Chapter 155
Triage
Sharon E. Mace, MD and Thom A. Mayer, MD
Key Points
Triage is the prioritization of care based on illness/
injury, severity, prognosis, and resource availability.
Triage identifies patients who cannot wait to be seen,
prioritizes all patients, and initiates diagnostic and
therapeutic measures.
Disaster triage differs from emergency department
triage. During a disaster with limited resources,
patients with little or no chance of survival are not
resuscitated.
The disaster triage categories are red (most urgent, first
priority), yellow (urgent, second priority), green
(nonurgent, walking wounded, third priority), and
black (dead or catastrophic).
Introduction and Background
Triage is the prioritization of patient care (or victims during
a disaster) based on illness/injury, severity, prognosis, and
resource availability. The purpose of triage is to identify
patients needing immediate resuscitation; to assign patients
to a predesignated patient care area, thereby prioritizing their
care; and to initiate diagnostic/therapeutic measures as
appropriate.
The term triage originated from the French verb trier
which means to sort. During the time of Napoleon, the
French military used triage to serve as a battlefield clearing
hospital for wounded soldiers. The U.S. military’s first use of
triage was during the Civil War. Triage on the battlefield was
a distribution center from which injured soldiers were sorted
or distributed to various hospitals. For the military during
World Wars I and II, triage was the procedure that deter-
mined which injured soldiers were able to be returned to the
battlefield. Military triage continued to evolve during the
Korean and Vietnam wars with the tenet of doing the “great-
est good for the greatest number of wounded and injured.”1
Refinements in battlefield medicine and military triage have
continued during more recent conflicts, including Iraq.
Other situations in which the triage process has been
employed, in addition to the battlefield, are during disasters,
following mass casualty incidents (MCI), and in emergency
departments (EDs). Triage during a disaster involves field
triage, which sorts disaster victims into categories ranging
from the walking wounded to those with injuries who are
salvageable to the unsalvageable and the dead.
Issues and Solutions
The Triage Process
The nurse assesses and determines priority of care (triages)
based not only on the patient’s physical, developmental, and
psychosocial needs but also on parameters of patient flow in
the emergency care system and of health care access. Accord-
ing to the Emergency Nurses Association (ENA), triage
should be done by an experienced nurse with competency in
triage.2,3 The nurse should accomplish the following during
triage: take history appropriate to the severity of the com-
plaint, obtain vital signs, ask predetermined ED/hospital-
required screening questions, and assign patient priority.
Triage may be either focused or comprehensive. Comprehen-
sive triage refers to taking a complete history, checking vital
signs, determining allergies, and, where appropriate, per-
forming a physical examination. Focused triage is generally
used for more minor illnesses or injuries and includes a more
limited history and screening prior to assessing patient prior-
ity. Triage bypass, which is addressed more fully later in this
chapter, refers to an approach that places patients directly
into ED rooms at times when space and staffing allow, and
triage is performed at the bedside.
The advantages of comprehensive triage include immedi-
ate identification of patients with life-threatening or emer-
gent conditions and administration of basic first aid measures.
In addition, the patient (and family) are met by an experi-
enced nurse who can address the patient/family’s physical,
psychosocial, and emotional issues.
One criticism of a comprehensive triage system is that it
takes too much time, thereby creating a “logjam” of patients
backed up waiting to be seen by the triage nurse.4 This has
led to a two-tier triage system with the triage nurse determin-
ing, from the chief complaint and an observation or “across
the room” assessment, who is taken immediately to the
patient care area versus waiting for additional assessment and
registration. The two-tiered triage system includes a primary
1087
1088 SECTION VI — The Practice Environment

nurse and a sorter nurse, and may be used to achieve com-
prehensive triage during high-volume periods.
Pediatric and geriatric patients take more time to triage
than other patients. Comprehensive triage is said to take only
2 to 5 minutes, although one study found that this occurred
only 22% of the time.5 A concern has been expressed that
this 2- to 5-minute time frame for triage may be unrealistic.4
There have also been studies indicating inconsistency in
triage assessment among experienced triage personnel and
between nurses and physicians.6-10 Whether focused triage,
comprehensive triage, or triage bypass is used, performance
improvement data should be monitored to assess efficacy.
Triage Categories
Emergency department triage has several functions, includ-
ing (1) identification of patients who should not wait to be
seen, and (2) prioritization of incoming patients. This is
accomplished by determining the patient’s illness/injury
severity or acuity. Acuity is the degree to which the patient’s
condition is life- or limb-threatening and whether immedi-
ate treatment is needed to alleviate symptoms.
There are various triage acuity systems ranging from two
to five levels (Table 155–1). In the United States, a three-level
triage system is most commonly used (69%), with 12% of
EDs using a four-level system, 3% using a five-level model,
and 16% using no acuity system or nonresponding according
to an ENA survey done in 2001.11 There is some evidence that
a five-level triage system is more effective than a three-level
triage system.12
Specific Triage Systems
Various triage systems have been used throughout the world:
the Australian Triage Scale, the Manchester Triage Scale, the
Canadian Triage and Acuity Scale, and the Emergency Sever-
ity Index (ESI)13-21 (Table 155–2). All four of these scales have
been validated for reliability and validity in adults.14-17
Emergency Severity Index
The ESI is a five-level triage system developed in the United
States that uses a flowchart-based triage algorithm.18-21 The
ESI uses patient acuity (stability of vital signs, degree of dis-
tress), as well as expected resource intensity and timeliness
(expected staff response, time to disposition), to define the
five categories (Table 155–3).
Pediatric Triage
Of the approximately 110.2 million patients seen in EDs in
the United States in 2002, about 30% were pediatric patients,
with 85% of those seen in general EDs.22 Furthermore, there
is some evidence that, in a general ED, adults may be “seen
sooner than equally ill pediatric patients, resulting in unac-
ceptable waiting times for seriously ill pediatric patients”
unless triage criteria are modified for pediatric patients.23
Improvement in pediatric patient flow with an increase in
pediatric triage acuity levels (e.g., a significant increase in the
emergent and urgent pediatric patients) resulted from incor-
porating specific pediatric acuity markers and from posting
age-specific abnormal signs and symptoms.23
Issues relevant to pediatric triage include inapplicability of
adult triage criteria to pediatric patients; the often subtle and
difficult-to-recognize signs and symptoms of illness/injury
in young children and infants, especially those less than 1
to 2 years of age; the frequent unreliability of the clinical
impression (even with experienced triage personnel); physi-
ology and behavior in children and infants, particularly in
infants, different from that in adults; greater morbidity and
mortality in pediatric patients than in adults for similar dis-
eases; and symptom variability during a given illness. Because

Table 155–1 Triage Acuity Systems by Level

2 Levels 3 Levels 4 Levels 5 Levels 5 Levels

Emergent Emergent Life threatening Resuscitation Critical

Nonemergent Urgent Emergent Emergent Emergent
Nonurgent Urgent Urgent Urgent
Nonurgent Nonurgent Nonurgent
Referred Fast track

Table 155–2 International Triage Systems

Australasian Manchester (United Kingdom) Canadian Emergency Severity Index

Physician/ Physician/ Physician/ Physician/

Staff Response Staff Response Staff Response Staff Response
Level Time (min) Level Time (min) Level Time (min) Level Time (min)

1 = Resuscitation 0 (Immediate) 1 = Immediate 0 (Immediate) 1 = Resuscitation 0 (Immediate) 1 = Unstable 0 (Immediate)

(Red)
2 = Emergency ≤10 2 = Very Urgent ≤10 2 = Emergent ≤15 2 = Threatened Minutes
(Orange)
3 = Urgent ≤30 3 = Urgent ≤60 3 = Urgent ≤30 3 = Stable ≤60
(Yellow)
4 = Semi-Urgent ≤60 4 = Standard ≤120 4 = Less Urgent ≤60 4 = Stable Could be
(Green) delayed
5 = Nonurgent ≤120 5 = Nonurgent ≤240 5 = Nonurgent ≤120 5 = Stable Could be
(Blue) delayed
 Chapter 155 — Triage 1089

Table 155–3 Emergency Severity Index (ESI)

ESI-1 ESI-2 ESI-3 ESI-4 ESI-5

Stability of vital Unstable Threatened Stable Stable Stable

functions (ABCs)
Life threat or Obvious Reasonably likely Unlikely (possible) No No
organ threat
Requires Immediately Sometimes Seldom No No
resuscitation
Severe pain or Yes Yes (sufficient, but not No No No
severe distress necessary for this
category)
Expected resource Maximum: staff at High: multiple, often Medium: multiple Low: one simple Low:
intensity bedside continuously; complex diagnostic diagnostic studies; diagnostic study; examination
mobilization of studies; frequent or brief period of or one simple only
outside resources consultation; continuous observation; or procedure
(remote) monitoring complex procedure
Physician/staff Immediate team effort Minutes Up to 1 hr Could be delayed Could be
response delayed
Expected time to 1.5 hr 4 hr 6 hr 2 hr 1 hr
disposition
Examples Cardiac arrest, Most chest pain, stable Most abdominal Closed extremity Sore throat,
intubated trauma trauma (mechanism pain, dehydration, trauma, simple minor burn,
patient, severe drug concerning), elderly esophageal food laceration, cystitis, recheck
overdose pneumonia patient, impaction, hip typical migraine
altered mental status, fracture
behavioral disturbance
(potential violence)

