Ryan C. Mirano, MD, MHSA

Purpose of ED triage: To prioritize incoming patients and to identify those who cannot wait to be seen

Three most common types of triage systems: Traffic director Spot-check Comprehensive triage

The emergency staff triages each patient and determines the priority of care based on physical, developmental and psychosocial needs as well as factors influencing access to health care and patient flow through the emergency care system.

Urgency refers to the need for time-critical intervention – it is not synonymous with severity

Triage assessment is not necessarily intended to make a diagnosis

Patients triaged to lower acuity categories may be safe to wait longer for assessment and treatment but may still require hospital admission

2 levels 3 levels 4 levels 5 levels

Emergent Emergent Life-threatening

Resuscitation

Non-emergent

Urgent Emergent Emergent

Non-urgent

Urgent Urgent

Non-urgent

Non-urgent

Referred

“Who should be seen first?” “How long can everybody wait?” ESI triage is a rapid sorting into five

groups with clinically meaningful differences in projected resource needs and therefore, associated operational needs.

Use of the ESI for this rapid sorting can lead to improved flow of patients through the ED.

Patient dying?

Shouldn’t wait?

How many resources?

None One Many Vital

signs

1

45

3

2

Yes

No

Yes

No

Consider

No

A

B

C

D

Does the patient require immediate life-saving intervention? Aimed at securing the ABC’s

Does the patient require an immediate airway, medication, or other hemodynamic intervention? (IV, supplemental O2, monitor, ECG or labs DO NOT count)

Does the patient meet any of the following criteria: Already intubated Apneic and pulseless Severe respiratory distress Acute mental status changes, or

unresponsive

Cardiac arrest/ Respiratory arrest Critically injured trauma patient who

presentsunresponsive

Overdose with a respiratory rate of 6 Severe respiratory distress with agonal

or gasping type respirations. Severe bradycardia or tachycardia with

signs of hypoperfusion Hypotension with signs of hypoperfusion

Trauma patient who requires immediatecrystalloid and colloid resuscitation

Chest pain, pale, diaphoretic, blood pressure palpatory

Weak and dizzy, heart rate < 50Anaphylactic reactionUnresponsive with strong odor of ETOHHypoglycemia with a change in mental

status

Is this a high risk situation? patient you would put in your last open

bed Is the patient confused, lethargic or

disoriented? Is the patient in severe pain or

distress? determined by clinical observation and/or

patient rating of greater than or equal to 7 on 0-10 pain scale

System Examples/diagnosis Signs/symptoms

Abdomen Abdominal pain in the elderly, Gastrointestinal bleeding

Severe pain or unstable vital signs; Tachycardia, vomiting blood or bright red blood per rectum

Cardiac Chest painAcute arterial occlusionHistory of angioplasty with chest painPericardial effusionInfective endocardititis

Constant or intermittent Absence of distal pulse Stable vital signs

Chest pain and dyspneaHistory of drug use

General Immunocompromised patientsOncology patients

May or may not have fever

Genitourinary

Testicular torsionAcute renal failure

Sudden onset of testicular pain; Unable to be dialyzed

System Examples/diagnosis Signs/symptoms

Gynecological

Ectopic pregnancy

Spontaneous abortion

(+ )pregnant, severe lower quadrant painBleeding and tachycardia even with stable blood pressure

Neurologic Rule out meningitisHistory of multiple CVDStroke

Headache, fever, lethargyMotor or speech deficitsSevere headache withmental status changes, high blood pressure

Respiratory Severe asthmaSpontaneous pneumothorax

Severe shortness of breathSudden dyspnea

Trauma Motor vehicle crash with transient loss of consciousnessBlunt and Penetrating Trauma

History of head trauma

Patient dying?

Shouldn’t wait?

How many resources?

None One Many Vital

signs

1

45

3

2

Yes

No

Yes

No

Consider

No

A

B

C

D

What is typically done for the patient who presents to the emergency department with this common complaint?

Resources can be hospital services, tests, procedures, consults or interventions that are above and beyond the physician history and physical, or very simple emergency department interventions such as applying a bandage.

