RESEARCH
OUTCOMES OF IMPLEMENTING RAPID TRIAGE
THE PEDIATRIC EMERGENCY DEPARTMENT
Authors: Stacy L. Doyle, MBA, RN, Jennifer Kingsnorth, MSN, RN, Cathie E. Guzzetta, PhD, RN, AHN-BC, FAAN,
Sara A. Jahnke, PhD, Johanna C. McKenna, MSN, RN, CPN, CPEN, and Kathleen Brown, MD,
Kansas City, MO, and Washington, DC
Introduction: Efficiency and effectiveness are often used as
quality indicators in emergency departments. With an aim to
improve patient throughput and departmental efficiency while
decreasing left-without-being-seen (LWBS) rates, this
two-group, pre-intervention, post-intervention study in a
pediatric emergency department evaluated the outcomes of
implementing rapid triage on arrival-to-triage time, fast track
utilization, and LWBS.
Methods: We implemented rapid triage assessment integrating
the Emergency Severity Index and fast track guidelines in our
pediatric emergency department. Arrival-to-triage times were
tracked for 1 month before and after the intervention (N = 13,910
patient visits) by recording the time the patient arrived in the
department and time triage assessment was complete. Fast track
utilization and LWBS rates were measured for all patients
sequentially included in pre-intervention (n = 60,373) and
post-intervention (n = 67,939) groups for 10 months.
Results: After the intervention, patients experienced a
significant decrease in arrival-to-triage times compared with
fficiency and effectiveness are quality indicators for
E every emergency department. Recognizing the need
to decrease length of stay (LOS) in pediatric emer-
gency departments, the Children’s Hospital Corporation of
America Emergency Department group set a national goal
to decrease LOS in pediatric emergency departments by
25%. Emergency department LOS can be segmented many
Stacy L. Doyle, Member, Kansas City Chapter, is Director of Emergency and
Urgent Care Services, Children’s Mercy Hospital and Clinics, Kansas City,
MO, and was formerly Interim Director, Emergency Medicine and Trauma
Center, Children’s National Medical Center, Washington, DC.
Jennifer Kingsnorth is Program Manager Trauma and Burn Services, Emergency
Medicine and Trauma Center, Children’s National Medical Center, Washington, DC.
Cathie E. Guzzetta is Associate Clinical Professor of Nursing Education, School
of Medicine and Health Sciences, George Washington University, and Nursing
Research Consultant, Children’s National Medical Center, Washington, DC.
Sara A. Jahnke is Principle Investigator, National Development and Research
Institutes, Kansas City, MO.
Johanna C. McKenna is Registered Nurse III, Emergency Medicine and
Trauma Center, Children’s National Medical Center, Washington, DC.
30 JOURNAL OF EMERGENCY NURSING
IN
the pre-intervention group (P < .001), with most patients
(88.3%) being triaged in less than 10 minutes after the
intervention. Following implementation of fast track guidelines,
patients were 14% more likely to be triaged to fast track
compared with pre-intervention patients (odds ratio [OR] = 1.14,
95% confidence interval [CI] = 1.11-1.67). Additionally, patients
with the lowest acuity were nearly 50% more likely to be
triaged to fast track compared with pre-intervention patients
(OR = 1.48, 95% CI = 1.35-1.63). Although LWBS rates were
insignificant, overall acuity level of this group was lower in the
post-intervention group.
Discussion: Although LWBS rates did not decrease with the
intervention, implementation of a rapid triage system and fast
track guidelines reduced arrival-to-triage times and decreased
acuity in the LWBS population. Implementing rapid triage and
fast track guidelines can affect nurse-sensitive patient
outcomes related to safety and care delivery in a pediatric
emergency department.
Key words: Fast track; Triage; Rapid triage; Pediatric ED; ESI
ways (eg, arrival to triage, arrival to provider, and arrival to
discharge). Each of these segments requires emergency
departments to assess process effectiveness and implement
process and/or system changes to expedite care delivery.
Our study explored ways in which nurses could signifi-
cantly affect nurse-sensitive patient outcomes such as care
delivery and LOS.
