Elsevier

Journal of Emergency Nursing

Volume 31, Issue 1, January–February 2005, Pages 39-50
Journal of Emergency Nursing

CLINICAL
Five-Level Triage: A Report from the ACEP/ENA Five-Level Triage Task Force

https://doi.org/10.1016/j.jen.2004.11.002Get rights and content

Section snippets

The “ideal” triage scale

The ideal acuity rating system should allow for quick sorting of patients and rapid identification of patients in need of immediate care. To maintain the accuracy of the scale, the definitions of each triage level must be clear. The triage acuity level should reflect the seriousness of illness or injury and should not be influenced by ED volume. The ideal triage scale must demonstrate the characteristics of reliability, validity, utility and relevance.

Excellent inter-rater reliability ensures

The current state of triage

There is neither consensus regarding whether to use a 3-, 4-, or 5-level scale, nor is there a single triage scale that has been adopted and implemented on an extensive basis in the United States.9., 10., 11. A recent study surveyed emergency departments throughout the United States regarding their triage system in use and reported that the majority (69.4%) of emergency departments use a 3-level triage system.12 However, a 4-level triage scale was used by 11.6%, a 5-level system was used by 3%,

Literature review of currently published 5-level triage scales

In marked contrast to 3-level scales used by emergency departments in the United States, both Australia and Canada mandated implementation of 5-level triage scales in the mid 1990s. These scales continue to be in use and provide an excellent universal database that allows emergency departments to accurately describe and compare their acuity throughout the country.13 The presence of a National Health System in both countries presents a stark contrast to the United States and was a key factor in

The Australasian Triage Scale

In 1994 Australia implemented the National Triage Scale (NTS), now renamed and referenced as the Australasian Triage Scale (ATS); it is currently used by every emergency department in Australia. The ATS is a 5-level triage urgency scale with each level having an associated time goal to initiation of medical evaluation. Table 1 describes unique characteristics of the scale. Data are aggregated by region and individual hospital results are made available on the Internet.13 Table 2 summarizes the

Canadian Triage and Acuity Scale

The Canadian Emergency Department Triage and Acuity Scale (CTAS) was developed in the mid 1990s by a group of physicians at Saint John Regional Hospital in New Brunswick and is based on the ATS. CTAS became a mandated reporting data element by the Canadian Institute of Health Information in 1997 and has been adopted by several hospitals in the United States. CTAS is similar in many ways to the NTS. Unique characteristics are described in Table 1. Both the ATS and CTAS also include fractile

Manchester Triage Scale

The Manchester Triage Scale (MTS) is a 5-level triage scale used by many emergency departments in Great Britain23., 24. since 1997. It is unique in its approach; there are 52 presentational flow chart diagrams, each designed to assist in the triage of a specific presenting complaint (eg, head injury and cough). Each of the flow charts depicts 6 key discriminators: life-threat, pain, hemorrhage, acuteness of onset, consciousness level, and temperature. The system requires the triage nurse to

The Emergency Severity Index

The Emergency Severity Index (ESI) is a 5-level triage algorithm developed by a group of emergency physicians and nurses in the United States in the late 1990s.25., 26., 27., 28., 29., 30. The ESI has been successfully implemented by a small number of hospitals in the United States and several European countries as well. There has been ongoing refinement and research on this scale since its initial publication by Wuerz et al in 2000.28., 29., 30., 46. The ESI is unique in its approach and

RELIABILITY

Reliability, or consistency, is fundamental to use of any measure. Measures are made more reliable, or improved, by reducing error in the use of the measure. Interrater reliability refers to the statistical measurement of agreement attained by 2 or more users of the scale. Inter-rater reliability should not be nurse specific, nor should the nurse be influenced by the volume and acuity of the department at any particular time.

Inter-rater reliability is most frequently reported in the triage

Pediatric use

CTAS has recently published its pediatric triage criteria based on expert consensus that has face validity. The ESI has integrated pediatric vital sign criteria in its algorithm. Neither the NTS nor MTS address pediatrics. None of the 5-level scales has been scientifically evaluated for use in the pediatric population. This is an important area for future research.

Risks/benefits of standardization

There are both benefits and risks to implementing any standard. Benefits of standardization in health care in general include: (1) improved data for benchmarking; (2) facilitation of various types of surveillance (bioterrorism, disease-specific, injury, and public health); and (3) support of clinical research.

Benefits of triage acuity standardization specifically include improvements in quality of care, patient safety and ED operations. Patient care improvements include the ability to

Descending and ascending triage scales

ED triage scales can be organized numerically or descriptively by designating levels or gradations of acuity.

Reimbursement

Apprehension exists that a 5-level triage system may decrease payment for medical services. There seem to be 2 major concerns: (1) that payers could simply cross-walk the triage categorization from patient presentation to the final service determination, and/or (2) that a relatively low triage determination might inordinately influence a payer's determination of the appropriateness of a patient's accessing the emergency department for care.

In the ED encounter, there are 2 basic categories of

Future possibilities

A number of issues still need to be addressed. A reliable and valid scale will allow concurrent analysis of nursing labor cost, work load, and staffing level appropriateness, perhaps in conjunction with computer-assisted triage. Case mix groups can be more fully developed and outcome effectiveness tracking can improve, including costs and patient/staff satisfaction. As a scale is refined, we can compare acuity and case mix from different hospitals.

However, many concerns still remain. Pediatric

Recommendation: triage scale standardization

Based on our review of the literature, the Task Force recommended approval of the following policy: “The American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA) believe that quality of patient care would benefit from implementing a standardized emergency department (ED) triage scale and acuity categorization process. Based on expert consensus of currently available evidence, ACEP and ENA support the adoption of a reliable, valid five-level triage scale.” The

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