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Eager to improve emergency department throughput while enhancing patient safety with more accurate and reliable triage, hospitals have turned to five-level triage systems that rank patients in terms of the severity of their condition.

“It predicts resource use and acuity of patients,” says Karen Toulson, RN, MSN, CEN, nurse manager of Christiana Hospital in Newark, Del., referring to the Emergency Severity Index (ESI) used at her facility. “You can predict how many patients are going to be admitted...We can plan ahead.”y seek ways to cope with greater patient volumes, say

Many hospitals have turned to five-level triage as thes Nancy Bonalumi, RN, MS, CEN, immediate past president of the Emergency Nurses Association (ENA).

“Emergency departments have become increasingly burdened with patients, and the number of visits is growing at phenomenal rates,” Bonalumi says. “Being able to accurately assess patients when they come in the door is really important if there are going to be long delays in getting care.”

Community and university hospitals in different regions across the country have embraced the new systems. Bonalumi reports that studies conducted by the ENA show the number of hospitals employing five-level triage increased 300% from 2001 to 2005.

“Clearly, there is a movement and a belief that using five-level triage is a good thing,” she says. “We’re seeing our members using that. I would say it’s a trend.”

Development of ESI

Two physicians — the late Richard C. Wuerz, MD, at Brigham and Women’s Hospital in Boston, and David R. Eitel, MD, MBA, at The York Hospital, York, Pa. — developed the Emergency Severity Index in the late 1990s. Debbie A. Travers, RN, PhD, CEN, at the University of North Carolina at Chapel Hill, worked with them to evaluate the system in 1999.

Travers’ research revealed that five-level triage was more effective and reliable than the three-level system that had been in use. And nurses preferred the five-level system.

Clinical staff at Lehigh Valley Hospital and Health Network (LVHHN) in Allentown, Pa., helped with early testing of ESI, a commonly used five-level system. ESI is based on patient acuity and, in large part, on resources needed to diagnose and treat the patient.
ESI is “more reliable and more valid” than the three-level triage system, says Courtney Vose, RN, MSN, CEN, director of emergency services at LVHHN. “The more reliable your tool, the more you can trust it,” Vose says.

Five-level triage helps ensure that patients who must wait in the ED are able to withstand the delay in care. “If you’re capacity ridden, like most emergency departments are, you need to make sure you’re putting your least sick patients in the waiting room,” Vose says.

Classifying patients

When using ESI, triage nurses assess arriving patients and follow a one-page algorithm to determine the proper acuity level (one through five). Patients in severe respiratory distress in need of intubation are ranked as level one, as are patients complaining of dizziness whose heart rates are less than 30, or 200 and above, according to the Emergency Severity Index, Version 4: Implementation Handbook. Between 1% and 3% of ED patients fall into this category, the handbook states.

“When a patient comes in, you ask yourself, ‘Can the patient wait?’ ” Toulson says. If the answer is “no,” the patient is classified as level one.

Level-two patients are at high risk with time-sensitive complaints, such as stroke symptoms or recent chest pain. Whereas level-one patients require immediate physician evaluation and treatment, nurses can start an IV, administer oxygen, or begin cardiac monitoring on level-two patients before a physician comes into the room. Between 20% and 30% of ED patients are level two, according to the handbook.

For less acute patients, the triage nurse determines the severity level by considering vital signs and the number of resources required for diagnosis and treatment. A level-three patient requires two or more resources, such as X-rays, lab work, sutures, an electrocardiogram, a specialty consult, or IV fluids. Conscious sedation counts as two resources. Pelvic exams and prescriptions are not factored in as resources. About 30% to 40% of ED visits are classified as level-three patients, the handbook states.

Patients classified as level four require one resource, and level five requires no resources. These two groups represent 20% to 35% of ED volume, according to the handbook. Christiana Hospital sends its level-four and level-five patients to a fast-track area, so they don’t have to wait as long and don’t tie up emergency beds, Toulson says.

Other five-level systems

Five-level triage systems have become the standard in the United Kingdom and Canada (see graphic, “Other Five-Level Triage Systems”). The Manchester Triage Scale is used in the U.K. and has a flow chart-based format, according to the Emergency Severity Index, Version 4: Implementation Handbook. Under this scale, nurses first identify a patient’s chief complaint and then follow one of 52 flow charts to conduct a structured interview and assign a triage level from one (immediate care needed) to five (care within four hours).

The Canadian Triage and Acuity Scale (CTAS), developed in the 1990s, evolved from an Australian system now known as the Australasian Triage Scale. This index focuses the triage nurse’s attention on symptom assessment, says Anna Sensenig, RN, BSN, nurse manager of the ED at Holy Cross Hospital in Silver Spring, Md. Holy Cross began using CTAS in 2002.

“The Canadian triage system breaks it into symptomatology: What is the presenting problem with the patient, and what are some of the discriminators that would alter the level, such as higher blood pressure, higher pain level,” says Kendra Cline, RN, assistant director and educator at the Reston Hospital Center ED in Reston, Va.
Reston began using CTAS last year, after its parent company, HCA Inc., launched a corporate initiative to switch to five-level triage. HCA Inc. allows its member hospitals to use either CTAS or ESI.

“The staff [at Reston Hospital Center] voted to use the CTAS model. They chose that because it’s based on nurse interpretation and care,” Cline says. “With young nurses coming through critical care areas due to the nursing shortage, they don’t always know what the doctor will be ordering or how to anticipate that.

“There’s a lot of evidence-based research that says you accurately move your patients better with a five-level system,” Cline says. “And we’ve found that to be true.”

Converting to five-level triage

Hospitals have found that adopting the five-level triage systems is relatively easy. “The change went well,” Toulson says. “We’re glad we did it. It has helped us a lot.”
Christiana requires all triage nurses to attend a class about ESI and pass a competency test.

Holy Cross held off-unit educational sessions and implemented five-level triage at the same time it installed a computer-documentation system that prompted nurses in determining the proper triage level. “You were able to make the decision independently, but it had you head in the right direction,” says Maureen Garcia, RN, BSN, educator for the ED at Holy Cross. “That helped make the transition smoother.” The hospital also keeps a reference book on hand for guidance.

HCA contracted with Triage First, a North Carolina consulting firm, to conduct two-day training sessions at facilities rolling out five-level triage. Reston Hospital Center now requires nurses to pass an annual competency test, and the hospital completes a 10-chart audit every weekday to monitor triage accuracy.

“It’s an ongoing learning process. It takes time to understand and learn it,” Cline says. “It’s like a different language. It’s completely different than what we did for years and years.”

Triage nurses at LVHHN spend 16 hours with a preceptor and must pass a test before they are allowed to triage patients independently. Chart audits verify the accuracy of their triage determinations.

“Nurses feel very comfortable with it,” Vose says. “You still need good critical thinking skills and [you must] be grounded in emergency nursing, but it gives you a good guideline.”

Debra Anscombe Wood, RN, is a freelance writer.

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