RESEARCH
USING SIMULATION TO ASSESS THE IMPACT
OF TRIAGE INTERRUPTIONS
Authors: Kimberly D. Johnson, PhD, RN, CEN, and Abeer Alhaj-Ali, BSN, Cincinnati, OH
Earn Up to 5.5 CE Hours. See page 489.
Contribution to Emergency Nursing Practice
• This research is innovative because simulation has not
previously been used to assess the impact of
interruptions on triage.
• Emergency nurse educators could use the methods and
results discussed in this project to guide departmental
training of triage nurses.
• Practicing in a simulated setting can help new triage
nurses hone their skills at managing interruptions while
providing veteran triage nurses with ways to recognize
factors that are affecting the accuracy of their triage.
Abstract
Introduction: Interruptions are common in the emergency
department and contribute to catastrophic errors. Care priorities
and acuity levels are assigned during triage, meaning that mistakes
and omissions during the triage process could have detrimental
effects on patients. The purpose of this project was to assess the
feasibility of investigating the impact of interruptions on triage and
the decision-making process in a simulated setting.
Methods: A 2-phase, sequential exploratory mixed method
design was used. Nine nurses from 3 emergency departments in a
Midwest area participated. A short demographic questionnaire
lmost 100,000 deaths per year are attributed to
A health care–related errors. 1,2 Interruptions have
been identified as a cause of errors and can be
Kimberly D. Johnson, Member, Greater Cincinnati Chapter, is Assistant
Professor, College of Nursing, University of Cincinnati, Cincinnati, OH.
Abeer Alhaj-Ali is a PhD student, University of Cincinnati, Cincinnati, OH.
This work was supported by a ENA Foundation/Sigma Theta Tau
International Research Grant.
For correspondence, write: Kimberly D. Johnson, PhD, RN, CEN,
University of Cincinnati, 3110 Vine St, Cincinnati, OH 45221; E-mail:
kimberly.johnson2@uc.edu.
J Emerg Nurs 2017;43:435-43.
0099-1767
Copyright © 2017 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.jen.2017.04.008
September 2017 VOLUME 43 • ISSUE 5
was used to collect information about the nurses’ education and
experience. The Emergency Severity Index (ESI) was used for
triage categorization. Each participant completed 2 scenarios (one
interrupted and one uninterrupted). After completion of the
scenarios, video-simulated recall interviews were used to assess
the simulation experience and the impact that interruptions had
on the triage decision-making process.
Results: Triage time had a mean of 10 minutes and ranged
between 4.34 minutes and 13.45 minutes. However, triage was
significantly longer during the interrupted scenarios.
Seventy-seven percent of the acuity assessments (ESI) were
correct. Of the 18 scenarios, 3 uninterrupted scenarios had
incorrect ESI scores, and one interrupted scenario had a missing
acuity score.
Discussion: This study provides the basis for future work that
looks at how nurses successfully manage interruptions and tests
interventions to assist triage nurses in managing or reducing
interruptions during this important patient assessment process.
Key words: Triage; Interruptions; Distractions; Emergency
department; Triage nurse role; Simulation; Video-simulated recall
interviews
detrimental to patient safety. 1,2 Frequently the care
provided during ED visits is interrupted. 3,4 One particular
area that is fraught with interruptions is the triage process,
and thus this part of the patient’s ED experience is
particularly vulnerable to errors. 5–7
With annual ED visits increasing to more than 130
million per year, 8 triage nurses are pressured to quickly and
accurately assess each patient. Triage assessment, defined as
assigning acuity to patients to determine treatment priority, is
the critical beginning of the treatment plan for ED patients.
The initial triage assessment can affect both the ED visit
quality and length. 5 Because of the nature of the emergency
department, nurses are exposed to frequent interruptions,
which may lead to inaccuracies in acuity assessment, thus
resulting in errors that may affect the quality of care. 6
Although errors and delays adversely affect patient outcomes, 9
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the true impact of triage interruptions on patients’ clinical
outcomes is unknown because few studies have investigated
this phenomenon. The purpose of this research was to
determine the feasibility of using a simulated setting to
investigate the impact of interruptions and how triage nurses
make data-based decisions in the presence of interruptions.
