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How to Use a 5-Level Triage System

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How to Use a 5-level Triage System
Western Governors University

Topic: The importance and application of a 5-level triage system.

Attention Getter: I am currently a Charge Nurse in the busiest emergency room in Nevada. We see an average of 300 patients a day with wait time in the lobby upwards of 12-14 hours.
Purpose: The purpose of my presentation is to inform. I want my audience to understand why a 5-level triage system is best practice and I want my audience members to have a basic understanding of a 5-level triage system and to be able to begin training in an ER triage setting.

Audience: The ideal audience for my presentation are nurses that are newly graduated or new to the ER setting. My topic is specific for my intended audience and is beneficial for them. This presentation can be easily altered to address nurses that will be working in a pediatric ER.

Significance: The ability to correctly triage a patient in an ER is crucial to patient safety and patient care. In a busy ER patients generally have to wait to be taken out of the waiting area. A triage nurse needs to be able to sort through the patients and decide who the priorities are. The intended audience will become the nurses making these decisions.

Thesis Statement: Research shows that a 5-level triage system is best practice because ESI and CTAS provide dependability and reliability and because the implementation of a standardized ER triage process improves patient care.

I. First Main Point: A 5-level triage system is best practice because ESI and CTAS provide dependability and reliability.
A. Previous triage systems broke levels down to Emergent, Urgent, and Non-Urgent. These previous systems had less standardization then the 5-level ESI system.
B. Chart reviews revealed that there was rarely any correlation between triage acuity assignments and patient outcomes: patients triaged as Non-Urgent were admitted sometimes; patients triaged into a higher acuity category of Emergent or Urgent were often discharged. The triage acuity was often assigned with no clear clinical indication for the level, and the nursing documentation to support the assigned triage level was also lacking. Therefore, patient outcomes and resource utilization could not be anticipated on the basis of triage level. (Daniels, 2007, p. 59)
C. According to a study done of ER professionals in 2010 they were very satisfied with ESI. They indicated that ESI is more accurate than other triage algorithms and reduces the subjectivity of triage.(Singer, Infante, Oppenheimer, West, & Siegel, 2012, p. 120)
II. Second Main Point: Learning a 5-level ESI triage process to improve patient care.
A. ESI Levels 1-5
a. Level 1 patients are patients that are in cardiac/respiratory arrest or require any life-saving interventions immediately.
b. Level 2 patients are patients that are in a typically high risk situation. For instance – chest pain, altered mental status, psychiatric conditions requiring supervision, and severe pain.
c. Level 3-5 patients are decided based on resources. Level 5 uses no resources, Level 4 uses one resource, and Level 3 requires multiple resources.
d. The Triage Algorithm shows how to triage patients using chief complaint, vital signs, and resources needed. It also shows pediatric considerations for triage.

Resources Not Resources
• Labs (blood, urine).
• ECG, X-rays.
• CT-MRI-ultrasound-angiography. • History & physical (including pelvic).
• Point-of-care testing.
• IV fluids (hydration). • Saline or heplock.
• IV or IM or nebulized medications. • PO medications.
• Tetanus immunization.
• Prescription refills.
• Specialty consultation. • Phone call to PCP.
• Simple procedure =1 (lac repair, foley cath).
• Complex procedure =2 (conscious sedation). • Simple wound care (dressings, recheck).
• Crutches, splints, slings.
D. Danger Zone Vital Signs. Consider uptriage to ESI 2 if any vital sign criterion is exceeded.
Pediatric Fever Considerations:
1. 1 to 28 days of age: assign at least ESI 2 if temp >38.0 C (100.4F).
2. 1-3 months of age: consider assigning ESI 2 if temp >38.0 C (100.4F).
3. 3 months to 3 yrs of age: consider assigning ESI 3 if: temp >39.0 C (102.2 F), or incomplete immunizations, or no obvious source of fever.
(ESI Triage Research Team, 2014, Appendix B)

Summary: In summary, hospitals that have implemented a 5-level triage system have had better patient outcomes. Triage nurses throughout an emergency room can now consistently assign a triage level that is appropriate for patient care and outcome. When implementing a 5-level triage system multiple nurses will triage the same patient at the same level.
1. Do I ever triage a patient based on times for an ER’s arrival to departure requirements?
No. Although many ERs are now tracking arrival to departure times you cannot triage a person based on the length of time for a resource. For instance, if you have a fast track area that sees level 4 patients and your CT department is behind in CTs you would not make your level 4 patient a level 3 to fall into the time requirements.
2. Why is there a significant difference between a 4-level and a 5-level triage system?
Education and training are probably the biggest factor. When the 5-level system was implemented there was training provided to staff members. This included an algorithm to follow. The 4-level system left the decision between levels to be made by each individual nurse.
3. Do you always have to completely follow the ESI algorithm?
No. Although this system works very well there are times that other factors have to be considered, such as, patient age, history, and medications

Daniels, J. H. (2007). Outcomes of Emergency Severity Index Five-Level Triage Implementation. Advanced Emergency Nursing Journal, 29(1), 59. Retrieved from
ESI Triage Research Team. (2014). Emergency Severity Index (ESI): A Triage Tool for Emergency Departments. Retrieved from
Singer, R. F., Infante, A. A., Oppenheimer, C. C., West, C. A., & Siegel, B. (2012, March). The use of and satisfaction with the emergency severity index. Journal of Emergency Nursing, 38(2), 120-126. Retrieved from

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