of the difficulties in determining acuity for infants less than
6 months old, some have recommended that EDs that see
relatively few pediatric patients assign all children less than
6 months old to the emergent category.24
Triage Categories and Triage Systems
for Pediatric Patients
Various acuity systems for specific diseases, illnesses, and
injuries in pediatric patients have been developed. Multiple
pediatric trauma scoring systems exist.25 Scoring systems for
specific respiratory diseases, such as “Croup Scores,” have
also been developed.26 Various scales for assessment of the
young infant with fever, such as the Yale observational scale,
have been used to specifically evaluate the febrile infant.27
Unfortunately, a comprehensive pediatric triage assessment
tool that applies to all types of pediatric illnesses and injuries
throughout the entire range of pediatric age groups (new-
borns, infants, toddlers, preschool age, early school years,
and adolescence) has yet to be developed and validated in
extensive numbers of pediatric patients.24 However, several
pediatric triage and/or assessment tools are available.
A commonly used triage acuity classification for pediatric
patients uses four levels28 :
Class 1—critical: life- or limb-threatening illness/injury
that needs immediate care
Class 2—acute: significant alteration in physical or mental
health that could potentially become life or limb threat-
ening and needs intervention as soon as possible
Class 3—urgent: significant physical or mental health
problems that are not life threatening and need inter-
vention in a timely fashion
Class 4—nonurgent: may receive care when convenient
These are similar to the adult four-level acuity classifications.
More recently, a five-level system has been suggested, again
similar to the adult five-level acuity classifications: level 1 =
critical, level 2 = emergent, level 3 = urgent, level 4 = nonur-
gent, and level 5 = fast track 29 (see Table 155–1).
Several important caveats have also been suggested. All
immunocompromised pediatric patients should be consid-
ered as being seriously ill even if their presenting symptoms
are not critical.30 Immunocompromised patients include
those on corticosteroids or immunosuppressives; patients
with chronic illnesses, malignancy, and sickle cell disease;
and the very young (particularly young infants), who may
not have the typical signs and symptoms of a serious or life-
threatening illness early during the course of their illness.
Such high-risk patients, including patients with a history
of premature birth, chronic illness, and being immuno-
compromised, may initially “look well” and then rapidly
deteriorate.
Child maltreatment should be considered in the differen-
tial diagnosis of all pediatric complaints. Key elements of
the suspected child abuse or neglect (SCAN) triage inter-
view include detailed documentation of a thorough history
with quotes, and an exact description of findings and
observations.28,31
Many of the specific pediatric triage systems are based
on the primary survey (airway, breathing, and circulation
[ABCs]) and a secondary survey from the American College
of Surgeons Committee on Trauma28,32,33 (Tables 155–4 and
155–5). A primary and secondary pediatric triage survey
using an A-to-J alphabetized mnemonic is included in the
Emergency Nursing Pediatric Course28 (see Table 155–4).
All of these various triage systems, whether adult or pedi-
atric, need to be validated for reliability and validity in large
numbers of pediatric patients. There is evidence that applica-
tion of the adult triage systems (see Table 155–2) may not
be valid for pediatric patients without the addition of pedi-
atric clinical observations and pediatric vital signs, which
may lead to a more reliable triage of younger children.23,34-36
1090 SECTION VI — The Practice Environment

Table 155–4 Primary and Secondary Pediatric Triage Survey

Primary Secondary

A = Airway ✔ Patency, positioning for air entry, audible F = Find Find out underlying history of current
sounds, airway obstruction (blood, mucus, illness or injury
edema, foreign body)
B = Breathing ✔ Increased or decreased work of G = Get vital signs Obtain vital signs, obtain orthostatic
respiration, quality of breath sounds; vital signs if condition warrants
nasal flaring; use of accessory muscles;
pattern; quality; rate
C = Circulation ✔ Color and temperature of skin; capillary H = Head-to-toe Perform a head-to-toe assessment
refill; strength and rate of peripheral assessment for a complete and thorough
pulses examination
C = Cervical collar Placement of a cervical collar when I = Initiate Initiate the Triage Documentation
indicated Record
C = Consciousness ✔ Level of consciousness (Glasgow I = Isolate Assess patient for rashes,
Coma Scale); response to environment; communicable diseases, or
muscle tone; pupil response immunosuppression, and place
in appropriate isolation
D = Dextrose ✔ Serum glucose level in patients with I = Intervention Perform triage interventions (first
altered mental status aid, medication administration,
diagnostic studies)
E = Expose Expose patient by undressing to identify J = Judgment Make appropriate triage classification
underlying injuries of patient acuity

Table 155–5 Triage Observation Tool (look, cry or speech, hygiene/dress), breathing (respiratory
effort and rate), and skin circulation (color, appearance)33
Triage Observation Tool (No/Yes) (see Chapter 10, General Approach to Poisoning).
Airway Obstructed airway (blood, vomit, foreign SAVE-A- CHILD GUIDE
bodies, facial burn)
Allergic reaction A pediatric triage mnemonic—“SAVE-a-CHILD”—was
Breathing Increased respiratory effort designed to aid in recognizing a seriously ill pediatric
Fatigue, nasal flaring patient.24 SAVE stands for the skin, activity, ventilation, and
Tachypnea
Tracheal tug, chest recession eye contact. SAVE is based on observations made before
Wheeze, stridor, grunting touching the child. The “CHILD” component stands for cry,
Bradypnea, hypoventilation heat, immune system, level of consciousness, and dehydra-
O2 saturation higher than expected for degree tion; this information is obtained from the parent (or care-
of respiratory effort
Circulation Tachycardia, bradycardia
giver) and a brief examination24 (Fig. 155–1).
Capillary return >2 sec Pediatric Triage Assessment and Interventions
Pale, mottled, or cyanosed
Peripheral pulses or perfusion Pediatric assessment may use any one or a combination
Obvious bleeding out of techniques (e.g., pediatric assessment triangle, SAVE-a-
Sunken eyes, dry oral mucosa
Decreased feeding, decreased urine output CHILD, primary/secondary survey using ABCs). Important
Disability Irritable or drowsy and hard to wake elements in the triage history include the chief complaint,
Responds only to pain history of present illness or injury, allergies, medications,
High-pitched cry immunizations, and past medical history.
Obvious pain
Expose Purpura
Several mnemonics for the history have been suggested.
Chickenpox or measles CIAMPEDS stands for chief complaint, immunizations
Risk Factors Oncology patient or immunosuppressed or isolation (communicable disease exposure), allergies,
Cardiac history medications, past medical history, events surrounding the
Infant <3 mo old illness or injury, diet or diapers (bowel/bladder history),
Diabetic or metabolic illness
Central line or Port-A-Cath and symptoms associated with the illness/injury. Alterna-
tively, the OLDCART mnemonic has also been used (onset
of symptoms, location of problem, duration of symptoms,
characteristics of symptoms, aggravating factors, relieving
Training and pediatric experience may also play a role in factors, and treatment before arrival). For patients in
nursing triage assessment of pediatric patients.37,38 pain, PQRST has been used: precipitating factors, quality of
pain, region/radiation of pain, severity, and time of pain
PEDIATRIC ASSESSMENT TRIANGLE
onset.
The pediatric assessment triangle refers to an “across-the- A problem-oriented method, the SOAPIE format, has been
room” assessment or a quick “eyeball” assessment of the recommended by the ENA for comprehensive triage docu-
pediatric patient.33 This is done while the triage nurse obtains mentation. SOAPIE follows the steps in the comprehen-
the history and chief complaint. The assessment triangle sive triage process from obtaining the history and vital
includes evaluation of the infant or child’s overall appearance signs, to assigning a triage category, to determining and
 Chapter 155 — Triage 1091

wounds (to be sutured later) and to potential intravenous

Save-A-Child
sites for children and infants who will likely needs intrave-
Recognition of the seriously ill pediatric patient nous fluids and/or medications. Such treatment interven-
tions in triage have been shown to decrease ED turnaround
Skin Mottled? time, thereby improving ED flow. Triage-initiated protocols
Cyanotic? can expedite care and improve patient/family satisfaction.
Petechiae?
Pallor? Customer Service at Triage
Activity Needs assistance/ Customer service has become an increasingly emphasized
Not ambulating? aspect of the provision of emergency medical care, and is
Responsive? especially pertinent to the care of children. Virtually every
Ventilation Retractions? hospital in the country has some patient satisfaction tool,
Head bobbing? which is used to assess the patient’s and family’s perception
Drooling?
Nasal flaring?
of the care that they received in the ED. While the axiom
Slow rate? “You never get a second chance to make a fi rst impression”
Fast rate? was not meant to specifically describe ED triage, it might well
Stridor? have been. Nearly 75% of patients presenting to the ED
Wheezing? undergo triage, which is their first contact with the medical
Eye Contact Glassy stare? care system. For that reason, triage nurses and other person-
Fails to engage/focus? nel assisting in the process should be trained in the impor-
Abuse Unexplained tance of delivering customer service excellence at the earliest
bruising/injuries? appropriate time. Mayer and Cates have suggested that this
Inappropriate parent? comprises three elements39 :
Cry High pitched, cephalic? • Making the customer service diagnosis as well as the
Irritable? clinical diagnosis
Heat High fever (>41°)? • Negotiating agreement and resolution of expectations
Hypothermia (36°)? • Building moments of truth into the clinical encounter
Immune System Sickle cell? By way of simple example, one of the most common clini-
AIDS? cal presentations in the pediatric and general ED is the child
Corticosteroids? with fever. While the clinical diagnosis is often apparent,
Level of Consciousness Irritable? even at triage, the customer service diagnosis comprises the
Lethargic? fear of more serious illness on the part of the parents and
Pain only? perhaps even the child. Addressing those concerns at triage
Convulsing?
Unresponsive? by providing reassurance at the earliest time is an extremely
important part of maximizing patient satisfaction. Similarly,
Dehydration Hollow eyes?
Capillary refill?
the parent’s expectations are often dramatically different
Cold hands, feet? from those of experienced health care providers, since the
Voiding? parents often are concerned that the child may have seizures,
Severe diarrhea? meningitis, or another life-threatening illness, whereas an
Vomiting: projectile, experienced clinician may understand from simple observa-
bilious, persistent?
Dry mucous membranes? tion of the child that these diagnoses are not likely. In order
to assure that the best customer service is provided, negotiat-
SAVE: Observations made prior to touching the child ing these expectations is important, and can also begin at
CHILD: History from caretaker and brief exam triage.
Finally, the concept of “moments of truth” was originally
FIGURE 155–1. SAVE-a-CHILD triage system for recognition of the
seriously ill pediatric patient. described by Jan Carlzon in a book of that same name.
Carlzon pointed out that customer perceptions are usually
not based on technical aspects, but rather comprise what
he described as “50,000 Moments of Truth per day, created
implementing diagnostic/therapeutic measures and reassess- by the service provider himself.”40 Thus the institution is
ing the patient. SOAPIE stands for subjective data (chief not assessed so much on the detailed provision of clinical
complaint); objective data such as vital signs; analysis of data, care, but on the moments of truth provided by the nurses,
leading to assigning acuity; plan, or what is to be done; ini- physicians, technicians, and other ED personnel. For example,
tiating diagnostic/therapeutic interventions per protocols simple statements (“scripts”) can be made, such as, “I have
and nursing practice; and evaluation, which indicates that three children of my own, and I remember how concerned
triage is a dynamic process with constant evaluation and I was the first time one of them developed a fever in the
re-evaluation. middle of the night.” Delivering excellent customer service
Triage interventions range from beginning diagnostic and assuring patient satisfaction require the same proactive
studies, such as radiologic studies and an electrocardiogram, approach that one would apply to clinical guidelines or pro-
to initiating therapeutic measures, including giving oral tocols. The customer service aspects of triage should be dis-
pain medications and antipyretics and applying dressings. cussed among the providers of clinical care, so that such
Other triage measures include applying topical anesthetics to scripts and procedures can be proactively developed.
1092 SECTION VI — The Practice Environment
Newer Concepts of Triage
Virtually all EDs encounter times when they are severely
capacity constrained. A number of creative process improve-
ments have been made to help assure that triage functions
expeditiously, even at times when there are a large number
of patients to be seen. These include advanced triage/advanced
initiatives (AT/AI), Team Triage and Treatment, triage bypass,
Triage Away, and secondary triage. Each of these is designed
to be used in various ways and addresses the substantial
capacity constraint issues faced by many EDs, including both
general and pediatric EDs.
AT/AI consists of a set of medically approved standing
orders and initiatives that may be implemented at the triage
area at times when rooms are not available in the treat-
ment area. These include protocols for minor extremity
trauma, urinary tract infections, abdominal pain, neutrope-
nic patients with fever, and pretreatment of lacerations with
topical anesthetic agents. Each of these protocols is discussed
in advance between the medical and nursing staff of the ED,
approved jointly, and implemented after training of the triage
nurses.
Triage bypass is utilized at times when several patients
have presented to triage, but there are adequate numbers of
physicians, nurses, and support personnel in the treatment
area to care for such patients in a timely fashion. Since these
patients will be seen by the same ED staff in the same treat-
ment areas, they bypass triage, are registered in the room,
and are triaged and treated by the same nurses and physicians
who will be caring for them. Because of the nature of patient
flow and the fact that most EDs become capacity constrained
by the mid-morning or afternoon hours, triage bypass is
predominantly utilized during the early to mid-morning
hours.
Team Triage and Treatment is a unique and innovative
approach to dealing with capacity constraints by assigning
an emergency physician (or physician assistant/nurse practi-
tioner), nurse, technician, and, in some cases, registrar to the
triage area at times when there are predictable delays in
patient care due to the number of treatment rooms available.
Following initial triage by the triage nurse, acutely ill or
injured patients are sent directly back to the treatment area.
Similarly, patients with minor (fast track) problems are sent
to such an area. The remainder of the patients are then evalu-
ated at the triage area by the team triage members. In a busy
level I trauma center that sees over 80,000 patients per year,
team triage is utilized approximately 8 hours per day and
substantially decompresses patient waiting times, improves
patient satisfaction, improves patient safety, and offers better
access to care for patients (T. Mayer, personal communica-
tion, May 2005). These data indicate that one third of such
patients are evaluated, treated, and have their treatment com-
pleted at the triage area, including patients with sufficient
severity of abdominal pain to warrant an abdominal com-
puted tomography scan. While this program requires an
investment in resources, the reduction in patients left without
treatment and the capacity for increasing volume more than
offset the cost of the investment in the program.
Triage Away is a program used in some EDs that have
chosen to evaluate patients at triage and, when it is deter-
mined that they have a minor illness or injury, simply triage
them away to other facilities. In some communities such
programs can be effective; however, it does require a clearly
specified primary health clinic or public health facility to
which the patients can be safely and efficiently triaged. Such
Triage Away programs are unusual, precisely because the
safety net capacity of the ED is not backed up by such primary
care or public health facilities in most communities.
Secondary triage refers to the combined effort of the emer-
gency physicians and nurses to re-triage patients who are
already in treatment rooms either to alternate rooms or to
hallway spaces at times when their workup and treatment
have not been completed, but additional patients are in need
of treatment areas in which they can be evaluated. Emer-
gency physicians and nurses should prospectively design pro-
tocols and procedures to assure that such secondary triage is
safe, efficient, and in the patient’s best interest.
Legal Considerations
According to the Consolidated Omnibus Budget Reconcilia-
tion Act passed in 1985, hospitals receiving Medicare funds
are mandated to evaluate all patients who arrive in the ED
and treat anyone with an emergent medical problem or any
woman in active labor. In addition, any transferred patients
must be stabilized and the receiving institution must have
agreed to accept the patient. Under the Emergency Medical
Treatment and Labor Act (EMTALA), patients can be trans-
ferred only when they need a higher level of care (or a service
not provided at the institution at which they present) and
only after an appropriate “screening” evaluation and stabili-
zation (see Chapter 150, Emergency Medical Treatment and
Labor Act [EMTALA]). It is inappropriate for a nurse or any
other medical personnel to arbitrarily triage a patient to
another facility. After an appropriate medical screening
examination, usually by the responsible physician, it is pos-
sible that triage nurses, while following written protocols,
could redirect patients to predesignated areas such as an out-
patient clinic. However, precise documentation and prees-
tablished written protocols are mandatory. Indeed, many
experts recommend that a chart be generated for any patient
presenting to the ED regardless of whether or not they are
evaluated and treated.
Prehospital Triage
Field triage by Emergency Medical Services (EMS) personnel
is the assessment of individual patients with the purpose
of determining the most appropriate receiving facility. The
development of trauma systems led to trauma triage in pre-
hospital care. This is based on the principle that patients with
life-threatening or serious multisystem injuries from trauma
have a better outcome when transported directly to a facility
staffed and equipped to provide resuscitation and definitive
treatment. The aim is to send all seriously injured patients to
a trauma center without overwhelming the resources of the
trauma center by over-triaging. Occasionally a trauma patient
may bypass the closest hospital to be transported directly to
the trauma center. System-wide prehospital EMS trauma
protocols provide guidelines to prehospital care providers for
differentiating which trauma patient is transported to the
trauma center or to the closest hospital for treatment.
With the advent of more sophisticated therapies and spe-
cialized hospitals, such as chest pain centers with around-
the-clock cardiac catheterization capabilities or stroke centers
capable of delivering organ/region-specific thrombolytics,