Background and Significance
The triage nurse’s assessment of a patient is an important
first step in an episode of care and can be an indicator of
how the patient’s ED experience will progress. 5 Interrup-
tions may lead to an incorrect triage decision, missed
symptom identification, incomplete assessment, or unasked
questions. Any of these factors could potentially delay care,
resulting in significant morbidity or mortality. 10,11 A
patient seeking treatment may have a triage interview
interrupted for myriad reasons that include addressing the
needs of other patients, visitors, or staff. The interruptions
then create delays in getting patients into a treatment area,
keep nurses from collecting appropriate triage data, or cause
nurses to make poor or erroneous triage decisions. 12–14
Errors during triage can decrease quality of care and have an
adverse impact on patient outcomes. 1,9,10
ED INTERRUPTIONS
The release of the Institute of Medicine report “Hospital-
Based Emergency Care: At the Breaking Point” alerted the
public that interruptions were one of the challenges
contributing to the struggle to provide high-quality emer-
gency care to patients. 15 Interruptions have been shown to
occur more often in emergency care than in other health care
settings. 6,7,13 Additionally, interruptions of ED providers
have been linked to both errors and delays in patient care. 12,16
The results of a prospective time-and-motion study showed
that emergency physicians were interrupted 6.6 times per
hour and that the interruptions were associated with a
significant increase in the time required to complete tasks
such as writing orders, dictating notes, or assessing patients;
providers failed to return to the original task 18.5% of the
time. 10 Another study reported that physicians and nurses
failed to return to task once interrupted 13% of the time. 3
Generalizing the results of these studies is difficult, primarily
because the categorization of interruptions and the target of
observation varied. It becomes clear that reducing medical
errors, as well as improving the efficiency and quality of care,
can be accomplished by tackling the underlying causes of
interruptions. 13 Unfortunately, few prior studies on inter-
ruptions have considered the importance of the triage process.
Given that triage begins the sequence of clinical care events,
436 JOURNAL OF EMERGENCY NURSING
sets priorities for the treatment team, and also begins the
health care customer experience, it stands to reason that the
triage process should be a primary target for intervention. To
best design an improvement intervention, understanding the
effect of triage interruptions on the quality of health care is
vital. 5,17
TRIAGE INTERRUPTIONS
Previous work by Johnson et al 5 identified the types and
frequency of interruptions that occur during the triage
process. These investigators reported that triage nurses were
interrupted an average of 16.6 times per shift for a variety of
reasons; top occurrences included being asked to grant ED
access to staff and visitors, being asked to furnish
conveniences to visitors (eg, a cup of water or a blanket)
13.2 times per shift, responding to patient care–related
requirements (eg, new patient arrivals and leaving the triage
area for missing supplies) 8.1 times per shift, and responding
to patients or family who ask, “How much longer?” 7.1 times
per shift. 5 Recurrent interruptions have been shown to
interfere with triage tasks that may affect patient care. 5,17
Methods
DESIGN
We used a 2-phase, sequential exploratory mixed methods
design 18 to investigate the impact of interruptions on the
triage assessment process. Mixed methods designs allow
researchers to gain dynamic insight into phenomena by
combining the strengths of quantitative and qualitative
methods. Our study included a quantitative arm in which
we used an observational immersive simulation design (Phase
I) followed by a qualitative arm in which we used a qualitative
descriptive approach (Phase II). In phase I, study participants
conducted simulated, video-recorded triage assessments on
standardized patients using 2 scripted scenarios. One scenario
included interruptions at predetermined time points, whereas
the other scenario was uninterrupted. This design allowed us
to observe how select interruptions specifically affect triage
accuracy and determine how participants reacted to these
interruptions as they occurred. Although participants were
aware that the patients were actors, they were given no details
about the scripts, including assigned diagnoses. In phase II,
we conducted video-simulated recall interviews (VSRIs) in
which the participants were shown their simulated triage
videos and were interviewed to explore their experiences and
decision making during the 2 scenarios. VSRI has been shown
to produce useful and insightful data for examining the way
people experience a specific event. 19 We received
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TABLE 1
Description of interruptions per scenario
Simulation scenario Times No. of
scenario interruptions,
used mean (SD)
Interrupted
Male, chest pain (ESI 2) 5 1.20 (0.447)
Male, abdominal pain (ESI 3) 4 1.75 (0.500)
Uninterrupted
Female, pulmonary embolism (ESI 2) 3 0
Female, animal bite (ESI 4) 6 0
ESI, Emergency Severity Index; SD, standard deviation.
