Acuity Assignation

An Ethnographic Exploration of Clinical Decision Making by Emergency Nurses at Initial Patient Presentation

Abstract

The purpose of the study was to explore nurses' understanding of patient acuity levels at the initial patient encounter in the emergency department (triage). The current literature describes factors that are thought to influence decision making in triage; there is still a lot of uncertainty about the processes and strategies used to assign acuity, and therefore, possible strategies for improving nursing practice. Twelve emergency nurses were observed in their triage role over 120 initial patient encounters during a 3-month period at a critical access hospital and a level II trauma center in the eastern United States. Emergency nurses in this environment understood acuity to be a function of patient presentation, complaint, duration of symptoms, and body habitus. Acuity determinations were also influenced by patient volume, unit leadership, communication with patients and providers, and length of time in triage. Physiologic data were neither rigorously collected nor considered as a primary determinant of acuity. Patient acuity decisions were dependent on the knowledge base of the nurse, critical cue recognition and application to the situation, and the social context in which decision making occurred. The understanding of initial determination of patient acuity must take into account multiple factors extraneous to the patient to ensure safe and efficient care.