5 level Triage

[jayne1975]

I have a question and would like some insight with regard to triage and how your facility uses the 5 level triage model in order to place patients waiting in the Emergency Room.

I work in a busy ER and have been filling in as a charge nurse when our regular ones are out for vacation or illness. I have noticed a very large gap in people's definitions of what nurses consider specifically level 2-4 triage patients.
Our policy at the facility is unfortunately very vague and leaves a lot to interpretation by each person and the online resources I've found break the triage into two obvious models.

One specifically delineates patients based on their medical appearance and response to questions presented by the triage nurse, and then bases their triage level on how long they can wait to see a physician.
Level 1: they need to see a physician immediately (active seizure, cardiac arrest, etc)
Level 2: they can wait 15 minutes to see a physician
Level 3: they can wait up to 30 minutes to see a physician
Level 4: they can safely wait up to one hour
Level 5: they can safely wait up to four hours

The second model I've seen starts out much the same way:
Level 1: they need immediate life saving intervention
Level 2: they are in distress and their vital signs indicate that a rapid decline may be imminent if they aren't treated expeditiously
Then, this model changes to triage based on the resources that may be needed while in the department:
Level 3: they may require several resources in the department in order to properly diagnose and treat their complaint/illness (abdominal pain requiring lab, xray or ultrasound)
Level 4: they may require one resource to properly diagnose (an xray or only lab work)
Level 5: they should not require any resources in the department other than evaluation and treatment by a physician (prescription refill, referral to outsourced care like a dentist)

It seems like nurses in our department are using pieces from each triage model and using them to make judgements about their own triage. We have several nurses who work at different facilities and some who have brought different experiences with them, and being a charge nurse makes it difficult to decide if patients are being 'over' or 'under' triaged.

An example: a patient had lab work done at his physicians office. The results arrived to the physician and they called the patient at home and told them to go to the ER because his potassium was 6. There was no indication in triage that he would have any reason for an elevated potassium, his vital signs were normal, and his EKG was read as Normal Sinus Rhythm.
Personally, I would consider this patient a 4. He needs to have his lab work repeated (an elevated potassium is a common finding on a hemolyzed specimen), but is otherwise in no distress with a normal EKG and normal vital signs. The triage nurse on duty at the time made him a 2.

Another example: a patient comes in by rescue as a restrained passenger in a motor vehicle accident. The collision was on the driver's side and the patient is complaining of shoulder and head pain. He denied loss of consciousness and was awake, alert, oriented x 4, remembered the collision and denies any changes in vision. His vital signs are stable. A nurse filling in from a trauma hospital nearby made him a 4 after triage. Another nurse argues with him about his triage level, indicating that the physician would order an xray and probably a CT head, so that would make him a 3.

I understand the second nurse is using the second model and was triaging based on the resources, but my question is... has anyone experienced the same sort of disparity in their practice with regard to triage, and what solutions or recommendations have you used in order to increase consistency in your hospital's triage practices?

[jayne1975]

If someone would move this post to the Emergency Department thread its probably more where it belongs! Thanks!

[RNAH01]

It is hard to discern what criteria should be used for triage and which nurse is right or wrong. Since triage is simply a means of sorting out who is the most, ill, i think it is better to over triage than to under triage, because something could get missed. However, more accuracy in triage leveling comes with experience and that is what nurses have always relied on.

[Codeyellow91]

This thread is about a month old but here's my take on this. Been in the ER for about 16 years. We have guidelines on how to properly label a patient according to the levels. For the thread starter -both description of the 5 level triage is correct; however - applying a level base on the description will still weigh on the triage nurse's assessment of the patient. I admit that I still get confused especially applying levels 3-5. I also work in a busy ER and majority of the patients we see are abdominal pain (normally level 3) chest pains (normally level 2 but still based on the age, race, and the symptom of the patient otherwise can be level 3), and simple fractures and earache for children (mostly level 4). If you're looking for answers on how to properly level a patient - then it will be hard - it's easier in writing because books and manuals are usually based on an average patient; but your assessment skills will differentiate between a level 3 or 4 even if 2 patients have similar complaints.

[jayne1975]

@Codeyellow91: Thanks for the reply, since it was more of what I was looking for in terms of how others are using the 5 tier system. From what you posted, you seem to be using the same sort of 'gut feeling' from experience triage that we use. Do you take into consideration how many resources the person is going to need when differentiating 3 and 4 or lean more toward how long they can wait to see a physician?

[essarge]

While gut feelings and resources play a large part, we as triage nurses, don't use level 5 as much as needed...or level 4 for that matter. We have fast track as well as emergency medicine in our ED. When a patient presents with abdominal pain, it is almost always a level 3. That being said however, a toothache, is sometimes a level 3 and placed in emergency medicine, which I find a waste of resources. While I understand that pain decribed by a patient as a "10" on a numerical scale, nurses need to pay close attention to vital signs and pt body language. If what they are saying, and what you are observing, consider making them a 4 and sending them to fast track. If they need to be moved, they can but we need to stop taking up beds that are needed for more critical patients!!

[multimediaproduction]

Triage -- which evolved from the French word "trier," which means "to sort" -- is used in emergency situations and in emergency rooms across the world as a way to designate a person's need for medical care based upon the degree of injury. According to the Agency for Healthcare Research and Quality, the five levels of triage are: Referred, Nonurgent, Urgent, Emergent and Resuscitation

[saliza]

HI..I m liza from Malaysia,currently im doing my Bachelor Science of Nursing in Open University Malaysia.
Happy today joining Nurse.com

tq

[GitanoRN]

saliza Welcome to the cite, wishing you a great weekend...Aloha~

[GitanoRN]

ED triage is a method of categorization based upon a number of concerns, including the severity of illness or injury, prioritization of patients for treatment, and making the most of ED operations. Having said that, hospitals are require to provide an appropriate medical screening exam to any person who comes to ED, and requests treatment or an examination for a medical condition. Furthermore, if the examination reveals an emergency medical condition, the hospital must also provide either necessary stabilizing treatment or appropriate transfer to another medical facility. However, qualifications for triage nurses since they are the first medical staff that all patients come in contact their evaluation is crucial, if they over triage they can use up vital beds in ED. Consequently, if they under triage, they can delay vital care. Therefore, triage nurses must be knowledgeable, experience, plus posses the qualifications necessary to function in a high stress environment.

[jing2heaven]

Im jhoanna working as a staff nurse and newly assigned in er...

[ciprian21]

same here jhoanna still trining to get more info ...this treand helped me a lot

[nurseonwheels]

Very interesting stuff here. Funny thing about all these systems is that they'll be obsolete years from now as this is an ever-changing field. Great posts.

[chicagonurse89]

Hi..just dropping by to see latest information about triaging!This post is very informative and helps me a lot!Thanks so much