Triage Area in the Emergency Room: How to start? HELP!

Specialties Emergency


Hello everyone!

Im a nurse in the Emergency room in one of the public hospitals in the Philippines. Right now, our ED has no triage system of some sort which means that patients do get backed up and sometimes are referred to the wrong department or beong passed around. But our main problem is congestion and that it takes a long time for patients to be seen in the ED!

I am one of the persons tasked to make the guidelines, protocols, setup, area, policies, rules and regulations and everything and all under the sun that has to do with setting up the triage area of our ED. In short, i will be one of the first triage nurses in the hospital! Right now, in my research, I am very confused where to start. Can anyone please give any idea on what I should do and how to start? We are only given a week to do this before we give our presentation. The setting up of the triage area is already approved so what is lacking are the guidelines and protocol. Any help would be greatly appreciated.


PS Mind you our ED has very little bed capacity. no trauma room (but am planning to put one). change of floor plan may be a lil problem but is possible.


270 Posts

Specializes in Mental and Behavioral Health.

You're going to have to allow your care to spill out into the waiting room. Put a curtain around an area of the waiting room for people who have to have care before the doctor can get to them, people who need O2, etc. Allow only one person to wait with a sick person to save room. Encourage that person to let you know it there is a change in condition. Stamp a number on everyone's hand as you check them in. 1's for respiratory /cardiac, 2's for fever/ vomiting, 3's for stable pt's with broken bones, 4's for "my back hurts".. you get the idea. Put a mask on anyone you think has an infection. Check and make sure that everyone is checked in, and that no one is on the floor in your waiting room.

I think you are brave. I'm going to pray for you.

canoehead, BSN, RN

6,890 Posts

Specializes in ER.

Our hospital uses the Canadian Triage and Acuity Scale as a fromat to decide who is sickest, and the sickest get seen first. The triage nurse scores patients that want to be seen, and does whatever nursing interventions are needed while they are waiting for a doctor. If you google that scale you'll find pages of information.

canoehead, BSN, RN

6,890 Posts

Specializes in ER.

Here are the guidelines that you can just pull up on a computer at the triage nurses' desk.

Crocuta, RN

172 Posts

Specializes in Med-Surg, ER.

Have you tried contacting the Emergency Nurses Association? Don't try to reinvent ED triage - other people have already done the work for you. I'd suggest starting with the research department at [email protected] . I also note that there does not appear to be a professional emergency nurses group in your country - it sounds like it's time to start one!

Good luck!


4 Posts

Thank you very much for all of your help! It is greatly appreciated and the points that you have given really will help me in the formation of our triage system. Thank you very much! I just have to make it a reality. Wish me luck!


2 Posts

You need to get some proffesional help! We did in our ER and it is a wonderful place to work now, with low wait times and more. We had this company Try them they also do international and one of the owners is Canadian.

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