1. Emergency Triage
Leenard Michael A. Sajulga, RN

2. Triage
• A French verb meaning “to sort.”
• Emergency triage
– a subspecialty of emergency nursing,
which requires specific, comprehensive
educational preparation

3. • 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;
comorbidities.

4. • The primary role of the triage nurse:
– 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.

5. PRIORITIZING CARE AND
TRIAGE CATEGORIES

6. Standardized 5-level triage
systems
• Australasian Triage Scale (ATS), Canadian
Triage and Acuity Scale (CTAS), Emergency
Severity Index (ESI)
• have been developed and proven through
research to possess utility, validity,
reliability, and safety

7. Triage Level 1—Immediately
Life-threatening or
Resuscitation
• Conditions requiring immediate clinician
assessment
• Any delay in treatment is potentially life-
or limb-threatening.

8. • Includes conditions such as:
– Airway or severe respiratory
compromise.
– Cardiac arrest.
– Severe shock.
– Symptomatic cervical spine injury.

9. – Multisystem trauma.
– Altered level of consciousness (LOC)
(GCS < 10).
– Eclampsia.
– Extremely violent patient.

10. Triage Level 2—Imminently
Life-threatening or
Emergent
• Conditions requiring clinician assessment
within 10 to 15 minutes of arrival.

11. • Conditions include:
– Head injuries.
– Severe trauma.
– Lethargy or agitation.
– Conscious overdose.
– Severe allergic reaction.
– Chemical exposure to the eyes.
– Chest pain.
– Back pain.

12. – GI bleed with unstable vital signs.
– Stroke with deficit.
– Severe asthma.
– Abdominal pain in patients older than
age 50.
– Vomiting and diarrhea with
dehydration.
– Fever in infants younger than age 3
months.

13. – Acute psychotic episode.
– Severe headache.
– Any pain greater than 7 on a scale of
10.
– Any sexual assault.
– Any neonate age 7 days or younger.

14. Triage Level 3—Potentially
Life-threatening/Time
Critical or Urgent
• Conditions requiring clinician assessment
within 30 minutes of arrival.

15. • Conditions include:
– Alert head injury with vomiting.
– Mild to moderate asthma.
– Moderate trauma.
– Abuse or neglect.
– GI bleed with stable vital signs.
– History of seizure, alert on arrival.

16. Triage Level 4—Potentially
Life-serious/Situational
Urgency or Semi-urgent
• Conditions requiring clinician assessment
within 1 hour of arrival.

17. • Conditions include:
– Alert head injury without vomiting.
– Minor trauma.
– Vomiting and diarrhea in patient older
than age 2 without evidence of
dehydration.
– Earache.
– Minor allergic reaction.
– Corneal foreign body.
– Chronic back pain.

18. Triage Level 5—Less/Non-
urgent
• Conditions requiring clinician assessment
within 2 hours of arrival.

19. • Conditions include:
– Minor trauma, not acute.
– Sore throat.
– Minor symptoms.
– Chronic abdominal pain.