Nursing Prioritization of Emergency Waiting Room Patients: A Multisite Observational Study

Introduction: Research has established the accuracy and reliability of emergency nursing triage. However, little is known about how emergency nurses use assigned triage scores to determine the order of emergency bed assignments. We define acuity-arrival order as the prioritization of patients first by acuity and then by time of arrival. Methods: An observational study was conducted across 6 emergency departments. Participants were emergency nurses in roles responsible for determining emergency bed assignments. Data were collected using demographic questionnaires, a structured data collection tool, and narrative field notes. Analysis included inductive content analysis and descriptive statistics. Results: Overall, 18 observation sessions were completed, including 37 nurse participants. Among 524 patient encounters, 325 bed assignment decisions were observed, of which 57.8% deviated from acuity-arrival order. Prioritization decisions were shaped by variable institutional norms and processes. In small departments, triage scoring was completed inconsistently and did not play a significant role in determining bed assignment order. In large departments, patient prioritization was heavily impacted by the presence of patient streaming processes. Across all study sites, nurses expressed distrust in assigned triage scores and the belief that patient prioritization is a complex and holistic decision. Discussion: Waiting emergency patients do not systematically receive bed assignments according to their assigned triage score or wait time. Instead, patient prioritization is determined through complex considerations of clinical acuity, waiting room safety, patient flow management logistics, and operational expectations. Patient prioritization has been found to be subjective and inconsistent, raising concerns about the quality, safety, and ethics of current emergency practice.