021; Stonko et al., 2018), higher admission rates

(Hinson et al., 2018), and an increase in the adverse outcomes (Al Hasni et al., 2019; Hinson et

al., 2018; Tam et al., 2018). Chmielewski and Moretz (2022) stated that a patient triage category

could impact ED patients’ throughput, assignments, and nursing and provider workloads.

Furthermore, under-triaging could lead to an inefficient workflow (Hoffman et al., 2022).

Factors Associated with Under-Triage

Numerous factors play a role in the under-triaging of patients. For example, a busier ED

(Ausserhofer et al., 2021) and a lack of staffing (Wolf et al., 2018) are associated with increased

under-triage rates. It was also found that older patients tend to be under-triaged more often than

younger patients (Ausserhofer et al., 2021; Oh & Kim, 2021; Rashid et al., 2021). Additionally,

patients with abnormal vital signs like bradycardia, tachycardia, or hypoxia are under-triaged at a

higher rate (Rashid et al., 2021). Inadequacy of triage education and training plays a role in

accurate decision-making (Delnavaz et al., 2018; Wolf & Delao, 2021). Wolf et al. (2018) noted

that barriers to triage accuracy include triaging based on quick looks, inappropriate use of

technology, education, experience, burnout, compassion fatigue, and language barriers. Wolf et

al. (2018) also suggest that using processes where filling a bed without an accurate assessment

can lead to triage inaccuracies.

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Strategies to Improve Triage Accuracy

Various strategies have been used to assess triage accuracy and knowledge improvement.

In the process improvement initiative by Brosinski et al. (2017), a face-to-face triage refresher

training lasting 90 minutes using a slide show presentation based on the ESI Implementation

Handbook improved an under-triage rate from 26.3% to 9.3%. The post-tests in the randomized

controlled trial by Ghazali et al. (2020) showed an improvement in triage knowledge and

accuracy for the staff after receiving a 140-minute triage refresher training using lecture,

discussion, and scenario-based cases. Hosseini et al. (2022) found that face-to-face training and

multimedia training improved triage accuracy when compared to the use of pamphlets. The

randomized quasi-experimental study by Yazdannik et al. (2018) found that using e-learning

increased triage knowledge of ESI to 78%, while workshop knowledge increased to 41%.

Additionally, Al Hasni et al. (2019) found that implementing ESI education through web-based

training, DVD, and competency cases improved triage accuracy, length of stay, and patient

satisfaction. Hoffman et al. (2022) did not find any improvement when using competency case

assessments. Coogle (2017) noted that using case scenarios and individualized feedback

improved triage accuracy; however, there was no improvement when using video-simulated

scenarios (Campbell et al., 2022). Pediatric triage accuracy was increased when paper-based case

studies and high-fidelity simulation were utilized (Recznik et al., 2019). Stonko et al. (2018)

used a web tool to improve adherence to the trauma activation protocol to decrease triage errors.

In nursing students, role-playing (Delnavaz et al., 2018) and simulation (Hu et al., 2021)

improved clinical reasoning and triage knowledge over didactic lectures (Delnavaz et al., 2018;

Hu et al., 2021). The ENA (2018) states that online courses and case studies can be educational

tools to evaluate triage proficiency.

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The literature review supports multiple factors leading to mistriages including how busy

the ED is, age, abnormal vital signs, lack of staffing, and education (Ausserhofer et al., 2021; Oh

& Kim, 2021; Rashid et al., 2021; Wolf et al., 2018). Researchers identified various strategies for

reducing the rates of mistriages in the ED setting, including refresher training using a lecture,

discussion, scenario-based scenarios, multimedia training, web-based training, simulation, and

competency cases (Al Hasni et al., 2019; Brosinski et al., 2017; Ghazali et al., 2020; Hosseini et

al., 2022; Recznik et al., 2019). When considering under-triage rates, it is essential to understand

triage accuracy in the ED, the impact of under-triaging a patient, factors contributing to under-

triaging patients, and ways to improve triage accuracy. Triage education can enhance a nurse’s

understanding of ESI and the algorithm to improve triage accuracy.

Theoretical Model

Kurt Lewin's change theory is a widely used theoretical framework in healthcare for

organizational change. Kurt Lewin's theory of change includes the unfreezing, changing or

movement, and refreezing phases (Butts & Rich, 2018) and was used to guide the framework of

this project (see Appendix B). According to Gilboy et al. (2020), these phases correspond to

triage nurses' actions in the nursing process. Data is gathered and a problem is identified in the

unfreezing phase of Kurt Lewin's change theory (Gilboy et al., 2020). The data shows an under-

triage rate of 20.59% which does not meet the frequently used threshold from the ESI

Implementation Handbook. The changing or movement phase of Kurt Lewin's change theory

involves selecting, organizing, and implementing appropriate strategies to address the problem

(Gilboy et al., 2020). During the movement phase, a literature search found that triage education

improved triage accuracy and knowledge (Tam et al., 2018). An emergency severity index (ESI)

triage refresher training was implemented through the online learning platform in an attempt to
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improve triage accuracy. The refreezing phase of Kurt Lewin's change theory is known as the

evaluation phase. During this phase, the change is monitored and adjusted to ensure that

permanent changes can be made (McFarlan & Simmons, 2019). Retrospective chart reviews

were completed to compare the triage accuracy to see if the target goal was met. The pre-and

post-education tests were compared to assess nurses' triage knowledge and application of ESI.

