Pediatric Corner

Nurses say 5-level triage is more reliable for children

New systems 'take the guesswork' out of triage

A growing number of ED nurses now use five-level triage systems, but not many studies have evaluated the use of these systems in children. New research says that a new five-level triage system, the Soterion Rapid Triage System, possesses high inter-rater reliability and validity when used to triage children younger than 13 years of age.1

ED nurses at Children's National Medical Center in Washington, DC, switched to the Emergency Severity Index (ESI) system in late 2006, says Stacy Doyle, RN, MBA nurse manager of the ED. "Unlike a three-level system that basically classifies "very ill," "somewhat ill," and "not ill," a five-level system gives a better clinical picture," she says.

For example, asthmatic children with significant trouble breathing may not need to be rushed to a code room, but they cannot remain in a waiting room, so they would be classified as a Level 2. "This means they would go straight to the back and get the treatment they need to avoid further deterioration, but they do not need the resources of an entire code or trauma team," says Doyle.

The new ESI system takes the guesswork and subjectivity out of triage, says Deborah A. Higgins, RN, BSN, nurse educator for the ED at Greater Baltimore Medical Center. The scale also addresses high-risk situations in which a patient's condition could deteriorate easily, or when a patient has symptoms of a condition that is time-sensitive to treatment, says Higgins.

For the pediatric population, the system provides guidelines for fever with age parameters, as well as "danger zone" vital signs that are age-related, says Higgins. "The high-risk situations also focus in on specific pediatric issues that need to be considered," she says. For example, if an infant under 28 days came into the ED with a temperature of more than 100.4° F, the child automatically would be triaged as a Level 2.

Greater Baltimore's ED nurses were given a four-hour training session before the ESI system was implemented. All were required to take a written competency test and pass with a grade of 90% or greater, with separate tests for pediatric and adult populations, Higgins says.

Separate tests were done to emphasize that children are not "little adults," says Higgins. "They are pediatric patients and need to be treated and assessed as such," she says. They present differently and have different needs than adults, Higgins says. "It is very important to be proficient in both areas, she says. "You never know what type of patient is going to walk through the doors."

Once ESI was instituted, all nurses that passed the written competency were required to demonstrate 10 real-time triage competencies, says Higgins. "Only the nurses that have passed both competencies are permitted to assign an ESI level on patients," she says.

Track accuracy of triage

At Greater Baltimore, weekly chart audits are done to track accuracy of triage levels, says Higgins. Previously, nurse educators performed the chart audits by looking at the ESI level, the patient's chief complaint, vital signs, and history to see if the appropriate level was assigned. If a problem was noted, the nurses were asked to explain their thought processes, says Higgins.

"This communication was done via e-mail with a requested response," she says. "In most cases, the nurse was on the right track. If they were off, we would individually remediate the nurse."

The ED is implementing a peer review chart audit process, which requires each triage nurse to audit two charts during each shift. "We have developed an audit tool that will allow the nurse to audit the entire triage assessment," says Higgins. "The educators will compile the results and see where we may need additional training or remediation."

To track the accuracy of the ESI levels, the ED compares its level charges with acuity assignments. Initially this was done every day, and it is now done once a week, says Doyle. The ED also looks at patients given a 4 or 5 acuity rating who wound up being admitted to the hospital. "We look at whether their condition changed after they got there, or was there something missed in the assessment," says Doyle. "We also look at kids with the highest acuity who went home. Did we overreact? Or perhaps we didn't get a good history, and they were upgraded higher than they should have been."

The ED also does "spot check" reviews with Doyle and the ED's clinical specialist pulling charts if, for example, there are a significant number of Level 2s in the department. "These are very unscientific, but we ask the nurse to tell us what they were thinking with each patient," says Doyle. "They may have been thinking along the right path, or the nurse may have upgraded someone because they didn't understand an element of the new system."

The remediation done with chart reviews is not a punitive process, stresses Doyle. "We really do want people to 'triage up' or decide on a higher acuity, rather than take a chance on a lower one with a longer wait time for a very ill child," she says.


  1. Maningas PA, Hime DA, Parker DE. The use of the soterion rapid triage system in children presenting to the Emergency Department. J Emerg Med 2006; 31:353-359.