EMERGENCY TRIAGE

Triage is a French verb meaning “to sort.” Emergency triage is a subspecialty of emergency nursing,
which requires specific, comprehensive educational preparation. 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; and comorbidities. Thus, the primary role of
the triage nurse is 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.
Priorities of Care and Triage Categories Standardized 5-level triage systems, such as the Australasian
Triage Scale (ATS), Canadian Triage and Acuity Scale (CTAS), and the Emergency Severity Index (ESI),
have been developed and proven through research to possess utility, validity, reliability, and safety. All
three systems utilize similar time frames and are evidence based (the Manchester Triage System [MTS] is
a consensus-based algorithm approach, which utilizes longer time frames)
TRIAGE LEVELS

Triage Level 1—Immediately Life- Triage Level 2—Imminently Life-threatening

threatening or Resuscitation or Emergent
1. Conditions requiring immediate clinician 1. Conditions requiring clinician assessment
assessment. within 10 to
Any delay in treatment is potentially life- or life 15 minutes of arrival.
threatening. 2. Conditions include:
2. Includes conditions such as: a. Head injuries.
a. Airway or severe respiratory compromise. b. Severe trauma.
b. Cardiac arrest. c. Lethargy or agitation.
d. Conscious overdose.
c. Severe shock.
e. Severe allergic reaction.
d. Symptomatic cervical spine injury.
f. Chemical exposure to the eyes.
e. Multisystem trauma.
g. Chest pain.
f. Altered level of consciousness (LOC) (GCS h. Back pain.
10). i. GI bleed with unstable vital signs.
g. Eclampsia. j. Stroke with deficit.
h. Extremely violent patient. k. Severe asthma.
l. Abdominal pain in patients older than age 50.
m. Vomiting and diarrhea with dehydration.
n. Fever in infants younger than age 3 months.
o. Acute psychotic episode.
p. Severe headache.
q. Any pain greater than 7 on a scale of 10.
r. Any sexual assault.
s. Any neonate age 7 days or younger.
Triage Level 3—Potentially Life-
threatening/Time
Critical or Urgent
1. Conditions requiring clinician assessment
within 30 minutes of arrival.
2. Conditions include:
a. Alert head injury with vomiting.
b. Mild to moderate asthma.
c. Moderate trauma.
d. Abuse or neglect.
e. GI bleed with stable vital signs.
f. History of seizure, alert on arrival.

Triage Level 5—Less/Non-urgent

1. Conditions requiring clinician assessment
within 2 hours
of arrival.
2. Conditions include:
a. Minor trauma, not acute.
b. Sore throat.
c. Minor symptoms.
d. Chronic abdominal pai

Triage Level 4—Potentially Life-serious/

Situational Urgency or Semi-urgent
1. Conditions requiring clinician assessment
within 1 hour
of arrival.
2. Conditions include:
a. Alert head injury without vomiting.
b. Minor trauma.
c. Vomiting and diarrhea in patient older than
age 2
without evidence of dehydration.
d. Earache.
e. Minor allergic reaction.
f. Corneal foreign body.
g. Chronic back pain.
5-LEVEL EMERGENCY SEVERITY INDEX (ESI)
The Emergency Severity Index (ESI) is a five-level emergency department (ED) triage algorithm that
provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least
urgent) on the basis of acuity and resource needs.

LEVEL 1 ESI – Immediate, Live-saving intervention required without delay

Example: Cardiac Arrest, Massive Bleeding

LEVEL 2 ESI – High Risk of Deterioration, or signs of a time-critical problem

Example: Cardiac-related chest pain, Asthma Attack
LEVEL 3 ESI – Urgent patients but with conditions that are not life-threatening, have stable vital
signs and often require 2 or more resources.
Example:

ESI Patient Presentation Interventions Resources

LEVEL
3 A 22-year-old male with Needs an exam, lab 2 or more
right lower quadrant studies, IV fluid, resources
abdominal pain since early abdominal CT, and
this morning + nausea, no perhaps surgical
appetite. consult.

LEVEL 4 ESI – Less urgent patients with conditions that are not life-threatening and have stable
vital signs. Conditions under level 4 requires only 1 resource or minimal testing/procedure to stabilize
the patient.
Example:

ESI Patient Presentation Interventions Resources

LEVEL
4 Healthy 19-year-old Needs an exam, throat Lab (throat
with sore throat and culture and culture)
fever. prescription.