Institutional Review Board approval from the first author’s
academic institution prior to initiation of study procedures.
SAMPLE AND SETTING
We recruited emergency nurses trained in triage assessment
from hospitals within a Midwestern city, including: (1) a
level I adult academic trauma center, (2) a suburban level III
trauma center, and (3) an urban hospital without a trauma
designation. Participants were eligible for the study if they
were an emergency nurse with at least 2 years of clinical
experience assessing patient acuity using the Emergency
Severity Index (ESI). We planned to recruit 20 nurses using
E-mail, flyers, presentations at ED staff meetings, and
discussions at shift change meetings. Recruitment materials
included an explanation of the scope and purpose of the
project, anticipated time commitment, and participant
payment information.
Standardized Patients
We partnered with actors who served as associates in the study.
Standardized patient (SP) simulation includes the use of trained
individuals to act as patients, family members, or others, thus
allowing students and practitioners to practice history taking,
physical examinations, and communication and diagnostic
skills. Standardized patient simulation has been used exten-
sively in evaluating clinical applications of knowledge and
improving skill development. 18–20 The simulation experiences
occurred in a simulation center maintained in the College of
Medicine at our university. The center replicated the ED
structure, including the patient waiting area, an admission area,
September 2017 VOLUME 43 • ISSUE 5
Johnson and Alhaj-Ali/RESEARCH
Type of Triage length, % Accuracy
interruption min, mean of ESI
(SD)
Family’s cell phone (2) 12.30 (1.599) 100
Coworker (4)
Family’s cell phone (3) 9.96 (2.167) 75
Coworker (4)
n/a 8.27 (3.566) 100
n/a 8.7 (2.027) 50
triage room, and 2 ED treatment bays with a cot, chair, and
medical diagnostic equipment.
PROCEDURES
Standardized Patient Training
SPs were hired from the College of Medicine’s SP pool to
simulate ED patients in an ED waiting room. The SP
profiles were created from the Agency for Healthcare
Research and Quality’s sample case studies, 19 which were
part of actual emergency care situations, and thus were used
to have a positive impact on the realism. Each of the 4
created scenarios included details from one practice case,
such as symptoms and vital signs. The SPs were instructed
regarding personal history details that were acceptable to
add to their story and statements to avoid that would
modify their acuity scores. Half of the scenarios included
scripted interruptions that occurred at specified times
during the triage process (see Table 1 for a list of sample
scenarios). Each SP was given 2 different scenarios to
perform. During the training session, a research team
member played the role of triage nurse. This 2-hour training
prior to the arrival of the participants allowed the principal
investigator (PI) to answer SP questions, provide instruc-
tion/guidance on roles and scripts, and make changes to the
scripts for clarity and uniformity. Research team members,
unaware of the ESI level of scenarios, participated in the
training and assigned each scenario an ESI score with 100%
agreement to the Agency for Healthcare Research and
Quality ESI assignment. Training continued until the SPs
could perform consistently for 2 of the researchers.
Additionally, the training triage interviews were observed
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by the PI while they occurred, and the SPs were then given
feedback and re-educated when deviations occurred.
Simulated Triage Interviews
When participants arrived at the simulation laboratory, a
study team member reviewed the informed consent
document with them, answered all their questions, and
obtained their signatures prior to beginning the study. Next,
each participant received a $100 gift card and completed a
demographic survey. Participants were oriented to the ED
environment and the chart they would be expected to
complete during the simulated triage process. The
participants were each given 30 minutes to review a blank
ED chart that would be used to complete the triage
assessments. Participants were instructed to complete as
much of the chart as necessary to determine the patient’s
acuity during the simulation. To simulate the need for
quick, accurate triage, participants were informed that their
triage interviews would need to be completed within 15
minutes. When they had familiarized themselves with the
charting, the participants were escorted to a “Triage Room”
and instructed to call the patient from the waiting room
when ready. Simulations took place over 2 days, with 9
participants completing the scenarios.
Each participant was randomly assigned to 2 simulated
scenarios, one interrupted and one uninterrupted, with the
order of the scenarios randomly assigned. Each scenario was
video recorded with audio for use in phase II.
Video-Stimulated Recall Interviews
Immediately after the second scenario, each participant
watched the video-recorded simulation of their interaction
with the SP in its entirety. Then participants met with a
study team member and watched the recording again. It
was during this viewing that the researcher stopped the
recording after each interruption episode to ask the
participant about the decision-making process. All
interviews were recorded and transcribed verbatim.
Accuracy of the transcripts was assessed by 2 independent
researchers. Transcripts were then reviewed by 3 re-
searchers and coded.
MATERIALS
Demographic Questionnaire
A short demographic questionnaire was used to collect
information about each participant’s education and expe-
rience in nursing, emergency nursing, and triage using the
ESI for triage categorization.
438 JOURNAL OF EMERGENCY NURSING
ESI
The ESI, a well-established psychometrically sound tool, 20
is used in the triage process to categorize ED patients. The
ESI focuses on patient acuity and resources needed in
treatment. 17 ESI levels range from 5—the least urgent level
with minimal resources needed—to 1, the most urgent
level, with patients requiring interventions that entail use of
multiple resources. The ESI was used in this project to
assign patient acuity during the simulation experiences. All
study participants were familiar with using the ESI because
of their experience in their normal work setting.
Triage Chart
After the simulations were completed, the charts were
independently reviewed for completeness by the research
team. Charts included (1) screening questions common to
our local emergency departments (eg, Ebola, falls, and
safety); (2) vital signs; (3) allergies; (4) acuity (ESI) assignment;
(5) medications; (6) surgical and medical history; and (7)
focused system assessments.
Qualitative Interview Guide
The research team, in consultation with on-site simulation
experts and experienced qualitative researchers, developed
open-ended interview questions to assess the impact of
interruptions on the participants’ decision-making process
and to evaluate their opinions of their simulation
experience. Interview questions included: (1) What were
your thoughts of doing these simulated activities with
standardized patients? (2) What were your thoughts at the
time when the interrupting person approached you? (3)
Why did you feel that you responded this way? (4) How did
you refocus on the patient after the interruption occurred?
(5) How big of an impact did this interruption have on your
triage effectiveness? (6) Was this simulation realistic? (7)
How would you improve the simulation experience?
DATA ANALYSIS
Phase 1 Data Analysis
We used descriptive and univariate statistics to clean the
data and test whether our data met assumptions. Frequency
distributions were created to understand sample demo-
graphics, triage duration and length, and the number and
length of interruptions experienced across the sample. We
analyzed the associations between work experience on triage
duration in both interrupted and uninterrupted scenarios
using Pearson correlation matrices and Point biserial
statistics. We ran χ 2 analyses to determine the impact of
VOLUME 43 • ISSUE 5 September 2017

TABLE 2
Correlations between triage duration and participant characteristics
Years as nurse Years in ED
Triage time 0.253 0.490 *
Years as nurse 0.913 **
Years in ED
Highest nursing degree
ED, Emergency department.
* P b .05.
** P b .01.
the number of interruptions, hospital, and highest nursing
degree on triage accuracy. Finally, we conducted t-tests to
determine whether triage durations between interrupted
and uninterrupted scenarios were significantly different.
Phase 2 Data Analysis
Guided by Colaizzi’s 7 steps in phenomenological data
analysis, 3 research team members independently analyzed
each transcript. First, the team members read the transcripts
in their entirety multiple times to gain an overall sense of the
entire content of the interview. The researchers coded each
transcript line by line, extracting significant statements and
recording these statements and their corresponding loca-
tions within the interviews in a separate document. Each
team member recorded his or her interpretation of the
meanings of these statements and clustered the meanings
into preliminary categories. The team then met to discuss
their findings and determine agreement of the initial coding
scheme between researchers. The protocol for disagreement
was to thoroughly discuss inconsistencies between team
members to reach consensus. In the event of an unresolved
disagreement, the PI would make the final decision
regarding the preliminary theme for further analysis (this
problem did not occur in this analysis). The researchers
reanalyzed the data using the developed preliminary coding
scheme and elevated the preliminary categories into themes.
The analysts met again to formulate a description and
fundamental structure of the phenomenon “experience of
decision making in the presence of triage interruptions.”
Once consensus had been reached among the analysts, the
researchers validated their findings by talking with
participants to receive feedback on the accuracy of their
description. The coding schema, description of the themes,
and representative exemplars were provided to 3 of the
study participants (triage nurses) to assess their validity prior
to finalization of the study findings.
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Johnson and Alhaj-Ali/RESEARCH
Highest nursing degree No. of interruptions
–0.598 ** 0.352
0.010 0.030
–0.294 –0.009
.085
Results
DESCRIPTIVE ANALYSIS
Although 12 participants were recruited, 3 did not attend.
The 9 participants were all female and came from 3 local
hospitals; 2 locations were represented by 4 participants
each, and 1 participant came from the third hospital.
Almost half (4/9) of the participants were certified
emergency nurses. Six participants reported their highest
degree as a bachelor of science in nursing, 2 held diploma or
associate degrees, and 1 participant possessed a doctoral
degree. The years of nursing experience in nursing varied
from 4 to 40 years (mean, 17.8; median, 14.0; interquartile
range [IQR], 4.75-30.5), while the years of ED experience
ranged from 3 to 36 years (mean, 13.5; median, 9.5; IQR,
4.75-17.0).
The participants completed 75.0% of the provided
triage documentation. However, focused assessments were
only completed in 45.8% of scenarios. The patient’s name,
height, weight, pain, and vital signs were recorded for all the
patients with 100% accuracy. Both a medication list and
medical history were recorded in 16 of the 18 scenarios.
Surgical history, smoking quit date, falls risk assessment,
and alcohol intake were addressed in 94.4% of scenarios.
The video-stimulated recall interviews, which included
the time to watch the interruption occur, varied in length
from 15 to 27 minutes, with the mean being 21.8 minutes.
The average interruption lasted 21.77 seconds and ranged
from 7 seconds to 49 seconds. Table 1 shows the details of
each scenario.
Phase I
Triage duration: The triage duration for all scenarios was
normally distributed with a mean of 9.93 minutes (standard
deviation [SD], 2.59), with a range between 4.34 and 13.45
minutes. Triage duration was significantly longer in the
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interrupted scenarios (t = –2.475, P = .025), with uninter-
rupted scenarios having a mean of 8.60 minutes (SD, 2.410),
whereas interrupted scenarios had a mean of 11.25 minutes
(SD, 2.137). No significant difference was found in the triage
duration (t = –.107, P = .211) between scenarios with a correct
acuity score with a mean of 9.97 minutes (SD, 2.88) and an
incorrect ESI with a mean of 9.80 minutes (SD, 1.515).
Correlations between triage duration and both ED and general
nursing experience can be found in Table 2. Although triage
durations were longer for participants who possessed more ED
experience, higher educational degrees were associated with
shorter triage duration.
Triage accuracy: The participants’ acuity assessments
(ESI) were correct in 77% of cases. Of the 18 scenarios (2
scenarios per participant), 3 had incorrect ESI scores and 1 had
a missing acuity score. The correct ESI was assigned for every
interrupted scenario except for one instance where no ESI was
documented. Conversely, of the 9 uninterrupted scenarios,
there were 3 incidents of incorrect ESI assignment. The 3 cases
of incorrect ESI scores were all for the same uninterrupted
scenario and were all assigned a more acute score by nurses
with more than 15 years of ED experience each.
