Appropriate patient assessment and accurate triage level acuity assignment is imperative for the delivery of care in the Emergency Department (ED). The Emergency Severity Index (ESI) is a triage tool used in EDs to measure patient assessment upon arrival. The ESI rates patients according to both acuity level and predicted resource utilization and categorizes them from level 1 (most critical) to level 5 (least critical). Research demonstrates that proper education of the staff nurses who are using this tool is necessary both initially and on an ongoing basis for successful use of the ESI tool. The purpose of this project is to conduct a needs assessment at a rural southeastern Ohio ED to determine accuracy of the application of the ESI 5-level triage system. A retrospective stratified random chart review of 120 ED patient charts during 2011 to ascertain triage level acuity assignment was performed. Inter-rater reliability between ESI expert and original triage nurse was performed to determine accuracy of triage acuity assignment by the original triage nurse. Inter-rater reliability between ESI expert and PI was performed to determine accuracy of triage acuity assignment by PI. Collection of statistics regarding time to placement for each ESI level and left without being seen (LWBS) were also obtained to determine if standards for ESI levels were being met. Finally, a pilot study to determine efficacy of the ESI 5-level triage web-based educational program was conducted with ten ED staff nurses. The weighted kappa between rater #3 (expert) and rater #1 (original triage nurse) is 0.49 with a 95% confidence interval of 0.29 to 0.68. There are a significant number of under-triaged patients 25/120 categorized as ESI level 3 which should have been ESI level 2. The weighted kappa between rater #3 (expert) and rater #2 (PI) is 0.60 with a 95% confidence interval of 0.40 to 0.81. As ESI level increases time to placement also increases. The average percent of patients who left without being seen was also calculated and ranged from 0-3.05%, increasing with ESI level. There was a 90% completion rate of the pilot study. Post-score results were higher than pre-score results by 13.9%, with a range of 60%-100%. Post study satisfaction surveys indicate that the participants did learn new skills for triaging patients accurately. The findings suggest that the staff nurses are currently under-triaging patients. The time to placement and left without being seen percentages increase with ESI level. Additionally, the findings suggest that completing the ESI web-based educational program increases staff nurse knowledge regarding appropriate triage assignment according to ESI guidelines. The results of this study are limited by its small sample size. In addition, retrospective chart review is limited by accuracy of information, pertinent missing data and the inability to personally interview patients. Future research should include a larger study sample as well as concurrent chart review of ESI acuity level assignment.