Triage switch could fail without these steps

If you switch to a five-level triage system without examining your processes, the entire process could fail, warns Elisabeth K. Weber, RN, MA, CEN, a Chicago-based consultant who specializes in emergency services and process improvement. Weber has implemented five-level triage systems at three EDs. "I suppose that if you have a perfectly running ED with no capacity or access issues, then you really do not have to review front-end processes along with a triage change," she says. "Otherwise, it is worthwhile."

The Des Plaines, IL-based Emergency Nurses Association will recommend a specific five-level triage system for use, although no time frame has been announced. Most EDs are expected to switch to the triage system that is endorsed. You can reap tremendous benefits from switching to a five-level triage system, but only if you eliminate existing problems, says Weber. (For more information on the five-level triage scale, see "Are you ready for a 5-level triage scale? Be prepared: Most EDs will switch soon," ED Nursing, January 2003, p. 29.)

"To take a five-category system and just drop it into an old system really misses a great opportunity," she says. "You have the chance to review your process to determine how it should work. If you don’t do this, the outcome may not be successful."

Here are the assessments that are critical for the switch to be successful:

Identify existing problems with triage.

If you have any "yes" answers to the following questions, you’ll need to review your entire triage process, says Weber:

  • Are there risk issues at triage?
  • Do patients wait beyond benchmarks to see providers?
  • Does the current system no longer meet the needs of the hospital due to volume, changes in ED population, or being part of a network that seeks consistency across the system?
  • Are patient satisfaction issues a problem?

You’ll need to identify existing patient flow bottlenecks from the time of a patient’s arrival until a provider is seen, advises Jean Mullally, RN, MBA, nurse manager at Louis Stokes Cleveland VA Medical Center, where a five-level triage system was implemented in December 2002. To identify bottlenecks, collect and analyze data such as the number of patients arriving each hour for a full 24-hour cycle for a month, she recommends. "This helps establish anticipated triage volume and may identify significant trends," says Mullally. A review of the frequency of top diagnosis codes was used to assign medical conditions to each of the five severity levels, she adds.

Get input from a variety of sources.

Weber suggests you ask the following individuals for ideas and suggestions for ways to improve triage: physicians, security, the lab, radiology, patients or a patient representative, registration clerks, secretaries, social workers, interpreters, residents, techs, pre-hospital providers, hospital volunteers, and administrators. "Even though triage is within the realm of nursing, I think it is valuable to ask basically anyone who interacts with triage in the ED," she says.

A small committee, in turn, can interview others using a self-developed tool or a formal meeting, in order to gather a wide variety of impressions of triage, suggests Weber. "It is amazing what kind of perceptions others have of the process," she says. For instance, some valuable tips came from hospital volunteers, reports Weber. "They see the broken process as a patient or consumer does," she says. "Radiology and security were also very helpful with their impressions."

Radiology set aside a room for quick "in-and-out" triage X-rays, says Weber. "They recognized that we could make the nonurgent population much happier if they did not have to queue behind all the urgent patients to have a simple single X-ray," she says. Security took on the task of walking some patients directly to the triage nurse instead of always staying at a command post, she reports.

Identify your goals.

When a five-level system was being implemented at Mullally’s facility, the following triage objectives were identified:

  • decrease time from patient arrival to provider assessment;
  • standardize assignment of triage severity by nursing staff;
  • identification and assignment of low-severity patients to fast-track area following triage;
  • improve information collection in triage using a customized triage note in the electronic medical record.

Here is how front-end processes were improved to meet these triage goals:

  • Fast track was restructured with additional providers and rooms to meet peak demands.
  • Additional nurses are assigned to triage during peak hours.

"We are doing focused audits to monitor time of arrival to provider evaluation, to track our progress toward meeting our target goals," she says.

Allow enough time.

The shortest implementation time for a new triage scale was eight months in Weber’s experience, she reports. "Triage is so important as a risk reduction strategy," she emphasizes. "Doing it right takes time to plan, implement, train, precept, and support." You should never do an implementation anytime a major regulatory visit is coming up, if you can help it, advises Weber. "Triage and front end redesign is a project for an entire year," she says.


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

Jean Mullally, RN, MBA, Nurse Manager, Louis Stokes Cleveland VA Medical Center, 10701 East Blvd., Cleveland, OH 44106. Telephone: (216) 791-3800, ext. 4595. Fax: (216) 421-3003. E-mail:

Elisabeth K. Weber, RN, MA, CEN, WebER Consultants, 1151 N. State St., No. 221, Chicago, IL 60610. Telephone: (312) 654-8752. Fax: (877) 858-6958. E-mail: