The document discusses emergency triage in a hospital emergency department. It describes triage as a process where a nurse rapidly evaluates patients upon arrival to determine the level of acuity and priority for care. The triage nurse assesses factors like chief complaint, appearance, vital signs, history and assigns the patient to one of five standardized triage levels, from level 1 being life-threatening to level 5 being non-urgent, with corresponding timeframes for clinician assessment. The primary role of the triage nurse is to make decisions about priority of care while monitoring for communicable diseases or violence.

1. Emergency Triage
Leenard Michael A. Sajulga, RN

2. Triage
• A French verb meaning “to sort.”
• Emergency triage
– a subspecialty of emergency nursing,
which requires specific, comprehensive
educational preparation

3. • 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 patient's:
– chief complaint; general appearance;
ABCD; environment; limited history;
comorbidities.

4. • 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.

5. PRIORITIZING CARE AND
TRIAGE CATEGORIES

6. 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

7. Triage Level 1—Immediately
Life-threatening or
Resuscitation
• Conditions requiring immediate clinician
assessment
• Any delay in treatment is potentially life-
or limb-threatening.

8. • Includes conditions such as:
– Airway or severe respiratory
compromise.
– Cardiac arrest.
– Severe shock.
– Symptomatic cervical spine injury.

9. – Multisystem trauma.
– Altered level of consciousness (LOC)
(GCS < 10).
– Eclampsia.
– Extremely violent patient.

10. Triage Level 2—Imminently
Life-threatening or
Emergent
• Conditions requiring clinician assessment
within 10 to 15 minutes of arrival.

11. • Conditions include:
– Head injuries.
– Severe trauma.
– Lethargy or agitation.
– Conscious overdose.
– Severe allergic reaction.
– Chemical exposure to the eyes.
– Chest pain.
– Back pain.

12. – 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.

13. – 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.

14. Triage Level 3—Potentially
Life-threatening/Time
Critical or Urgent
• Conditions requiring clinician assessment
within 30 minutes of arrival.

15. • 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.

16. Triage Level 4—Potentially
Life-serious/Situational
Urgency or Semi-urgent
• Conditions requiring clinician assessment
within 1 hour of arrival.

17. • 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.

18. Triage Level 5—Less/Non-
urgent
• Conditions requiring clinician assessment
within 2 hours of arrival.

19. • Conditions include:
– Minor trauma, not acute.
– Sore throat.
– Minor symptoms.
– Chronic abdominal pain.