On the Level(s)
A five-tier triage scale system, which better streamlines emergency care, gains popularity among ED nurses

By Debra Anscombe Wood, RN
June 8, 2004

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.”

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.”