LEVEL 5 ESI – Low-risk patient with stable vital signs ad no resources are needed.
Example:

ESI Patient Presentation Interventions Resources

LEVEL
5 An 11-year-old presents to triage with Needs an None
his mother, who reports that her son has exam and
had a cough and runny nose for a week. prescription.
The child is running around the waiting
room and asking his mother for a snack.
Vital signs are within normal limits.
PSYCHOLOGICAL CONSIDERATIONS
Serious disease or trauma disrupts physiologic and psychological equilibrium, necessitating
physiologic and psychological repair.
Approach to Patient
 1. Understand and accept the basic anxieties of the acutely ill or traumatized patient. Be aware
of the patient’s fear of death, disablement, and isolation.
a. Personalize the situation as much as possible. Speak, react, and respond in a warm
manner.
b. Give explanations on a level that the patient can grasp.
c. Accept the rights of the patient and family to have and display their own feelings.
d. Maintain a calm and reassuring manner.
e. Include the patient’s family or significant others.

2. Understand and support the patient’s feelings concerning loss of control (emotional, physical,
and intellectual).
3. Treat the unconscious patient as if conscious. Touch, call by name, and explain every
procedure that is done. Avoid making negative comments about the patient’s condition.
a. Orient the patient to person, time, and place as soon as s/he is conscious; reinforce by
repeating this information.
b. Bring the patient back to reality in a calm and reassuring way.
c. Encourage the family, when possible, to orient the patient to reality.
4. Be prepared to handle all aspects of acute illness and trauma; know what to expect and what
to do. This alleviates the nurse’s anxieties and increases the patient’s confidence.

Approach to Family.
1.Inform the family where the patient is, and give as much information as possible about the treatment
she is receiving.

2. Consider allowing a family member to be present during the resuscitation. Assign a staff person to
the family member to explain procedures and offer comfort.

3. Recognize the anxiety of the family and allow them to talk about their feelings. Acknowledge
expressions of remorse, anger, guilt, and criticism.

4. Allow the family to relive the events, actions, and feelings preceding admission to the ED.

5. Deal with reality as gently and quickly as possible; avoid encouraging and supporting denial.

6. Assist the family to cope with sudden and unexpected death. Some helpful measures include the
following:
a. Take the family to a private place.
b. Talk to all of the family together so they can mourn together.
c. Assure the family that everything possible was done; inform them of the treatment rendered.
d. Avoid using euphemisms such as “passed on.” Show the family that you care by touching,
offering coffee.
e. Allow family to talk about the deceased—permits ventilation of feelings of loss. Encourage
family to talk about events preceding admission to the ED.
f. Encourage family to support each other and to express emotions freely—grief, loss, anger,
helplessness, tears, disbelief.
g. Avoid volunteering unnecessary information (eg: patient was drinking).
h. Avoid giving sedation to family members—may mask or delay the grieving process, which
is necessary to achieve emotional equilibrium and prevent prolonged depression.
i. Be cognizant of cultural and religious beliefs and needs.
j. Encourage family members to view the body if they wish—to do so helps to integrate the
loss (cover mutilated areas).
i. Prepare the family for visual images and explain any legal requirements.
ii. Go with family to see the body.
iii. Show acceptance of the body by touching to give family permission to touch and
talk to the body.
iv. Spend a few minutes with the family, listening to them.
v. Allow the family some private time with the body, if appropriate.

7. Encourage the ED staff to discuss among themselves their reaction to the event to share intense
feelings for review and for group support.

Republic of the Philippines

UNIVERSITY OF EASTERN PHILIPPINES
College of Nursing and Allied Health Sciences
Catarman, Northern Samar
 NCM 118 – CARE OF CLIENTS WITH LIFE THREATENING
CONDITIONS, ACUTELY ILL/MULTI ORGAN PROBLEMS, HIGH
ACUITY AND EMERGENCY SITUATIONS

BSN 4C Group 1

Prepared by:
Lutao, Kenneth S.
Magpayo, Ellen Claire L.
Mendoza, Daniela P.
Mengullo, Mariah Nicah B.
Miranda, Troy Albert N.
Montes, Jerome L.
Munez, Riza Quenia L.
Ogayre, Joebel Rose G.
Oliva, Emee N.
Ong, Rheana L.
Orio, Herald Rose D.

Evelyn M. Balanquit, MAN

Clinical Instructor