The online training was evaluated to review its effectiveness and the need for adding the training

to an annual competency. The use of a theoretical framework provides a theory-driven approach

to the project.

Methodology

This quality improvement project focused on quantitative data to assess the project

outcome. Quality improvement projects can use various methods to improve patient outcomes.

According to Fowler (2021), a quality improvement project is a systematic approach process

with measurable results. Methods used for quality improvement projects include Plan Do Study

Act (PDSA), Lean, Six Sigma, and focus, analyze, develop, and execute (Fowler, 2021). This

project focused on the A3 methodology based on lean principles. The A3 process is the method

of choice for this MTF. This method measured the under-triage rate and compared the baseline

and target data. A3 methodology identifies the problem, root causes, and probable

countermeasures, and evaluates the countermeasures. A3 methodology follows a Plan-Do-

Check-Act (Ojo et al., 2022).

The use of lean principles in quality improvement projects allows the process to be

evaluated systematically to identify waste and inefficiencies and create solutions to improve

efficiency, remove waste, and reduce cost (Vashi et al., 2019). A widespread tool for directing

decision-making and the usage of lean methodology is the A3 problem-solving approach

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(Elsasser et al., 2018). This method is known for having eight to nine steps and can be

summarized on a standard A3 paper (Elsasser et al., 2018). In the study by Williams et al.

(2022), a nine-step A3 method was implemented and improved the average length of stay for

fast-track patients in the ED from 205 minutes to 150.4 minutes. The use of the A3 method

allows progress to be conveyed weekly and changes to be made based on data (Williams et al.,

2022). Maliszewski et al. (2020) used the A3 method as a dynamic document to summarize the

problem and solutions on one sheet of paper to improve door-to-electrocardiography (DTE)

times in the ED. The lean principles and the A3 method improved DTE from 17 minutes to seven

minutes (Maliszewski et al., 2020).

The eight steps included in the A3 methodology at this MTF include:

1. Clarify the problem/problem statement

2. Breakdown the problem/identify the performance gap

3. Set the target

4. Determine the root causes

5. Develop prioritized projects/countermeasures

6. Implement countermeasures

7. Monitor performance and confirm results

8. Sustain success/transfer knowledge

The problem for this project is the under-triage rate of 20.59%. The performance gap

identified is that the nurses in the ED at the MTF only receive an initial two-hour ESI triage

training after being in the department for six months and annual triage chart audits are completed

on each nurse. However, further education is not offered. The under-triage rate will be measured

with a baseline of 20.59% and a target of 10% or less. The root causes of this problem include
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lack of refresher training, lack of adherence to the ESI algorithm, lack of awareness of the ESI

algorithm, and lack of monitoring of the under-triage rate. The prioritized countermeasure

includes implementing an ESI triage refresher training offered through the online learning

platform of the hospital. The countermeasure implementation occurred from January 17, 2023, to

March 14, 2023. Retrospective chart reviews were conducted to measure the outcomes from

March 15 to March 21, 2023. The sustained success was determined based on the results and

dissemination of this information occurred in the summer of 2023. This step-by-step approach

enables adjustments based on progress and intended goals.

Setting

This project occurred at a southeastern MTF, a fully accredited Level III Trauma Center.

The unit where this project was implemented was in the ED, which cares for adult and pediatric

patients. This 34-bed ED includes one adult trauma room, one pediatric trauma room, and four

different zones for patient care. The average daily census is approximately 200 patients.

Population

The population participating in this project includes registered nurses (RNs) in the

emergency department. The RNs consist of day and night shift nurses. In addition, permanent

full-time, part-time, and contract nurses are included. Therefore, this project impacts all

participants and the patients they triage.

Inclusion/Exclusion Criteria for the Population

Inclusion and exclusion were based on the participant's role, length of time in the

department, and previous training. Inclusion criteria for this project include all RNs in the

emergency department who have been in the department for at least six months and have

received initial triage training at this facility. Exclusion criteria include licensed practical nurses
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(LPNs), medics, paramedics, RNs who have not been in the department for at least six months,

and RNs who have not received initial triage training at this facility.

Recruitment

Before project initiation, the principal investigator (PI) attended day and night shift

huddles on 11 January 2023 and 16 January 2023 to provide information regarding the project

and how to access the online ESI triage refresher training. Moreover, a flyer was designed and

placed in the emergency department conference room and break room (see Appendix C). All

questions were answered during the huddles.

Consent

Consent was obtained from all study participants before completing the online training

(see Appendix D). Participants were notified that participation is optional and will not affect

their job assignment or performance evaluation. Participants were informed that all information

obtained would be kept confidential. Participants were advised that they could withdraw from the

project at any time by notifying the principal investigator (PI).

