CNOs: Here's How to Optimize Emergency Department Nursing

Strong evidence-based emergency triage education is essential to a robust ED, says this nurse leader.

For many patients, the emergency department (ED) is the first point of contact they will have with a health system. From the nurse's perspective, it's a place where care delivery can be chaotic and disorganized.

Crowded emergency rooms and workplace violence are big obstacles that get in the way of providing safe and efficient care delivery, and it's the CNO's responsibility to make sure that the ED nurses are prepared to handle as many different scenarios as possible.  

According to Ryan Oglesby, president of the Emergency Nurses Association (ENA), having access to strong evidence-based research and education to improve patient outcomes and throughput is essential to a robust ED.

"We're big proponents of a healthy work environment, including safety from violence and other things in the emergency department," Oglesby said, "but also a healthy work environment as it relates to leadership support and the ability for emergency nurses to have the resources that they need when they're providing care."

Emergency triage education

Efficient triage is critical in the emergency department. According to Oglesby, inaccurate triage decisions and actions can cause delays in l care, increase mortality risk and complications, and lead to longer lengths of stay.

"Standardized triage education along with [a] well-executed triage process is really essential to prioritizing care in the emergency department and throughput," Oglesby said.

To combat this issue, the ENA developed the Emergency Nursing Triage Education Program (ENTEP).

"The inspiration behind the Emergency Nursing Triage Education Program was a lot of research and feedback that came from our members as it relates to the difficulties and challenges they were having with triage and ED throughput," Oglesby said.

A work group, consisting of ENA members and staff to support triage education, created a method of verification of triage competency, Oglesby explained, as a way to address the significant knowledge gaps in triage education.

"From there, the work began to evaluate the best approach and to develop triage competencies, formalizing and executing on some of that research…and then putting together a standardized triage program," Oglesby said.

ENTEP consists of blended online and live classroom education, and is the only available evidence-based triage verification program, according to Oglesby. Key topics include critical thinking and decision-making, the emergency severity index and related documentation, effective communication, and real-life triage scenarios. The program covers all age populations, including senior, adult, and pediatric care, as well as specialty populations.

"Not only do we provide the comprehensive education program, but also a verification of those competencies at the conclusion of the course," Oglesby said. "It addresses the challenges of triage and promotes a safe space for dialogue and learning around some of that evidence-based practice."

According to Oglesby, the ENA has received positive feedback from nurses that have been through the verification process and a significant number of nurses have already been verified. The instructor pool for the program has grown as well.

How CNOs can help

CNOs can help build the confidence of ED nurses by encouraging nurse-led initiatives and including them in policy creation and revision, as well as allowing them to invest in their own education and certification. CNOs and other nurse leaders must provide comprehensive ED-specific orientation programs and provide nurses of all skill levels with the knowledge and practical expertise they need to work effectively in the ED, Oglesby explained.

"With that comes strong preceptor programs that allow for mentorship and guidance during those critical early experiences in the emergency department," Oglesby said.

CNOs can also help with ongoing education and training focused on critical thinking, clinical decision-making and judgement, and advanced assessment skills. Oglesby recommended creating a shared governance or shared leadership model where nurses have a voice in developing policies and protocols surrounding how they practice in their daily work.

For CNOs who might want to implement more emergency triage education, Oglesby explained that the first step is to evaluate current triage processes and identify gaps in consistency, documentation, or clinical decision-making. Leadership buy-in from CNEs, CNOs, and ED leaders is also critical, and signifies that quality care begins at the front door of the ED.

"Making space for structured training in the orientation to the emergency department as well as ongoing education plans for continued competency are also important," Oglesby said, "and supporting nurses with time and resources to fully engage in those learning opportunities is key."