the expansion and increased importance of “prehospital” or
“field” triage are likely.
Disaster Triage
A disaster is an event that exceeds the capabilities of the
response (e.g., the need is greater than the resources), result-
ing in disruption of normal function.41,42 In order to more
concisely describe and reflect the degree (or stage) of disaster,
the Potential Injury Causing Event (PICE) nomenclature has
been developed.43
Triage during a disaster is different from ED triage. The
purpose of ED triage is to identify critically ill patients and
assure that they receive immediate resuscitation, while the
principle of disaster management is to “do the most good for
the most people.”1 It is possible during a disaster with limited
response resources that, in order to maximize care for the
majority of victims, some patients who have little or no
chance of survival will not be not resuscitated.44 It is often a
difficult concept for health care providers to ration resources
and not expend efforts to resuscitate patients who are con-
sidered near death in order to save others. Comfort care
should be provided to the dying patients when resources
become available.
As with ED triage, there is no universally accepted stan-
dardized system for disaster or MCI triage, although several
No
Position airway
No
Unsalvageable
FIGURE 155–2. Simple Triage and Rapid
Treatment (START) tool.
Chapter 155 — Triage 1093
triage systems have been suggested. One MCI/disaster triage
tool is the Simple Triage and Rapid Treatment (START) tech-
nique.45 This is based on a rapid assessment of respiration,
perfusion, and mental status (RPM). Casualties who are
ambulatory are asked to move away from the immediate area
of the incident. These “walking wounded” are categorized as
“green” or minor. The remaining patients are sorted into
unsalvageable, immediate, and delayed (Fig. 155–2). If the
patient has a patent airway and is breathing, by assessing
the respiratory rate (>30 per minute or < 30 per minute), the
radial pulse (present or absent), and the mental status (follows
commands: yes or no), the patient can be categorized. Unsal-
vageable patients are patients who are not breathing even
after positioning their airway and are classified “black” or
deceased. “Red” (immediate) patients have an immediate
threat to life or limb but, if given immediate care, will prob-
ably survive. Examples include a patient with altered mental
status, labored respirations, or shock. “Yellow” (delayed)
patients have significant injuries but can probably tolerate a
45- to 60-minute wait without undue risk.
This color-coded four-category system is probably the
most common disaster/MCI triage system in the United
States. “Red” casualties are the first priority and are “most
urgent.” Patients classified “Yellow” are the second priority
and are “urgent.” “Green” patients comprise the “walking
Start triage
Respirations
Yes
<30
≥30
Yes Immediate Radial pulse
Immediate
No Yes
Control Mental
bleeding status
Immediate Follow
commands
No Yes
Immediate Delayed
1094 SECTION VI — The Practice Environment

wounded” or “nonurgent” and are the third priority. Dead Yes Secondary
patients and catastrophically injured patients with a negligi- Able to walk? Minor
triage
ble chance of survival belong to the “Black” triage category.
The MASS triage model has been used by the U.S. military
in order to quickly assign large numbers of casualties into No Position Breathing
treatment categories.42 MASS triage incorporates the pro- Breathing? Immediate
upper airway
cesses of “move, access, sort, and send.” Patients are grouped
APNEIC
into four categories based on the “ID-ME” mnemonic:
“immediate, delayed, minimal, and expectant.”42 Minimal
Palpable Deceased
patients are stable patients with minor injuries, such as con- Yes pulse
tusions and minor lacerations, whose medical care could be
delayed for days without any untoward effect from the delay. Yes
At the disaster or MCI scene, the triage officer should request APNEIC
5 rescue Deceased
that “Everyone who can hear me [the triage officer] and breaths
needs medical attention should move to the area with the
green flag.” This will separate out the ambulatory “minimal” Breathing
group or walking wounded. <15 o r > 45
The “delayed” patients need definitive medical care but Respiratory
rate
will quickly decompensate if their care is delayed initially.
Patients with open fractures, deep lacerations with pulses/ Immediate
15– 45
distal circulation, hemodynamically stable abdominal inju-
ries, or stable head injuries belong to the “delayed” category. Palpable No
To sort this delayed group of patients after separating out the Immediate
pulse?
ambulatory walking wounded, the “MOVE” command is to
ask the remaining casualties to raise a hand (or leg) so that Yes
they can be helped. “P” (inappropriate posturing)
After separating out the “minimal” and “delayed” groups, AVPU Immediate
the rescuers proceed immediately to those who are left. These
patients are in the immediate or expectant categories. The
immediate patients are patients with an obvious threat to life
Evaluate
or limb. These casualties generally have a problem with the infants first
ABCs, such as shock, respiratory distress, altered mental “A”, “V,” or “P”
in secondary Delayed
status, or a severe abdominal, chest, or head injury. These triage using (appropriate)
patients often need immediate life-saving care. The expect- the entire JS
ant patients are patients near death who probably will not algorithm
survive no matter what treatment is rendered. A patient in FIGURE 155–3. JumpSTART pediatric mass casualty incident triage.
traumatic arrest, a patient with a penetrating chest wound in Abbreviations: AVPU, alert, responsive to voice, responsive to postur-
shock, or a trauma patient who is not breathing would be ing, or unresponsive. (From Romig LE: Pediatric triage: a system to Jump
classified as “expectant” since they are near death and have START your triage of young patients at MCIs. J Emerg Med Serv
27(7):52–58, 60–63, 2002.)
a minimal chance of surviving.
The Secondary Assessment of Victim Endpoint (SAVE)
triage system was developed to identify patients who have
the greatest possibility of benefit from care delivered under and the focus on patient safety and quality, triage will be
austere field conditions.46 SAVE is employed when patient expected to perform an even more complex and important
transport to a definitive care facility is not available for days role in the future.48,49 Triage in the redesigned ED of the
and treatment within the “golden hour” at a medical center future will have new systems and processes and expanded
is nonexistent.45 The three patient groups according to the technology to streamline patient flow. Current technology
SAVE triage are: (1) patients who will die no matter what such as in-room registration and discharge by mobile patient
treatment is rendered, (2) patients destined to survive whether registrars using laptop computers may be replaced by hand-
or not care is given, and (3) patients for whom significant held devices. Registrars may not even need to be physically
benefit will be obtained from “austere field interventions.” present in the room to interview patients but could use vid-
Casualties who would benefit most from early evacuation eoconferencing techniques. More elaborate instantaneous
(e.g., a patient with intra-abdominal hemorrhage) are desig- patient tracking systems are possible. Real-time communica-
nated as “first out.” tion via cell phones/walkie-talkies or microchip tracking
JumpSTART is a modification of the START disaster triage technology will allow the triage nurse to instantly see and
for pediatric patients ages 1 to 8 years47 (Fig. 155–3) (see communicate with patients and families in the waiting room
Chapter 152, Disaster Preparedness for Children). and other areas. Patient pagers can be distributed to patients
and families (and to ED staff) to notify them of room avail-
Future of Triage ability, radiology, and other testing availability. Medical
With the increasing ED volume and ED patient acuity in an information, including medications, allergies, and past
era of diminishing resources, and the public’s demand for medical history, will be automatically available via computer,
more rapid treatment along with governmental regulations rather than manually entered, in a fashion that protects