Design

This project consisted of a convenience sampling of ED RNs. Retrospective chart

reviews were conducted pre-and post-implementation to assess triage accuracy. Retrospective

chart reviews are a low-cost project design method that allows access to data promptly (Marincic

et al., 2017). In addition, pre-and post-education tests were collected to evaluate nurses'

knowledge and application of ESI. The pre-and post-tests were compared to assess the nurses’

prior knowledge and the education given.

The PI of this project is the triage specialist of the ED and completed 1350 retrospective

chart reviews pre-implementation to assess ESI triage category accuracy. During this review, 278
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were under-triaged (20.59%). The ESI algorithm was used to determine ESI accuracy.

Implementation included the ED RNs completing an online ESI triage refresher training through

the online learning platform of the hospital. Before the training, the RNs completed an online

pre-test of ten competency cases from the ESI Implementation Handbook. The participants then

completed the 30-minute online slide show. The slide show focused on essential concepts when

assigning an ESI triage category. After completing the online training, the participants completed

an online post-test consisting of the same ten competency cases from the pre-test. Lastly, the

participants answered survey questions regarding gender, age, years of experience in the

emergency department, years of triage experience, and the year of initial triage training.

Data Review Process

Quantitative data was measured in this project. Gilboy et al. (2020) state that quality

improvement plans should focus on the Institute of Medicine's (IOM) aims of quality care. This

project concentrated on the IOM's aim of safety. The triage quality improvement indicator was

the assignment of the correct ESI level to evaluate safety. Retrospective chart reviews were

conducted pre-and post-implementation using the electronic health record (EHR), MHS Genesis.

The under-triage rate was assessed and compared for triage accuracy. Subsequent data focused

on the IOM's aim of efficiency noted by the length of stay in the ED and pre-and post-test results

were compared to assess the improvement in triage knowledge. The length of stay for an under-

triage patient was compared to all ED patients. The data needed for the under-triage rate and the

length of stay were collected from the EHR. Pre-and post-test data were collected from the

online training platform, Relias. Demographic information, including gender, age, years of

experience in the ED, years of triage experience, and the year of the initial triage training, was
 21

obtained through Relias. Each chart and nurse was given a unique identifier to maintain privacy

and confidentiality.

The collected data includes the under-triage rate, length of stay in the ED, pre-and post-

education test results, and demographic information. The under-triage rate percentages were

compared to assess triage accuracy pre-and post-implementation. All patients' mean length of

stay was compared to those of under-triage patients pre-and post-implementation. The pre-and

post-education test percentages were compared to assess ESI triage knowledge and application.

The descriptive variables of gender, age, years of experience in the emergency department, years

of triage experience, and the year of the triage training were analyzed using descriptive statistics.

Data were collected from MHS Genesis and Relias to ensure data accuracy. The triage specialist

reviewed the data entry for any outliers or errors.

Risks and Benefits

There were no risks to participants. Confidentiality of recorded information was

maintained through unique identifiers and data was secured in a locked area. Additionally,

participants were notified that participation was not mandatory and did not affect their job

assignment or performance evaluation. The benefits of this study include increasing triage

accuracy, which can decrease the patient's length of stay in the ED, increase the throughput of

the ED patients, decrease the risk of deterioration of patients, and appropriately use resources.

Compensation

The DNP quality improvement project focused on improving RN triage accuracy. The

participants in this project are already compensated for their role as staff nurses. Therefore, no

further compensation was offered to participants.

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Timeline

DNP planning began in the summer of 2022. During this time, the problem was

identified, stakeholders were identified, local and national data was obtained, a needs and gap

analysis was completed, the initial literature search was conducted, and the PICOT question was

finalized. In fall 2022, the literature review was finalized, CITI training (see Appendix E) was

completed, the IRB application was submitted and approved (see Appendix F), a letter of support

was obtained from the agency (see Appendix G), and agency IRB application was submitted and

approved (see Appendix H). Permissions were obtained from the ENA for the use of the

materials in the ESI Implementation Handbook (see Appendix I). Spring 2023 involved

implementing the DNP project, data collection with analysis, and finishing the manuscript.

Recruiting of participants, education of staff, and consenting participants were completed from

11 January 2023 through 16 January 2023. Implementation begun on 17 January and ended 14

March 2023. Midpoint data collection and analysis took place from 14 February 2023 to 21

February 2023. The final project data collection and analysis began 15 March 2023 through 3

April 2023. Summer 2023 entailed the final project manuscript submission, project

dissemination, DNP project presentation, and electronic portfolio submission. Three months after

the completion of the project, all data was shredded (see Appendix J).

Budget and Resources

The budget included monies for printed recruitment flyers, copies of the consent form,

and an editor. Resources needed for this project included access to data, an online learning

platform, and a method to analyze data. Data were collected through retrospective chart reviews
 23

pre-and post-implementation from MHS Genesis. Demographic information about the

participants was obtained from Relias. Relias is the online learning management system used by

the healthcare organization that tracks and reports a variety of training. The online training was

developed from the ESI Implementation Handbook, a free resource (see Appendix K).

