Five-Level Triage Streamlines ED Care
Monday September 20, 2004
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The Emergency Severity Index (ESI) developed by two East Coast physicians in the late 1990s aims to put such concerns to rest by using a five-level triage system that better streamlines emergency care.
The new system "decreases the ambiguity of who
is the most acute patient, and the most acute patients are seen in a more timely fashion," says Mary Auffrey, RN, MS, CEN, a clinical educator at
HealthAlliance, Leominster, Mass. The Leominster campus ED began using the ESI in January 2004. "Nurses are very excited by it because at any given time, they know the sickest patients are ... being seen and not [kept] in the waiting room."
The late Richard C. Wuerz, MD, of Brigham and Women's Hospital in Boston, and David R. Eitel, MD, MBA, at York Hospital in York, Penn., developed the ESI. Debbie Travers, RN, PhD, CEN, seeking a better way to classify patients arriving in the ED, worked with Wuerz to evaluate the system at the University of North Carolina at Chapel Hill in 1999. Her research found that five-level triage was more effective and reliable than the three-level system and that nurses liked it better.1
The ESI is a one-page algorithm - "very simple and straightforward to use," says Travers. The nurse assesses whether the patient has a life-threatening condition or if the problem will soon be potentially fatal. The nurse also considers vital signs and, for lower-acuity patients, the number of resources required. The triage nurse then assigns a triage
level, with Level 1 being the most acute and
Level 5 the least.
Travers found that "we've been able to reproduce the triage ratings better with the five-level [system] than with a three-level [one]. Before, we didn't get good reliability." She said physicians began accepting the ratings, rather than dismissing them as an
individual nurse's predisposition toward certain ratings.
"It makes nurses more credible to use a system that can be applied consistently from one nurse to the next," she says.
As hospitals learned about the success of the new system, physicians and nurses working with ESI
realized the need for a training manual to help other facilities make the transition to five-level triage. Wuerz drafted an early version, which was revised and completed by Travers, Eitel, Nicki Gilboy, RN, MS, CEN, and Paula Tanabe, RN, PhD, CEN, CCRN. More than 1,000 facilities have purchased the book, titled The Emergency Severity Index Implementation Handbook: A Five-Level Triage System, from the Emergency Nurses Association.
A Five-Level Standard
The ENA and the American College of Emergency Physicians (ACEP) issued a joint statement in September 2003 in support of a standardized ED triage scale and acuity categorization process, plus the adoption of a reliable and valid five-level triage scale. A standard would help researchers compare and contrast acuity at hospitals and allow facilities
to benchmark how they're doing.
The ENA/ACEP Joint Five-Level Triage Task Force continues to meet and has yet to say whether it will recommend Wuerz and Eitel's ESI. Canadian and Australian hospitals have used five-level triage for years, but the foreign systems differ from ESI. Travers, a member of the task force, said she's not wedded to ESI, but strongly believes the time has come to switch to a five-level system.
"Nurses are good at triage," says Travers, "and
we need to use the best system possible to reflect
the good decisions nurses can make at triage."
Some U.S. hospitals making the transition to five-level triage have developed their own hybrid scales. Mount Sinai Hospital Medical Center of Chicago, which changed to a five-tier system six months ago, uses a blend of the Canadian Triage and Acuity Scale and the ESI. The hospital made the switch after observing that many patients left the ED without treatment. Phyllis Grice, RN, BSN, TNS, emergency services director, says she wanted to learn more
about these patients and saw an opportunity to
find out with five-tier triage: "I feel a five-level
system would provide better information than the traditional three-tier model."
Sutter Health in California began moving to a
five-tier system more than two years ago. It, too, developed its own system, based on the Canadian acuity scale, but including consideration of the number of resources the patient would need. One major
difference with the Sutter Health system: It considers a level one patient the least urgent and a five the
most acute.
"We wanted to take the approach that the more resources should go in the same direction with acuity of the patient," says Catherine Ross, RN, CCRN, director of emergency services and the trauma-
neurointensive care unit at Sutter Roseville Medical Center. "As your condition requires more need, then that increases up the [numeric] triage level."
Moving Toward Five
Sutter Health began implementing five-level triage in the Sacramento-Sierra region before rolling it out throughout its 28-hospital system. It rotates nurses through the triage position, so all RNs working in the ED know how to triage with the five-tier scale. Ross says that its former three-tier system was easier for nurses, but it resulted in the bulk of patients' being
classified in the middle.
"Whenever you make a change in a process, there is a learning curve," says Ross. "This meant they had to use more differentiation. Overall, they say it was
a big help. Nurses at triage took some time to get comfortable with it."
Auffrey says that making the switch to five levels isn't easy, especially in an ED like hers where most
of the nurses have worked for decades using a
three-level system. But once nurses at HealthAlliance
began working with it, she says, they liked it.
HealthAlliance spent a year preparing for the
transition and involved its informational services team, registration staff, and others from the hospital in the planning process. Changes were made to the tracking board, to software, and to forms. The
transition team attended ESI seminars before
conducting four-hour training sessions with ED nurses.
"It was truly an exercise in the whole change process," says Auffrey. "We went through all the steps of researching and determining which [system] we were going to use, whom we needed to participate, and how we were going to educate. We tried to
consider all the problems ahead of time so we could facilitate the process as much as we could for the
staff. Preparation was key."
Children's Memorial Hospital in Chicago made the transition several years ago. ED Director Cathleen Shanahan, RN, MS, says her nurses now feel very comfortable with it. However, "it was a big culture change," she adds, but education about the reasons for changing to a five-level system helped smooth
the way.
Five-Level Benefits
Besides more clearly stratifying patient acuity levels, five-level systems seem to improve patient flow. And Shanahan believes it enhances communication
between ED physicians and nurses.
"One beautiful thing this system does is that it requires physicians and nurses to speak often about the decisions they made to put patients in [a particular] category," says Shanahan. "When I put a very sick, level-two child in a room, I want the doctor to follow me. Usually as I'm settling the child, the doctor comes in behind me. That's how the flow of patients seen right away happens."
When Mount Sinai learned that low-acuity, level-five patients were skipping out, it added an extra physician assistant to its fast-track area to see these patients, says Grice: "It's helped us capture those nonurgent patients who were leaving."
Sutter Roseville also diverts low-acuity patients to a fast-track screening by a doctor or physician assistant, so these patients don't take up space in an ED bed. "It's reduced the glut of bodies and traffic in the back," says Ross.
Patients still expect first-come, first-seen service, but nurses find the five-tier system helps in explaining why others may have been taken into the ED ahead of them. Nurses can describe the criteria used to determine acuity and priorities. Ross says patients more readily accept the numeric scale, rather than simply being told their condition is nonurgent.
And when a bed is freed up, nurses don't have to shuffle through a stack of patients in the middle of
a three-level triage scale. They can easily identify
the person at the highest acuity level among the patients still waiting.
"It gives a better definition of the patients to be seen and helps nurses decide whom they are going to bring back when they have an empty gurney," says Ross. "When you can be more precise about how you're evaluating patients, ... it's a win for everybody."
Debra Anscombe Wood, RN, is a freelance writer based in Orlando, Fla.
Reference
1. Travers DA, Waller AE, Bowling JM, Flowers D, Tintinalli J. Five-level triage system more effective than three-level in tertiary emergency department. J Emerg Nurs. 2002;28(5):395-400.
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