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Nurse-led ED triage matched expert ratings 85% of the time, but undertriage remained a safety concern

Journal of Emergency Nursing (PubMed)Jul 11, 2026

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Brief summary

In 2,584 adult ED records, nurse-assigned three-tier triage agreed exactly with blinded expert physicians 85.3% of the time, but undertriage occurred in 12% and affected 21.8% of expert-rated red cases.

What NurseJet pulled from the source

This retrospective cross-sectional study evaluated a modified three-tier red, yellow, and green triage protocol at a tertiary emergency department in India. Investigators systematically sampled every fifth adult trauma and nontrauma visit from June through August 2025, analyzing 2,584 records. Nurse-assigned triage was compared with a blinded reference standard from two independent emergency physicians, with senior adjudication. Nurses achieved 85.3% exact agreement (95% CI 83.9% to 86.5%) and a weighted kappa of 0.78. Severe mismatches occurred in 0.4% of records, but undertriage was more common than overtriage, 12% versus 3%. For 751 expert-rated red cases, nurse triage had 79% sensitivity and 97% specificity; 21.8% were undertriaged and 1.5% were assigned green. Trauma and an alert presentation independently predicted incorrect triage. Mistriage was not significantly associated with discharge mortality in this sample.

Why this matters for nurses

Triage decisions shape time to assessment and use of limited emergency resources. This study matters for ED nurses because it shows strong overall agreement while identifying a clinically important undertriage pattern, especially among trauma and alert-appearing patients who may seem less urgent.

Bedside takeaway

Worth knowing that nurse-led ED triage agreed exactly with experts in 85.3% of 2,584 encounters, but 12% were undertriaged and more than one in five expert-rated red cases received a lower category.

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Key takeaways

The study compared nurse triage with a blinded physician reference standard across 2,584 systematically sampled adult ED records.
Exact agreement was 85.3%, with good overall weighted agreement and only 0.4% severe mismatches.
Undertriage occurred in 12%, compared with 3% overtriage, and red-case sensitivity was 79%.
Trauma and alert presentation were independent predictors of an incorrect nurse-assigned triage category.

Practice implications

The undertriage signal supports focused review of trauma presentations, ambulatory bias, and reassessment practices where appropriate. It does not validate this modified protocol for every ED or replace the facility's triage scale, reassessment rules, required competencies, or clinical judgment.

Limitations & cautions

This was a retrospective, single-center study of a modified local protocol over three months in India. The expert reference raters had a quadratic-weighted kappa of 0.61 before adjudication, and the cross-sectional design cannot show that training or decision-support changes would improve triage accuracy or patient outcomes.
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Citations

Exact source links

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Journal of Emergency Nursing (PubMed)

Journal of Emergency Nursing (PubMed). Diagnostic Accuracy of Nurse-Led ED Triage Using the Modified All India Institute of Medical Sciences Triage Protocol: A Cross-Sectional Study in a Tertiary-Care Center in India.

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https://pubmed.ncbi.nlm.nih.gov/42435022/

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This summary does not replace clinical judgment, facility policy, provider orders, or official guidelines. Verify practice changes against the original source and local protocol.

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International Emergency Nursing (PubMed)Jun 29, 2026Systematic Review

A network meta-analysis of 24 randomized trials involving 8,014 adults with difficult IV access found that ultrasound guidance improved first-attempt and overall cannulation success versus standard practice, while local warming showed narrower benefits supported by less evidence.

Emergency Med-SurgAI summaryReview source

Systematic ReviewResearchWorkflowNew Grad FriendlyAI summary · original source linked below

Difficult intravenous access can lead to repeated attempts, treatment delays, pain, and added cost. This systematic review searched four databases through February 1, 2026 and used a network meta-analysis to compare 11 active interventions across 24 randomized trials with 8,014 adults. Compared with standard practice, ultrasound guidance improved first-attempt success (OR 5.58, 95% CI 2.74 to 11.36) and was the only intervention with a significant overall-success benefit (OR 4.12, 95% CI 2.07 to 8.19). Local warming also improved first-attempt success and reduced procedure time and pain, but rested on more limited evidence. Near-infrared devices reduced attempts and improved satisfaction, while long catheters were associated with more pain and longer procedures. The authors judged ultrasound the most consistently supported option but cautioned that a sparse evidence network and assumptions behind indirect comparisons temper certainty.

Key takeaways

The network meta-analysis included 24 randomized controlled trials, 8,014 adults, and 11 difficult-access interventions.
Ultrasound guidance improved both first-attempt and overall cannulation success compared with standard practice.
Local warming improved first-attempt success and reduced procedure time and pain, but its evidence base was more limited.
The sparse comparison network and its transitivity assumption limit certainty about intervention rankings.

Why this matters on shift

Obtaining vascular access is a frequent nursing task, and repeated failed attempts can delay treatment while increasing pain. This review matters for emergency and med-surg nurses because it compares common escalation options in one analysis and separates the most consistently supported approach from promising but less certain alternatives.

Bedside takeaway

Worth knowing that across 24 randomized trials, ultrasound guidance had the most consistent evidence for first-attempt and overall success in adults with difficult IV access, while local warming showed narrower benefits with less evidence.

Nursing implications

For nurses following an approved difficult-access pathway, the findings support timely escalation to an ultrasound-trained clinician when standard attempts are unlikely to succeed and consideration of local warming where protocol permits. The rankings should not replace patient assessment, local competency requirements, or the unit's vascular-access policy.

Limitations & cautions

The analysis combined trials of 11 interventions through direct and indirect comparisons, so rankings depend on the assumption that studies were sufficiently comparable. The network was sparse, evidence for some options was limited, and the abstract does not provide certainty ratings or enough setting detail to establish one universal pathway.
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Citations · exact source links

International Emergency Nursing (PubMed). Comparative effectiveness of interventions for difficult intravenous access in adults: A systematic review and network meta-analysis of randomized controlled trials.

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Infection Control and Hospital Epidemiology (PubMed)Jul 10, 2026Research Article

In a single-center quasi-experimental pre-post study, a nurse-led antimicrobial-stewardship workflow in a medical emergency unit was associated with higher antibiotic-guideline adherence (82.4% to 91.0%) and more cultures collected before antibiotics (23.0% to 40.3%).

Med-Surg EmergencyAI summaryReview source

Research ArticleResearchInfection ControlQuality ImprovementAI summary · original source linked below

Emergency units make high-volume, time-sensitive antibiotic decisions but are often underrepresented in antimicrobial-stewardship programs. In this quasi-experimental pre-post study at a tertiary hospital, trained stewardship nurses first audited antimicrobial-use patterns and identified intervention targets. During the intervention phase, they reviewed antibiotic prescriptions, reinforced adherence to institutional guidance, monitored device-related practices and diagnostic use, and joined audit-and-feedback discussions with clinical teams. Guideline adherence increased from 82.4% at baseline to 91.0% during the intervention. The proportion of cultures obtained before antibiotics rose from 23.0% to 40.3%, culture positivity increased from 8.0% to 22.0%, and antibiotic de-escalation also increased, although the abstract did not provide a numerical de-escalation estimate. The authors concluded that integrating trained nurses into emergency-unit stewardship was feasible and was associated with more rational antimicrobial and diagnostic practices, but the nonrandomized design does not prove that the intervention caused the changes.

Key takeaways

The intervention embedded trained stewardship nurses into prescription review, device-practice monitoring, diagnostic review, and audit-and-feedback with the emergency clinical team.
Adherence to the hospital's antibiotic guidelines increased from 82.4% before the intervention to 91.0% during it.
Cultures collected before antibiotic initiation increased from 23.0% to 40.3%, while culture positivity rose from 8.0% to 22.0%.
Antibiotic de-escalation increased, but the abstract did not report its size or patient-centered clinical outcomes.

Why this matters on shift

Nurses already see antibiotic timing, specimen collection, device care, and response to therapy unfold at the bedside, placing them in a strong position to spot stewardship gaps. This study matters because it tested a nursing role that connected those observations to real-time review and team feedback in a busy emergency setting.

Bedside takeaway

Worth knowing that a nurse-led emergency-unit stewardship audit was linked to higher guideline adherence and more cultures before antibiotics, but the single-center pre-post design cannot establish cause or patient benefit.

Nursing implications

For infection-prevention and emergency nurses, the findings support formal nurse participation in locally approved stewardship workflows, particularly checking whether ordered cultures are obtained before the first antibiotic when clinically feasible and escalating guideline mismatches through the designated team. The study does not justify independent antibiotic changes outside local scope, orders, or stewardship policy.

Limitations & cautions

This was a single-center, nonrandomized pre-post study, so secular changes, case mix, staffing, or clinician behavior may have contributed to the differences. The abstract does not report the number of patients or prescriptions, intervention and baseline durations, statistical uncertainty, antibiotic consumption, adverse events, resistance outcomes, or patient outcomes.
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Citations · exact source links

Infection Control and Hospital Epidemiology (PubMed). Evaluating a nurse-led, audit-based antimicrobial stewardship in the medical emergency unit of a tertiary level hospital.

