Pick the right five-level triage system: Here’s how

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

Have you been wondering when your ED will switch to a five-level triage scale? There’s no time like the present, urges Paula Tanabe, PhD, RN, co-chair of the Des Plaines, IL-based Emergency Nurses Association (ENA) task force on five-level triage formed jointly in 2003 with the Dallas-based American College of Emergency Physicians (ACEP).

In October 2003, the task force recommended that EDs make the switch to a valid and reliable five-level triage scale, but no specific system was named. [To access the position statement, go to the ENA web site (www.ena.org). Under "Publications" heading, scroll down and click on "Position Statements."]

"After extensively reviewing the literature, the group ultimately recommended that individual institutions come to their own decision about which five-level system to implement," reports Nancy Bonalumi, RN, MS, CEN, director of the ENA and director of emergency services for PinnacleHealth System in Harrisburg, PA. The task force still is hard at work on further exploration of the topic, she adds. "ENA is not endorsing any particular system right now, as the work of the task force is not yet complete."

It’s not even certain that the task force will ever recommend a specific system, adds Tanabe. "Right now, our point is that three-level systems are not reliable or valid," she says. "There are much better data on five-level systems, and they can do much more for EDs."

Although there are currently few EDs using five-level systems, that number is expected to change in the near future, says Tanabe, pointing to data that showed about 3% of EDs used five-level triage in 2001, as opposed to 69% using three-level triage systems.1 "I suspect that over the next five years, these numbers will shift to a dramatic increase in five-level systems," she predicts.

The recent ENA/ACEP recommendation will jump-start the process for many EDs that were waiting for official word, adds Rebecca S. McNair, RN, CEN, president of Asheville, NC-based TriageFirst, which provides consulting and educational services for EDs, and a member of the ENA/ACEP task force. "It is the standard now, so hopefully everybody will be switching," she says.

Should you switch now?

Here’s the question: Do you switch to a five-level system now or wait for the task force to recommend a specific system? If you’re waiting to switch, you’re making a mistake, advises McNair. "Don’t hang back and wait," she says. "People just need to relax, pick one, and take the plunge. Whichever five-level system you pick, it’s going to be better than the three-level system you’re working with now."

If after further review, the ENA/ACEP task force comes to the conclusion that one particular system is better than the others, it will be an easy transition from whatever five-level system you wind up using, adds McNair.

There is good data showing that several five-level scales are reliable and valid, says Tanabe, adding that the task force plans to publish a review of existing systems in the coming months.

When selecting a five-level triage system, do the following:

1. Review the literature.

"A good literature search will provide multiple references available on the Canadian, Australasian, and Emergency Severity Index five-level triage systems," says Tanabe. (See resources at the end of this article.)

2. Consider individual needs of your ED.

According to McNair, the main question you must answer is: Should a triage system be based on timeliness of care, expected need for resources, or both?

At St. Joseph’s Hospital and Medical Center in Phoenix, ESI was selected with the goal of improving triage and reducing delays, according to Kim Flanders, RN, BSN, CEN, clinical nurse manager for emergency services. "We went to ESI to improve consistency and also because of the readily available resources to use for instruction," she reports.

As a result of the switch, the ED’s average arrival-to-bed time decreased from more than two hours to fewer than 50 minutes over a four-month period, reports Flanders.

"We believe this is due to ensuring that the right patients get placed in the right bed at the right time," she says. "We are also able to more objectively triage charts retrospectively and provide definitive feedback to staff to continue the improvement momentum."

3. Make a collaborative decision.

ED nurses and physicians need to read the literature and collaboratively come to a decision about which system will work best, says Tanabe.

At St. Joseph’s, a team including the ED manager, educator, and eight experienced triage nurses was formed to evaluate the different five-level systems and determine how they would be implemented, says.

Once ED nurses are educated about the importance and scope of the triage process and the attributes of different triage scales, they then are able to give effective input to help in the selection process, emphasizes McNair. "The leadership team, including the medical director and nurse manager, along with clinicians and educators, should be able to take this information and make a decision," she says.


1. Emergency Nurses Association. 2001 ENA National Benchmark Guide: Emergency Departments. Des Plaines, IL; 2002.


For more information on choosing the right five-level triage system, contact:

  • Nancy Bonalumi, RN, MS, CEN, Director, Emergency Services, Pinnacle Health System, P.O. Box 8700, Harrisburg, PA 17101-8700. Telephone: (717) 782-3275. E-mail: nbonalumi@pinnaclehealth.org.
  • 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: k3ander@chw.edu.
  • Rebecca S. McNair, RN, CEN, President, TriageFirst, P.O. Box 8662, Asheville, NC 28814. Telephone: (828) 658-1371. Fax: (828) 645-8858. E-mail: triagefirst@mindspring.com. Web: www.triagefirst.com.
  • Paula Tanabe, PhD, RN, Post-Doctoral Research Fellow, Institute for Health Services Research and Policy Studies, Northwestern University, Feinberg School of Medicine, 339 E. Chicago Ave., Wieboldt Hall, No. 714, Chicago, IL 60611. Telephone: (312) 503-2831. Fax: (312) 503-2936. E-mail: p-tanabe@northwestern.edu.

The Emergency Severity Index Implementation Handbook: A Five-Level Triage System is available from the Emergency Nurses Association (ENA). The set includes a handbook, a poster of the algorithm, a laminated pocket card, and reproducible practice and competency case worksheets that can be used in teaching situations. The cost is $60 for members and $100 for nonmembers. To order, go to the ENA web site (www.ena.org) and click on "Marketplace" and the product title.

An implementation manual for the Canadian Triage and Acuity Scale (CTAS) is available on the Canadian Association of Emergency Physicians (CAEP) web site (www.caep.ca). Click on "Policies & Guidelines," "CTAS," and "CTAS Implementation Guidelines." To obtain CTAS teaching materials, contact CAEP, Suite 104, 1785 Alta Vista, Ottawa, ON Canada K1G 3Y6. Telephone: (800) 463-1158 or (613) 523-3343. Fax: (613) 523-0190. E-mail: ctas@caep.ca.

Information on the Australasian Triage Scale can be accessed on the Australasian College for Emergency Medicine web site (www.acem.org.au). Click on "Policies" and "Australiasian Triage Scale."