Education is the key for switch to 5-level triage

Be sure your go live’ day isn’t a disaster

(Editor’s note: This is the second of a two-part series on switching to a five-level triage system. This month, we’ll cover effective strategies to avoid problems during the transition. Last month, we covered how to choose the right five-level system for your ED.)

When you picture the day your ED makes the switch to five-level triage, do you have visions of confused nurses, mistriaged patients, and a chaotic waiting room? Unless you take the correct steps to prepare nursing staff, these gloom-and-doom scenarios will occur.

For most EDs, switching to five-level triage no longer is a question of if, but when. A task force formed jointly by the Des Plaines, IL-based Emergency Nurses Association (ENA) and the Dallas-based American College of Emergency Physicians (ACEP) recently recommended that EDs switch to five-level triage, but did not endorse a specific system. It is not yet known if the task force will ultimately recommend a specific system. To ensure a smooth transition during your ED’s switch to five-level triage, follow these steps:

• Choose a core group of nurses to train others.

At St. Joseph’s Hospital and Medical Center in Phoenix, eight experienced ED nurses were given materials on the five-level Emergency Severity Index (ESI) and charged with becoming experts on the new triage system.

"We created a core triage group that learned the new system and only worked triage for three months," says Kim Flanders, RN, BSN, CEN, clinical nurse manager for emergency services.

During this period, the eight nurses were taken out of the regular ED schedule to train the second "ring" of ED nurses. "We have just completed the training of this group. Our intent is to continue training in this method until all staff have been provided hands-on training in the new system," she reports.

From the second group, more experienced nurses will again be asked to train another group of nurses, and so on.

"I will again be taken out of the count to mentor this group, but only for two weeks this time," says Susan Jackson, RN, one of the eight ED nurses who trained the first group. "By the time I get to the next group, some of the nurses I am training now will be ready to take on the role of the training nurse, and so on."

This way, all new nurses hired throughout the year will be trained, and recently trained nurses will have enough time to become comfortable with the new system before they begin to triage patients, she adds.

• Show nurses the benefits in a concrete way.

Jackson and the nursing educator held three-hour classes on the ESI, with nurses asked to rate the acuity of 15 sample patients and compare their assigned triage levels using a three-level triage system with the group.

"I asked them to go around the room and call out what acuity they got for each question," says Jackson. "This exercise was very powerful, because it showed the huge variance you can get even in a small group [with the three-level system]."

Next, the nurses were asked to give the acuity levels of another 15 sample patients, but this time, the nurses used the ESI system as a guide. "In each and every class, everyone was 100% in agreement with the answers," reports Jackson.

• Have an additional nurse at triage during the training period.

After the first group of nurses was trained, Jackson exclusively worked triage for a month, acting as a full-time troubleshooter and resource person at triage. "They each got one eight-hour day with me. During that time, I worked alongside them as their own personal educator," she says. "Being right there on the spot, I could answer questions as they came up."

As these nurses gained enough experience, they were able to function as a "first nurse" at triage, to back up a second nurse who was learning the process, explains Jackson. "If nurses were working triage and trying to learn the system at the same time, it would become too difficult," she says.

Jackson is going to hold the triage course on a quarterly basis, each time being taken off the schedule for two weeks to train nurses. "Our manager has made this a compulsory course, so by running it every four months, we should catch all the new staff," she says.

• Have nurses observe for a period of time.

Before nurses actually use the five-level system, Jackson recommends having them sit and watch the process for a few days.

"I found it difficult to teach them why I was asking certain questions and how I came to the decisions I did about the ESI level," she says. "I found that if nurses just watched and listened, they could soon pick it up."

The benefits of five-level triage already are becoming obvious, says Jackson. "We have decreased our waiting times significantly," she reports. "We’re finding that our sicker patients are now being more satisfactorily recognized and therefore being seen quicker."


For more information on switching to a five-level triage system, contact:

  • Susan Jackson, RN, Emergency Department, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ 85013. Telephone: (602) 406-3000. Fax: (602) 406-7150. E-mail:
  • Kim Flanders, RN, BSN, CEN, Clinical Nurse Manager, Emergency Services, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ 85013. Telephone: (602) 406-5147. E-mail: