Effectiveness of Nurse-Initiated Sono Triage on Nurses’ Competence and Triage Rates in a Tertiary Care Emergency Department in New Delhi, India

Authors

  • Milan Tirwa School of Nursing and Research Sciences, Sharda University, Greater Noida, 201310 Uttar Pradesh, India
  • Pity Koul School of Nursing and Research Sciences, Sharda University, Greater Noida, 201310 Uttar Pradesh, India

DOI:

https://doi.org/10.31674/mjn.2026.v17i03.014

Abstract

Background: Point of Care Ultrasound is used in patient care, trauma, education, training, war, and disaster settings. Triage is a dynamic process, and in a busy high-volume department with limited information from patients, the emergency physician (EP) must triage the patient within a short period and with a high stress level; these factors increase the chance of error by the emergency physician. The nurses are also expected to do the triaging. It is imperative to do task shifting for the nurses; they can be empowered to conduct Sono triage to reduce the rate of under-triaging for better health outcomes with early identification and prompt management. Objectives: The pilot study assessed the effectiveness of Nurse-Initiated Sono triage (NISt) in enhancing nurses' knowledge and skills while improving patient triage accuracy in the emergency department (ED). Methods: A quasi-experimental pretest-post-test design was implemented at Tertiary care centre, New Delhi, India. A total of 15 nurses and 150 patients participated in the study. Data were analyzed using descriptive and inferential statistics. Results: Pre-intervention assessments showed limited knowledge and no prior training in extended focused assessment with sonography in trauma (e-FAST). Post-intervention findings demonstrated a significant increase in nurses' knowledge (mean score improvement from 17.3 to 20.9, p = 0.006) and skill acquisition. Also, 3% of patients initially triaged to the yellow zone were re-triaged to the red zone. Most nurses (mean acceptability score = 4.5) supported implementing NISt as a nurse-led initiative. Conclusion: The results suggest that nurse-initiated Sono triage can improve early identification of critically ill patients, facilitating timely interventions.

Keywords:

e-FAST, Emergency Department, Nurse-Initiated Sono Triage, Nurse Training, Patient Triage, Trauma Triage Protocol

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References

Alharbi, R. J., Shrestha, S., Lewis, V., & Miller, C. (2021). The effectiveness of trauma care systems at different stages of development in reducing mortality: A systematic review and meta-analysis. World Journal of Emergency Surgery, 16(1), 38. https://doi.org/10.1186/s13017-021-00381-0

AlMarzooq, A. M. (2020). Emergency department nurses’ knowledge regarding triage. International Journal of Nursing, 7(2), 29–44. https://doi.org/10.15640/ijn.v7n2a5

Biçer, M. A., Güner, N. G., Karakayalı, O., Akdeniz, S., Yürümez, Y., Özsaraç, M., & Güneysu, F. (2025). Comparing the effectiveness of point-of-care ultrasound and conventional triage in patients presenting to the emergency department with abdominal pain. Internal and Emergency Medicine, 1-9. https://doi.org/10.1007/s11739-025-04115-x

Desai, N., & Harris, T. (2018). Extended focused assessment with sonography in trauma. BJA Education, 18(2), 57–62. https://doi.org/10.1016/j.bjae.2017.10.003

Gimenes, F. R. E., Stabile, A. M., Bernardes, R. M., Santos, V. B., Menegueti, M. G., do Prado, P. R., ... & Rabeh, S. A. N. (2024). Advancing digital education technologies by empowering nurses with point-of-care ultrasound: Protocol for a mixed methods study. JMIR Research Protocols, 13, e58030. https://doi.org/10.2196/58030

Hinds, A., Kay, S., & Evans, K. (2025). Refresher training for emergency department triage nurses – A scoping review. Australasian Emergency Care, 28(3), 204–212. https://doi.org/10.1016/j.auec.2025.03.006

Idris, S. (2022). The relationship between knowledge and skills of nurses and triage measures in the emergency room of the Islam Malahayati Hospital in Medan in 2022. Science Midwifery, 10(5), 3705–3712. https://doi.org/10.35335/midwifery.v10i5.915

Jenpanitpong, C., Yuksen, C., Trakulsrichai, S., Sricharoen, P., Leela-Amornsin, S., Savatmongkorngul, S., & Sanguanwit, P. (2025). Predictive performance of prehospital trauma triage tools for resuscitative interventions within 24 hours in high-risk or life-threatening prehospital trauma patients. BMC Emergency Medicine, 25(1), 26. https://doi.org/10.1186/s12873-025-01188-x

Jeppesen, E., Cuevas-Østrem, M., Gram-Knutsen, C., & Uleberg, O. (2020). Undertriage in trauma: an ignored quality indicator? Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 28(1), 34. https://doi.org/10.1186/s13049-020-00729-6

Knutsen, K., & Solbakken, R. (2025). Utilisation of point-of-care ultrasound by critical care nurses: A scoping review protocol. BMJ Open, 15(6), e100911. https://doi.org/10.1136/bmjopen-2025-100911

Lee, W. W., Filiatrault, L., Abu-Laban, R., Rashidi, A., Yau, L., & Liu, N. (2016). Effect of triage nurse-initiated radiography using the Ottawa ankle rules on emergency department length of stay at a tertiary centre. Canadian Journal of Emergency Medicine, 18(2), 90–97. https://doi.org/10.1017/cem.2015.67

Lowe, T., Skaggs, H., & Am Dinh, V. (2023). Evaluating the effect of nursing-performed point-of-care ultrasound on septic emergency department patients. Cureus, 15(6). e40519. https://doi.org/10.7759/cureus.40519

Maiti, D., Easow, T. M., & Jyothi, R. (2024). Enhancing triage systems in emergency units: An extensive review. RGUHS Journal of Nursing Sciences, 14(2), 10–16. https://doi.org/10.26463/rjns.14_2_13

Mitchell, R., White, L., Elton, L., Luke, C., Bornstein, S., & Atua, V. (2024). Triage implementation in resource-limited emergency departments: sharing tools and experience from the Pacific region. International Journal of Emergency Medicine, 17(1), 21. https://doi.org/10.1186/s12245-024-00583-8

Moon, S. H., & Cho, I. Y. (2022). The effect of competency-based triage education application on emergency nurses’ triage competency and performance. Healthcare, 10(4), 596. https://doi.org/10.3390/healthcare10040596

Moosavi, S., Ionescu, A., Griffiths, E., Adenwalla, F., Davies, A., & Rees, E. (2023). Does nurse-led point-of-care ultrasound (POCUS) improve the triage of elderly community patients with suspected heart failure? A feasibility study. European Journal of Cardiovascular Nursing, 22(Suppl. 1), zvad064.061. https://doi.org/10.1093/eurjcn/zvad064.061

Moro, F., Chiarini, V., Scquizzato, T., Brogi, E., Tartaglione, M., Scharonow, M., ... & Gamberini, L. (2025). Variables for reporting studies on extended-focused assessment with sonography for trauma (e-FAST): An international Delphi consensus study. Injury, 56(1), 111931. https://doi.org/10.1016/j.injury.2024.111931

Nicola, R., & Dogra, V. (2016). Ultrasound: The triage tool in the emergency department—Using ultrasound first. British Journal of Radiology, 89(1061), 20150790. https://doi.org/10.1259/bjr.20150790

Peng, J., & Xiang, H. (2016). Trauma undertriage and overtriage rates: Are we using the wrong formulas? American Journal of Emergency Medicine, 34(11), 2191–2192. https://doi.org/10.1016/j.ajem.2016.08.061

Sahu, A. K., Bhoi, S., Galwankar, S., Aggarwal, P., Murmu, L., Nayer, J., ... & Kumar, A. (2020). All India Institute of Medical Sciences triage protocol (ATP): ATP of a busy emergency department. Journal of Emergencies, Trauma, and Shock, 13(2), 107–109. https://doi.org/10.4103/JETS.JETS_137_19

Storti, M., Musella, L., & Cianci, V. (2013). L’utilizzo della tecnica ad ultrasuoni FAST eseguita dagli infermieri del Dipartimento di Emergenza: una revisione sistematica [Nurse-performed FAST ultrasound in the emergency department: A systematic review]. Professioni Infermieristiche, 66(1), 5–16. https://doi.org/10.7429/pi.2013.661005

Su, H., Wang, N., Li, Z., Dong, X., Chen, G., & Cao, L. (2025). The experiences of critical care nurses implementing point-of-care ultrasound: A qualitative study. Nursing in Critical Care, 30(4), e70104. https://doi.org/10.1111/nicc.70104

Sztajnkrycer, M. D., Baez, A. A., & Luke, A. (2006). FAST ultrasound as an adjunct to triage using the START mass casualty triage system. Prehospital Emergency Care, 10(1), 96–102. https://doi.org/10.1080/10903120500373058

Weile, J., Frederiksen, C. A., Laursen, C. B., Graumann, O., Sloth, E., & Kirkegaard, H. (2020). Point-of-care ultrasound induced changes in management of unselected patients in the emergency department-a prospective single-blinded observational trial. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 28(1), 47. https://doi.org/10.1186/s13049-020-00740-x

Yamada, T., Kimura, T., Shigetomi, K., Shinohara, T., Ouchi, S., Mabuchi, S., ... & Hashimoto, M. (2025). Barriers to and facilitators of point-of-care ultrasound utilization among physicians, nurse practitioners, and nurses in Japan: A comparative study. The Ultrasound Journal, 17(1), 1. https://doi.org/10.1186/s13089-025-00399-4

Yancey, C. C., & O’Rourke, M. C. (2022). Emergency department triage. In StatPearls. StatPearls Publishing.

Published

10-01-2026

How to Cite

Tirwa, M. ., & Koul, P. (2026). Effectiveness of Nurse-Initiated Sono Triage on Nurses’ Competence and Triage Rates in a Tertiary Care Emergency Department in New Delhi, India. The Malaysian Journal of Nursing (MJN), 17(3), 141-152. https://doi.org/10.31674/mjn.2026.v17i03.014

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