Three-level systems were quite common until the advent of more precise 5-level systems. The 3-level systems divide patients into the groups “emergent” (cannot safely wait until a space in the clinical area becomes available), “urgent” (can safely wait a short amount of time until a space in the clinical area becomes available), and “non-urgent” (can safely wait a long time until a space in the clinical area becomes available).
Currently, over half of US emergency departments use a 5-level system (i.e., ESI, CTAS/Canadian, Australian or modified versions).
The Emergency Severity Index (ESI), the most prevalent 5-level system used in the US, is a 5-level triage rule that categorizes patients into five groups as follows:
ESI 1 – Severely unstable, must be seen immediately by a physician, often require an intervention (i.e. intubation) to be stabilized. ESI 1 cases represent 2% of all patients and 73% of ESI 1 cases are admitted.
ESI 2 – Potentially unstable, must be seen promptly by a physician (within 10 minutes), often require laboratory and radiology testing, medication, and (often) admission. ESI 2 cases represent 22% of all patients and 54% of ESI 2 cases are admitted.
ESI 3 – Stable and should be seen urgently by a physician (within 30 minutes), often require laboratory and radiology testing, medication, and are most often are discharged. ESI 3 cases represent 39% of all patients and 24% of ESI 3 cases are admitted.
ESI 4 – Stable, may be seen non-urgently by a physician (or MLP), require minimal testing or a procedure, and are expected to be discharged. ESI 4 cases represent 27% of all patients and 2% of ESI 4 cases are admitted.
ESI 5 – Stable, may be seen non-urgently by a physician (or MLP), require no testing or a procedure, and are expected to be discharged. ESI 5 cases represent 10% of all patients and 0% of ESI 5 cases are admitted.
(Note that use of the word ‘stable’ above is from the perspective of whether patient likely to deteriorate while awaiting the physician assessment and is not equivalent to the EMTALA definition.)
In correlating ESI to a 3-level system, ESI 1 and 2 are considered “emergent,” ESI 3 is considered “urgent,” and ESI 4 and 5 are considered “non-urgent.” Since ESI is standardized and tested, its use allows emergency departments to be compared by acuity and inpatient bed utilization. Additionally, it is possible to look at a group of ESI-assigned patients to predict the number of inpatient beds needed before they are requested.
In a study of 32,000 patients triaged in Europe (using the Canadian Emergency Department Triage and Acuity Scale, CTAS), 85% were completed within 10 minutes of arrival. In 98%, the duration of the triage process was under 5 minutes. And, VHA, a healthcare cooperative, demonstrated an average arrive-to-triage time of 5 minutes, with the best performer reaching 1 minute. Furthermore, the time needed to perform triage was an average of 4 minutes, with the best performer reaching 2 minutes.
Appropriate front-end staffing is needed to minimize door-to-triage times. Triage staffing needs should be adjusted to correspond with increased demand during day and time periods with a higher number of patient arrivals. Often this can be accurately predicted by looking at previous trends. Protocols should be in place for adding additional triage personnel temporarily as demand scales up, rather than after a large backlog has already occurred. Ancillary personnel should assist triage nurses in performing tasks that do not require a trained triage nurse, such as identifying open beds, preparing empty stretchers, or taking vital signs, allowing each triage nurse to become significantly more productive.
Inefficient processes can lead to significant door-to-triage delays. When patients encounter multiple staff (i.e. greeter, security guard, registration) before the triage nurse, there will be unnecessary delays in door-to-triage time. Non-patient care processes should be done in parallel to patient care processes whenever possible, so as not to cause delays in patient assessment and treatment. Many emergency departments have been successful with bedside registration using mobile workstations to shorten door to ESI times.
Appropriate education and mentoring can help nurses inexperienced with triage quickly become top performers. Triage systems such as ESI can be learned easily and effectively, especially using widely available printed materials as a guide.
Whenever possible, patients should be brought back to the treatment area immediately (bypassing a triage area) when there are adequate open beds available. If all ED nurses have been educated on performing triage, triage can be completed in individual treatment rooms, shortening door-to-triage times, as well as door-to-doctor times. Triage performed in individual rooms significantly expands the number of effective “triage nurses,” eliminating the bottleneck at the front. For very low acuity cases (i.e., suture removal, minor abrasion), the in-treatment room triage process can be abbreviated or even eliminated (saving nursing resources), as certain cases can be quickly evaluated and discharged by a physician or mid-level provider without any nursing assessment or intervention needed.
The door-to-triage time is a key indicator of a basic yet vital emergency department process and should be regularly tracked. The goal for every comprehensive emergency department should be to assign a triage score that accurately identifies emergent and urgent cases in less than 5 minutes.
Mark Reiter, MD, MBA, is CEO of Emergency Excellence (www.emergencyexcellence.com) and is a faculty member at the emergency medicine residency program at St. Luke’s Hospital in Bethlehem, PA
Tom Scaletta, MD, is President of Emergency Excellence and is the medical director at Edward Hospital in Naperville, IL.
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