Implementation of a triage self – review package: Enabling consistency in triage practice for nurses in the Emergency Department.

Stacey Williamson1, Elizabeth Ward, Tracey Ingvorsen, Vanessa Leonard-Roberts, Danielle Waddell, Adam Watts

1Northern Health, Epping, Australia

Background: Integral to the provision of emergency nursing practice is the ability to safely undertake triage for patients presenting to the emergency department (ED).Triage trained emergency nurses are required to make major decisions which impact on time to treatment for critically ill patients as well as department  performance thresholds 1.

Emergency nurses undertaking postgraduate training within Northern Health undergo extensive theoretical and practical triage training utilising the Emergency Triage Education Kit (ETEK). ETEK provides a nationally consistent approach to the educational preparation of emergency clinicians for the triage role, while promoting consistency in the application of the Australasian Triage Scale (ATS)1.

Aim:   To promote best clinical practice and consistency with the triage process in our ED.  From quality performance indicators there were knowledge deficits and inconsistency in triage practice evident, requiring the development of a structured approach to self-review of triage practice.

Method:  A triage self – review package was developed by the emergency nursing education team with the intent that all practicing triage staff members complete in 2013, and again in 2016-2017.

Each individual package included 12 of the nurses individual triages, randomly selected to include at least 2 from each ATS triage category, 1-5.   A mixture of adult, paediatric and mental health triages were selected.  Self-reflection by the staff member, as well as peer review by a member of the education team, was undertaken utilising the supplied ETEK audit tool.  Expected triage performance was discussed against ETEK criteria and any resultant deficits were identified as opportunities for improvement.

Conclusion: To ensure ongoing competence and consistency in triage practice, the triage self-review package enables a critique of performance and assists with the ongoing professional development of the triage nurse.


1.Gerdtz,M.,Considine,J.,Sands, N.,Stewart,C.,Crellin, D., Pollock,W. et al, Emergency Triage Education Kit. Australian Government Department of Health and Ageing, Canberra; 2007


Stacey Williamson – Clinical nurse educator in the Emergency Department at The Northern Hospital, Victoria. Responsible for the education and support of nurses undertaking postgraduate emergency nursing studies in conjunction with Deakin and Melbourne University.

Elizabeth ward – Clinical support nurse in the Emergency Department at The Northern Hospital Victoria. Responsible for the education and support of nurses undertaking Postgraduate Emergency nursing studies on conjunction with Deakin and Melbourne University.