patient confidentiality according to the Health Information
Portability and Accountability Act. Individual patient data
will be connected to patient data banks within and between
hospitals so clinical information for purposes of research and
new therapies as well as syndromic surveillance (for new
diseases or bioterrorist threats) is available while maintain-
ing individual patient confidentiality and patient rights.50
The ED of the future will also incorporate the principles of
family-centered care so that the ED provision of care occurs
in a caring, comfortable environment attentive to the emo-
tional, social, and cultural needs of patients and families.
Such advances, however, are dependent on the necessary
financial resources and continuing technological advances.
Summary
Triage is a critical and necessary component of ED care.
Triage is essential for the early recognition of the seriously ill
patient and rapid initiation of therapy, which reduces mor-
bidity and mortality. Early initiation of therapy not only
saves lives, but also decreases hospital and intensive care unit
length of stay, and lowers morbidity, ultimately decreasing
health care costs. An efficient triage can expedite patient
care, improve ED flow, and increase patient and family sat-
isfaction, thereby decreasing litigation, and, most impor-
tantly, improve patient care and outcome by rapidly initiating
care to the seriously ill or injured.
REFERENCES
1. Auf der Heide E: Triage. In Disaster Response: Principles of Prepara-
tion and Coordination. St. Louis: CV Mosby, 1989.
2. Thompson JD, Dains JE: Comprehensive Triage: A Manual for Devel-
oping and Implementing a Nursing Care System. Reston, VA: Reston
Publishing Co, 1982.
*3. Emergency Nurses Association: Standards of Emergency Nursing Prac-
tice, 4th ed. Des Plains, IL: Emergency Nurses Association, 1999, p
23.
4. Gilboy N: The evolution of triage. In Gilboy N, Tanabe P, Travers DA,
et al: The Emergency Severity Index Implementation Handbook: A
Five-Level Triage System. Des Plaines, IL: Emergency Nurses Associa-
tion, 2003, pp 2–5.
5. Travers D: Triage: how long does it take? How long should it take? J
Emerg Nurs 25:238–240, 1999.
6. Wuerz R, Fernandez CMB, Alarcon J: Inconsistency of emergency
department triage. Ann Emerg Med 32:431–435, 1998.
7. Gill JM, Reese CL 4th, Diamond JJ: Disagreement among health care
professionals about the urgent care needs of emergency department
patients. Ann Emerg Med 28:474–479, 1996.
8. Brillman JC, Doezema D, Tandberg D, et al: Triage: limitations in
predicting need for emergent care and hospital admission. Ann Emerg
Med 27:493–500, 1996.
9. Bergeron S, Gouin S, Bailey B, et al: Comparison of triage assessments
among pediatric registered nurses and pediatric emergency physicians.
Acad Emerg Med 9:1397–1401, 2002.
10. Nakagawa J, Ouk S, Schwartz B, et al: Interobserver agreement in
emergency department triage. Ann Emerg Med 41:191–195, 2003.
11. MacLean S: 2001 ENA National Benchmark Guide: Emergency Depart-
ments. Des Plaines, IL: Emergency Nurses Association, 2001.
*12. Travers DA, Waller AE, Bowling JM, et al: Five-level triage system:
more effective than three-level in tertiary emergency department.
J Emerg Nurs 28:395–400, 2002.
13. Australasian College for Emergency Medicine: National triage scale.
Emerg Med Australas 6:145–146, 1994.
14. Cameron PA, Bradt DA, Ashby R: Emergency medicine in Australia.
Ann Emerg Med 28:342–346, 1996.
*Selected readings.
Chapter 155 — Triage 1095
15. Cronin JG: The introduction of the Manchester Triage Scale to an
emergency department in the Republic of Ireland. Accid Emerg Nurs
11:121–125, 2003.
16. Beveridge R, Ducharme J, Janes L, et al: Reliability of the Canadian
emergency department Triage and Acuity Scale: interrater agreement.
Ann Emerg Med 34:155–159, 1999.
17. Beveridge RC, Ducharme J: Emergency department triage and acuity:
development of a national model [Abstract]. Acad Emerg Med 4:475,
1997.
18. Zimmerman PG: The case for a universal reliable 5-tier triage acuity
scale for U.S. emergency departments. J Emerg Nurs 27:246–254,
2001.
19. Wuerz RC, Milne LW, Eitel DR, et al: Reliability and validity of a new
five-level triage instrument. Acad Emerg Med 7:236–242, 2000.
20. Wuerz RC, Travers D, Gilboy N, et al: Implementation and refi nement
of the Emergency Severity Index. Acad Emerg Med 8:170–176, 2001.
*21. Tanabe P, Gimbel R, Yarnold PR, et al: Reliability and validity of scores
