Hospital Triage Standards: A Qualitative Study and Content Analysis based on Experts’ Experiences in Iran


Introduction: The lack of a fixed and clear protocol causes confusion for nurses resulting in care performance delay in the emergency room (ER). Given that the purpose of triage is to examine the patient upon arrival in ER for the rapid classification and prioritization of emergency patients in need of treatment, it seems that the development and implementation of hospital triage standards can greatly affect this purpose. Objective: The present study was conducted to review the experiences of experts in hospital triage in terms of determining the standards of hospital ER triage. Methods: This qualitative research was conducted through content analysis method based on Donabedian model. Participants include experts (Politician, Nurse Supervisor, Nurse, Midwife, Faculty of Nursing, Emergency Medicine Specialist) working in educational and private hospitals and single-specialized ERs. Data were collected through in-depth and semi-structured interviews lasting between 25-60 minutes. The main interview questions were: What are the structural standards of a good triage?  What are the process standards for a good triage?  What are the standards of a good triage? Data analyzed through Content Directed Analysis with Shannon and Hsieh approach. Results: Totally, 21 experts the mean age of 46.9±1.8 (ranged from 30 to 57) years and the mean work experience of 18.9± 8.21 years were participated, of whom 16 (76.2%) persons were male. From the analysis, we extracted 48 codes, 14 subcategories and 3 main categories of "structural standards", "process standards" and "outcome standards". Conclusions: Guidelines are needed so that the nurse in charge of triage can quickly and accurately undertake the important responsibility of patient triage. Additionally, having structure and process and outcome standards improves triage performance.

1. Abdelwahab R, Yang H, Teka HG. A quality improvement study of the emergency centre triage in a tertiary teaching hospital in northern Ethiopia. Af J Emerg Med. 2017;7(4):160-6.
2. Seyedhosseini-Davarani S, Hesari E, Afzalimoghadam M, Tavakoli N, Seyedhosseini J, Hossein-Nejed H, et al. Validity of triage performed by nurses educated by Train-of-Trainer workshop participants; a cross-sectional study for assessment of cascade training system. Adv J Emerg Med. 2020;4(1):e2.
3. Seyedhosseini-Davarani S, Nejati A, Hossein-Nejad H, Mousavi S-M, Sedaghat M, Arbab M, et al. Outcome-Based Validity and Reliability Assessment of Raters Regarding the Admission Triage Level in the Emergency Department: a Cross-Sectional Study. Adv J Emerg Med. 2018;2(3):e32.
4. Najafi Z, Zakeri H, Abbaszadeh A, Ebrahimi M, Mirhaghi A. Does Emergency Severity index predict acuity among traumatic brain injury patients. Eur J Emerg Med. 2018;17(3):103-8.
5. Safari S, Rahmati F, Baratloo A, Motamedi M, Forouzanfar MM, Hashemi B, et al. Hospital and pre-hospital triage systems in disaster and normal conditions; a review article. Iran J Emerg Med. 2015;2(1):2-10.
6. Speziale HS, Streubert HJ, Carpenter DR. Qualitative research in nursing: Advancing the humanistic imperative: Lippincott Williams & Wilkins; 2011.
7. Polit DF, Yang F. Measurement and the measurement of change: a primer for the health professions: Wolters Kluwer Philadelphia, PA; 2016.
8. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277-88.
9. Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs. 2008;62(1):107-15.
10. Buschhorn HM ST, Sholl JM, Baumann MR. Emergency medical services triage using the emergency severity index: is it reliable and valid? J Emerg Nurs. 2013;39(5):55-63.
11. Bijani M KA. Challenges and Barriers Affecting the Quality of Triage in Emergency Departments: A Qualitative Study. Galen Med J. 2019;8:1-6.
12. Broadbent M ML, Dwyer T. Implications of the emergency department triage environment on triage practice for clients with a mental illness at triage in an Australian context. Australas Emerg Nurs J. 2014;17(1):23-9.
13. Ebrahimi M MA, Mazlom R, Heydari A. The role descriptions of triage nurse in emergency department: a Delphi study. Scientifica. 2016;2016:5269815.
14. Bijani M TC, Rakhshan M, Fararouei M. Professional capability in triage nurses in emergency department: A qualitative study. Rev Latinoam Hiperte. 2018;13(6):554-60.
15. Usui M YT. Guiding patients to appropriate care: developing Japanese outpatient triage nurse competencies. Nagoya J Med Sci. 2019 Nov; 81(4): 597–612.
16. Wolf LA LA, Delao AM,Perhats C, Moon MD, Zavotsky KE. Triaging the emergency department, not the patient: United States emergency nurses’ experience of the triage process. J Emerg Nurs. 2018;44(3):258-66.
17. Ghanbari A HF, Lyili EK , Khomeiran RT , Momeni M. Assessing Emergency Nurses’ Clinical Competency: An Exploratory Factor Analysis Study. Iran J Nurs Midwifery Res. 2017;22(4):280-6.
18. Chan JNH CJ. Patient satisfaction with triage nursing care in Hong Kong. J Adv Nurs. 2005;50(5):498-507.
19. Lin CC LH, Han CY, Chen LC, Hsieh CL. Professional resilience among nurses working in an overcrowded emergency department in Taiwan. Int Emerg Nurs. 2019;42:44-50.
20. Aacharya RP GC, Denier Y. Emergency department triage: an ethical analysis. BMC Emerg Med. 2011;11(1):1-13.
21. Rowe BH, Villa‐Roel C, Guo X, Bullard MJ, Ospina M, Vandermeer B, et al. The role of triage nurse ordering on mitigating overcrowding in emergency departments: a systematic review. Acad Emerg Med. 2011;18(12):1349-57.
22. Elder E JA, Crilly J. Review article: systematic review of three key strategies designed to improve patient flow through the emergency department. Emerg Med Australas. 2015;27(5):394-404.
23. Bahena D AC. Provider in triage: is this a place for nurse practitioners? Adv Emerg Nurs J. 2013;35(4):332-43.
24. Yokota T IS, Yamada Y, Yamauchi H. Medical triage and legal protection in Japan. Lancet. 2002;359(9321):1949.
25. Person J SL, Hart P. The culture of an emergency department: an ethnographic study. Int Emerg Nurs. 2013;21(4):222-7.
26. Pich J HM, Sundin D,Kable A. Patient-related violence at triage: A qualitative descriptive study. Int Emerg Nurs. 2011;19(1):12-9.
27. Mirhaghi A HA, Ebrahimi M,Bahmani M Nonemergent patients in the emergency department: an ethnographic study. Trauma Mon. 2016;21(4):e23260.
28. Ramacciati N CA, Addey B. Violence against nurses in the triage area: an Italian qualitative study. Int Emerg Nurs. 2015;23(4):274-80.
29. Ferri P SS, Accoto A, et al. Violence against nurses in the triage area: a mixed-methods study. J Emerg Nurs. 2020;46(3):384-97.
30. Rosenberg K. RN shortages negatively impact patient safety. Am J Nurs. 2019;119(3):51.
31. Li H CB, Zhu XP. Quantification of burnout in emergency nurses: A systematic review and meta-analysis. Int Emerg Nurs. 2018;39:46-53.
32. Fry M. An ethnography: Understanding emergency nursing practice belief systems. Int Emerg Nurs. 2012;20(3):120-5.
33. Corkin D, Kenny J. Quality patient care: challenges and opportunities. Nurs Manag. 2017;24(7):32-6.
34. Mirhaghi A. Triage system should be compatible with culture of care in emergency department. Med Klin Intensivmed Notfmed. 2016;111(2):138-9.
35. Jordi K GF, Gaddis GM, Cignacco E, Denhaerynck K, Schwendimann R. Nurses’ accuracy and self-perceived ability using the Emergency Severity Index triage tool: a cross-sectional study in four Swiss hospitals. Scand J Trauma Resusc Emerg Med. 2015;23:62.
36. Chen SS CJ, Ng CJ, Chen PL. Factors that influence the accuracy of triage nurses' judgement in emergency departments. Emerg Med J. 2010;27(6):451-5.
37. Scrofine S FV. Triage: the sorting of patients. J Emerg Nurs. 2014;40(3):289-90.
38. Unwin M KL, Rigby S. Why are we waiting? Patients’ perspectives for accessing emergency department services with non-urgent complaints. Int Emerg Nurs. 2016;29:3-8.
39. McCusker J VA, Lévesque JF, Ciampi A, . Increases in emergency department occupancy are associated with adverse 30‐day outcomes. Acad Emerg Med. 2014;21(10):1092-100.
40. Mirhaghi A. Comment On:" A Review of Factors Affecting Patient Satisfaction With Nurse Led Triage in Emergency Departments" by Rehman SA and Ali PA. Int Emerg Nurs. 2016;29:45.
41. Aloyce R LS, Brysiewicz P. Assessment of knowledge and skills of triage amongst nurses working in the emergency centres in Dar es Salaam,Tanzania. Af J Emerg Med. 2014;4(1):14-8.
42. Najafi Z AZ, Zakeri H, Mirhaghi A. Determination of mis-triage in trauma patients: a systematic review. Eur J Trauma Emerg Surg. 2019;45(5):821-39.
43. Parenti N RM, Iannone P, Percudani D, Dowding D. A systematic review on the validity and reliability of an emergency department triage scale, the Manchester Triage System. Int J Nurs Stud. 2014;51(7):1062-9.
44. Magalhães-Barbosa MC de RJ, Prata-Barbosa A, de Souza Lopes C. Validity of triage systems for paediatric emergency care: a systematic review. Emerg Med J. 2017;34(11):711-9.
45. Rehman SA AP. A review of factors affecting patient satisfaction with nurse led triage in emergency departments. Int Emerg Nurs. 2016;29:38-44.
46. Horwitz LI GJ, Bradley EH. US emergency department performance on wait time and length of visit. Ann Emerg Med. 2010;55(2):133-41.
47. Oredsson S JH, Rognes J, Lind L, et al. A systematic review of triage-related interventions to improve patient flow in emergency departments. Scand J Trauma Resusc Emerg Med. 2011;19:43.
48. Roudi M MJ, Ebrahimi M, Mirhaghi A, Shakeri MT. Comparison between Emergency Severity Index plus peak flow meter and Emergency Severity Index in the dyspneic patients with chronic obstructive pulmonary disease: A randomized clinical trial. Turk J Emerg Med. 2019;19(2):68-72.
49. Reisi Z SB, Adienh M, Hemmatipour A, Abdolahi Shahvali E. The level of awareness of the emergency department nurses of the triage principles in teaching hospitals. J Nurs Midwifery Sci. 2018;5(1):32-7.
50. Mirhaghi AH, Roudbari M. A survey on knowledge level of the nurses about hospital triage. Iran J Crit Care Nurs. 2011;3(4):165-70.
51. Considine J BM, Thomas S. Do knowledge and experience have specific roles in triage decision‐making? Acad Emerg Med. 2007;14(8):722-6.
IssueVol 5 No 4 (2021): Autumn (October) QRcode
SectionOriginal article
DOI 10.18502/fem.v5i4.6695
Emergency Nursing Expert Opinion Qualitative Research Standard of Care Triage

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
Najafi Z, Abbaszadeh A, Vaezi H, Rassouli M, Mirhaghi A, Zohari Anboohi S. Hospital Triage Standards: A Qualitative Study and Content Analysis based on Experts’ Experiences in Iran. Front Emerg Med. 5(4):e43.


Download data is not yet available.