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Archives of Academic Emergency Medicine (PubMed)Feb 1, 2026Research Article

In a single-center diagnostic accuracy study of 279 adults screened at emergency triage, manual fever checking by nurses detected fever with 100% sensitivity but lower specificity, while a non-contact forehead infrared thermometer was the more reliable way to confirm fever, especially when its cutoff was lowered to 37.5 degrees C.

EmergencyAI summaryReview source

Research ArticleResearchNew Grad FriendlyAI summary · original source linked below

This single-center diagnostic accuracy study evaluated adult patients in the triage area of an emergency department in Tehran, Iran, between May and September 2023. Five emergency nurses assessed each patient with three index tests, patient-perceived fever (PPF), manual fever checking (MFC), and a non-contact frontal infrared thermometer (NCFIT), followed by a tympanic thermometer as the reference standard (fever defined as 38 degrees C or higher). Among 279 patients (mean age 52.2 years, 52% male), the tympanic thermometer identified 147 as febrile and 132 as non-febrile. Manual fever checking was the most sensitive index test at 100% (95% CI 97.5 to 100.0), with a negative likelihood ratio of 0 and accuracy of 93.9% (95% CI 89.9 to 96.0). The NCFIT had the lowest sensitivity (85.71%; 95% CI 78.9 to 90.9) but the highest specificity (98.48%; 95% CI 93.6 to 99.5) and accuracy (97.5%; 95% CI 93.1 to 99.8). When the NCFIT fever threshold was lowered to 37.5 degrees C, its sensitivity rose to 99% (95% CI 97.4 to 99.9) while specificity stayed at 98% (95% CI 94 to 99.6). The authors concluded that manual checking and patient-perceived fever could rule fever out but needed the NCFIT or tympanic thermometer to rule it in.

Key takeaways

Manual fever checking by nurses was the most sensitive method at 100% (95% CI 97.5 to 100.0), with a negative likelihood ratio of 0.
The non-contact forehead infrared thermometer had the lowest sensitivity (85.71%) but the highest specificity (98.48%) and accuracy (97.5%).
Lowering the forehead scanner's fever threshold to 37.5 degrees C raised its sensitivity to 99% while specificity held at 98%.
Manual checking and patient-perceived fever could rule out fever but required the forehead scanner or tympanic thermometer to confirm it.

Why this matters on shift

Fever screening at triage shapes early decisions about isolation, workups, and urgency, and nurses often rely on a quick touch of the skin or the patient's own report. This study may matter for nurses because it puts numbers on how well those quick checks perform, showing that a hands-on check rarely missed a real fever but tended to over-call it, so a normal touch was reassuring while a positive one deserved confirmation.

Bedside takeaway

Be aware that in one ED study, a nurse's hands-on fever check ruled fever out with 100% sensitivity but over-called it, while a non-contact forehead scanner was more reliable for confirming fever, especially at a 37.5 degrees C threshold.

Nursing implications

For emergency nurses, the findings suggest that a hands-on fever check or the patient's own sense of fever is a reasonable way to rule fever out, given the perfect sensitivity seen here, but a device reading is needed to confirm it before acting. Where a non-contact forehead thermometer is used for screening, this study found a 37.5 degrees C cutoff caught far more true fevers than the standard 38 degrees C setting.

Limitations & cautions

This was a single-center study of 279 adults in one emergency department triage area over a few months in 2023, so results may not transfer to other settings, populations, or devices. Only five nurses performed the manual checks, the tympanic thermometer served as the reference rather than a core temperature standard, and the very high manual-check sensitivity may reflect local technique and the specific patient mix.
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Citations · exact source links

Archives of Academic Emergency Medicine (PubMed). Comparing the Accuracy of Patient-Perceived Fever, Manual Fever Checking, and Non-Contact Frontal Infrared Thermometer; A Cross-sectional Study.

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Key takeaways

Practice implications

Limitations & cautions

Exact source links

More updates for this clinical area

Ultrasound guidance had the strongest overall evidence for difficult IV access across 24 randomized trials

A nurse-led stewardship audit raised antibiotic-guideline adherence and pre-treatment culture collection in an emergency unit

Nurses' manual fever check caught every fever but over-called it, while a forehead scanner was better for confirming fever