Evaluation Plan

Statistical Considerations

The demographic information obtained from the post-module survey includes gender,

age, years of experience in the ED, years of triage experience, and the year of initial triage

training. This information was analyzed using descriptive statistics (frequencies, %). Descriptive

statistics (mean average) were used to compare the lengths of stay of all patients and under-

triaged patients pre-and post-implementation. Descriptive statistics (frequencies, %) were used to

compare pre-and-post education test percentages and pre-and post-implementation under-triage

rates. Using Microsoft Excel ® Analyze Data, the paired t-test was used to compare pre-and

post-education test mean averages to determine statistical significance. In addition, a z-test was

used to compare the proportions of the pre-and post-implementation chart reviews for statistical

significance using the website Statistics Kingdom ®.

Data Maintenance and Security

Data were collected from retrospective chart reviews from the electronic health record,

MHS Genesis, pre-and post-implementation. Each chart was given a unique identifier. Pre-and

post-test data were collected from the online training platform, Relias. Each nurse who

completed the pre-and post-test was given a unique identifier. These unique identifiers were used

for the demographic information collected from the post-training module survey. All data was

stored on the PIs personal drive on the computer, which requires common access card (CAC)
 24

access and a pin. The computer was kept behind a badge access-only door. Data was shredded

three months after project completion. The PI is the only individual with access to this data.

Results

During this study, 24 RNs consented to participate. Out of the 24 RNs, three participants

withdrew from the study for various reasons. Participant demographic information is noted in

Table 1. The study was comprised of five males (23.81%) and 16 females (76.19%). Three

participants were from the ages of 31-35 (14.286%), four were 36-40 (19.048%), and 14 were 41

and above (66.67%). Years of experience ranged from 0-5 (three participants, 14.286%), 6-10

(eight participants, 38.095%), 11-15 (six participants, 28.571%), 15-20 (three participants,

14.286%), and 21 or more years (one participant, 4.762%). The initial year of triage training

ranged from 1993-2020, and 5 participants did not answer this question. Years of triage

experience went from 0-5 (five participants, 23.81%), 6-10 (eight participants, 38.095%), 11-15

(six participants, 28.571%), 15-20 (one participant, 4.762%), and 21 and more (one participant,

4.762%). The pre-and post-test results were compared at the midpoint of implementation and

post-implementation (Figure 1). Midpoint results consisted of 11 participants with an average of

69.09% pre-test and 69.09% post-test. Post-implementation results consisted of 21 participants

with an average pre-test of 64.7619% (SD=13.3) and post-test of 65.2381% (SD=15) (Figure 2).

The results of the pre-and post-test post-implementation were not statistically significant (p-

value= 0.8947) when using a paired t-test. The PI conducted a total of 1800 retrospective chart

reviews during this study. Chart reviews before ESI training revealed 278 out of 1350 (20.59%)

were under-triaged, during the midpoint of implementation, 34 out 225 (15.11%) were under-

triaged, and post-implementation 37 out 225 (16.44%) were under-triaged (Figure 3). The results

of the pre-and post-implementation chart reviews were not statistically significant (p

 25

value=0.1496) using a two-sample z-test. Figure 4 shows the average length of stay for all ED

and under-triaged patients before, midpoint, and after ESI training. The average length of stay

before ESI training was 323.67 minutes for under-triage patients and 235 mins for all ED

patients. At the midpoint of implementation, the average length of stay for all ED patients was

187 minutes and 235 mins for under-triaged patients. Post-implementation, the average length of

stay for all ED patients was 218 minutes and 236 minutes for under-triaged patients.

Discussion

This project aimed to decrease the under-triage rate to 10% or less, decrease the average

patient’s length of stay, and improve RNs' knowledge and utilization of the ESI algorithm. The

results of this study did not show a decrease in the under-triage rate to 10% or less. However, it

did show an improvement in the under-triage rate from 20.59% pre-implementation to 16.44%

post-implementation. The results showed an improvement in all ED and under-triage patients’

length of stay. Pre-implementation for all ED patients was 235 minutes and 323.67 minutes for

under-triage patients, while post-implementation showed 218 minutes for all ED patients and

236 minutes for under-triaged patients. There was no significant increase in the mean pre-and

post-test scores, 64.7619% and 65.2381%, respectively. These results do not support the

effectiveness of the slide show on nurses' knowledge of ESI and the algorithm. However, the

findings of this reveal that more effective triage training is needed to improve accuracy.

Implications for Clinical Practice

The findings of the pre-and post-test test support the ENA's statement that triage accuracy

is approximately 60% in the U.S. (ENA, 2022). There is a large margin for improvement in

clinical practice noted by the pre-and post-test results. Increasing triage education to annual
 26

training and monitoring triage accuracy more often may improve triage accuracy. When triage

nurses do not effectively apply or understand the ESI algorithm, it can impact patient care,

including patient wait times, outcomes, and flow.

Implications for Quality/Safety

Quality and safety in nursing ensures quality care is provided to patients. Conducting

more frequent chart reviews and reviewing the adverse outcomes with staff are ways to improve

triage accuracy. Discussing the quality indicators evaluated is essential so the staff understands

the expectations. Mistriages should also be shared with the staff so they are aware of the errors

being made.

