In the modern emergency department (ED), “triage” is an inclusive term for a series of front-end processes that begin the patient assessment process. Triage helps prioritize which patients are treated when EDs experience treatment space limitations. The Emergency Nurses Association (ENA) notes, “Triage ensures that the most severe acuity patients with the highest need have the correct resources applied as quickly as possible.”
The English term “triage” derives from the French verb trier , meaning “to sort.” The concept was developed and refined in the early 19th century by Napoleon’s military to risk-stratify French wounded soldiers on the battlefields. It was recognized that there were three major categories of wounded soldiers: (1) those who were too seriously ill to survive, (2) those with minor wounds that did not threaten life or limb, and (3) those between these two extremes who had injuries that were amenable to treatment given the technology at the time. It was decided that the last group should be taken first, as they could benefit the most from the treatment. This mode of triage is still used in the prehospital setting to prioritize medical responses during disasters and mass casualty events.
Triage Overview
Currently, the term “triage” refers to these steps in the ED patient intake process:
- 1.
First point of contact for ambulatory patients: When a patient arrives unannounced, there should be an organized, efficient process by which a patient begins the care process. Although hospitals differ in the details, most place an experienced nurse close to the ED’s ambulatory entrance to interact with arriving patients. The nurse performing this process might also be referred to as the “greet” or “pivot” nurse.
- 2.
First point of contact for ambulance arrivals: Many EDs have a separate system using a different nurse for receiving the emergency medical services (EMS) report and initiating care for patients arriving by ambulance. This is a much more efficient encounter because the prehospital providers’ report is a succinct assessment of the patient’s problem that does not involve interviewing the patient. The nurse will often “eyeball” the patient while receiving the EMS report and make a quick judgment that will concur with (or differ from) that of the prehospital provider.
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Application of a standardized triage scale to the patient: This process quantifies the nurse’s assessment into a standardized, reliable scale that can be used to
- a.
Determine the order in which patients are seen
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Allow comparisons to be made over time about longer-term trends in the acuity of a hospital’s patient mix
Most contemporary EDs have a “pull until full” philosophy, meaning if there is an open bed, arriving patients are directly bedded without wait; assignment of the triage score is not needed for prioritization because an open bed is available. However, due to regulatory imperatives and the benefit of understanding long-term trends of arrival acuity, every patient arriving will receive this score.
- a.
- 4.
Initiation of a nursing database: Over time, and in a manner specific to every institution, documentation requirements of the triage nurse have expanded exponentially. In addition to documenting a succinct chief complaint and any patient allergies, triage screens may also require that the nurse documents the patient’s medications, any history of travel to areas with severe or unusual infectious diseases, whether the patient is a victim of domestic violence, the presence of any recent infectious disease (e.g., tuberculosis) exposures, and any additional questions that may identify other regional health-related issues.
The benefit of a more extensive nursing database development process at triage is the potential for earlier identification of certain medical issues that might involve a higher level of isolation or an earlier mental health consultation. The risk is that this inexorable expansion of required triage fields leads to a longer and more complicated intake process, resulting in either the necessity to devote more workforce to the initial evaluation or to have the triage process become an “entry blocker,” leading to increased queuing behind triage.
- 5.
Segmentation: This is the process by which certain patient problem categories are managed in a manner specific to that type of problem. The best example is that of a “fast track,” where patients with apparent (to the triage nurse) minor problems who can remain vertical (i.e., do not need a stretcher) are sent to a specific area of the ED, often with a higher patient-to-nurse ratio and smaller cubicles with chairs rather than stretchers. The stricter the segmentation process in a given hospital, the greater the requirement for an accurate nursing triage assessment.
Triage Scales
Emergency Severity Index
The development of triage severity scales has paralleled the development of emergency medicine. Many hospital EDs started quantifying patient severity by using their own systems that often had three levels (e.g., emergency, urgent, and nonurgent). In the 1990s it was recognized that a better triage scale was needed in the United States, and the 5-level Emergency Severity Index (ESI) was developed by two emergency physicians, Richard Wuerz and David Eitel. The scale was refined by the ENA and the Agency for Healthcare Research and Quality (AHRQ) and is now owned by the ENA.
The scale places patients in the two highest severity categories (1 and 2, with 1 being the most severe) according to the patients’ vital signs, mentation, and chief complaint. Patients are divided among the three lower severity categories (3, 4, 5) by the number of resources that the nurse expects the patient will need (see Fig. 6.1 ). The distribution of patients in each category is outlined in Table 6.1 . Unlike many of the other triage scales (see the following sections), the ESI provides more leeway for the triage nurse to use their clinical judgment in assigning the score. It is also the only major triage system that uses resource utilization in assigning the score.