RESOURCES NOT RESOURCES

Labs (blood, urine) History & physical(including pelvic)

ECG, X-rays, CT-MRI-ultrasoundangiography

Point-of-care testing

IV fluids (hydration) Saline or heplock

IV, IM or nebulized medications PO medications

Specialty consultation Phone call to PCP

Simple procedure = 1(laceration repair, Foley cath)Complex procedure = 2(conscious sedation)

Simple wound care (dressings, recheck) Crutches, splints, slings

ESI Level

Patient Presentation Interventions Resources

5 Healthy 52-year-old male ran out of blood pressure medication yesterday; BP 150/92

Needs an exam and prescription

None

4 Healthy 19-year-old with sore throat and fever

Needs an exam, CBC and possibly throat culture, prescriptions

Lab tests (throat culture and CBC)

4 Healthy 29-year-old female with a urinary tract infection, denies vaginal discharge

Needs an exam, urine, and urine C&S, preg test, and prescriptions

Lab (Urinalysis, Urine C&S, Pregnancy test)

3 A 22-year-old male with right lower quadrant abdominal pain since early this morning (+) nausea, no appetite

Needs an exam, lab studies, IV fluid, abdominal CT, and perhaps surgical consult

2 or more

Before assigning a patient to ESI level 3, the staff needs to look at the patient's vital signs and decide whether they are outside the accepted parameters

Danger zone vital signs: Adults(>8 years old) = Pulse <50 or >100

RR <10 or >30 BP <90/60 SaO2 <80%

Patient dying?

Shouldn’t wait?

How many resources?

None One Many Vital

signs

1

45

3

2

Yes

No

Yes

No

Consider

No

A

B

C

D

LEVELS AREA ASSIGNEDPATIENT SHOULD

BE SEEN BY PROVIDER WITHIN

1 - Resuscitation Resuscitation Area 0 minutes

2 - Emergent Critical Beds 10 minutes

3 - Urgent Acute Beds 30 minutes

4 - Semi-urgent Acute or Primary Care 60 minutes

5 - Nonurgent Primary Care 120 minutes

A 44-year-old female is retching continuously into a large basin as her son wheels her into the triage area. Her son tells you that his diabetic mother has been vomiting for the past 5 hours and now it is “just this yellow stuff.” “She hasn't eaten or taken her insulin,” he tells you. No known drug allergies (NKDA). VS: BP 148/70, P 126, RR 24

Answer: ESI level 2: high risk. A 44-year-old diabetic with continuous vomiting is at risk for diabetic ketoacidosis. The patient's vital signs are a concern as her heart rate and respiratory rate are both elevated. It is not safe for this patient to wait for an extended period of time in the waiting room

“I have this infection in my cuticle,” reports a 26-year-old healthy female. “It started hurting 2 days ago and today I noticed the pus.” The patient has a small paronychia on her right 2nd finger. NKDA, T 37.8° F, RR 14, HR 62, BP 108/70

Answer: ESI level 4: one resource. This young lady needs to have an incision and drainage of her paronychia. She will require no other resources.

“My mother is just not acting herself,” reports the daughter of a 72-year-old female. “She is sleeping more than usual and complains that it hurts to pee.” VS: T 100.8° F, HR 98, RR 22, BP 122/80. The patient responds to verbal stimuli but is disoriented to time and place

Answer: ESI level 2: new onset confusion, lethargy, or disorientation. The daughter reports that her mother has a change in level of consciousness. The reason for her change in mental status may be a urinary tract infection that has advanced to bacteremia. She has an acute change in mental status and is therefore high risk.

A 76-year-old male is brought to the ED because of severe abdominal pain. He tells you “it feels like someone is ripping me apart.” The pain began about 30 minutes prior to admission and he rates the intensity as 10/10. He has hypertension for which he takes a diuretic. No allergies. The patient is sitting in a wheelchair moaning in pain. His skin is cool and diaphoretic. VS: HR 122, BP 88/68, RR 24, SpO2 94%

Answer: ESI level 1: requires immediate lifesaving intervention. The patient is presenting with signs of shock-hypotensive, tachycardic, with decreased peripheral perfusion. He has a history of hypertension and is presenting with signs and symptoms that could be attributed to a dissecting aortic abdominal aneurysm. He needs immediate IV access, aggressive fluid resuscitation, and perhaps blood prior to surgery

A 68-year-old female presents to the ED with her right arm in a sling. She was walking out to the mailbox and slipped on the ice. “I put my arm out to break my fall. I was lucky I didn't hit my head.” Right arm with good circulation, sensation, and movement, obvious deformity noted. PMH: arthritis, medications: ibuprofen, NKDA. Vital signs within normal limits. She rates her pain as 6/10.

Answer: ESI level 3: two or more resources. It looks like this patient has a displaced fracture and will need to have a closed reduction prior to casting or splinting. At a minimum, she needs x-rays and an orthopedic consult. Her vital signs are stable, so there is no need to up-triage her to an ESI level 2. Her pain is currently a 6/10.

Review of all negative outcomes which occurred due to a mis-triage

Measurement of time from patient arrival to being seen by a physician for each ESI triage category

Measurement of length of stay for each ESI triage category

Measurement of admission rates for each ESI triage category