Implications for Education

This quality improvement project has revealed the need for a standardized triage

education process and policy within the ED. Nurses should receive annual triage training to

become more proficient in triage accuracy. Additionally, the department should focus on

establishing a policy for yearly triage refresher training and providing the training in various

modalities. The training should be given in a learning environment free from interruptions

(Gilboy et al., 2020).

Limitations

Several limitations were noted during this project. One limitation was the small size

(n=21). This sample size may reflect only some triage nurses in the emergency department since

participants completed this voluntarily. Another limitation found is that RNs completed the

online module during their shift. This may have also led to distractions during pre-and post-

testing and while participants were going through the slide show. Additionally, there was only

one delivery method, which may have been less conducive to all learning styles. Implementation
 27

of the project was conducted during preparation for accreditation. Therefore, this project may not

have taken precedence, with the focus on accreditation. The pre-and post-test were pulled from

the ESI Implementation Handbook; if an RN has seen the competency cases before, their prior

knowledge may have influenced their score. Lastly, post-implementation data were collected

over one week versus the six months of pre-implementation data.

Dissemination

The results of this study were disseminated to DEM leadership, stakeholders, and staff. A

scholarly presentation was given to Jacksonville State University (JSU) peers, faculty, and the

College of Health Professions and Wellness members. The PI of this study shared the results

with the local ENA chapter via Facebook and with the ENA group on the ENA website. Lastly,

the manuscript is available on the JSU repository.

Sustainability

The DNP project is feasible to continue after the results are disseminated. Leadership in

the ED is supportive of the implementation of the project. Resources needed to continue with this

project include the triage specialist, access to the online learning platform, and access to the

electronic health record (EHR). The ED has a triage specialist who has access to the EHR.

Access to Relias is available and accessible for all ED employees. The sustainability plan is for

ESI triage refresher training to become a yearly requirement for ED triage nurses. The annual

training will be written into the triage competency qualifications policy for ED nurses. With the

training being uploaded into Relias, it is available for other MTFs to access and utilize.

Plans for Future Scholarship

This project has opened the doors to increasing possibilities to improve triage accuracy

and education. Future research would include a study to improve overall triage accuracy to 90%,
 28

including under-and over-triage. Additionally, different deliveries, such as face-to-face options,

should be highly considered when conducting future studies to allow staff to ask questions

during training. Lastly, provide staff access to the algorithm and a list of resources using a pocket

or badge card.

Conclusion

ESI is a triage tool that prioritizes care based on acuity and patient resources. Triage

accuracy reduces adverse patient outcomes, enhances ED operations, and improves patient flow.

Early identification of inaccurate triages can reduce negative ED episodes (Tam et al., 2018).

Implementing an ESI triage refresher training can increase triage accuracy by enhancing nurses'

understanding and familiarity with the ESI algorithm.

References

Al Hasni, A. K., & Al-Rawajfah, O. M. (2019). Effectiveness of implementing emergency

severity index triage system in a primary health care center in Oman: A quasi-

experimental study. Journal of Emergency Nursing, 45(6), 717.e1–717.e11.

https://doi.org/10.1016/j.jen.2019.08.001
 29

Ausserhofer, D., Zaboli, A., Pfeifer, N., Solazzo, P., Magnarelli, G., Marsoner, T., Siller, M., &

Turcato, G. (2021). Errors in nurse-led triage: An observational study. International

Journal of Nursing Studies, 113. https://doi.org/10.1016/j.ijnurstu.2020.103788

Brosinski, C. M., Riddell, A. J., & Valdez, S. (2017). Improving triage accuracy: A staff

development approach. Clinical Nurse Specialist CNS, 31(3), 145–148.

https://doi.org/10.1097/NUR.0000000000000291

Butts, J., & Rich. K. (2018). Philosophies and theories for advanced nursing practice. (3rd ed.).

Burlington, MA: Jones & Bartlett Learning.

Campbell, D., Fetters, L., Getzinger, J., Perko, A., & Slater, S. (2022). A clinical nurse

specialist-driven project to improve emergency department triage accuracy. Clinical

Nurse Specialist, 36(1), 45. https://doi.org/10.1097/NUR.0000000000000641

Chmielewski N, & Moretz J. (2022). ESI triage distribution in U.S. emergency

departments. Advanced Emergency Nursing Journal. 44(1), 46-53.

https://doi.org/10.1097/TME.0000000000000390

Coogle C. J. (2017). Improving emergency severity index score with an e-mail: Can it be this

easy?. Journal of Emergency Nursing, 43(4), 360–361.

https://doi.org/10.1016/j.jen.2017.03.014

Delnavaz, S., Hassankhani, H., Roshangar, F., Dadashzadeh, A., Sarbakhsh, P., Ghafourifard,

M., & Fathiazar, E. (2018). Comparison of scenario based triage education by lecture and

role-playing on knowledge and practice of nursing students. Nurse Education Today, 70,

54–59. https://doi.org/10.1016/j.nedt.2018.08.006

Elsasser, E. J., White, C. A., & Jones, M. R. (2018). Implementation of a transformational plan
 30

of care at a Veterans Affairs medical center. American Journal of Health-System

Pharmacy, 75, S72–S76. https://doi.org/10.2146/ajhp170485

Emergency Nurses Association (ENA). (2018). Triage qualifications and competency.