Kathleen Brown is Medical Unit Director, Emergency Medicine and Trauma
Center, Children’s National Medical Center, Washington, DC.
Funded in part by Children’s National Medical Center, Division of Nursing,
Washington, DC.
For correspondence, write: Stacy L. Doyle, MBA, RN, Emergency Depart-
ment, Children’s Mercy Hospital, 2401 Gilham Rd, Kansas City, MO
64108; E-mail: sdoyle@cmh.edu.
J Emerg Nurs 2012;38:30-35.
Available online 22 January 2011.
0099-1767/$36.00
Copyright © 2012 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
doi: 10.1016/j.jen.2010.08.013
VOLUME 38 • ISSUE 1 January 2012

Our exploration focused on the patient arrival-to-
triage segment of LOS in our pediatric emergency depart-
ment; specifically, we focused on rapid triage because of its
potential impact on patient safety as well as throughput.
Triage is an independent nursing function empowering
nurses to determine process and efficiency to make deci-
sions and determine the next level of care. The goal of
triage is to provide a rapid assessment of patients, sorting
those requiring emergent treatment from those requiring
routine care to improve outcomes. Triage must be reliable,
specific, and sensitive in addressing patient conditions.1
Several challenges exist in improving patient safety and
arrival-to-triage time in pediatric emergency departments,
with the most significant challenge related to overcrowding
and its effects on LOS and left-without-being-seen (LWBS)
rates. LWBS rates are frequently evaluated as a metric of
ED efficiency because it has been documented that patients
who leave without being seen do so because of prolonged
wait times.2,3 Research by Kyriacou et al.4 found a strong
correlation between wait times and LWBS rates. Although
the LWBS population carries high medico-legal risk
because such patients have not been evaluated and treated,
these patients usually have a lower acuity,2,3 which med-
iates some of this risk.
In some instances, fast track (FT) areas have been
reported to decrease total LOS, decrease LWBS rates,
and increase patient satisfaction.5 These positive out-
comes occur because patients who are identified as having
lower acuity levels are then mobilized to a separate FT
area for expedited evaluation. Increased attention to the
importance and efficacy of tiered triage systems is recom-
mended to provide sequencing of patient care within a
time frame dependent on condition. As a result, the
ENA Joint Five-Level Triage Task Force, in conjunction
with the American College of Emergency Physicians,
issued a position statement supporting the implementa-
tion of a reliable and valid 5-level triage scale.6 The
Emergency Severity Index (ESI), a 5-level triage scale,
has been found to be a reliable and valid tool for assign-
ing acuity in the ED setting,7 with improved specificity;1
however, there is limited information about the efficacy
of this system in the pediatric ED setting.8 Despite the
lack of information in pediatrics regarding the ESI and
only moderate reliability documented in one published
study,9 no other rating system has been shown to be
valid or reliable in triaging pediatric patients. Further-
more, literature is lacking and standards are few regarding
the triage process and the time frame in which assess-
ments should be completed in any ED setting.
To address this gap in the literature and contribute to
the Children’s Hospital Corporation of America’s national
January 2012 VOLUME 38 • ISSUE 1
Doyle et al/RESEARCH
goal of reducing LOS, the aims of our 2-group, pre-inter-
vention, post-intervention study were to (1) assess the out-
comes of implementing a rapid triage nursing assessment in
a pediatric emergency department, which included asses-
sing patient acuity using the 5-level ESI triage scale, and
(2) increase initial throughput by reducing wait times for
triage and LWBS rates. We also evaluated the effects of
implementing formal FT guidelines measured by FT utili-
zation and LWBS rates. To achieve these aims, the follow-
ing research hypotheses were evaluated:
1. Implementing a rapid triage nursing assessment, which in-
cludes assigning patient acuity using the 5-level ESI triage
scale, will decrease patient arrival-to-triage times and
LWBS rates.
2. Implementing a rapid triage nursing assessment and formal
FT guidelines will increase the rate of FT utilization and de-
crease the rates of patient/families that LWBS.
