How do you triage? How do you assign levels?

[RhiaRN75]

We have a five level triage system. Since we're a small hospital, all the ED nurses rotate through assignments, including triage.

For those in similiar situations.... how do you assign levels? For me, I tend to look at it as "is it an emergency or not?" Level 1= I take you back so you don't die now. Level 2= I take you back because you may die soon. Level 3= I take you back if there's a room (or hall bed) available because you are very sick. If one is not available, I start trying to make one available. Level 4= Your doctor could have handled this, it's been going on for days or more, etc. Level 5= there is no reason why an OTC remedy at the 24hr WalMart couldn't fix this.

That's just the basic concept, not my 'this is the only way it can ever be' rule, lol.

Anyhow, some of my coworkers assign levels based on resources. In all honesty, the policy kinda reads that way because a true emergency uses more resources. However, I don't make a c/o "I have a yeast infection" a level 3 because the doc working tonight is going to do a ton of tests. 'It's just like my last yeast infection' + WalMart + generic OTC= level 5. Yes, I have seen a pt with a yeast infection end up having US or CT because of the 'horrible pain', etc. In the end, it's still a yeast infection, no matter how many tests get thrown at it. At the most, a pt will get a script for diflucan or a dose in the ED. So ok, a level 4 maybe... but a 3?

Don't get me wrong, I have great coworkers. There's not a one of them I wouldn't want taking care of me or mine. I was just wondering if maybe I should be a little more generous with my level assignments? I really don't give someone a level 5 because I think they are wasting my time, I do it because.... well, some things just don't require a trip to the ED. I'm sorry. You can be the absolute coolest human on the planet, you may end up as my fave pt of the night, but a level 5 is a level 5.

[RhiaRN75, RN]

If the policy kinda reads that way, then I respectfully suggest that all of you kinda do it that way. Otherwise you have nothing to back you up if that vag discharge turns out to also be an emergent appy, ruptured tubal pregnancy, or whatever else.

Ok. I think I'm not getting my point across very well. Or perhaps I'm just wrong, won't be the first time.

As I understand, the policy uses resources required as a part of determining triage level.

Consider the yeast infection. This fictional pt has stable VS, no abdominal pain, a burning/itching sensation, classic discharge, and states "I have another yeast infection." She wants us to administer a one time pill that will cure her with no hassle. With due respect, I'm not sure how this could wind up as an appy, tubal, etc. After all, the basic purpose of triage is to sort the yeast infection from the appy/tubal and make sure that the appy/tubal has priority.

To me, resources required v/s resources used (by a doc who is fond of super-duper workups) are not one in the same. So, for the yeast infection, the resource required is a MSE and instructions to buy monistat. Level 5 technically but I might still go level 4. However, if she gets back to the doc and complains about how bad that burning itch is, it's a 15/10, and he ends up going through a super-duper workup, resources used are level 3.

Now, the possible surgical abdomen is also a level 3 if the pt is lucky, a level 2 if not. So I find it a bit disturbing to have a possible surgical abdomen and a yeast infection both triaged as a level 3.

The policy feels that all level 5 pts will have level 5 resources used. (Not level 4 or 3 resources, those resources are not required.) If someone is a little sicker, they require more resources, so the acuity is higher and thus the level higher.

What I see happen is that some nurses take a guess as to what all the current provider might order and then assigns a level with that in mind. This leads to the following*::

Susie: I see we have five patients waiting for this one available room. Who's next, and what's the level.

Triage: Ms. Yeasty is the next to come back per time, but I'm kinda worried about little Bobby who cried with every bump in the road on the way here, threw up earlier, is walking a little hunched, and looks like he feels bad. Ms. Yeasty is a 4, Bobby a 3.

Susie: Why is Ms. Yeasty a 4? You know Dr. HereNow will do a pelvic and maybe labs, and give her a dose of diflucan here and a script for home. Does Bobby have a fever?

Triage: No, but he's rather pale and he just looks bad. Ms. Yeasty has been to the cafeteria and has been chatting on the phone in no distress. I think Bobby might be an appy.

Susie: Ms Yeasty sure has been here for a long time.

Triaging up can be about as dangerous as triaging down, IMO.

Am I clear as mud yet? :)

*In real life, anytime I say 'possible appy' the typical response is 'shall I fix a bed in the hall?' I'm just trying to be consistent with my example.

[RedSox33RN]

I see what you are saying, Rhia. In terms of what a pt comes in "saying" is a yeast infection, I would triage her a level 4, with my reasoning being that in our facility (not sure of others), she WILL be getting a pelvic and since they're doing the pelvic, they will be doing a GC/Chlam & wet prep, which constitutes one resource. I would also send this woman to fast-track (unless closed). Stuff like that is obviously harder to triage since you obviously can't SEE what is going on in your triage booth, and are basing it on subjective and objective info. Some providers in our ER may just do a quick pelvic and not send labs, but in fast track, they figure as long as they are down there they might as well culture it.

I work triage for 7 hours of my 12 hour shift (long explanation, but I work 1p-1a, and work as second triage nurse until 8, then move to either ER or fast track. If a 2nd triage RN is not needed, I'll work as float in main ER with a pt assignment until needed in triage or fast track. It's a crazy way to work, but I love it!), so I've gotten pretty comfortable with what PA's and MD's are working and what I know each will "work up" and what they'll "treat & street". That said, I hardly ever triage anyone a Level 5. Usually only med refills (although must say I got BURNED a few weeks ago with one pt that came in looking for HTN meds. Turned out she actually had IVC papers taken out on her and it became a big mess!! Not that I knew, but still, I felt bad that Fast Track had to deal with that) and the FF that comes in with a recurrent complaint I know they won't work up, but even still I may make it a 4.

