A Triage Nurse on the Sorting Decision Nobody Measures

Dolores "Dee" Gatewood is a composite — a fictional triage nurse assembled from published research, clinical literature, and the occupational knowledge that real triage nurses have described in peer-reviewed focus groups and grounded theory studies. She is not real. Her observations are.

We spoke with her anyway.

Every emergency department has a front door, and someone has to stand at it.

In more than 70% of U.S. emergency departments, that person uses the Emergency Severity Index, a five-level algorithm that sorts arriving patients from "immediate life-saving intervention required" to "no resources expected."¹ The algorithm is structured. The decision is not mechanical. And the person making it works in a gap that almost no outcome metric can see.

Dee Gatewood has been a triage nurse for seventeen years at a Level 1 trauma center. Above her triage desk, she says, there's a handwritten sign: The Wait Starts Here.

She didn't put it there. She's never taken it down.

You've called triage "the most important job nobody's watching." What does that mean in practice?

Dee: It means when I catch the guy whose back pain is actually an aortic dissection and I route him straight through, the chart downstream just shows a patient who got timely care. Looks like the system worked. And it did work. But the reason it worked was a decision I made in ninety seconds that doesn't appear anywhere in the record as a distinct act. The ESI level I assigned is there. Why I assigned it? Gone. What I noticed about his skin color, his breathing, the way he was bracing against the wall like he was trying to hold himself together literally. None of that travels with him.

Then the metrics come back. Door-to-doctor time, length of stay, admission rate. All things that happened after my decision. My decision is the hidden input to every one of those numbers, and it's evaluated by comparing it to what happened next, which is itself shaped by what I decided.²

Most important job nobody's watching.

There's a piece of research I find genuinely unsettling. Experienced triage nurses tend to under-triage, while less experienced nurses tend to over-triage.³ You've been doing this for seventeen years. Does that land?

Dee: It more than lands. It keeps me up at night.

When you're new, you're terrified. Every chest pain is a heart attack, every headache is a bleed. You route everyone up because you can't confidently say it's not the worst thing. And honestly? That's safer. Annoying for the department, because now you've got low-acuity patients occupying high-acuity beds, but safer.

When you've been doing it for years, you get extraordinarily good at recognizing what's routine. And that's where it gets dangerous. Because the skill that makes you fast and efficient, the pattern recognition, knowing what a thousand chest pains looked like, that same skill makes you slightly more likely to dismiss the one that doesn't fit. The elderly woman on beta-blockers whose heart rate looks normal at 82 but should actually be 130.⁴ You glance at the vitals, they look fine, you move on. A newer nurse might have flagged it because she didn't know enough to be reassured.

So the routing decision's contribution to the outcome is embedded and invisible.

Dee: And it goes both directions. When I undertriage someone and they get worse in the waiting room, the chart shows a deterioration event. Maybe a code. The contributing cause, that I put them in the wrong line, may or may not get reconstructed afterward. The pathway from my decision to the bad outcome isn't automatically preserved.⁵

There's no black box recorder for triage. Just the number I wrote down.

Researchers have identified four domains of triage decision-making. Three are clinical. The fourth is called "creating space."⁶ What is that?

Dee: That's the one that made me cry when I read it. Because someone finally named it.

Okay. You walk into triage and there are eight people in the waiting area. Two of them are yelling. One is bleeding visibly. There's a family that's been waiting four hours and they're at the desk demanding answers. Behind you the charge nurse is telling you there are no beds. The clinical decision, what ESI level does this patient get, has to happen inside that. And "creating space" is everything I do to make the environment survivable enough for the clinical decision to be any good. De-escalating the yelling. Acknowledging the family. Managing my own fatigue. The noise, the interruptions, the fact that I'm running on vending machine coffee and a granola bar from six hours ago.

None of that is a documented clinical act. But if I can't create space, the clinical judgment degrades. The research on environmental distractors confirms it: noise and task interruptions are identified contributors to triage inaccuracy.⁷ So the invisible work of managing the environment is a precondition for the invisible work of making the routing decision.

Invisibility stacked on invisibility. Nobody's measuring any of it.

Is triage one decision?

Dee: No.

Can you say more?

Dee: It's supposed to be. Patient arrives, you assess, you assign a level, they enter the queue. Clean. One decision. But what actually happens is I'm re-triaging the entire waiting room constantly. That person I put at Level 3 forty minutes ago, are they still a 3? That kid who was fine when she came in, is she still fine? I'm making routing decisions continuously, under shifting conditions, and there's no corresponding record at each iteration.⁸

The system sees aggregate throughput. It sees the accumulation of dozens of continuous routing decisions. It doesn't see any individual one. It's like measuring a river by looking at the ocean.

The ESI algorithm itself doesn't produce racial disparities in triage. But the research shows significant ones. Black patients have an 18.5% greater relative risk of under-triage compared to White patients.⁹ Where does that enter?

Dee: [long pause]

It enters in the judgment space around the algorithm. The algorithm says: assess acuity, estimate resources, check vitals. It doesn't say whose pain to take seriously. It doesn't say whose affect to read as distress versus drama. That's me. My pattern recognition, my clinical gestalt, my unconscious calibration of what a "high-risk presentation" looks like.

The algorithm exists to standardize and protect against exactly this kind of bias. But it can't reach the judgment that precedes it. And that judgment determines physical location, which team sees the patient, how quickly, with what resources.¹⁰ A wrong call there cascades forward, and it cascades invisibly.

I wish I could tell you I'm immune to it. I can tell you I think about it every shift.

What would you want someone designing a sorting system, any sorting system, to understand about your job?

Dee: That the record of the sort is not the sort.

The ESI number I assign is a trace of what I documented. The decision included what I noticed, what I weighed, what I almost did differently, what options were available to me at that moment in that department on that shift. None of that is preserved.

And if you measure the sort by what happened after it, by the outcomes downstream, you're measuring something that my decision already shaped. You can't evaluate the routing by looking at the queue it created. The queue is the routing decision's consequence.

Footnotes

1. Gilboy, N. et al., Emergency Severity Index Handbook, Fifth Edition, EMSC Improvement Center. https://media.emscimprovement.center/documents/Emergency_Severity_Index_Handbook.pdf ↩

2. Hinson, J.S. et al., "Association Between Emergency Department Undertriage or Overtriage With Timeliness of Care and Patient Outcomes," Annals of Emergency Medicine, 2026. https://www.annemergmed.com/article/S0196-0644(25)01386-1/abstract ↩

3. Gruber, M. et al., "The effect of emergency department nurse experience on triage decision making," International Emergency Nursing, 2022. https://www.sciencedirect.com/article/pii/S2772501422000124 ↩

4. ESI Handbook, Fifth Edition, guidance on geriatric patients and medication-adjusted vital sign interpretation. https://media.emscimprovement.center/documents/Emergency_Severity_Index_Handbook.pdf ↩

5. da Costa, L.G.V. et al., "Accuracy of emergency department triage using the ESI," International Journal of Emergency Medicine, 2017. https://intjem.biomedcentral.com/articles/10.1186/s12245-017-0161-8 ↩

6. Reay, G. et al., "Emergency department triage decision-making by registered nurses: An instrument development study," Journal of Advanced Nursing, 2024. https://pubmed.ncbi.nlm.nih.gov/38825956/ ↩

7. Faure, H. et al., "Effects of environmental distractors on nurse emergency triage accuracy," PMC, 2020. https://pmc.ncbi.nlm.nih.gov/articles/PMC7648299/ ↩

8. ScienceDirect, "The work of patient flow management: A grounded theory study of emergency nurses," 2024. https://www.sciencedirect.com/article/pii/S1755599X24000521 ↩

9. EMRA Health Policy Journal Club, "Final Destination." https://www.emra.org/emresident/article/hpjc-triage ↩

10. Chmielewski, N. and Moretz, J., "ESI Triage Distribution in U.S. Emergency Departments," Beckman Coulter/AENJ. https://media.beckmancoulter.com/-/media/diagnostics/products/solutions/triagego/docs/2022_esitriagedistributioninus.pdf ↩