Methods
DESIGN, SAMPLE, AND SETTING
This 2-group pre- and post-intervention outcomes study
was approved by our hospital’s Institutional Review Board.
All patient ED visits during the study period were included
in the study.
More than 70,000 patients and their families are seen
in our pediatric emergency department at Children’s
National Medical Center, Washington, DC, each year.
We are an academic medical center and the only pediatric
trauma center in our region. We care for acutely injured
and ill children and provide emergency care for patients
with chronic illnesses who are followed up in our facility.
Our emergency department operates 24 hours a day, 365
days a year. The ED treatment area is composed of 3
triage assessment bays, 3 initial assessment rooms, 42
patient treatment rooms (including 4 resuscitation areas),
and 8 observation rooms. During daytime hours (9 AM to
5:30 PM), FT utilizes 2 to 3 of the ED patient treatment
rooms. In the evening hours (5:30 PM to 3 AM ), FT
expands to 5 spaces by relocating to a nearby clinic space.
A variable staffing pattern is utilized, increasing staffing
during a 24-hour period, to match historically proven
high-volume trends.
PROCEDURES
Data for arrival to triage were gathered for 1 month
before the intervention and compared with the same
month the following year after the intervention (n =
13,910). Pre-intervention data for LWBS and FT utiliza-
tion were collected monthly for each patient sequentially
admitted for 10 months and included 60,373 subjects for
WWW.JENONLINE.ORG 31
RESEARCH/Doyle et al
the pre-intervention group. Post-intervention data were
collected monthly for patients sequentially admitted for
the same 10 months the following year and included
67,939 subjects.
PRE-INTERVENTION PROTOCOL
Prior to the intervention, upon arrival in the emergency
department, patients were entered into the electronic track-
ing system by a registration clerk and queued for assess-
ment by the next available triage nurse. Triage assessment
included a complete nursing assessment with recording of a
weight and a full set of vital signs. When the triage area was
not busy, patients were seen by a nurse immediately, but
during times of high census, wait times for triage assess-
ment could be longer than 4 hours. As a result of these wait
times, a subset of patients left without being seen by a pro-
vider and care for some patients with a higher acuity was
delayed because they were inadvertently queued with
patients who had a lower acuity.
Although we used a 5-level triage system for our pre-
intervention group, it was a “home grown” system without
established validity or reliability. Frequently patients were
triaged based on a provider’s personal experience and the
current state of the emergency department (eg, wait times,
preferences of medical providers working in the emergency
department, and number of patients waiting for care in the
emergency department versus the FT). Similarly, assign-
ment of patients to FT was done on the basis of a loose
set of guidelines, often taking into consideration the same
factors as acuity assignment.
INTERVENTION PROTOCOL
We implemented the ESI to standardize patient acuity
levels. The ESI is a 5-level triage classification system, with
level 1 being most acute and level 5 being least acute.10
These levels are based on the patient’s clinical condition
(for levels 1 and 2) and anticipated resource utilization
(for levels 3, 4, and 5). The more anticipated resources a
patient will receive, the higher their triage level (eg, level
3 patients require more resources than level 4 patients).
Patients requiring no resources are assigned to level 5.10
All ED nursing staff members (more than 60 nurses) were
trained in ESI during a 6-week period. Training included
the ENA didactic content modified for pediatrics, followed
by practical orientation with a clinical nurse specialist in
triage using the ESI. After training was complete, chart
audits were conducted with each triage nurse to assess cor-
rect application of the ESI algorithm.
Also introduced at the same time was a rapid triage
process. This process was designed to sort patients, accord-
ing to their triage acuity level, to the appropriate ED area/
32 JOURNAL OF EMERGENCY NURSING
provider for initial treatment/assessment. Triage was shor-
tened to encompass only pertinent elements of the history
and physical, replacing the previously used full nursing
assessment to expedite the nurse’s triage decision. Immedi-
ately upon arrival in the emergency department, patients
were seen at the entry desk by a nurse instead of by a regis-
tration clerk. Level 1 patients, representing those in need of
immediate medical attention, were escorted to a treatment
room by any available licensed ED staff. Level 2 patients
were those who had the potential for clinical deterioration
if they did not receive medical intervention in the next 20
minutes. Once the triage nurse assigned acuity level 2,
patients were moved to ED treatment rooms by a flow
nurse to hand off patient care, for the collection of addi-
tional history and physical data, and for initiation of nur-
sing care and expedited provider assessment. Level 3 and 4
patients not meeting FT guidelines were assessed by the
assessment nurse. Nurse-initiated protocols and/or path-
ways were started during these interactions. Level 4 and
5 patients meeting FT guidelines were moved to FT for
an initial nursing assessment and initiation of protocol
and/or pathway-driven care.
Based on clinic capabilities and anticipated visit time,
our interdisciplinary ED team developed and implemen-
ted guidelines to determine which ED patients could be
seen in FT. These guidelines vary during the year because
the proportion of patients who present to our institution
with specific chief complaints varies seasonally. The goal
is to provide a standardized approach to our patient
population and eliminate variance for appropriate FT care
independent of practitioner preferences. By standardizing
the guidelines for triage and educating all nursing and
physician staff, we hoped to move a greater number of
patients to the FT area where they could receive a stan-
dard set of interventions, thereby decreasing variability in
that patient population.
OUTCOME MEASURES
The outcomes we assessed were arrival-to-triage times,
LWBS rates, and FT utilization. To assess the time from
arrival to triage, data collection took place with all patients
sequentially entering our pediatric emergency department
for 1 month to measure pre-intervention times and again
for 1 month a year later to measure post-intervention times.
Before the intervention, patients were entered into the sys-
tem upon arrival at triage by a registration clerk; this became
their arrival time. They then waited for triage assessment, at
which time the triage nurse recorded the time of their triage,
which became their triage time. During the post-intervention
period, the patient time of entry was stamped as he/she
entered the door of the triage area. That time was later
VOLUME 38 • ISSUE 1 January 2012

FIGURE 1
Arrival-to-triage times at the pre-implementation and post-implementation periods.
entered into the system by a registration clerk and became
the arrival time. Patients were then triaged immediately; this
time was recorded by the triage nurse as the triage time. This
change in protocol ensured that time to triage was not under-
estimated after the intervention.
LWBS rates were recorded daily as the number of
patients presenting for treatment, checking into the emer-
gency department, and then leaving prior to being seen by
a provider as a percent of the entire population.
Triage acuity and FT utilization were recorded for each
patient for 10 months during the pre-intervention period
and for the same 10 months 1 year later (post-intervention).
FT utilization was calculated as a percent of total ED
patients being seen in FT.
DATA ANALYSIS PROCEDURES
Descriptive statistics (such as means and frequencies) were
calculated for arrival-to-triage times, FT utilization, and
LWBS rates. Comparisons between the pre- and post-inter-
vention groups for arrival-to-triage times were calculated
with an independent samples t test. Logistic regression was
performed to determine the likelihood of FT utilization
before the intervention compared with after the interven-
tion. Because FT utilization is most likely to affect those with
the least acuity, the overall logistic regression comparing FT
January 2012 VOLUME 38 • ISSUE 1
Doyle et al/RESEARCH
utilization for the pre-intervention and post-intervention
data were restricted to those with an acuity of level 4 or 5.
Separate regression models were constructed for the level 4
and level 5 acuity groups. Because the intervention was not
designed to change FT utilization in more severe acuity
levels, no a priori hypotheses were posed for ESI 1, 2, or 3
levels. Mean acuity levels at pre- and post-intervention for
LWBS patients were compared using an independent sam-
ples t test and re-examined using the Mann- Whitney U rank
test. Chi-square analysis was performed to compare the
number of patients who LWBS at each acuity level before
and after the intervention. The level of significance was set
at .05.
Arrival-to-triage times were calculated separately for
the pre- and post-intervention periods and then compared.
Implausible recorded times (eg, negative numbers or more
than 200 minutes) were deleted from the dataset (n = 643,
4.6%) and assumed to be mistakes in data entry.
Results
ARRIVAL-TO-TRIAGE TIME
During the pre-intervention period the average length of
time from arrival to triage was approximately 40 minutes
(M = 40.4, standard deviation [SD] = 44.0) compared with
WWW.JENONLINE.ORG 33
RESEARCH/Doyle et al
the post-intervention period, in which the average arrival to
triage was significantly reduced to less than 10 minutes
(M = 9.1, SD = 8.6, t = 48.0, P < .001). During the
pre-intervention period, only 21% of patients (n = 1486)
were seen in less than 10 minutes, with a majority of
patients seen between 10.1 and 30.0 minutes (n = 2327;
33.4%) and 30.1 and 60.0 minutes (n = 1629; 23.4%).
Furthermore, during the pre-intervention period nearly a
fifth of the patients (n = 1199; 17.2%) were not triaged
until they had been in the emergency department between
1 and 2 hours, with 4.6% (n = 321) of patients waiting
longer than 2 hours. After the intervention, nearly 88%
(n = 5569) of all patients were seen in less than 10 minutes
(Figure 1).
FAST TRACK UTILIZATION
Before the intervention, 35.4% (n = 19,937) of the patients
entering the emergency department were triaged to FT.
After the intervention, the rate of FT utilization was
38.4% (n = 23,428). Post-intervention patients were 14%
more likely to be sent to FT compared with pre-intervention
patients (odds ratio [OR] = 1.14, 95% confidence interval
[CI] = 1.11-1.67, P < .001). Nearly half of the patients
fell within the ESI level 4 for triage acuity both before the
intervention (47.6%) and after the intervention (46.0%).
These patients had similar rates of FT utilization before
and after the intervention (62.0% vs 61.1%, respectively).
After the intervention, those at level 4 were slightly less
likely to be sent to FT (OR = 0.96, 95% CI = 0.93-
0.99, P = .02). Before the intervention, 72.7% (n =
2435) of patients in the lowest acuity level were sent
to FT, whereas after the intervention, 79.8% (n =
5787) of these patients were sent to FT. Patients with
the least acuity were almost 50% more likely to be sent
to FT after adoption of the new FT guidelines (OR =
1.48, 95% CI = 1.35-1.63, P < .001).
LEFT WITHOUT BEING SEEN
The overall rate of LWBS was consistently 3.3% for both
groups. However, overall triage acuity was lower after the
intervention (M = 3.9, SD = 0.6) compared with before the
intervention (M = 3.8, SD = 0.6; t = –6.8, P < .001)
among those who LWBS. Before the intervention, more
than one fourth (n = 486) of LWBS patients were acuity
level 3, compared with after the intervention, when the rate
was 21.6% (n = 437; χ2 = 10.2, P = .001). Of those who
LWBS before the intervention, 66.6% (n =1245) were
level 4 acuity compared with 62.7% after the intervention
(n = 1265; χ2 = 6.8, P = .009). The largest shift in LWBS
rates was in the lowest acuity level, with 7.1% versus
15.5% after the intervention (χ2 = 67.5, P < .001).
34 JOURNAL OF EMERGENCY NURSING
Discussion
Implementation of the new triage process, which included
the use of the ESI scale and rapid triage, significantly
decreased arrival-to-triage time for patients entering our
pediatric emergency department. Following implementa-
tion of the new process, nearly all patients were seen by a
nurse in less than 10 minutes after entering the depart-
ment. Whereas pre-intervention arrival-to-triage time
exceeded 2 hours for nearly 5% (n = 321) of patients,
few experienced similar wait times after the intervention.
Previous research11 reported that the percentage of patients
seen within the recommended arrival-to-provider time has
been decreasing nationwide, making interventions to cut
minutes from triage times highly desirable.
Particularly for patients with the lowest acuity level,
implementation of the ESI triage system meant patients
were significantly more likely to be triaged to FT rather
than being treated in the main emergency department.