Because 3 uninterrupted scenarios were assigned
incorrect acuity scores, further investigation was warranted.
To ensure that the researchers set the correct ESI value for
the scenario, 2 outside reviewers watched all of the
scenario’s videos and then provided an ESI score based on
the SP’s performance. In all cases, the scenario was scored as
a 4, which was the expected ESI score.
The χ 2 analysis revealed no relationship between triage
accuracy and the participants’ place of employment χ 2 (2,
N = 9) = 1.36, P = .505; the presence of interruptions χ 2 (1,
N = 18) = 1.286, P = .257; the number of interruptions χ 2
(2, N = 18) = 2.089, P = .352; or the highest educational
degree of the participant χ 2 (2, N = 9) = 4.018, P = .134.
Phase II
The qualitative analysis of the interviews revealed many
themes concerning how the participants dealt with the
interruptions and consequently how they made decisions
during that time. These themes were: (1) control, (2)
common, (3) nature of the interruption, (4) refocus, and (5)
rationale for incorrect ESI assignment.
Control: One third of the participants reported the “need
to control” the triage environment. The participants reported
that interruptions have a “big impact because they take the
control away from the nurse but also that the interruptions
need to be controlled by the nurse…. Interruptions impacted
effectiveness because it decreases the nurse’s control of the
situation” (Participant 8). One participant stated that
440 JOURNAL OF EMERGENCY NURSING
interruptions “could have a big impact on triage because it
disturbs the flow,” thus leading to loss of concentration and
the potential to miss important patient information.
Common: All of the participants reported that
interruptions are common in the triage environment. One
participant reported that interruptions did not bother her
because she had “a mindset of ER. You know how to deal
with the situation” (Participant 3). A second participant
said, “These interruptions are a common problem in the
ER” (Participant 5). Another remarked that it is “just sort of
part of the usual triage, like, usual experience” (Participant
6). Another echoed the sentiment by stating, “I’m really
used to being interrupted” (Participant 4).
Interruption nature: Patient care–related interruptions
are less offensive than noncare- related interruptions.
Although not all of the participants reported having trouble
getting back on track, all of the participants who
experienced non-patient care–related interruptions reported
needing to take time to refocus on the patient they were
triaging. Participants reported that they felt annoyed and
wanted to say, “I have stuff to do!! Get out of my way!!”
(Participant 8). Most of the persons who participated in the
scenario in which the “registration clerk” enters to verify the
right chart stated that this interruption was not disruptive
because “she was relevant with the situation.”
Refocus: Most participants reported using the chart as a
prompt for refocusing. However, the participants who
reported being annoyed with the interruption said that they
had difficulty refocusing because they lost their place in the
chart. Another participant reported that the ability to
refocus “depends on person’s reaction, like, how they are
acting. If they are cooperative, it’s easier” (Participant 6).
Two other participants reported that they have a normal
order of triage they follow.
Rationale for incorrect ESI assignments: Some ESI
assignment decisions were influenced by emotional reactions
to the patient. The 3 participants who assigned inaccurate ESI
scores explained that they “bumped up” the acuity score
because of the patient’s anxiety level (Participant 4 and
Participant 7). The one participant who forgot to assign an
ESI during her interrupted scenario reported that she forgot
because she was “thrown off track” (Participant 3).
Simulation experience: The participants were asked to
evaluate the usefulness of this simulation experience for
assessing triage accuracy. All participants reported that the
simulations were realistic and that the SPs were believable.
Four participants provided recommendations for improve-
ment. They stated that having the vital signs already available
to them was disruptive to their assessment process. Two of
those participants reported the collection of vital signs as an
important time for patient assessment and observation. One
VOLUME 43 • ISSUE 5 September 2017

participant (#8) explained that she “uses vitals to get to know
the patient.” Two participants reported that using the paper
charting method was not ideal. One participant reported that
only having one interruption during a triage interview was
unrealistic and that we should “have more interruptions for
the next time” (Participant 1).