https://enau.ena.org/Users/LearningActivityAssetSingleViewer.aspx?LearningActivityAs

setID=T27Vl5LHrmlMFXp%2f5Xo5Pg%3d%3d

Emergency Nurses Association (ENA). (2022). ENA's triage offerings.

https://www.ena.org/enau/educational-offerings/triage

Fowler, S. B. (2021). Quality improvement, evidence-based practice, and research. Home

Healthcare Now, 39(3), 178. https://doi.org/10.1097/NHH.0000000000000941

Ghazali, S. A., Abdullah, K. L., Moy, F. M., Ahmad, R., & Hussin, E. O. D. (2020). The impact

of adult trauma triage training on decision-making skills and accuracy of triage decision

at emergency departments in Malaysia: A randomized control trial. International

Emergency Nursing, 51. https://doi.org/10.1016/j.ienj.2020.100889

Gilboy, N., Tanabe, P., Travers, D., & Rosenau, A. M. (2020). Emergency severity index (ESI):

A triage tool for emergency department care (Version 4). Schaumburg, IL: Emergency

Nurses Association. https://www.ena.org/docs/defaultsource/education-document-

library/esi-implementation-handbook-2020.pdf?sfvrsn=fdc327df_2

Hinson, J. S., Martinez, D. A., Schmitz, P. S. K., Toerper, M., Radu, D., Scheulen, J., Stewart de

Ramirez, S. A., & Levin, S. (2018). Accuracy of emergency department triage using the

emergency severity index and independent predictors of under-triage and over-triage in

Brazil: A retrospective cohort analysis. International Journal of Emergency

Medicine, 11(1), 1–N.PAG. https://doi.org/10.1186/s12245-017-0161-8

Hoffman, S., Voss, J. A., Hendrickx, L., & Gibson, N. (2022). Effect of emergency severity
 31

index annual competency assessment on mistriage. Journal of Nursing Care

Quality, 37(4), 356–361. https://doi.org/10.1097/NCQ.0000000000000638

Hosseini, S.A., Mojtahedzadeh, R., Mohammadi, A., Gharib, M.& Asadzandi, S. (2022).

Effective triage training for nurses: Comparison of face to face, pamphlet, and

multimedia training. Journal of e-Learning and Knowledge Society, 18(1), 101-106.

https://doi.org/10.20368/1971-8829/1135442

Hu, F., Yang, J., Yang, B. X., Zhang, F.-J., Yu, S.-H., Liu, Q., Wang, A.-L., Luo, D., Zhu, X.-P.,

& Chen, J. (2021). The impact of simulation-based triage education on nursing students'

self-reported clinical reasoning ability: A quasi-experimental study. Nurse Education in

Practice, 50, 1-8. https://doi.org/10.1016/j.nepr.2020.102949

Maliszewski, B., Whalen, M., Lindauer, C., Williams, K., Gardner, H., & Baptiste, D.-L. (2020).

Quality improvement in the emergency department: A project to reduce door-to-

electrocardiography times for patients presenting with chest pain. Journal of Emergency

Nursing, 46(4), 497–504. https://doi.org/10.1016/j.jen.2020.03.004

Marincic, P. Z., Hardin, A., Salazar, M. V., Scott, S., Fan, S. X., & Gaillard, P. R. (2017).

Diabetes self-management education and medical nutrition therapy improve patient

outcomes: A pilot study documenting the efficacy of registered dietitian nutritionist

interventions through retrospective chart review. Journal of the Academy of Nutrition

and Dietetics, 117(8), 1254–1264. https://doi.org/10.1016/j.jand.2017.01.023

McFarlan, S., O, B. D., & Simmons, E. (2019). Nurse-leader collaborative improvement

project: Improving patient experience in the emergency department. Journal of

Emergency Nursing, 45(2), 137–143. https://doi.org/10.1016/j.jen.2018.11.007

Mistry, B., Stewart De Ramirez, S., Kelen, G., Schmitz, P. S. K., Balhara, K. S., Levin, S.,
 32

Martinez, D., Psoter, K., Anton, X., & Hinson, J. S. (2018). Accuracy and reliability of

emergency department triage using the emergency severity index: An international

multicenter assessment. Annals of Emergency Medicine, 71(5), 581–587.

https://doi.org/10.1016/j.annemergmed.2017.09.036

Oh, B. Y., & Kim, K. (2021). Factors associated with the undertriage of patients with abdominal

pain in an emergency room. International Emergency Nursing, 54, 1-6.

https://doi.org/10.1016/j.ienj.2020.100933

Ojo, B., Feldman, R., Rampersad, S., & Subramanyam, R. (2022). Lean methodology in quality

improvement. Pediatric Anesthesia, 32(11), 1209-1215.

https://doi.org/10.1111/pan.14439

Rashid, K., Ullah, M., Ahmed, S. T., Sajid, M. Z., Hayat, M. A., Nawaz, B., & Abbas, K. (2021).

