This is What It's Like To Be a Triage Nurse in The ED

Healthcare workers throw around the term triage like seasoned Italian bakers throw around pizza dough, but many laymen do not understand the full extent of the triage process or what it means to be a triage nurse. The word triage originates from the French word “trier” which translates into English “to sort.” One of the first documented occasions of a medical triage system occurred during the Battle of Jena in 1806 when the lead physician categorized people into three groups to assess who required the most urgent evacuation from the battlegrounds: dangerously wounded, less dangerously wounded, and slightly wounded. The physician that developed this system also takes credit for being the first to utilize ambulances, or horse-drawn buggies with a medical team, to expedite care. 

Triaging has always been a critical part of war medicine, but the priorities for triaging during battle or massive casualty incidents have a slightly different goal than the typical emergency department triage system. Rather than trying to save the sickest people first, they focus on saving as many people that have a higher likelihood of surviving and going back to being active soldiers in the war. Modern-day mass casualty triage systems are categorized by color:

• Black (dead)
• Red (immediate)
• Yellow (delayed)
• Green (minimal)

As an emergency nurse, I have thankfully never been directly involved in a mass casualty incident such as the shootings in Las Vegas or Orlando in recent years. However, I have been a part of scenarios in which we were given a “heads up” by local law enforcement that an active shooter was in the service area of the hospital. We were instructed to start preparing for potential “mass cas” patients. In this case, the charge nurse designated one nurse as the triage nurse that would stand out in the ambulance bay and have the job of triaging by color and making the decision of which patient should receive which level of care. This horrendous scenario goes against everything that we stand for as nurses when you have to make the call that someone might be too injured to even attempt to save their life; when the resources could be allocated to save four other lives instead. 

More often, though, the triage system plays an active role in every Emergency Department each time a patient walks, or wheels, through the doors. 

In America, the standard triage system is called the ESI, or Emergency Severity Index, and is a number system from 1 to 5 with 1 being the most critical, and 5 being the most non-acute. An ESI level 1 means that the patient requires “life-saving measures” and needs treatment immediately. A patient scored a 2 indicates that the patient has a high-risk scenario or could have vital signs that are in the dangerous category. Nurses dictate levels 3 to 5 based on the number of resources the patient is going to require which include radiology tests, blood work, medications, procedures, or EKGs. Patients that require multiple resources are level 3’s, 1 resource are level 4’s, and no resources are level 5’s. This numeric system helps indicate which patients in a crowded waiting room should receive the first room once one opens up, and helps physicians see who might be the highest risk and should be evaluated first. 

Acting as the role of a triage nurse on a busy day can leave you with exhaustion that differs from working a typical assignment in the ED. You have one of the highest liabilities within the department because you are responsible for deciding who sees a doctor first, and who can sit and wait for four more hours. If you make the wrong decision, a patient could be sent back out to wait and have a fatal event while someone else was seen before them. Sometimes working in triage feels like a long game of twenty questions; a good nurse needs to be experienced enough to know which questions to ask that will help them decide how sick they might actually be. 

Working in a triage room for twelve hours can provide some of the most comical stories since you get to hear a little bit about every patient’s problems that day. The line of “Sir/ma’am, what brings you into the Emergency Department today?” gives a wide-open arena for patients to fill in the missing space with their choice of stupidity. In many ways, wearing a mask for the past two years has been extremely helpful in hiding my reactions as patients begin to explain the reason for their ED visit. Responses such as “I just tripped and fell onto the soda bottle and it is stuck, well you know where,” to “I just was minding my own business, and someone came and stabbed me,” to “I have this toenail, and there is a part of it that is about to fall off,” are all statements I have heard, and the challenge to remain non-reactionary can be a true struggle. 

The job is complex. You become the gatekeeper for the department and are often placed in a tricky situation when a family member knows their loved one is in the department, but they are either critically ill or might not want the family back, and the triage nurse has to take the wrath from the family about not being allowed back. On busy days, the triage nurse constantly has to deal with sick, hurting, and often grumpy patients who have been waiting for hours and hours to be seen, and the toll weighs on you both physically and emotionally. It is a mixture of customer service and being the face of the department, as well as implementing astute medical knowledge and assessment skills. The triage process is much more complex than many people might expect, and triage nurses often go unrecognized by patients as playing such a vital role in patient safety. 

Hopefully, patients will change their response from “why did they get to go back before me, I have been here for two hours already,” to “thank you for saving lives and asking the right questions to help the entire community out.” 

ncbi.nlm.nih.gov/pmc/articles/PMC5649292/