Discussion
This study is the first to assess the practicality of using SPs to
test how participants respond to interruptions during triage.
Previous work has shown that simulation, both
computer-based and patient-based simulators (eg, SIM
MAN), has been used successfully to train nurses. 21
Although using SPs is not a new trend in health research,
this study is the first to use SPs to explore triage accuracy in
relation to interruptions. 22–24
TRIAGE DURATION
Longer triage durations were associated with more ED
experience. Gerdtz and Bucknall 25 reported that assigning
acuity during triage averaged 3.36 minutes, with non-
interrupted triage lasting 3.47 minutes and interrupted
triage lasting 4.05 minutes, which is significantly lower than
the 8.6 and 11.3 minutes, respectively, in this study.
However, the difference may be due to the data collection
methods. In our scenarios, the participant was required to
retrieve the SP from the waiting room, and our participants
were tasked with completing the triage assessment, which
included more than assigning acuity scores. Higher degrees
were associated with shorter triage durations, which may be
indicative of the role of experience, coupled with an ability
to focus on the assessment’s important aspects and skip the
screenings that are often added into the triage assessment.
However, we were unable to assess mediating, moderating, and
multicollinear relationships for these variables because of the
small sample size. One explanation for this finding is that a
more experienced nurse becomes more confident in perform-
ing the necessary tasks and therefore required less time to make
a triage decision compared with more novice nurses. 26
TRIAGE ACUITY
The correct ESI was assigned for every interruption scenario
except one, in which no ESI was documented. Conversely,
the uninterrupted scenario had 3 incidents of incorrect ESI
assignment. The incorrect ESI scores were all for the same
uninterrupted scenario, and in each instance, the participant
gave a higher acuity score. The ESI for the uninterrupted
scenario was a 4, but 2 participants assigned it an ESI of 3,
September 2017 VOLUME 43 • ISSUE 5
Johnson and Alhaj-Ali/RESEARCH
and another participant assigned it an ESI of 2. Upon
discussion with the participants, each reported that she
would have assigned an ESI of 4 except for the anxiety that
the woman displayed. Because of the patient’s anxiety, they
made the decision to assign a more acute ESI score. This
decision may be explained by connecting a judgment
confidence with perceived difficulty of that judgment.
Previous studies have shown overconfidence with difficult
judgment and underconfidence with easy judgment. 27–29
Interestingly, most of the incorrect ESI assignments
occurred in the uninterrupted scenarios. More experienced
participants were more likely to assign an incorrect ESI, but
participants consistently reported that interruptions and
distractions had less of an impact on more experienced
nurses. Retraining in ESI algorithms may be useful in the
more experienced nurses, and enhanced education added to
quality improvement projects might improve overall
accuracy rates. 30–32 Providing this training in a simulation
laboratory using SPs may be an appropriate method to
refresh ESI protocols for more experienced nurses.
Previous research on overtriaging (assigning a higher
acuity) is mixed. Although our findings of overtriage coincides
with Kilner’s findings 25 of the nurse’s tendency to overtriage,
it contradicts the work of Considine et al 33 and Platts-Mills et
al, 11 who reported that ED nurses were more likely to
undertriage (ie, assign a lower acuity to) older patients.
Although in our study the triage acuity was incorrect in 22%
of scenarios, no significant difference was found between the
interrupted and uninterrupted scenarios. Again, this finding
may be due to the small sample size.
When considering all of the scenarios, interrupted and
uninterrupted, the participants in this study correctly
assigned an ESI 78% of the time, whereas previous
research 34,35 places accurate acuity rates much lower, at
58% and 56%. It is unclear why our study had a higher
accuracy. Perhaps the simulated environment affected the
amount of time the participants spent assessing the patient.
Participants did not have the pressure of a full waiting room,
but we did place a 15-minute limit on the scenario, thus
mimicking the time pressure of triage in reality; the
participants were aware of this stipulation before beginning.
