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New Triage System Gaining in Popularity

Monday September 8, 2003
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A triage nurse decides which patients will be seen by a physician and in which order. Inaccurate decisions can lead to delays in patient care and contribute to poor patient outcomes. Therefore, triage nurse's decisions must be accurate. But the current three-level triage system is still used by 69% of EDs across the country, according to the Emergency Nurses Association (ENA), may no longer be the best way to decide who needs care first.
The concept of a five-level triage system is gaining popularity among ED nurses and physicians. A joint task force of the ENA and the American College of Emergency Physicians recently met in Chicago to draft a policy statement regarding five-level triage. The adoption of a national triage system for the US would allow EDs across the country to obtain accurate data to describe their patient mix and allow EDs to benchmark against other departments throughout the country. In addition to determining patient acuity, a good triage system will help describe the individual ED's case mix or acuity level and be a reliable and valid research-based system.
Reliability of triage means two different triage nurses will assign the same triage level to the same patient. Validity means the triage system is accurately measuring acuity. While no gold standard for triage validity exists, hospital admission and mortality rates are often used to measure validity of the triage level. So a higher acuity level patient would be more likely to be admitted to the hospital than a lower acuity level patient.
Without good reliability and validity, EDs cannot accurately describe the acuity or case mix of patients in their departments, which in turn means they will have difficulty making strong arguments for increasing staffing or making other improvements.
There are currently three five-level triage systems with published data on reliability and validity in use throughout the world. The Emergency Severity Index (ESI) is a five-level triage system developed by a group of ED nurses and physicians in the US.
The ESI has undergone extensive testing and demonstrates excellent reliability and validity, according to articles published in Academic Emergency Medicine.
The Emergency Severity Index Implementation Manual: A Five-Level Triage System provides an in-depth explanation of the ESI's algorithmic approach to assessing patients upon arrival and determining acuity levels.
Level 1 reflects the highest acuity. Patients in this level require immediate evaluation. Level 5 is the lowest acuity level and describes a patient who will require no resources or significant care in the ED.
Not only does the algorithm consider how long a patient can wait but how many resources it will take to get the patient to an ultimate disposition from the ED. Experienced ED nurses can easily predict the amount of resources - which are clearly defined in the algorithm - a patient will need
The algorithm is easy to follow. The triage nurse first determines life threats to airway, breathing, and circulation. If patients are intubated, apneic, pulseless, or not breathing, they are considered ESI Level 1 and need immediate care.
If these criteria are not met, the triage nurse then determines if the patient is high risk; is experiencing new onset confusion, lethargy or disorientation; or is in severe pain or distress. If any of these conditions is met, the patient is considered ESI Level 2. Placement of these patients should be facilitated as rapidly as possible.
Patients who do not require any resources are considered ESI Level 5, while those requiring one resource are ESI Level 4. Those patients requiring two or more resources are ESI Level 3.
For example, a patient who simply needs a prescription refill is an ESI Level 5. A patient with a sprained ankle needs an x-ray (one resource) and is an ESI Level 4. A patient with abdominal pain will require two or more resources - laboratory tests and intravenous analgesics - and is an ESI Level 3 patient.
ESI Level 3 patients have their vital signs assessed by the triage nurse. If the algorithm's vital sign criteria are violated, the triage nurse can consider moving the patient to ESI Level 2.
Vital signs are required only for ESI Level 3 patients. This initially seems wrong. However, experienced triage nurses are easily able to identify ESI Level 1 and 2 patients without vital signs. And ESI Level 4 and 5 patients present with minor complaints, so vital signs usually do not add value in determining the triage level.
The ESI is a unique triage system that has proven not only to be reliable and valid but easy to teach to experienced ED nurses. As discussion occurs nationally during the next year, five-level triage systems will become more popular. Now is the time to evaluate the literature and prepare for a new way of triaging our overcrowded EDs.
Paula Tanabe, RN, PhD, is a postdoctoral research fellow at the Institute for Health Services Research and Policy Studies at Northwestern University's Feinberg School of Medicine in Chicago.
Bibliography
Wuerz R, Fernandes C, Alarcon J. Inconsistency of emergency department triage. Annals of Emergency Med. 1998;32:431-435.
Brillman JC, Doezema D, Tandberg D, et. Al. Triage: Limitations in predicting need for emergent care and hospital admission. Ann Emerg Med. 1996;27:493-499.
Gill J, Reese C, Diamond J. Disagreement among health care professionals about the urgent care needs of emergency department patients. Ann Emerg Med.1996; 28:474-479.
Travers D, Waller A, Bowling JM, Flowers D, Tintinalli J. Five-level triage system more effective than three-level in tertiary emergency department. J Emer Nurs. 2002;28:395-40.
Gilboy N, Tanabe P, Travers D, Eitel D, Wuerz R. The Emergency Severity Index Implementation Handbook; A Five-Level Triage System. Des Plaines, Emergency Nurses Association. 2003.l