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Background: The Emergency Severity Index (ESI) may not recognize high-risk patients with heart failure (HF) efficiently.Aim: This study aimed to compare the diagnostic validity and mistriage rates of the ESI plus the Capnometer (Capno) and ESI alone among dyspneic patients with HF.Method: This quasi-experimental group (random assignment) study was conducted within April 2019-February 2020. Patients were randomly assigned to the ESI+Capno and ESI groups. Triage levels, resources used, disposition and door to an electrocardiogram, and physician visit were compared among patients admitted to the Cardiac Care Unit (CCU), the Cardiac Unit (CU), or discharged from the ED. Interobserver agreement (Kappa) was used to assess the reliability of the ESI.Results: In this study, 65 HF patients were assigned to the ESI+Capno (n=36) and ESI (n=29) groups. The undertriage rates were 0% and 10% and the overtriage rates were 10% and 31% in the ESI+Capno and ESI groups, respectively. Sensitivity, specificity, and accuracy to recognize high-risk HF patients were 100%, 60%, and 90% for the ESI+Capno group and 62.5%, 42.86%, and 48.36% for the ESI group.Implications for Practice: The addition of Capno to the ESI increased the validity of triage decisions to recognize high-risk HF patients, compared to the ESI alone. It is recommended that decisions regarding triage HF patients be made after that an End-tidal Co2 is considered into the decision-making process.

Introduction: Triage in the interactive atmosphere of the emergency department (ED) has been described as complex and challenging. The influence of nurses’ belief systems on triage decision making has not to the authors’ knowledge been addressed. This study attempted to gain an understanding of the ED nurses’ culture of practice with respect to contextual factors that affect triage decision making. Methods: A focused micro-ethnographic study based on Spradley’s developmental research sequence (DRS) has been conducted in the emergency department of the Mashhad University hospital, Iran, from February 2014 to February 2015. Data were collected during 300 hours of participant observations that were accompanied by formal and informal interviews, then analyzed based on Spradley’s DRS. Results: Nine study participants were formally interviewed. From these interviews, eight core beliefs emerged related to nurses’ culture of practice: namely, triage decision making is arbitrary; the facility/locale of the emergency medicine department is the pivotal contextual factor affecting decision making; not every nurse can be assigned to triage; each patient assumes the existence of an emergency condition; the on-duty physician must be known; triage decision making must be considered plausible by colleagues; “they” tell us something, we should do something else; and triage guidelines are not practical. Conclusion: Contextual factors have a strong tendency to guide triage decision making and violate the principle of patient acuity (that is, that patients with the most acute medical conditions should be prioritized). In response, triage guidelines need to integrate the priorities of patients, nurses, physicians, and administrators.