Triage• A French verb meaning “to sort.”• Emergency triage – a subspecialty of emergency nursing, which requires specific, comprehensive educational preparation
• Patients entering an emergency department (ED) are greeted by a triage nurse, who will perform a rapid evaluation of the patient to determine a level of acuity or priority of care• The triage nurse will assess the patients: – chief complaint; general appearance; ABCD; environment; limited history; comorbidities.
• The primary role of the triage nurse: – to make acuity and disposition decisions and set priorities while maintaining an awareness for potentially violent or communicable disease situations• Secondary triage decisions involve the initiation of triage extended practices.
Standardized 5-level triage systems• Australasian Triage Scale (ATS), Canadian Triage and Acuity Scale (CTAS), Emergency Severity Index (ESI)• have been developed and proven through research to possess utility, validity, reliability, and safety
Triage Level 1—Immediately Life-threatening or Resuscitation• Conditions requiring immediate clinician assessment• Any delay in treatment is potentially life- or limb-threatening.
• Includes conditions such as: – Airway or severe respiratory compromise. – Cardiac arrest. – Severe shock. – Symptomatic cervical spine injury.
Triage Level 2—Imminently Life-threatening or Emergent• Conditions requiring clinician assessment within 10 to 15 minutes of arrival.
• Conditions include: – Head injuries. – Severe trauma. – Lethargy or agitation. – Conscious overdose. – Severe allergic reaction. – Chemical exposure to the eyes. – Chest pain. – Back pain.
– GI bleed with unstable vital signs.– Stroke with deficit.– Severe asthma.– Abdominal pain in patients older than age 50.– Vomiting and diarrhea with dehydration.– Fever in infants younger than age 3 months.
– Acute psychotic episode.– Severe headache.– Any pain greater than 7 on a scale of 10.– Any sexual assault.– Any neonate age 7 days or younger.
Triage Level 3—Potentially Life-threatening/Time Critical or Urgent• Conditions requiring clinician assessment within 30 minutes of arrival.
• Conditions include: – Alert head injury with vomiting. – Mild to moderate asthma. – Moderate trauma. – Abuse or neglect. – GI bleed with stable vital signs. – History of seizure, alert on arrival.
Triage Level 4—Potentially Life-serious/Situational Urgency or Semi-urgent• Conditions requiring clinician assessment within 1 hour of arrival.
• Conditions include: – Alert head injury without vomiting. – Minor trauma. – Vomiting and diarrhea in patient older than age 2 without evidence of dehydration. – Earache. – Minor allergic reaction. – Corneal foreign body. – Chronic back pain.
Triage Level 5—Less/Non- urgent• Conditions requiring clinician assessment within 2 hours of arrival.
• Conditions include: – Minor trauma, not acute. – Sore throat. – Minor symptoms. – Chronic abdominal pain.