Working under pressure (timed simulation scenario) tends
to increase the level of urgency that led to increased time
spent in completing the task. 27
DECISION MAKING
It is important for triage nurses to make accurate acuity
assessments. To accomplish this task, they need to be able to
control their environment. When controlling the environ-
ment is not possible because of circumstances such as
WWW.JENONLINE.ORG 441
RESEARCH/Johnson and Alhaj-Ali
interruptions, the nurse needs to be able to refocus on the
patient they are triaging. Refocusing may be easier to do
when an interruption is based on patient care rather than
other issues. The participants who were interrupted for
non-patient care–related issues reported feeling annoyed in
those instances, and it was during one such occasion that an
acuity score was not recorded for a patient in this study.
Similarly, Berg et al 3 found that interruptions are handled
differently based on whether they are viewed as disruptive or
nondisruptive on the basis of the nature of interruption and
how relative it is to patient care.
As in a previous study, 5 nurses reported that interruptions
are common in the emergency department. The participants in
our study stated that they are accustomed to dealing with them.
Because interruptions are ubiquitous to the emergency
department, we must be able to identify which interruptions
are problematic and how they affect the care of patients.
Other factors that affect nurse triage decisions that may
lead to errors should be explored as well. Some of these factors
include ED crowding level, ED nurse shortage, patient
anxiety level, family member presence, and nurses’ personal
factors. Because triage can be affected by so many outside
influences, we must determine which factors have the biggest
impact on patient care. The ramifications of interruptions on
the triage process require a comprehensive assessment and
evaluation to design interventions to effectively assist the
nurse in managing interruptions. Simulated environments
have been used successfully to improve confidence in triage
training 21 and to assist in designing interventions to decrease
the effects of interruptions on patient care. 13
Limitations
This study enabled a comparison of interrupted and
uninterrupted simulation scenarios and their effects on triage
duration and accuracy. However, a larger sample is required to
determine if the errors and missed acuity assignments are
generalizable to a larger population. We did not simulate a
realistic arrival time between new ED patients, so the accurate
pressures of triage may not have been fully realized. Although
we purposely had the participants use paper charts instead of
computerized point-and-click charting, participants who were
familiar with paper charting may have had an advantage when
reverting back to this charting method. The use of paper charts
also may have contributed to the lower rate of chart
completion. 36 Further research designed to examine the effect
of ED interruptions on triage duration, accuracy, and decision
making in different situations using larger samples and more
rigorous data collection strategies is also needed. However, this
project lays the foundation for designing those studies.
442 JOURNAL OF EMERGENCY NURSING
Implications for Emergency Nursing
This study forms a foundation for understanding how ED
interruptions affect triage nurses and how quality of triage care
affects patient safety and quality of care. The results of this
study support the importance of using simulation as a
learning strategy in nursing. Practicing in a simulated setting
might be a good way for new triage nurses to hone their skills
at managing interruptions. Practicing in this manner also
provides veteran triage nurses with ways to recognize what is
affecting the accuracy of their triage. This information will aid
researchers, educators, and clinicians in evaluating compe-
tencies using simulation, as well as collaboratively designing
interventions that may decrease interruptions and their
effects. Furthermore, regularly incorporating triage simula-
tions into nurses’ training or retraining could improve ESI
assignment accuracy and patient care. 31
Conclusion
Interruptions in the emergency department have been
shown to lead to errors and delays. Errors and delays
degrade the quality of care 1 while adversely affecting
outcomes. The impact of interruptions is compounded in
triage, where errors and delays during this time propagate
through the patient’s entire care episode. The findings of
this study will be the basis for future work that examines
how nurses successfully manage interruptions. Additionally,
it tests interventions to assist triage nurses in managing or
reducing interruptions during the important patient
assessment process.
Triage is the important initial assessment in which
acuity is assigned to a patient. Interruptions during this
process can cause delays and interfere with providing safe
and efficient patient care. Interruptions during this time
increase the process time for triage and can cause system
delays to the ED process. Additionally, interruptions can
lead to errors in assessment and documentation. Therefore,
the necessity to identify potentially harmful interruptions
and develop interventions to mitigate the adverse impact of
these interruptions becomes apparent, thus allowing us to
decrease errors and delays, which will lead to improving
patient outcomes and ED process time.
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