Are you ready for a 5-level triage scale? Be prepared: Most EDs will switch soon

You’ll need to start planning for this dramatic change now

Brace yourself. Most emergency departments (EDs) in the country will switch to a national five-level triage classification system following the expected endorsement of the Des Plaines, IL-based Emergency Nurses Association (ENA). If you’re included in the majority of the nation’s EDs that currently use a three-level system, you’ll need at least six months for the transition, sources advise.

"Recognize the magnitude of the change," says Paula Tanabe, RN, PhD, CCRN, CEN, research coordinator at Northwestern Memorial Hospital in Chicago, which implemented the Emergency Severity Index (ESI) in August 2000.

A specific five-level triage system will be recommended for use this year, says Jean A. Proehl, RN, MN, CEN, CCRN, past president of the ENA and emergency clinical nurse specialist nurse at Dartmouth-Hitchcock Medical Center in Lebanon, NH, which uses the five-level Canadian Triage and Acuity Scale. Five-level systems have demonstrated reliability and validity, but three and four-level systems have not,1-3 she says. "I think it is time we caught up with Australia, the United Kingdom, and Canada, who have been working toward this for years," she says.

According to 2001 ENA data, 66.7% of EDs use a three-level system, while only 3% use a five-level system, says Proehl. "I already see a big trend of moving toward five-level systems, and I expect this to increase significantly," she predicts.4 Begin discussing the five-level triage system in your ED now, Proehl recommends. "If you start to spread the word to staff, it will be easier down the road when the chosen system is announced," she says.

4 items to consider

Here are steps to take to facilitate a switch to a five-level triage system:

• Consider how staff will be trained. The amount of training required will depend on the triage scale chosen, Proehl says. "Some require more training, and others require less," she says. "For example, the Canadian system uses a six- to eight-hour training program." Experienced triage nurses simply will need to learn a new categorization scheme, says Proehl, but for nurses without triage experience, education also must address the triage process itself. "This should always include time with an experienced triage nurse," she says. "A uniform national scale will make it easier to orient nurses who are new to your ED, especially travelers."

At Dartmouth-Hitchcock Medical Center, some staff members initially were reluctant to attend an all-day class because they were experienced ED nurses, Proehl says. "However, the course was well-received and highly regarded after they had attended it," she adds.

Before Tanabe’s ED switched to the five-level system, every triage nurse was required to attend a four-hour class. "The class outlined the benefits of the change and reviewed the triage algorithm in detail," Tanabe says. The remainder of the class focused on reviewing cases and classifying patients with the new five-level system, she says.

• Add extra support during the transition period. Having extra nursing support for the "go live" day was key. Tanabe says. Two advanced practice nurses and one educator assisted triage nurses for three weeks, 24 hours a day, by answering questions and ensuring that categorization was correct, she says. Every triage nurse was required to be observed by one of these three experts for eight hours, says Tanabe. "In the first week, we scheduled some of the stronger nurses that we wanted to be triage preceptors," she says. After these nurses were "signed off" as experts on the new triage scale, they were allowed to work with and sign off the other triage nurses, Tanabe says.

The ED has about 100 nurses, and about 75 were triage nurses at that time, she says. "The key to successful implementation was devoting the time, training, expertise, and support to the process, both prior to and during implementation," Tanabe explains.

• Implement a quality improvement process. Proehl’s ED does ongoing quality assurance to assess individual triage nurses’ decisions. "We have not found any major problems, although a few nurses have needed some remediation," she says.

Tanabe says each week, the ED’s clinical nurse specialist sits down with three nurses. Each nurse reviews five ED records for the quality improvement documentation indicators. One of these indicators is the accuracy of the triage category, says Tanabe. "Any mistriages are identified and discussed," she says. "These cases are then re-typed and a discussion is written, explaining the rationale for the correct triage category." These are distributed to all the staff, she says. "This has been very well received by the staff and is a great learning tool," adds Tanabe.

• Be realistic with expectations. Be clear about what five-level triage can and can’t do, Tanabe advises. She says that several nurses and physicians complained that the five-level scale wasn’t shortening delays. "We needed to emphasize that changing to a five-category triage system will not decrease wait times," she says. "However, it will ensure that the sickest patients are not left waiting."

Triage will be standardized

You will recognize significant benefits with the standardized use of a five-level scale, sources report. They include:

• Improved ability to benchmark. This will help EDs more accurately compare data across the country, so you can benchmark more accurately, says Proehl. "To say you have 30% Level 1 patients doesn’t really mean much unless you are using a standardized system," she says.

Without a standard triage system, important decisions that affect EDs may be based on inaccurate comparisons, according to Debbie Travers, RN, MSN, a triage nurse and researcher at the University of North Carolina in Chapel Hill. Travers participated in the development of the five-level ESI, which is used by a dozen hospitals. For example, some policy-makers have claimed that a large percentage of ED visits are for nonurgent conditions, she says. "However, with no national standard for triage acuity and the poor reliability and validity of current three-level triage systems, it is difficult to determine whether patients’ visits to the ED are urgent or not," says Travers.

In a three-level system, one hospital might rate patients with an ankle injury as Level 2, while another would rate them as Level 3, explains Travers. "Even nurses at the same hospital might rate such patients differently," she says.

• Better patient flow. The five-level scales are more efficient because they allow triage nurses to more easily pick out the patients who cannot wait and those who can be sent to a fast track or urgent care clinic, says Travers. As a result, you’ll be able to more accurately reflect your workload and allocate resources and staffing accordingly, says Proehl. "It will also be more legally defensible as a triage scheme because it’s national and it’s backed by ENA," she adds.

• Improved patient care. With the use of a five-level scale, patients will be assessed and prioritized more consistently, Proehl says. "This will lead to improved care and decrease the risk of patient deterioration in the waiting room," she says. The five-level scale also can be used to trigger automatic clinical guidelines by having the triage nurse enter information about the patient’s level into the hospital computer upon the patient’s arrival, Travers adds. "For example, if the triage level is 2 and the patient’s chief complaint is chest pain, the system could trigger a clinical guideline for patients with potential cardiac ischemia," Travers explains.


1. Travers DA, Waller AE, Bowling JM, et al. Five-level triage system more effective than three-level in Tertiary Emergency Department. J Emerg Nurs 2002; 28:395-400.

2. Eitel DR, Travers D, Gilboy N, et al. Implementation and validation of the Emergency Severity Index (ESI) triage algorithm: Admission rates by triage level (abstract). Ann Emerg Med 2001; 38:S31.

3. Zimmerman PG. The case for a universal, valid, reliable 5-tier triage acuity scale for U.S. emergency departments. J Emerg Nurs 2002; 27:246-254.

4. Emergency Nurses Association. 2001 ENA National Benchmark Guide: Emergency Departments. Des Plaines, IL; 2001.


For more information on the use of a five-level triage scale, contact:

Jean A. Proehl, RN, MN, CEN, CCRN, Emergency Clinical Nurse Specialist, Dartmouth-Hitchcock Medical Center, One Medical Center, Lebanon, NH 03756. Telephone: (603) 650-6049. Fax: (603) 650-4516. E-mail:

Paula Tanabe, RN, PhD, CCRN, CEN, Research Coordinator, Northwestern Memorial Hospital, 251 E. Huron St., Chicago IL, 60611. E-mail:

Debbie Travers, RN, MSN, University of North Carolina Hospitals, 101 Manning Drive, Chapel Hill, NC 27516. Telephone: (919) 966-4721. Fax: (919) 966-3049. E-mail: