Hrev_master Abstract Emergency Department (ED) triage in hospitals is part of their emergency structure carried out by nurses in emergency units. There have not been many studies available on nurses’ perform- ance in triage based on the Emergency Severity Index (ESI). This present study aimed to investigate the nurses’ performance in triage with regard to the ESI and its relation to clinical outcome measures in the emergency department. This was a cross-sectional study. The hospitalization record of 600 patients who arrived at the emergency department of Sanandaj Social Security Hospital was randomly assessed based on the accuracy of triage performed by nurses. The data analysis procedure was done by employing STATA software version 12, as well as Fisher’s exact test, inde- pendent t-test, and one-way ANOVA. Findings of the study revealed that nurses’ overall performance in triage showed that 82.67% of nurses had perfect triage accuracy, 12.17% had low- level triage accuracy and 5.17% had high-level triage accuracy. There was an association between nurses’ performance in triage with disposition of patients (p=0.029) and length of stay (p=0.009). Results of the study showed the acceptable perform- ance of emergency nurses in triage using the ESI and provided a foundation for identifying effective factors for decreasing the length of stay and disposition of patients in emergency care units. Introduction Triage is the process of determining the priority of patients’ treatments by the severity of their condition or likelihood of recov- ery with and without treatment according to the urgency of their need for care.1 Triage is a priority classification system that was designed based on the severity of the problem to do the best ther- apeutic proceedings for patients in less time.2 At times when demand for medical care is more than the hospital’s capacity and efficiency, triage has the capability of effectiveness and trustful- ness, since the population congestion is known as a major threat to patient safety and quality care worldwide.3 Triage systems are used mostly in all emergency centers around the world and their effi- ciency has been proven. However, the type of triage system used in each center is under discussion.4 An effective triage system must work in such a way that it could have the capability to decide on each patient quickly with high precision. Simplicity in the run and reliability are considered the most important characteristics of a standard well-known triage system.5 A qualified triage increases the quality-of-care services for patients, increasing satisfaction, reducing the waiting time, reducing mortality rate, and increasing productivity and efficiency of emergency care units parallel to reducing their relevant costs.5,6 Emergency Care Journal 2022; volume 18:10638 Correspondence: Sina Valiee, School of Nursing and Midwifery, Kurdistan University of Medical Sciences, Pasdaran St., 66177-13446, Sanandaj, Kurdistan, Iran. Tel.: +98.9188734619; Fax: +98.8733660092 E-mail: Valiee@muk.ac.ir Key words: Triage; emergency; nurse; emergency severity index. Acknowledgments: This study is results of the MSN thesis of first author which is approved in Student Research Committee, Kurdistan University of Medical Sciences. This study has been approved by the Research Council of Kurdistan University of Medical Sciences no. IR.MUK.REC.1400.033. The researchers express their greatest gratefulness to all the nurses, whose participation made this research possible. Contributors: NSH, MIBS, SV: Conception and design, data collection, analysis and interpretation, writing the manuscript, critical revision of the manuscript; BN: Statistic advisor, Editing the manuscript, critical revision of the manuscript. Funding: This study was supported by the research fund of the Kurdistan University of Medical Sciences no. IR.MUK.REC.1400.033. Conflict of interest: The authors declare conflict of interest. Ethics approval and consent to participate: The present study was approved by the Ethics Committee of Kurdistan University of Medical Sciences with code IR.MUK.REC.1400.033. In the data collection procedure, evaluating data, and examining the available resources in the files, the confidentiality of patients' information, as well as integrity and honesty, were all observed. In addition, eth- ical guidelines were observed when using other sources and conducting research. Availability of data and materials: The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to their containing information that could compromise the privacy of research participants and clinical institution. Received for publication: 24 May 2022. Revision received: 21 November 2022. Accepted for publication: 2 December 2022. This work is licensed under a Creative Commons Attribution 4.0 License (by- nc 4.0). ©Copyright: the Author(s), 2022 Licensee PAGEPress, Italy Emergency Care Journal 2022; 18:10638 doi:10.4081/ecj.2022.10638 Publisher's note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Emergency Care Journal 2022; 18:10638] [page 71] Accuracy of nurses’ performance in triage using the emergency severity index and its relationship with clinical outcome measures Nazer Shabrandi,1 Mohammad Iraj Bagheri-Saveh,2,3 Bijan Nouri,4 Sina Valiee2,3 1Students Research Committee, Kurdistan University of Medical Sciences, Sanandaj; 2Clinical Care Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj; 3Faculty of Nursing and Midwifery, Kurdistan University of Medical Sciences, Sanandaj; 4Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran Non -co mmerc ial us e o nly There are various systems have been designed and introduced for triage. Among these systems, the Australian Triage system, Canada, Manchester, and ESI have gained the most advanced rate of acceptance.7,8 In Iran, the emergency system index has been used in the healthcare system of the country, and the guidelines for the launching of the hospital triage system in emergency depart- ments by the Ministry of Health and Medical Education in 2011 have been communicated to all hospitals.9 The ESI of a triage system has a 5-level which is guided by algorithms for clinical decision making, which provides the nurse with the abilities to evaluate the patient quickly, make appropriate decisions for the necessary resources, and score the health care team based on their performance. This is a user-friendly algorithm. Reduces triage assignment mentality and is more precise than other triage systems, therefore it could be defined as a well-known medium among the authorities of emergency departments.5-8 The ESI is widely employed in emergency departments in U.S states and this application is increasingly accepted on an international level.5-8 ESI pattern facilitates quick assignment through 3 main questions: Does this patient need immediate lifesaving interven- tion? Does this patient in a high-risk situation? How many facili- ties are needed to take care of this patient? Since the knowledge and skills of nurses are very important in the lab test, several stud- ies have examined the role of knowledge and awareness in priori- tizing patients.5-10 Initial triage acuity assignation had the most significant effect on the transfer time of patients and the nurse who decides on triage, directly affects hospitalization services, and inaccuracy in triage could lead to severe consequences. More than half of all incidents that lead to death have occurred as a result of a delay in treatment in the emergency department.5,11 Also, the delay in the hospitaliza- tion of patients from the emergency department to hospitalized sector increases the length of hospitalization and as a result, increases the cost of hospitalization.12 Accurate and rapid triage of patients is the key to successful performance in an emergency department and if the inaccurate level of triage is selected based on misinterpretation or ignoring patient variables and triage criteria, the nurse will have a triage error.10-13 Triage errors could occur in the form of causing patients at an under-triage level that leads to waiting and intensifying the patient’s health condition, on the other hand, over-triage, may result in limited access of other patients who need immediate emergency care to the emergency department.13,14 Ignoring high- risk situations and improper interpretation of vital sign data are the main causes of under-triage. Under triage, delay in diagnosis and treatment of patients results in adverse consequences and death rate. Under-triage in the emergency departments could lead to side effects for hospitalized patients during their stay length in the hos- pital on the other hand over-triage could result in misuse of the hospital facilities and staff’s focus deviation from their important roles in the hospital. In the last decades, accurate triage of patients leads to a lower level of mortality rate and productivity of resource facilities. To achieve the optimal goal of safety provided for patient care, under-triage should be minimized and on the other hand, in order to reach a high productivity level, the over-triage should be lowered.15,16 In Iran, patients’ triage in emergency departments is generally carried out by nurses who play a key role in triage,17,18 in a study by Mirhaghi and Roudbari, showed that the nurses were not skill- ful in-hospital triage,19 and in another study by Javadi et al., nurs- es’ familiarity and knowledge in triage was in a lower level.20 In another study by Ausserhofer et al., 16.3 % of the nurses had triage errors.15 There are few studies that have been conducted on the preva- lence of patients’ triage errors namely under-triage and over-triage outcomes in emergency departments in Iran. In addition to the above-mentioned points, emergency nursing managers need evi- dence-based data to ensure the correct implementation of the triage and identify the nurses need to train in this field and familiarity with the inadequacies failure to adopt strategies for reforming, improving, and enhancing the quality of triage and increasing the motivation for the correct triage implementation. Therefore, the present study investigated the accuracy of emergency department triage using the ESI and its relationship with clinical outcome measures in Sanandaj Social Security Hospital in 2021. Materials and Methods This was a cross-sectional study. The hospitalization record of 600 patients referred to the emergency department of Sanandaj Social Security Hospital in 2021 was randomly assessed based on the accuracy of triage performed by nurses and its relation with clinical outcome measures was compared. The statistical popula- tion of the study includes all hospitalization records of the patients’ who were referred to the emergency department of Sanandaj Social Security Hospital in 2021, who were all hospitalized. The criteria for inclusion were all of those who were hospitalized in the emer- gency department, which was triaged based on the ESI, and the exclusion criteria were incomplete medical history data, and lack of triage recording in patients’ hospitalization background. In order to collect the data, registrations forms were used based on patients’ hospitalization records. The hospitalization records were randomly selected and triage conducted by the nurse (nurse performance) was documented and then final triage by the researcher based on the ESI index checklist (final standard) was also checked, if the performed triage was parallel to the researchers’ triage, accepted, and if the triage was under level, the nurse’s performance scored under-triage and if the level was above, it was scored as over-triage. Clinical outcome measures include the triage assessment time, disposition of patient, the dura- tion of the patient’s presence in the emergency department, and final diagnosis, discharge, hospitalization, and death rate. Nurses’ demographic information (age, gender, marital status, academic level, working resume, working resume in an emergency depart- ment, triage training resume, and working shift) and patient’s demographic information (age, gender, pregnancy, arrival date, arrival time, arrival type, last 24 hours arrival, The main complaint, drug allergy, medical records), and triage characteristics (triage assessment date, working shift, triage assessment time, triage level, doctor’s visiting time, triage assessment length, level of con- sciousness, airway hazards, respiratory distress, Cyanosis, SPO2 under 90%, shock signs, necessary equipment, vital signs), and patients form procedures (arrival time, working shift admission, entrance to an emergency department time, hospitalization length in emergency department) was documented from their file. According to the initial reports, every year approximately 15,000 arrivals are admitted to social security hospital emergency services. Regarding the ratio of 16% (p) triage error in the Ausserhofer et al. study15 and by considering the confidence level of 95 (1-α) percent and error of 3% (d) sample size 600 were assessed by using the following equation. This sample size was randomly extracted from files of 2021 by using the table of random numbers. Article [page 72] [Emergency Care Journal 2022; 18:10638] Non -co mmerc ial us e o nly The present study was approved by the Ethics Committee of Kurdistan University of Medical Sciences with code IR.MUK.REC.1400.033. In the data collection procedure, evaluat- ing data, and examining the available resources in the files, the confidentiality of patients’ information, as well as integrity and honesty, were all observed. In addition, ethical guidelines were observed when using other sources and conducting research. In the data analysis procedure, the STATA software, version 12, was used. In the first phase of the data analysis, the mean, and standard deviation were estimated for the qualitative variables, the distribution table, and for the quantitative variables. Then, to esti- mate the analytical objectives, Fisher’s exact test was used to investigate the relationship between qualitative variables and if quantitative variables were normal, independent t-test and one- way ANOVA, and if not, Mann-Whitney U test and Kruskal-Wallis test nonparametric tests were used. The assumption of normality of quantitative variables was assessed by using the Shapiro-Wilk test. The significance level was equal to 5 percent. Results The statistical population of this study was 600 patients, 249 male (41.50%), and 351 female (58.50%). The peak of arrival rage to the hospital was Saturdays (31.17%), and the frequent com- plaints were related to trauma (17.20%), then chest pain (12.35%). The peak of arrival time to the hospital was at morning shift work (40.17%), the mean and standard deviation of the triage assess- ment time was 1.49 ± 0.6 minutes. The standard deviation and mean of the duration length of hospitalization in emergency department were 189.89 ±129.95 minutes and the standard devia- tion and mean of the duration of the disposition of patients were 126.82 ±88.83 minutes. The average age and standard deviation of patients referred to the emergency department were 45.28±21.83 years (Table 1). Nurses who took part in the triage were; men 71.67%, and women %28.33, who all passed the triage training courses. The mean and standard deviation of the age of nurses were 38.39±5.24, and the criteria for the mean and standard deviation of nurses’ resumes in the emergency department were 4.84±3.17 (Table 2). About half of the patients were discharged (49.67%) and the rest were transferred to the wards (50.33%). The highest rate of transfer was to the internal sector (23%; Table 3). Results of the study showed that nurses’ triage acuity was 82.67%, 12.17 % under-triage, and 5.17 % over-triage. The highest level of triage was related to the triage level 3; 38.67%, level2; 33.5 %, level 4; 27.83% (Table 4). There was an association between nurses’ gender and triage performance (p=0.026) (Table 5). Also, there was an association between nurses’ performance in triage and disposition of patients (p=0.029), and length of stay (p=0.009), but there was no association between shift work of patients’ visit and triage assessment length with nurses’ perform- ance. There was an association between patients’ chief complaints and nurses’ performance (p=0.001). But there was no association Article Table 1. Demographic and Clinical Characteristics of Patients Arrived to Triage. Variable Freq Percent Gender Male 249 41.50 Female 351 58.50 Pregnancy Yes 37 6.17 No 563 93.83 Arrival date Saturday 187 31.17 Sunday 89 14.83 Monday 111 18.50 Tuesday 80 13.33 Wednesday 73 12.17 Thursday 53 8.83 Friday 7 1.17 Referral Personal 559 93.17 EMS 41 6.83 Complaint Chest pain 74 12.35 Poisoning 12 2.00 Trauma 103 17.20 Abdominal pain 60 10.02 GIB 12 2.00 Falling 11 1.84 Fever 33 5.51 Vomiting 32 5.34 Rectum bleeding 16 2.67 Weakness 30 5.01 Kidney pain 17 2.84 Dyspnea 18 3.01 Respiratory distress 14 2.34 Hyperglycemia 23 3.84 Incision 17 2.84 Head injury 10 1.67 HTN 28 4.67 Epigastric pain 20 3.34 Edema 9 1.50 Catheterization 12 2.00 Vaginal bleeding 11 1.84 Palpitation 8 1.34 Dysentery 10 1.67 Melena 14 2.34 Headache 5 0.83 Table 2. Demographic characteristics of nurses in the emergency department. Variable Freq Percent Gender Male 430 71.67 Female 170 28.33 Marital status Single 8 1.33 Married 592 98.67 Academic level BSN 598 99.67 MSN 2 0.33 Work shift Fixed 3 0.50 Rotating 597 99.50 Training Yes 600 100.00 No 0 0.00 Age M±SD 38.39 5.24 Work Experience M±SD 14.45 4.70 Emergency work experience M±SD 4.84 3.17 [Emergency Care Journal 2022; 18:10638] [page 73] Non -co mmerc ial us e o nly was observed between sex, arrival time, and last 24 hours’ emer- gency referral with nurses’ performance. There was an association between medical records, medication records, triage level, and facility-level with nurses’ performance (p=0.0001). All of the vital signs, except pulse rate, had an association with nurses’ perform- ance (p<0.05) (Table 6). There was an association between nurses’ performance in triage with disposition of patients (p=0.029) and length of stay (p=0.009; Table 7). Discussion Results of the study showed that nurses’ triage acuity was 82.67%, 12.17% under-triage, and 5.17% over-triage. In another study by Mirhaghi and Roudbari, under-triage of 8.57% and over- triage of 48% were reported.19 In another study by Cherry et al., 22% was categorized in the under-triage group.21 In a related study by Hinson et al., for triaged patients in high ESI levels, 8.7% was considered the over-triage category. Patients who on arrival were triaged in mid-level %13.6 assessed as over-triage, and 5.8% assessed as under-triage, 18.4 % of those who assessed as under- triage in ESI level, were considered as under-triage category.22 Rehn et al., reported the under-triage at 10% and over-triage at 55%.23 Lehmann et al., reported under-triage at 0.4% and over- triage at 79%.24 Chen et al., reported that nearly 24.3% of nurses fall into the under-triage category and %19.7 in the over-triage cat- egory, and factors like working resume in an emergency depart- ment, triage training resume, hospital level, and triage methods are considered as effective factors on triage performance among nurs- es.25 Investigating nurses’ skills and performance in different edu- cational centers necessities the primary triage training and con- ducting periodic retraining in covered centers for the relevant authorities. More serious education in the field of promoting nurs- es’ ability to identify and classify patients and more accuracy in identifying the high-risk situation of patients referred to the emer- gency department seems necessary. There was an association between nurses’ performance with Article Table 3. Clinical measure outcomes of the patients arriving to the triage. Variable Freq Percent Work shift arrival Morning 241 40.17 Noon 197 32.83 Night 162 27.00 Disposition Transfer 302 50.33 Discharge 298 49.67 Ward (Transferred) Internal 138 23.00 Surgical 32 5.33 Pediatric 12 2.00 CCU 56 9.33 ICU 32 5.33 NICU 17 2.83 Elective 16 2.67 Table 4. Nurses’ Performance in Triage Based on the Emergency Severity Index. Variable Freq Percent ESI triage level 2 201 33.50 3 232 38.67 4 167 27.83 Nurse’s triage level 2 165 27.50 3 266 44.33 4 169 28.17 ESI performance Accurate 496 82.67 Under 73 12.17 Over 31 5.17 Table 5. Association between demographic characteristics of nurses and the performance of the emergency department triage. Variable ESI Performance P-Value Accurate Under n(%) Over n(%) Gender n (%) Male 357 (83.02) 57 (13.26) 16 (8.82) 0.026 Female 139 (81.76) 16 (9.41) 15 (8.82) Marital status n (%) Single 8 (100.00) 0 (0.00) 0 (0.00) 0.742 Married 488 (82.43) 73 (12.33) 31 (5.24) Academic level n (%) BSN 494 (82.61) 73 (12.21) 31 (5.18) 1.000 MSN 2(100.00) 0 (0.00) 0 (0.00) Work shift n (%) Fixed 3(100.00) 0 (0.00) 0 (0.00) 1.000 Rotating 493 (82.58) 73 (12.23) 31 (5.19) Training n (%) Yes 496 (82.67) 73 (12.17) 31 (5.17) 1.00 No 0 (0.00) 0 (0.00) 0 (0.00) Age mean (SD) 38.37(5.25) 38.52(5.19) 38.29 (5.37) 0.885 Work experience mean (SD) 14.41(4.71) 14.76(4.59) 14.22 (4.77) 0.631 Emergency work experience mean (SD) 4.89 (3.20) 4.75 (3.11) 4.16 (2.73) 0.375 [page 74] [Emergency Care Journal 2022; 18:10638] Non -co mmerc ial us e o nly Table 6. Association between demographical and clinical characteristics of patients with nurses’ performance in triage based on the emergency severity index. Variable ESI Performance P-Value Over n(%) Under n(%) Correct n(%) Sex Male 15 (6.02) 29 (11.65) 205 (82.33) 0.703 Female 16 (4.56) 44 (12.54) 291 (82.91) Pregnancy Yes 2 (5.41) 7 (18.92) 28 (75.68) 0.424 No 29 (5.15) 66 (11.72) 468 (83.13) Arrival time Saturday 10 (5.35) 22 (11.76) 155 (82.89) Sunday 5 (5.62) 8 (8.99) 76 (85.39) Monday 7 (6.31) 16(14.41) 88 (79.28) Tuesday 3 (3.75) 6 (7.50) 71 (88.75) 0.471 Wednesday 6 (8.22) 12(16.44) 55 (75.34) Thursday 0 (0.00) 7 (13.21) 46 (86.79) Friday 0 (0.00) 2 (28.57) 5 (71.43) Referral Personal 28 (5.01) 66 (11.81) 465 (83.18) EMS 3 (7.32) 7 (17.07) 31 (75.61) 0.465 Last 24 hours referral to emergency Yes 4 (12.12) 5 (15.15) 24 (72.73) No 27 (4.76) 68 (11.99) 472 (83.25) 0.139 Chief complaint Chest pain 0 (0.00) 14 (18.92) 60 (81.08) Poisoning 0 (0.00) 2 (16.67) 10 (83.33) Trauma 1 (0.97) 2 (1.94) 100 (97.09) Abdominal pain 5 (8.33) 7 (11.67) 48 (80.00) GIB 0 (0.00) 1 (8.33) 11 (91.67) Falling 1 (9.09) 0 (0.00) 10 (90.91) Fever 5 (15.15) 3 (9.09) 25 (75.76) Vomiting 6 (18.75)| 4 (12.50) 22 (68.75) Rectum bleeding 1 (6.25) 3 (18.75) 22 (68.75) Weakness 2 (6.67) 1 (3.33) 27 (90.00) Kidney pain 0 (0.00) 3 (17.65) 14 (82.35) Dyspnea 0 (0.00) 5 (27.78) 13 (72.22) Respiratory distress 0 (0.00) 2 (14.29) 12 (85.71) Hyperglycemia 1 (4.35) 5 (21.74) 17 (73.91) Incision 1 (5.88) 0 (0.00) 16 (94.12) Head injury 2 (20.00) 3 (30.00) 5 (50.00) HTN 1 (3.57) 4 (14.29) 23 (82.14) Epigastric pain 2 (10.00) 2 (10.00) 16 (80.00) 0.001 Edema 0 (0.00) 2 (22.22) 7 (77.78) Catheterization 1 (8.33) 4 (33.33) 7 (58.33) Vaginal bleeding 1 (9.09) 2 (18.18) 8 (72.73) Palpitation 0 (0.00) 2 (25.00) 6 (75.00) Dysentery 0 (0.00) 1 (10.00) 9 (90.00) Melena 0 (0.00) 1 (7.14) 13 (92.86) Headache 1 (20.00) 0 (0.00) 4 (80.00) Drug allergy Yes 1 (2.56) 4 (10.26) 34 (87.18) 0.835 No 30 (5.35) 69 (12.30) 462 (82.35) Medical record Yes 8 (3.39) 51 (21.61) 177 (75.00) 0.000 No 23 (6.32) 22 (6.04) 319 (87.64) Medication record Yes 7 (3.13) 50 (22.32) 167 (74.55) 0.000 No 24 (6.38) 23 (6.12) 329 (87.50) Triage level 1 0 (0.00) 1 (25.00) 3 (75.00) 0.000 2 16 (8.74) 9 (4.92) 158 (86.34) 3 11 (4.37) 49 (19.44) 192 (76.19) 4 4 (2.48) 14 (8.70) 143 (88.82) Article [Emergency Care Journal 2022; 18:10638] [page 75] Non -co mmerc ial us e o nly disposition of patients and hospitalization length of stay. In their study, Dadashzade et al., showed that the most significant factors in triage assessment that affected hospital personnel are experience and adroitness, and in out of personnel dimension was related to patient’s vital signs.26 Khatiban et al., study, showed that problem- based triage training could reduce the triage assessment in emer- gency departments and nurses’ performance improvement.27 Therefore, the more efforts to improve nurses’ performance in triage the more improvements in patients’ clinical outcome meas- ures in emergency departments. In this study, the highest level of triage was related to triage level 3; 38.67%, level2; 33/50%, level 4; 27/83%. In the study by Hinson et al., patients were triaged in 3 levels; half of them were 49.1% in level 3 (ESI3), one-third 32.5% in (ESI 4 or 5), and just 18.3 %were triaged in (ESI 1 or 2).22 In this study, the frequent complaints were related to trauma patients and then chest pain, and abdominal pain patients. In a study by Rahmati et al., the most fre- quent complaints in emergency departments were related to the nursery and surgical groups, and the most frequent dissatisfactions were related to the care services quality, staff misbehavior, and impoliteness.28 In another study showed that, the most frequent complaints in female emergency departments related to joint prob- lems and in male emergency departments were respiratory dis- eases.29 Regarding the high arrival statistics of trauma patients and chest pain in this research context, providing a standardized work- flow, teamwork enforcement, training courses for nurses about the acuity of triage for trauma patients and chest pain cases can be helpful. In our study, the average time length from admission in the emergency department to hospitalization was 189.89 minutes. In a study, the average time length from admission to the emergency department to hospitalization was 236 minutes (4 hours).30 Tabibi et al., showed that the average length of hospitalization in case study hospitals was 244 minutes (4 hours).31 Therefore, although the length of hospitalization in the emergency department can be affected by various factors, promoting nurses’ performance in triage can somehow reduce the length of hospitalization among patients. Generally, regarding the results of the present study, it is highly recommended that nurses should be provided with theoretical and practical triage training courses and highlighting effective factors to reduce the duration of patient`s disposition and length of stay in the emergency departments and also consider the fact that, there is an association between the nurses’ performance with patients com- plaints, it is recommended that nurses pass the triage training courses and related training courses, therefore they could be famil- Article Table 6. Association between demographical and clinical characteristics of patients with nurses’ performance in triage based on the emergency severity index. Variable ESI Performance P-Value Over n(%) Under n(%) Correct n(%) Level of