on the Emergency Severity Index version 3. Acad Emerg Med 11:59–65,
2004.
22. National Center for Health Statistics: Injury Data and Resources—
National Hospital Ambulatory Medical Care Survey, 2002 Emergency
Department Summary. Centers for Disease Control and Prevention
web site, 2000. Available at http://www.cdc.gov
23. Cain P, Waldrop RD, Jones J: Improved pediatric patient flow in a
general emergency department by altering triage criteria. Acad Emerg
Med 3:65–71, 1996.
24. Wiebe RA, Rosen LM: Triage in the emergency department. Emerg
Med Clin North Am 9:491–505, 1991.
25. Marcin JP, Pollack MM: Triage scoring systems, severity of illness
measures, and mortality prediction models in pediatric trauma. Crit
Care Med 30:S456–S467, 2002.
26. Macfarlane PI, Suri S: Steroids in the management of croup. BMJ
312:510, 1996.
27. McCarthy PL, Sharpe MR, Spiesel SZ, et al: Observation scales to
identify serious illness in febrile children. Pediatrics 70:802–809,
1982.
*28. Murphy KA: Introduction to pediatric triage. In Pediatric Triage
Guidelines. St. Louis: CV Mosby, 1997, pp 1–7.
29. O’Neill KA, Molczan K: Pediatric triage: a 2-tier, 5-level system in the
United States. Pediatr Emerg Care 19:285–290, 2003.
30. Rambler CL, Mohammed N: Triage. In Kitt S, Selfridge-Thomas J,
Proehl JA, et al (eds): Emergency Nursing: A Physiologic and Clinical
Perspective. Philadelphia: WB Saunders, 1994, pp 19–27.
31. Mace SE: Child physical abuse: a state-of-the-art approach. Pediatr
Emerg Med Pract 2:1–20, 2004.
32. Selfridge-Thomas J: Patient assessment and priority setting. In Manual
of Emergency Nursing. Philadelphia: WB Saunders, 1995, pp 3–18.
33. Thomas DO: Special considerations for the emergency department.
Nurs Clin North Am 37:145–159, 2002.
*34. Browne GJ: Paediatric emergency departments: old needs, new chal-
lenges and future opportunities. Emerg Med 13:409–417, 2001.
35. Phillips S, Rond PC, Kelly SM, et al: The need for pediatric-specific
triage criteria: results from the Florida trauma triage study. Pediatr
Emerg Care 12:394–399, 1996.
36. Gorelick MH, Lee C, Cronan K: Pediatric Emergency Assessment Tool
(PEAT): a risk-adjustment measure for pediatric emergency patients.
Acad Emerg Med 8:156–162, 2001.
37. Durojaiye L, O’Meara M: A study of triage of paediatric patients in
Australia. Emerg Med 14:67–76, 2003.
38. Crellin DJ, Johnston L: Who is responsible for pediatric triage decisions
in Australian emergency departments? A description of the educa-
tional and experimental preparation of general and pediatric emer-
gency nurses. Pediatr Emerg Care 18:382–388, 2002.
39. Mayer TA, Cates RJ: Leadership for Great Customer Service. Chicago:
Health Administration Press, 2004.
40. Carlzon J: Moments of Truth: New Strategies for Today’s Customer-
Driven Economy. New York: Harper Collins, 1987.
41. Aghababian RV: Pediatric Disaster Life Support–PDLS: Caring for
Children during Disaster. Boston: University of Massachusetts Medical
School, 1995.
42. All-hazards course overview and disaster paradigm. In Pepe PE,
Schwartz RB (eds): Basic Disaster Life Support BDLS Provider Manual.
2004, pp 1–28.
43. Koenig KL, Dinerman N, Kuehl AE: PICE nomenclature: a new system
to describe disaster. Prehospital Disaster Med 9:S65, 1994.
1096 SECTION VI — The Practice Environment
44. Waeckerle JF: Disaster planning and response. N Engl J Med 324:815–
821, 1991.
45. Schultz CH, Koenig KL, Noji EK: A medical disaster response to reduce
immediate mortality after an earthquake. N Engl J Med 334:438–444,
1996.
46. Benson M, Koenig KL, Schultz CH: Disaster triage: START, then
SAVE—a new method of dynamic triage for victims of a catastrophic
earthquake. Prehospital Disaster Med 11:117–124, 1996.
47. Romig LE: Pediatric triage: a system to Jump START your triage of
young patients at MCIs. J Emerg Med Serv 27(7):52–58, 60–63, 2002.
*48. Fields W (Chair, Safety Net Task Force): Defending America’s safety
net. American College of Emergency Physicians web site, April 2000.
Available at http://www.acep.org
*49. Richardson LD, Asplin BR, Lowe RA: Emergency department crowd-
ing as a health policy issue: past development, future directions. Ann
Emerg Med 40:388–393, 2002.
50. Barthell EN, Aaronsky D, Cochrane DG, et al; Frontlines Work Group:
The Frontlines of Medicine Project progress report: standardized com-
munication of emergency department triage data for syndromic sur-
veillance. Ann Emerg Med 44:247–252, 2004.