Document Type: Original Article


1 Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran

2 Department of Internal Medicine, Tabriz branch, Islamic Azad University, Tabriz, Iran

3 Emergency Medicine Research Team, Tabriz University of Medical Sciences, Tabriz, Iran

4 Student Research Committee, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran


 Objective: Triage refers to the evaluation and categorization of patients for better management to deliver services. A good triage system should be able to accurately specify the patients who require urgent care. Thus, this study aimed to evaluate the accuracy of emergency nurses in correct triage using Emergency Severity Index (ESI) triage.
Methods: In this descriptive cross-sectional study 750 patients, who referred to the emergency department (ED) of Sina teaching hospital, participated from 23 July to 22 August in 2015. Participants were selected using convenience sampling method. The patients’ triage level was determined by physicians and nurses separately and the results were compared. To define the level of agreement between two groups (inter-rater agreement), the kappa index was evaluated. Data were analyzed using SPSS version 17.
Results: Among 750 patients, 577 patients (76.9%) were classified in correct triage group, 90 patients (12%) in undertriage group and 83 patients (11.1%) in overtriage group. Kappa agreement coefficient between the ESI triage level of physicians and nurses was 0.659 (95% CI: 0.646-0.667). There was statistically significant difference between the triage level of physicians and nurses (P < 0.001).
Conclusion: This study showed that there was moderate agreement between the triages of physicians and nurses. It seems that improving nurses’ skills and knowledge might increase the accuracy of emergency nurses in patients’ correct triage. Therefore, planning programs based on training correct triage for emergency nurses is strongly suggested.


Main Subjects

1. Khatiban M, Khazaei A, Karampourian A, Soltanian A, Kimiaie Asadi H, Salimi R, et al. The effects of the

Emergency Severity Index triage education via problem based learning on the triage nurses’ performance and the patients’ length of stay in the Emergency Department. Journal of Clinical Research in Paramedical Sciences 2014; 3(2): 63-74. [in Persian].

2. Tabatabai A, Mohammadnejad E, Salari A. Nursing students’ awareness of triage in the emergency ward. Hakim Seyed Esmail Jorjani Journal 2014; 1(1): 30-4. [In Persian].

3. Kamrani F, Ghaemipour F, Nikravan M, Alavi Majd H. Prevalence of miss triage and outcomes under triage of patients in emergency department. Journal of Health Promotion Management 2013; 2(3): 17-23. [in Persian]

4. Gilboy N, Tanabe P, Travers D, Rosenau AM. Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care. 4th ed. Rockville, MD: AHRQ Publication; 2012.

5. Kariman H, Joorabian J, Shahrami A, Alimohammadi H, Noori Z, Safari S. Accuracy of emergency severity index of triage in Imam Hossein hospital-Tehran, Iran (2011). Journal of Gorgan University of Medical Sciences 2013; 15(1): 115-20. [in Persian]

6. Esmailian M, Zamani M, Azadi F, Ghasemi F. Interrater agreement of emergency nurses and physicians in Emergency Severity Index (ESI) Triage. Emerg (Tehran) 2014; 2(4): 158-61. doi: 10.22037/emergency.v2i4.6449.

7. Grossmann FF, Zumbrunn T, Ciprian S, Stephan FP, Woy N, Bingisser R, et al. Undertriage in older emergency department patients–tilting against windmills? PLoS One 2014; 9(8): e106203. doi:10.1371/journal.pone.0106203.

8. Newgard CD, Staudenmayer K, Hsia RY, Mann NC, Bulger EM, Holmes JF, et al. The cost of overtriage: more than one-third of low-risk injured patients were taken to major trauma centers. Health Aff (Millwood) 2013; 32(9): 1591-9. doi: 10.1377/hlthaff.2012.1142.

9. Faul M, Wald MM, Sullivent EE, Sasser SM, Kapil V, Lerner EB, et al. Large cost savings realized from the 2006 Field Triage Guideline: reduction in overtriage in U.S. trauma centers. Prehosp Emerg Care 2012; 16(2): 222-9. doi:10.3109/10903127.2011.615013.

10. Eshghi M, Rahmani F, Derakhti B, Abdollahi F, Tajoddini S. Patient satisfaction in the emergency department: a case of Sina hospital in Tabriz. Journal of Emergency Practice and Trauma 2016; 2(1): 16-20. doi: 10.15171/jept.2015.06.

11. Lehmann R, Brounts L, Lesperance K, Eckert M, Casey L, Beekley A, et al. A simplified set of trauma triage criteria to safely reduce overtriage: a prospective study. Arch Surg 2009; 144(9): 853-8. doi: 10.1001/archsurg.2009.153.

12. Kalantarimeibidi M, Yadollahi A, Esfandiari S. The effect of education on the knowledge and practice of emergency department’s nurses regarding the patients’ triage. Iran J Emerg Med 2014; 1(1):40-44.

13. Tanabe P, Gimbel R, Yarnold PR, Kyriacou DN, Adams JG. Reliability and validity of scores on The Emergency Severity Index version 3. Acad Emerg Med 2004; 11(1):59-65. doi: 10.1197/S1069-6563(03)00585-2.

14. Wuerz RC, Milne LW, Eitel DR, Travers D, Gilboy N. Reliability and validity of a new five-level triage

instrument. Acad Emerg Med 2000; 7(3): 236-42. doi:10.1111/j.1553-2712.2000.tb01066.x.

15. Platts-Mills TF, Travers D, Biese K, McCall B, Kizer S, LaMantia M, et al. Accuracy of the Emergency Severity Index triage instrument for identifying elder emergency department patients receiving an immediate life-savingintervention. Acad Emerg Med 2010; 17(3): 238-43. doi: 10.1111/j.1553-2712.2010.00670.x.

 16. Goransson KE, von Rosen A. Interrater agreement: a comparison between two emergency department triage scales. Eur J Emerg Med 2011; 18(2): 68-72. doi: 10.1097/ MEJ.0b013e32833ce4eb.

17. Abbasi E, Nosrati A, Nabipour I, Emami SR. Assessment of the level of knowledge of physicians in Bushehr province about preparedness and response for nuclear emergency. Iranian Sought Medical Journal 2005; 7(2): 183-89. [in Persian]

18. Worster A, Sardo A, Eva K, Fernandes CM, Upadhye S. Triage tool inter-rater reliability: a comparison of live versus paper case scenarios. J Emerg Nurs 2007; 33(4): 319- 23. doi: 10.1016/j.jen.2006.12.016.

 19. Buschhorn HM, Strout TD, Sholl JM, Baumann MR. Emergency medical services triage using the emergency severity index: is it reliable and valid? J Emerg Nurs 2013; 39(5): e55-63. doi:10.1016/j.jen.2011.11.003.

20. KällbergAS, GöranssonKE, Östergren J, Florin J, Ehrenberg A. Medical errors and complaintsin emergency department care in Sweden as reported by care providers, healthcare staff, and patients - a national review. Eur J Emerg Med 2013; 20(1): 33-8. doi: 10.1097/MEJ.0b013e32834fe917.

 21. Mirhaghi AH, Roudbari M. Survey on knowledge level of the nurses about hospital triage. Iranian Journal of Critical Care Nursing 2011; 3(4): 167-74. [in Persian]

22. Sedaghat S, Aghababaeian H, Taheri N, Sadeghi Moghaddam A, Maniey M, Araghi Ahvazi L. Study on the level of knowledge and performance of North Khuzestan medical emergency 115 personnel on prehospital triage. Iran J Crit Care Nurs 2012; 5(2): 103-8.

23. Considine J, Botti M, Thomas S. Do knowledge and experience have specific roles in triage decision‐making? Acad Emerg Med 2007; 14(8): 722-6.

24. Hitchcock R. Speeding up the ED care process. Three hospital organizations mitigate overcrowding by improving patient flow, processes and documentation. Health Management Technology 2012; 33(12): 6-8.

 25. Göransson KE, Ehrenberg A, Marklund B, Ehnfors M. Emergency department triage: is there a link between nurses’ personal characteristics and accuracy in triage decisions? Accid Emerg Nurs 2006; 14(2): 83-8. doi: 10.1016/j.aaen.2005.12.001

 26. Hedayati H, Mogharrab M, Moasheri N, Sharifzadeh G. Studying of BUMS’ students’ knowledge about hospital triage in 2011. Modern Care Journal 2013; 9(3): 237- 44. [In Persian]

 27. Dadashzadeh A, Abdollahzadeh F, Shams Vahdati S, Lotfi M, Ghojazadeh M, Bagheri Mehmandousti S. Causes of delay in patient triage in the emergency departments of Tabriz hospitals. Turk J Emerg Med 2011; 11(3): 95-8. doi: 10.5505/1304.7361.2011.59354.

28. Azhough R, Shams Vahdati S, Faraji F, Faraji M, Ghorbanian M, Ramouz A, Tajoddini S. One-day triage course for nurses, it is essential. Journal of Emergency Practice and Trauma 2015; 1(2): 52-5.