And since we are more and more sending off urine to the lab, even the simple UTI sx gets a level 4 (no point-of-care for urine - except UPreg - in our ER, which really chaps me. It's just as easy for us to dip a urine as it is for the lab, and quicker results. It can always be sent off if needed) since we have to send to lab.

Once I get to Level 3 and above, especially with c/p, it can get more tricky. I know MANY nurses that make ALL c/p a level 2, no matter what, even if it seems muscular or may be from a chronic cough. C/p and CVA sx are ones that you REALLY need the ESI "danger" vitals and a good hx. If there is ANY kind of cardiac hx, or hx of current drug/cocaine use, they're level 2, and if I don't have a bed, I start a cardiac work-up according to our protocols. If it's a guy that had been moving furniture and having c/p, can be reproduced, no health probs or hx, I'll still do an EKG and have the MD sign off on it (if no beds), but would feel comfortable making him a Level 3 if EKG is okay.

Those ones are the most tricky, and especially with women. I "go with my gut" on a lot of the women with c/p in their 40's and 50's, especially when they say they have GERD and "some stomach upset". I've seen too many women having STEMI with vague sx like that.

I'd love to know how others will triage c/p and CVA sx. I really dislike that our registration can even USE a term like CVA Symptoms when quick-registering before they come back to triage (this is if we're full, which is most of the time. If a bed is available, they go right back, don't get me wrong). I know they have to use something, but a lot of times I will end up changing that term so it doesn't look like the chronic migraine FF is sitting in the WR having a stroke!

We are having EVERYONE who triages in our dept re-take the ESI course every 2 years, which I think is a good idea. I've worked some places that demand every c/p is a level 2, and some places that don't. It's good if we're all on the same page with that.

[RhiaRN75, RN]

Everyone, thanks for the input!

I re-read my posts and I really wasn't trying to argue, except maybe with myself :) If it seemed that way, I apologize.

Driving home this AM, I caught myself musing as I changed gears. Hmmm.... 1st gear, short time, a little longer in 2nd, and I can cruise all day in 5th. LOL at myself. Right or wrong, if I'm mulling it all over so much that I see philosophy in driving a standard, I'm thinking about it waaayyy too much.

So I'll be a little more generous with my lower level triages. Read over the ESI stuff yet again, and see what happens.

Again, I appreciate all the input.

[Altra, BSN, RN]

Ok. I think I'm not getting my point across very well. Or perhaps I'm just wrong, won't be the first time.

As I understand, the policy uses resources required as a part of determining triage level.

I may not have been clear. (it's been known to happen )

In my experience, ESI is used to tabulate the resources needed to do a differential diagnosis of a chief complaint and assign a "Level" which corresponds to that number of resources. Any chief complaint of lady partsl bad ju ju requires a pelvic exam and specimen collection for diagnosis, and so ends up being a Level 3, although a Level 3 that goes to urgent care unless they are busting at the seams. (as a side note, the triage system used at the first ER where I worked, before they adopted ESI, also specifically gave "points" for any lady partsl complaint and/or female abd pain because of the specialized resources required for those complaints - the gyne bed, etc.)

As always, even the simple finger lac has the option to be given a higher level if there are abnormal vital signs or something else about the patient that raises your Triage Nurse Radar.

I fully recognize that your MDs' practices may vary somewhat, and that there may be resulting differences in resources used.

I am emphatically saying, however, that it would be advisable to be very clear about what your policy says, because if your actual practice deviates from the policy -- that is a ticking time bomb.

"Let's be careful out there ..." --- Hill St. Blues

[Altra, BSN, RN]

I'd love to know how others will triage c/p and CVA sx. I really dislike that our registration can even USE a term like CVA Symptoms when quick-registering before they come back to triage.

Can the triage nurse change the chief complaint on the tracking board?

I make *frequent use* of that feature in our EDIS ...

Don't get me started on the descriptions used by registration ... that's a whole other topic.

[Jennifer, RN]

After watching the the 5 Level Triage DVD a couple years ago I made up this little cheat sheet to help me remember the ESI levels. This is solely based on the instructional dvd and really the 5 levels the author of the original question uses are right on. Hope this is of some help to you....Rick

5 LEVEL TRIAGE SUMMARY

ESI 1 Needs life saving interventions

ESI 2 Needs immediate Rx but not life saving Rx

ESI 3 Needs 2 or more resources but not a level 2

ESI 4 Needs 1 resource

ESI 5 Needs no resources other than physician exam

DEFINITION of RESOURCES

Lab, EKG, X-ray, IV Fluids, IM/IV/Inhaler Meds, Consult with Specialist,

Simple procedures i.e.; suturing, ear/eye irrigation, DSD change etc.= 1 Resource

Procedural Sedation = 2 Resources

What is not a Resource

Finger stick BS, Urine Dip, Saline Lock(must administer fluids to qualify for a resource), oral med, Tetorifice, PCP consult

CRITERIA For ESI 3 Upgrade to ESI 2

************ Pulse Resp SO2 Temp

100.4

180 >50 100.4 (? Consider)

3 months- 3yrs >160 >40 102.2 (? Consider)

3 yrs-8yrs----- >140 >30

>8yrs---------- >100 >20

Valid pain >7/10 if pain unresolved through triage intervention i.e. ice elevation tetracaine etc.

Agree with this except I would probably bump the SO2 up to 95% for kids, since they really should be in the upper 90's.

As a triage nurse, you have to look at your patient and make quick assessments, based on initial vital signs as well as how the patient looks and presents themselves. If in doubt, always triage up a level. Triage can be tricky.