Using a comprehensive triage system offers which advantage

Chapter 7 Triage

Triage is the process of rapidly sorting patients who present to the emergency department (ED) to determine who needs to be seen immediately and who is safe to wait. This process requires the skills of an experienced emergency nurse. Recently, improving the flow by streamlining the triage process has been the focus of many process improvement efforts in emergency departments.

Environment

In today’s busy ED, the triage function has become even more critical. The number of persons seeking medical care in EDs grew by 32% between 1996 and 2006.2 This number is expected to continue to grow in light of the aging population, the number of uninsured patients, and issues surrounding access to primary care. In fact, in 2005, 20% of the United States population had made one or more visits to an ED within the past year.2 In 2002 The Joint Commission3 released a sentinel event alert that identified EDs as the location for more than half of all reported sentinel events involving patient death or permanent disability because of delays in treatment. In nearly one third of these occurrences, overcrowding was deemed to be a contributing factor. Given this environment, an effective triage process is crucial to the smooth functioning of an ED.

The word “triage” comes from the French word trier, which means to sort or choose. Today, hospital triage refers to the quick sorting of patients who present to the ED for care. The purpose of triage is to put the right person in the right place at the right time for the right reason. The triage concept has been used since Napoleonic times when soldiers wounded in battle were sorted according to injury severity. Those with mortal wounds were separated from combatants who potentially could be saved. The goal of rapid treatment was to maximize survival and return as many soldiers as possible to the battlefield. The triage concept is still in use in the military and has since become a standard part of civilian ED operations.

In the late 1950s and early 1960s, health care delivery models in the United States changed dramatically. Physicians moved away from independent practices and formed office-based practice groups with regular clinic hours. Instead of house calls, patients now were seen by appointment. At the same time, a nationwide move toward medical specialization began, leaving fewer doctors available for primary care. Hospitals were also evolving. As a result of advances in diagnostic technology and the introduction of intensive care units, hospitals assumed a new role, becoming 24-hour medical resources rather than just a place to stay when seriously ill. With the growth of hospital-based services, EDs began to deal with an onslaught of patients, many with nonurgent complaints. The practice of seeing patients on a first-come, first-served basis rapidly became outmoded, so severity-based triage systems were implemented.

Triage Severity Rating Systems

Several different triage severity rating systems are described in the literature and are used in various parts of the world. Each system has unique features that are described briefly later.

Triage severity rating systems are evaluated along several dimensions; two important considerations are validity and reliability. Validity refers to the accuracy of the triage severity rating system. In other words, how well does it measure what it is intended to measure? Do the different triage levels truly reflect differences in severity? For example, you would expect a high admission rate for patients identified as very ill.

Reliability is another important characteristic of a triage severity rating system. This refers to the degree of consistency (or agreement) among those using the method. Will different triage nurses assign the same patient the same severity level? Over time, will each triage nurse consistently assign similar patients the same severity level? Importantly, criteria for each triage level need to remain constant. A patient’s assigned severity rating cannot vary simply because the department is busy or a particular nurse is performing triage.

A triage severity rating system serves as more than just a means of scoring an individual’s severity of condition; it becomes a language, a precise shorthand, for communicating patient severity to the ED as a whole. Reliable data also make it possible to compare different EDs and to look at changes within an ED over time. For example, staff may report that the pediatric population they are caring for is sicker. ED leadership can look at the case mix data for the pediatric population over time to determine if the staff’s perception is correct. Another example, staff may report that fast track needs to open earlier in the day because so many low-acuity patients are waiting for a long time to be seen. ED leadership can look at arrival time and patient acuity to see if a change in hours is prudent.

Studies have demonstrated poor inter-rater (between different raters) and intra-rater (the same rater on another occasion) reliability with three-level triage severity rating systems.5–7 This is largely because there are no universal definitions for each level. Table 7-2 defines two-, three-, and four-level triage systems and the definitions for each triage level.

TABLE 7-2 OVERVIEW OF TWO-, THREE-, AND FOUR-LEVEL TRIAGE ACUITY RATING SYSTEMS

Five-Level Triage

In 2003, The ENA’s Board of Directors approved the following position statement developed by ENA and the American College of Emergency Physicians’ (ACEP) Joint Five-Level Triage Task Force:

In 2004 the Joint Five-Level Triage Task Force identified the Canadian Triage and Acuity Scale (CTAS) or the Emergency Severity Index (ESI) as good options based on a review of the published evidence on five-level triage systems.9

Currently, there are four research-based, five-level triage severity rating scales in use around the world. In each scale, level 1 represents the highest severity (most acute), whereas level 5 is used to designate the patients with the least acute conditions.

The Emergency Severity Index

Two American emergency physicians working with a team of emergency physicians and nurses created the Emergency Severity Index (ESI).20 This research-based, five-level scale categorizes patients by severity and expected resource needs (Fig. 7-1). Severity is defined as the stability of vital functions and the potential for life, limb, or organ threat. Resource consumption, a component unique to the ESI, is defined as the number of different resources a patient is expected to consume to reach a disposition. The experienced emergency nurse is capable of estimating resource consumption based on previous, similar patient encounters.

Like other five-level systems, research has demonstrated that the ESI is valid and reliable.20–24 The system itself consists of an easy-to-use algorithm designed to rapidly sort patients into one of five mutually exclusive categories. Educational materials include an online course, a training DVD, and a handbook.25,26

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