How do you triage? How do you assign levels?

Specialties Emergency

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Specializes in ER.

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.

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Specializes in ER, Trauma.

I think your system is excellant! It puts in words my system perfectly. I triage based on how much the patient scares me (meaning how likely to die). During a lull, you might triage by resources, but that's a setup for a tragedy. If you've got 2 critical or major beds, and 10 patients on the verge of dying, you've got 10 level 1's. Period. Keep up the great and very intuitive work.

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Specializes in Med Surg/Tele/ER.

We have a protocols that we go by and most of us are pretty close on assigning levels of urgency. We usually triage 6 hrs at a time, unless the other nurses do not qualify for triage.

Fast Track....doctor office stuff, & simple breaks....or you do not need to be here!

Non Urgent...stuff that won't kill you anytime soon

Urgent...needs attention now

Emergent...could & will possibly die if interventions are not taken

then your code blues, traumas.

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Specializes in ICU,OR,PACU,ER.

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.

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Specializes in ER, cardiac, addictions.

I agree with Rickbos's "cheat sheet." I would focus largely on how quickly the patient needs (not wants) to be seen, and what sort of interventions are likely to be needed. A cardiac arrest, or near arrest, is obviously a 1. An active chest pain is an example of a 2. Most abdominal pains, requiring blood work &c, are a 3. Sprains, uncomplicated lacerations and UTIs are a 4. Typical 5s are dental pain or "I'm out of Ventolin and I can't afford to get my prescription refilled."

When in doubt, I err on the side of caution.

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Specializes in ER.

Ok, that makes sense. Another question...

Do you consider resources needed, or what the doc is likely to do? For example, the patient who is out of ventolin. She's not in distress, but it's been hot and she has some wheezes. So, is she a level 5 because a couple of puffs will make her better..... or a lever 3 because the doc will probably order a neb, chest x-ray, and maybe even bloodwork 'just in case' she's developing pneumonia. (She's not, she just needs the ventolin.) If she has an SL placed with the bloodwork, she may get an IV steroid. I would place her at a level 4. She could be a level 5 because she just *needs* an MSE and a script. Per probable workup she's a level 3. If you want to consider ventolin as a possible life-saving RX, she's a level 2!

To be cynical, if she would smoke less for a couple of days she would feel better and could afford the ventolin, but triage isn't about the 'could be', lol.

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Specializes in ER, cardiac, addictions.

Yes, of course it depends on the patient's condition on arrival to the ER. My hypothetical patient who ran out of Ventolin was not in respiratory distress----if she were, that would take precedence over her request for a refill. :)

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Specializes in Emergency Medicine.

Triage? I remember the word. Still a place you go sometimes when I come to work.

"Pull 'till Full". Everyone goes back NOW!

From STEMI's and traumatic amputations to Back or Knee Pain since 1985

and for some reason it's an emergency NOW.:eek:

Critical Decision Making is gone...

Assessment Skills gone...

Autonomy is gone...

Prioritization is gone...

...all in the name of customer service.

I'm just another cattle-herder in the ER game administration makes us play.

"Welcome, How can I make you mostly satisfied with your visit today"? :uhoh3:

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.
"Pull 'till Full". Everyone goes back NOW!

Yep. We're doing bedside triage, too. Meh.

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Specializes in ED staff.

Yeah, we do the resource thing too but just started it. I am reluctant however to make someone we see once a week with belly pain a 3. SSDD ya know (Same Sh*t Different Day). With resources in mind everything is standardized. I think all of us (ER nurses) will be using it before long.

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Specializes in Emergency & Trauma/Adult ICU.
We have a five level triage system.

...

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.

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.

In the ERs where I have worked, any chief complaint of vag discharge is a level 3 - not because they're sick by the ER definition of sick - but because the pelvic exam, labs, and oh so often ... IV pain meds ( :rolleyes: ) mean that chief complaint equals a level 3 in resources.

The ESI system works because it's objective. You always have the option to "level up" someone who's chief complaint is relatively benign but just doesn't look good -- but triaging "down" is the fastest way to get burned. Badly.

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Specializes in ER, L&D, RR, Rural nursing.

In Canada we are all seem going towards the CTAS score, it sums up what many of you already do. However it is a wonderful way of assigning scores without putting a personal take on it. It also gives you, as a triage nurse a way of justifying your rationale to the more vocal people (pts and staff!) It is widely accepted, understood and used. Our wait times suck,but those who really need EMERGENT care will get it!!! The others, are "unfortunately well enough to wait"---yes it has been said, out loud to pts!

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