Implementing a more reliable scale such as the ESI with
formal FT guidelines provided a road map for consistency
in triaging patients. The system appeared to eliminate some
of the bias related to FT provider preferences by clearly
indicating which patients were eligible for FT. Although
we did not evaluate wait times or length of stay in our
study, research has found that implementation of an FT
area can have a positive impact on these metrics without
increasing ED returns or patient mortality.12,13
Overall, rates of LWBS did not decrease with imple-
mentation of the intervention; however, rates of acuity
were lower for those who LWBS after the intervention
compared with before the intervention. The intervention
was effective in reaching those with higher acuity before
they left and identifying those who potentially needed
additional medical attention. The increased LWBS rate
in patients with lower acuities was consistent with other
studies as well.2,14 Findings related to the rate of LWBS
were not as positive as in some other published studies.
Chan et al.15 reported an overall decrease in LWBS of
3.2% when they implemented a program that included
patient tracking, bedside registration, placement of patients
in open ED beds, and ancillary testing and care at triage.
Our findings suggest that while the rapid triage system did
improve rates of LWBS for some, additional focused inter-
ventions are needed to create a significant impact on
LWBS rates overall.
In general, results of the rapid triage and ESI imple-
mentation are promising as a means of improving initial
throughput and care for pediatric ED patients. Findings
that the overall rate of LWBS did not change point to
the complex challenges of improving care for those who
VOLUME 38 • ISSUE 1 January 2012

choose not to stay for treatment. While other studies have
focused on overall length of stay,15 to our knowledge, none
have evaluated the effects of independent nursing interven-
tions that affect nurse-sensitive patient outcomes related to
the arrival-to-triage segment of care delivery in a pediatric
emergency department.
LIMITATIONS
As we found in our study, the volatility of the emergency
department can contribute to the difficulties of conducting
research. Inconsistencies in volumes, acuities, and staffing
skill mix can affect arrival-to-triage times, FT utilization,
and LWBS. Without another metric such as ICD-9 codes,
we cannot be sure that patients seen after the intervention
would not have been assigned a lower acuity or sent to FT
before the intervention. Our study findings can only be
generalized to other similar high-volume pediatric trauma
centers. Further evaluation in other settings (eg, other
pediatric emergency departments, adult settings, and com-
munity emergency departments) is warranted to validate
our results. Additionally, implausible data points were
removed from pre- and post-intervention data, which, while
likely the results of data entry errors, could have been valid
data points. It is also recommended that patient/parent
satisfaction be included in future studies to evaluate the
patient and family perception of the intervention.
Finally, benchmarks for patient times in emergency
departments have not been established, and although some
groups are trying to develop strategies to track and trend
times to evaluate efficiency, currently no recommended
indicators are available. With a lack of best practice bench-
marks in this area, it is difficult to gauge the amount of
improvement necessary.
IMPLICATIONS FOR EMERGENCY NURSES
The results of the study, especially the dramatic decrease in
arrival-to-triage times, illustrate the efficiency and safety
improvements that are possible by reorganizing nursing prac-
tice in the emergency department. Additionally, switching to
a valid and reliable triage system leads to appropriately triaging
patients to the proper resources. By tracking patient through-
put data, nurses can develop systems to generate positive out-
comes for the community they serve with the potential for
little negative financial impact on facilities and staffing.
Conclusions
Although the overall LWBS rate did not decrease with our
intervention, a significant positive reduction in arrival-to-
triage time and a lower acuity of those who chose to LWBS
were achieved. These findings suggest that implementing
January 2012 VOLUME 38 • ISSUE 1
Doyle et al/RESEARCH
rapid triage and FT guidelines can affect nurse-sensitive
patient outcomes related to safety and throughput in a
pediatric emergency department. Further evaluation in
other settings is warranted.
Acknowledgments
We thank Jennifer E. Marsh, PhD, JD, for her statistical consultation prior
to initiating this study and Jackie Bartlett, MSN, MBA, HCM, RN, and
Donna O’Malley, MSN, RN, for their thoughtful review of an earlier ver-
sion of this manuscript.
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