Accuracy of emergency room triage using emergency severity index (ESI): Independent

predictor of under and over triage. Cureus, 13(12), e20229.

https://doi.org/10.7759/cureus.20229

Recznik, C. T., Simko, L. C., Travers, D., & Devido, J. (2019). Pediatric triage education for the

general emergency nurse: A randomized crossover trial comparing simulation with paper-

case studies. Journal of Emergency Nursing, 45(4), 394–402.

https://doi.org/10.1016/j.jen.2019.01.009

Stonko, D. P., O, N. D. C., Dennis, B. M., Smith, M., Gray, J., & Guillamondegui, O. D. (2018).

Trauma quality improvement: Reducing triage errors by automating the level assignment

process. Journal of Surgical Education, 75(6), 1551–1557.

https://doi.org/10.1016/j.jsurg.2018.03.014

Tam, H.L., Chung, S.F. & Lou, C.K. (2018). A review of triage accuracy and future
 33

direction. BMC Emergency Medicine, 18(58), 1-7. https://doi.org/10.1186/s12873-018-

0215-0

Vashi, A. A., Sheikhi, F. H., Nashton, L. A., Ellman, J., Rajagopal, P., & Asch, S. M. (2019).

Applying lean principles to reduce wait times in a VA emergency department. Military

Medicine, 184(1/2), e169–e178. https://doi.org/10.1093/milmed/usy165

Williams, D., Fredendall, L. D., Hair, G., Kilton, J., Mueller, C., Gray, J. D., Graver, C., & Kim,

J. (2022). Quality improvement: Implementing nurse standard work in emergency

department fast-track area to reduce patient length of stay. Journal of Emergency

Nursing. 1-12. https://doi.org/10.1016/j.jen.2022.07.00

Wolf, L. A., Delao, A. M., Perhats, C., Moon, M. D., & Zavotsky, K. E. (2018). Triaging the

emergency department, not the patient: United States emergency nurses' experience of

the triage process. Journal of Emergency Nursing, 44(3), 258.

https://doi.org/10.1016/j.jen.2017.06.010

Wolf, L. A., & Delao, A. M. (2021). Establishing research priorities for the emergency severity

index using a modified Delphi approach. Journal of Emergency Nursing, 47(1), 50–57.

https://doi.org/10.1016/j.jen.2020.09.005

Worth, M., Davis, L. L., Wallace, D. C., Bartlett, R., & Travers, D. (2019). Are emergency

departments in the United States following recommendations by the emergency severity

index to promote quality triage and reliability? Journal of Emergency Nursing, 45(6),

677–684. https://doi.org/10.1016/j.jen.2019.05.006

Yazdannik A, Dsatjerdi EI, Mohamadirizi S. (2018). Utilizing mobile health method to

emergency nurses' knowledge about emergency severity index triage. Journal of

Education and Health Promotion.7(1), 1-5. https://doi.org/10.4103/2277-9531.246100

 34

Table 1

Participant Demographic Information

Demographic Features Frequency Percentages

Gender
Male 5 23.81
Female 16 76.190
Age
20-25 0 0
26-30 0 0
31-35 3 14.286
 35

36-40 4 19.048
41 or above 14 66.667
Years of Experience in the
ED
0-5 3 14.286
6-10 8 38.095
11-15 6 28.571
15-20 3 14.286
21 or more 1 4.762
Year of Initial Triage
Training
1993 1 4.762
2002 1 4.762
2006 1 4.762
2008 1 4.762
2009 1 4.762
2011 1 4.762
2012 1 4.762
2014 2 9.524
2015 1 4.762
2016 4 19.048
2017 1 4.762
2020 1 4.762
No Answer 5 23.81
Years of Triage Experience
0-5 5 23.81
6-10 8 38.095
11-15 6 28.571
15-20 1 4.762
21 or more 1 4.762

Figure 1

Pre-and Post-Test Results

 36

Pre-and Post-Test Results

120

100

80

60

40

20

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Pre-Test Post-Test

Figure 2

Pre-and Post Test Means

 37

Pre-and Post-Test Means

70
69
68
67
66
65
64
63
62
Midpoint Post-Implementation

Pre-Test Post-Test

Figure 3

Retrospective Chart Reviews

 38

Retrospective Chart Reviews

25.00%

20.00%

15.00%

10.00% 20.59%
15.11% 16.44%

5.00%

0.00%
Pre-Implementation Midpoint Post-Implementation

Figure 4

Average Length of Stay

 39

Average Length of Stay (Minutes)

350

300

250

200

150

100

50

0
Pre-Implementation Midpoint Post-Implementation

All ED Patients Under-triaged Patients

Appendix A

SWOT Analysis: Emergency Department at Southeastern MTF

 40

Strengths Weaknesses Opportunities Threats

-Established initial -No policies - Utilize the triage -Staff buy-in
triage training and regarding triage specialist to develop -Staff shortages
yearly chart audits refresher training in training programs and -No formal policies
-Triage specialist in the organization or departmental policies regarding triage
the ED accrediting bodies training established
-DEM leadership by credentialing
support of the project agencies

