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Sutter Health in California began moving to a five-tier system more than two years ago. It, too, developed its own system, based on the Canadian acuity scale but including consideration of the number of resources the patient would need. One major difference with the Sutter Health system: It considers a Level 1 patient the least urgent and a 5 the most acute.

“We wanted to take the approach that the more resources should go in the same direction with acuity of the patient,” says Catherine Ross, RN, CCRN, director of emergency services and the trauma-neurointensive care unit at Sutter Roseville Medical Center. “As your condition requires more need, then that increases up the [numeric] triage level.”

Making the switch

Sutter Health began implementing five-level triage in the Sacramento-Sierra region before rolling it out throughout its 28-hospital system. It rotates nurses through the triage position, so all RNs working in the ED know how to triage with the five-tier scale. Ross says that its former three-tier system was easier for nurses, but it resulted in the bulk of patients being classified in the middle.

“Whenever you make a change in a process, there is a learning curve,” Ross says. “This meant they had to use more differentiation. Overall, they say it was a big help. Nurses at triage took some time to get comfortable with it.”

Auffrey says that making the switch to five levels isn’t easy, especially in an ED like hers where most of the nurses have worked for decades using a three-level system. But once nurses at HealthAlliance began working with it, she says, they liked it.

HealthAlliance spent a year preparing for the transition and involved its informational services team, registration staff, and others from the hospital in the planning process. Changes were made to the tracking board, to software, and to forms. The transition team attended ESI seminars before conducting four-hour training sessions with ED nurses.

Children’s Memorial Hospital in Chicago made the transition several years ago. ED Director Cathleen Shanahan, RN, MS, says her nurses now feel comfortable with it. However, “it was a big culture change,” she adds, but education about the reasons for changing to a five-level system helped smooth the transition.

Improved flow

Besides more clearly stratifying patient acuity levels, five-level systems seem to improve patient flow. Shanahan believes it enhances communication between ED physicians and nurses.

“One beautiful thing this system does is that it requires physicians and nurses to speak often about the decisions they made to put patients in [a particular] category,” Shanahan says. “When I put a very sick, Level 2 child in a room, I want the doctor to follow me. Usually, as I’m settling the child, the doctor comes in behind me. That’s how the flow of patients seen right away happens.”

When Mount Sinai learned that low-acuity, Level 5 patients were skipping out, it added an extra physician assistant to its fast-track area to see these patients, Grice says. “It’s helped us capture those nonurgent patients who were leaving.”

Sutter Roseville also diverts low-acuity patients to a fast-track screening by a doctor or physician assistant, so these patients don’t take up space in an ED bed. “It’s reduced the glut of bodies and traffic in the back,” Ross says.

Patients still expect first-come, first-seen service, but nurses find the five-tier system helps in explaining why others may have been taken into the ED ahead of them. Nurses can describe the criteria used to determine acuity and priorities. Ross says patients more readily accept the numeric scale, rather than simply being told their condition is nonurgent.

“It gives a better definition of the patients to be seen and helps nurses decide whom they are going to bring back when they have an empty gurney,” Ross says. “When you can be more precise about how you’re evaluating patients ... it’s a win for everybody.”