consciousness A 30 (5.22) 68 (11.83) 477 (82.96) 0.592 V 1 (4.76) 5 (23.81) 15 (71.43) P 0 (0.00) 0 (0.00) 2 (100.00) U 0 (0.00) 0 (0.00) 2 (100.00) Airway Yes 0 (0.00) 0 (0.00) 4 (100.00) 1.000 No 31 (5.20) 73 (12.25) 492 (82.55) Respiratory distress Yes 0 (0.00) 0 (0.00) 2 (100.00) 1.000 No 31 (5.18) 73 (12.21) 494 (82.61) Cyanosis Yes 0 (0.00) 0 (0.00) 1 (100.00) 1.000 No 31 (5.18) 73 (12.19) 495 (82.64) Shock Yes 0 (0.00) 0 (0.00) 1 (100.00) 1 No 31 (5.18) 73 (12.19) 495 (82.64) Spo2 <90 0 (0.00) 3 (20.00) 12 (80.00) 0.520 90 31 (5.30) 70 (11.97) 484 (82.74) Facilities More than two 23 (5.50) 63 (15.07) 332 (79.43) 0.005 One 8 (4.42) 10 (5.52) 163 (90.06) Non 0 (0.00) 0 (0.00) 1 (100.00) Age Mean(SD) 43.70 (21.35) 54.67 (17.82) 43.99 (22.15) 0.000 PR Mean(SD) 81.90 (19.18) 84.95 (16.89) 83.98 (13.07) 0.541 RR Mean(SD) 27.22 (35.61) 19.38 (1.67) 18.82 (1.82) 0.012 T Mean(SD) 36.79 (0.69) 36.76 (0.50) 36.62 (0.87) 0.038 SPo2 Mean(SD) 95.80 (1.35) 94.82 (2.05) 95.26 (2.51) 0.014 BPS Mean(SD) 124.48 (28.22) 132.32 (23.35) 126.09 (22.97) 0.046 BPD Mean(SD) 76.35 (11.81) 82.08 (16.85) 76.03 (13.20) 0.014 [page 76] [Emergency Care Journal 2022; 18:10638] Non -co mmerc ial us e o nly iar with recording a full medical background of patients and become familiar with the most frequent complaints of the patients arrived to triage. Also, implicating the findings of this study in the courses of nursing students as future nurses the adverse conse- quences of inaccurate triage could be decreased. Limitations Considering the research method, inaccurate recording of information by triage nurses was considered as one of the limita- tions of the present study, which could not be handled by the researcher, and also considering the retrospective nature of the study, the information in the patient’s file was not fully recorded, so the researcher had to replace another patient’s file. It is recom- mended to investigate the nurses’ performance in triage by other methods like prospective and observational. Also it recommended to compare the nurses` performance with other gold standards and triage methods. Conclusions The results of the study showed that the performance of the majority of nurses was acceptable and their performance was asso- ciated with the patient’s disposition and length of stay. Therefore, improving nurses’ performance by identifying effective factors in clinical outcome measures can help provide faster and more accu- rate services in emergency departments. References 1. Esmailian M, Zamani M, Azadi F, Ghasemi F. Inter-rater agreement of emergency nurses and physicians in Emergency Severity Index (ESI) Triage. Emergency 2014;2:158. 2. Ghafarypour-Jahrom M, Taghizadeh M, Heidari K, Derakhshanfar H. Validity and reliability of the emergency severity index and Australasian triage system in pediatric emergency care of Mofid Children’s Hospital in Iran. Bull Emerg Trauma 2018;6:329. 3. Daemi A. The role of electronic triage system in management of hospital emergency department. Bull Emerg Trauma 2016;4:62. 4. Trinder MW, Wellman SW, Nasim S, Weber DG. Evaluation of the trauma triage accuracy in a Level 1 Australian trauma cen- tre. Emerg Med Australasia 2018;30:699-704. 5. Hinson JS, Martinez DA, Cabral S, et al. Triage performance in emergency medicine: a systematic review. Ann Emerg Med 2019;74:140-52. 6. Barzanji A, Abdi K, Yaghobi M, et al. Triage room principles and recommendations for 2019 novel coronavirus. Adv Biomed Res 2021;10:24. 7. Bazyar J, Farrokhi M, Khankeh H. Triage systems in mass casualty incidents and disasters: a review study with a world- wide approach. Open Access Macedonian J Med Sci 2019;7:482. 8. Zachariasse JM, van der Hagen V, Seiger N, et al. Performance of triage systems in emergency care: a systematic review and meta-analysis. BMJ Open 2019;9:e026471. 9. Safari S, Rahmati F, Baratloo A, et al. Hospital and pre-hospi- tal triage systems in disaster and normal conditions; a review article. Iranian J Emerg Med 2015;2:2-10. 10. Zakeri H, Saleh LA, Niroumand S, Ziadi-Lotfabadi M. Comparison the emergency severity index and manchester triage system in trauma patients. Bull Emerg Trauma 2022;10:65. 11. Soni KD, Kaushik G, Gupta A, et al. From emergency depart- ment to intensive care unit, does the delay matter to trauma patients? J Emerg Trauma Shock 2018;11:189. 12. Stohl S, Sprung CL, Lippert A, et al. Impact of triage-to- admission time on patient outcome in European intensive care units: a prospective, multi-national study. J Critical Care 2019;53:11-7. 