Appendix B

Theoretical Model
 41

Kurt Lewin’s Change Theory

Changing or
Unfreezing Refreezing
Movement
Assessment phase Implementation Evaluation phase
Data gathered phase Monitored the
Problem identified Selected, results of the
organized, change and
implemented adjusted the
strategies to change based on
address the results
problem

(Gilboy et al., 2020; McFarlan & Simmons, 2019)

Appendix C

DNP Project Recruitment Flyer

 42

Appendix D

Participant Consent Form

 43

(Page 1 of 3 – DNP Project Consent)

 44

(Page 2 of 3 – DNP Project Consent)

 45

SIGNATURE PAGE OF CONSENT FORM

FOR RESEARCH INVOLVING ADULTS
Permission Form for Research on

Implementing an Emergency Severity Index (ESI) Triage Refresher Training to Decrease the
Under-Triage Rate in the Emergency Department (ED)
_____________________________________________________________
(Title of Project)

I have read a description of the DNP Project, and I understand the procedure described on the
attached page(s). I have also received a copy of the DNP project description.

I _______________________________________ agree to participate in the DNP project study.

(Complete Name of Participant)

__________________________________________________ __________________

Signature Date

(Page 3 of 3 –DNP Project Consent)

 46

Appendix E

CITI Training Certificate

 47

Appendix F

JSU IRB Approval Letter

 48

Appendix G

Agency Letter of Support

28 September 2022

Dear Sir or Madam,

This letter confirms my wholehearted support for Jacksonville State University graduate nursing student,
Monique Wallace. Ms. Wallace has received our approval to focus on “Implementing an Emergency
Severity Index (ESI) Triage Refresher Training to Reduce Under-Triage Rate in the Emergency
Department (ED)” over the coming year.

We are excited to support her as she works toward improving patient care delivery in our facility.

Please let me know if I can assist in any way.

Very respectfully,

VICKI M. LANIER, MD, FACEP

Deputy Commander | Emergency Services
Chief | Department of Emergency Medicine
Womack Army Medical Center | Fort Bragg, NC
Home of the Airborne and Special Operations Forces
☎(o) 910-643-2080  ☎(c) 910-709-0428/910-874-1261 | vicki.m.lanier.civ@health.mil
 49

Appendix H

Agency IRB Approval Letter

50
 51

Appendix I

ESI Implementation Handbook Permissions

Monique Wallace <mwallace12@stu.jsu.edu>
Mon 9/12/2022 2:55 PM
To:education@ena.org <education@ena.org>
To Whom it May Concern,

My name is Monique Wallace and I am a DNP student at Jacksonville State University. For my
DNP project, I want to create an ESI Triage Refresher Training at Womack Army Medical
Center at Fort Bragg, NC utilizing the ESI Implementation Handbook. 

The ESI Implementation Handbook has the following statement:

"All rights reserved. No part of the material protected by this copyright may be reproduced or
utilized in any form, electronic or mechanical, including photocopying, recording, or by any
information storage and retrieval system, without written permission from the copyright owner."

I am requesting permission to utilize the ESI Implementation Handbook as my resource to create

this training through the online training platform at Womack Army Medical Center. In addition, I
would like to utilize the figures, tables, practice cases, competency cases, Appendix A, and
Appendix B in the ESI Implementation Handbook for my training. 

I am also asking permission to publish the content that is utilized in my training if my manuscript
gets published. I am available to speak with your permissions team if they need a better
understanding, my contact number is 910-988-7483.

Thank you for your time and consideration.

V/r,
Monique Wallace
mwallace12@stu.jsu.edu
910-988-7483

RE: ESI Implementation Handbook Permissions

ENA University <enau@ena.org>
Mon 9/12/2022 5:11 PM
 52

To:
 Monique Wallace <mwallace12@stu.jsu.edu>

You don't often get email from enau@ena.org. Learn why this is important

Hello-
 
The ESI Implementation Handbook is a free resource and can be used with appropriate
citations/references in written work. Please click here for additional ESI resources on the ENA
University page. 
 
Thank you,
 
Katie Collaro
Senior Course Management Representative 
EMERGENCY NURSES ASSOCIATION
930 E. Woodfield Road, Schaumburg, IL 60173
 53

Appendix J

Project Timeline

Task Summer 2022 Fall 2022 Spring 2023 Summer 2023

Problem and x
stakeholders
identified
Local and x
national data
obtained
Needs and gap x
analysis
Initial literature x
search
PICOT question x
finalized
Review of x
literature
finalized
Citi training x
complete
IRB application x
submitted and
approved
Letter of support x
obtained
Agency approval x
granted
ESI permissions x
obtained
Implementation x
of project
Data collection x
and analysis
Finishing x
manuscript
Final project x
manuscript
submitted
Project x
dissemination
Presentation of x
project
Electronic x
portfolio
 54

complete
Data shredded x

Appendix K
 55

Budget & Resources

Item Budget Actual Cost

Printed recruitment flyers $100 $10
Copy of consent forms $200 $20
Editor $1000 $250
MHS Genesis, electronic No Cost No Cost
health record
Relias, an online learning No Cost No Cost
platform
ESI Implementation No Cost No Cost
Handbook