How to Triage Like a Pro and Prioritize Patients Under Pressure
Disclaimer: Always refer to your organization for the most up-to-date and organization-specific information regarding triaging. This is not meant to replace any company triage policy or education. Everything in this article is based on personal experience by the author.
Knowing how to triage is one of the most important skills a nurse can add to their arsenal. Once we know how to properly triage patients, our entire practice runs more smoothly. In my opinion, this also translates into our personal lives, as we learn how to prioritize things based on importance and urgency.
In ER nursing, we use numbers 1–5 to assign to patients based on the Emergency Severity Index (ESI). These numbers help the department prioritize patients and ensure that higher-risk patients are evaluated first. This system is different from what you would see in a restaurant, which typically follows a first-come, first-served process. For example, a patient who is assigned an ESI 4 by the triage nurse and has been in the waiting room for two hours will likely be bumped behind a patient who just walked in the doors with an ESI 2 who requires emergent care.
What does the ESI scale mean?
Based on the ESI Handbook, an ESI 1 is any patient who requires immediate life-saving intervention. A level 2 is any patient who is deemed high risk by the triage RN. ESI 3–5 are based on the number of resources the patient may need — 5 being no resources, 4 requiring one resource, and 3 being anything that requires more than one resource.
ESI 5
A patient who walks into the ER while on vacation and forgot their antihypertensive medication at home, therefore going to the local ER to request a medication refill, is a typical ESI 5. The patient only requires an exam by the provider and a refill to be sent, no additional resources are needed.
ESI 4
A patient presents to the triage booth in the ER with complaints of a sore throat. The patient has stable vital signs, is 20 years old, and has no other symptoms. As the triage nurse, you determine that the patient will likely only need a throat swab to test for strep. One resource utilized would make this patient an ESI 4. However, if you determine the patient may need additional resources such as a CT scan or blood work, then the patient could be upgraded to an ESI 3.
ESI 3
A common ESI 3 is a patient who presents with abdominal pain and will likely need imaging, blood work, and possibly medications. If the patient is 35 years old, has no major medical history, stable vital signs, and does not appear to be in distress, an ESI 3 is typically an appropriate number to assign. However, if the nurse is concerned about borderline or unstable vital signs, then this patient with abdominal pain would benefit from a higher triage level of an ESI 2.
ESI 2
ESI 2 is for patients who are at high risk for deterioration and should be assigned a room with the highest priority. These are often patients who come in with chest pain, suicidal ideation (SI), or any other condition that the triage nurse deems high risk for rapid decline.
For example, if a 45-year-old male came into the ER with crushing chest pain while mowing the lawn, the triage nurse would likely obtain an EKG so the ER attending can rule out a STEMI. If there is no STEMI, the patient will likely be assigned an ESI 2, as they still need a more rapid evaluation by the ER team.
ESI 1
ESI 1 is reserved for patients who need immediate life-saving interventions. The most obvious example is a patient who arrives via EMS and is actively receiving chest compressions or has sustained a traumatic injury that requires immediate life-saving care by the team. These patients, for obvious reasons, cannot sit in the ER lobby waiting for a room.
Key Takeaways on Triage Assessment
I hope this helps anyone who is curious about how triage nurses assign levels of priority to patients. The triage nurse has a critically important job, as they are typically the first medical professional to lay eyes on a patient when they present to the ER. The initial intake is the beginning of the story that dictates the direction of care for the patient. The triage note is what the charge nurses, doctors, primary nurses, and other members of the medical team use to get a snapshot of why the patient has presented to the ER that day.
While this can be a stressful position, the nurse will sharpen their clinical skills and become stronger in their practice through the ability to triage effectively. Most nurses naturally triage their own patients in their head based on what needs to be prioritized first, but knowing how to assign an ESI level to a patient who has just arrived from the public is a very specific and valuable skill.
Always refer to your organization's policy regarding triaging patients. Most healthcare organizations require modules to be completed before a nurse is allowed to begin triaging, as well as separate on-the-job training.
🤔Nurses, share your thoughts in the discussion forum below!