13. Moon S-H, Shim JL, Park K-S, Park C-S. Triage accuracy and causes of mistriage using the Korean Triage and Acuity Scale. PLoS One 2019;14:e0216972. Article [Emergency Care Journal 2022; 18:10638] [page 77] Table 7. Association between nurses’ performance and clinical measure outcome of the patients. Variable ESI Performance P-Value Correct n(%) Under n(%) Over n(%) Referral shift Morning 194 (80.50) 30 (12.45) 17 (7.05) 0.527 Evening 167 (84.77) 23 (11.68) 7 (3.55) Night 135 (83.33) 20 (12.35) 7 (4.32) Disposition Transfer 242 (80.13) 47 (15.56) 13 (4.30) 0.029 Discharge 254 (85.23) 26 (8.72) 18 (6.04) Ward (Transferred) Internal 107 (77.54) 23 (16.67) 8 (8.80) 0.408 Surgical 26 (81.25) 4 (12.50) 2 (6.25) Pediatric 11 (91.67) 0 (0.00) 1 (8.33) CCU 46 (82.14) 10 (17.86) 0 (0.00) ICU 26 (81.25) 5 (15.63) 1 (3.13) NICU 14 (82\.35) 3 (17.65) 0 (0.00) ELECTIVE 13 (81.25) 2 (12.50) 1 (6.25) Discharge 253 (85.19) 26 (8.75) 18 (6.06) Triage length mean (SD) 1.47 (0.58) 1.56 (0.68) 1.54 (0.56) 0.402 Emergency hospitalization length mean (SD) 187.50 (132.57) 222.12 (127.22) 152.32 (65.59) 0.009 Disposition length mean (SD) 127.08 (90.84) 136.21 (87.68) 100.48 (44.99) 0.313 Non -co mmerc ial us e o nly 14. Najafi Z, Abbaszadeh A, Zakeri H, Mirhaghi A. Determination of mis-triage in trauma patients: a systematic review. Eur J Trauma Emergency Surg 2019;45:821-39. 15. Ausserhofer D, Zaboli A, Pfeifer N, et al. Errors in nurse-led triage: An observational study. Int J Nursing Stud 2021;113:103788. 16. Lentz BA, Jenson A, Hinson JS, et al. Validity of ED: address- ing heterogeneous definitions of over-triage and under-triage. Am Of Emerg Med 2017;35:1023-5. 17. Ebrahimi M, Mirhaghi A, Mazlom R, et al. The role descrip- tions of triage nurse in emergency department: a Delphi study. Scientifica. 2016;2016:5269815. 18. Javadi N, Rostamnia L, Raznahan R, Ghanbari V. Triage train- ing in iran from 2010 to 2020: A systematic review on educa- tional intervention studies. Iranian J Nursing Midwifery Res 2021;26:189. 19. Mirhaghi A, Roudbari M. A survey of emergency department nurses on hospital triage. Iran J Crit Care Nurs 2010;3:165-70. 20. Javadi S, Salimi T, Sareban MT, Dehghani MA. Knowledge and Practice of Nurses Regarding Patients’ Triage in Emergency Department. Iranian J Emerg Med 2016;3:15-22. 21. Cherry RA, Bradburn E, Nichols PA, et al. Outcome assess- ment of blunt trauma patients who are undertriaged. Surgery 2010;148:239-45. 22. Hinson JS, Martinez DA, Schmitz PS, et al. Accuracy of emer- gency department triage using the Emergency Severity Index and independent predictors of under-triage and over-triage in Brazil: a retrospective cohort analysis. Int J Emerg Med 2018;11:1-10. 23. Rehn M, Eken T, Krüger AJ, et al. Precision of field triage in patients brought to a trauma centre after introducing trauma team activation guidelines. Scandinavian J Trauma Resuscit Emerg Med 2009;17:1-10. 24. Lehmann R, Brounts L, Lesperance K, et al. A simplified set of trauma triage criteria to safely reduce overtriage: a prospective study. Arch Surg 2009;144:853-8. 25. Chen S-S, Chen J-C, Ng C-J, et al. Factors that influence the accuracy of triage nurses’ judgement in emergency depart- ments. Emerg Med J 2010;27:451-5. 26. Dadashzade A, Abdolahzade F, Lotfi M, Ghujazade M. The necessory experiences and educational activies for the role of triage in Tabriz emergency departments. J Caring Sci 2008;10:31-7. 27. Khatiban M, Khazaei A, Karampourian A, 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. J Clin Res Paramed Sci 2014;3:63-74. 28. Rahmati F, Gholamalipoor H, Hashemi B, et al. The reasons of emergency department patients’ dissatisfaction. Iran J Emerg Med 2015;2:59-63. 29. Afshinjoo M, Moghadam M, Tourabi Ahmadi M. The relation- ship between causes and demographics of patients admitted to emergency departments of Zanjan University of Medical Sciences in the Zanjan city. Iranian J Emerg Care 2017;1:52- 60. 30. Kamrani F, Ghaemipour F, Nikravan M, Alavi Majd H. Prevalence of miss triage and outcomes under triage of patients in emergency department. J Health Promot Manag 2013;2:17- 23. 31. Tabibi SJ, Najafi B, Shoaie S. Waiting time in the emergency department in selected hospitals of Iran University of Medical Sciences in 2007. Pejouhesh dar Pezeshki (Research in Medicine) 2009;33:117-22. Article [page 78] [Emergency Care Journal 2022; 18:10638] Non -co mmerc ial us e o nly