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Nurse researchers have found that five-level triage is more effective and reliable than the former three-level system, and nurses like it better. The new system decreases uncertainty over who is the most acute patient.

Hospitals have relied for years on three-level triage systems to differentiate true emergencies from nonurgent cases. Trouble is, most ED patients fall in the urgent middle category, leaving nurses wondering who from this group should be seen first.

The Emergency Severity Index, developed by two East Coast physicians in the late 1990s, aims to put such concerns to rest by using a five-level triage system that better streamlines emergency care.

The new system “decreases the ambiguity of who is the most acute patient, and the most acute patients are seen in a more timely fashion,” says Mary Auffrey, RN, MS, CEN, a clinical educator at HealthAlliance in Leominster, Mass. The Leominster campus ED began using the ESI in January. “Nurses are very excited by it because at any given time, they know the sickest patients are ... being seen and not [kept] in the waiting room.”

The late Richard Wuerz, MD, of Brigham and Women’s Hospital in Boston, and David Eitel, MD, MBA, of York Hospital in Pennsylvania developed the ESI. Debbie Travers, RN, PhD, CEN, seeking a better way to classify patients arriving in the ED, worked with Wuerz to evaluate the system at the University of North Carolina at Chapel Hill in 1999. Her research found that five-level triage was more effective and reliable than the former three-level system, and nurses liked it better.

The ESI is a one-page algorithm, “very simple and straightforward to use,” Travers says. The nurse assesses whether the patient has a life-threatening condition or if the problem will soon be potentially fatal. The nurse also considers vital signs and, for lower-acuity patients, the number of resources required. The triage nurse then assigns a triage level, with Level 1 being the most acute and Level 5 the least.

Travers found that “we’ve been able to reproduce the triage ratings better with the five-level [system] than with a three-level [one]. Before, we didn’t get good reliability.” She said physicians began accepting the ratings, rather than dismissing them as an individual nurse’s predisposition toward certain ratings.

“It makes nurses more credible to use a system that can be applied consistently from one nurse to the next,” she says.

As hospitals learned about the success of the new system, physicians and nurses working with ESI realized the need for a training manual to help other facilities make a transition to five-level triage.

Wuerz drafted an early version, which was revised and completed by Travers, Eitel, Nicki Gilboy, RN, MS, CEN, and Paula Tanabe, RN, PhD, CCRN, CEN. More than 1,000 facilities have purchased the book, The Emergency Severity Index Implementation Handbook: A Five-Level Triage System, from the Emergency Nurses Association.

Standard system

The ENA and the American College of Emergency Physicians issued a joint statement in September in support of a standardized ED triage scale and acuity categorization process, plus the adoption of a reliable and valid five-level triage scale. A standard would help researchers compare and contrast acuity at hospitals and allow facilities to benchmark how they’re doing.

The ENA/ACEP Joint Five-Level Triage Task Force continues to meet and has yet to say whether it will recommend Wuerz and Eitel’s ESI. Canadian and Australian hospitals have used five-level triage for years, but the foreign systems differ from ESI. Travers, a member of the task force, said she’s not wedded to ESI, but strongly believes the time has come to switch to a five-level system.

“Nurses are good at triage,” Travers says, “and we need to use the best system possible to reflect the good decisions nurses can make at triage.”

Some U.S. hospitals making the transition to five-level triage have developed their own hybrid scales. Mount Sinai Hospital Medical Center of Chicago, which changed to a five-tier system six months ago, uses a blend of the Canadian Triage and Acuity Scale and the ESI. The hospital made the switch after observing that many patients left the ED without treatment. Phyllis Grice, RN, BSN, emergency services director, says she wanted to learn more about these patients and saw an opportunity to find out with five-tier triage: “I feel a five-level system would provide better information than the traditional three-tier model.”