Study: 5-level triage scale is safe for pediatrics

New research focuses on children

Has your ED switched to a five-level triage system, or are you in the process of doing so? If so, you’re probably familiar with ample research showing its validity in adult patients. But until now, no studies have focused on children.

"All of the original work on the Emergency Severity Index [ESI] was done with patients greater than 14 years of age, and then later in a mixed pediatric and adult population with a small number of pediatric patients," says Tania D. Strout, RN, BSN, research nurse for the department of emergency medicine at Maine Medical Center in Portland, ME.

When the ED was beginning to decide on a new triage system, there were concerns about whether the tool would work in pediatric patients. "It’s difficult to keep one triage instrument for kids and have a separate one for adults," she says. "As we see a good portion of pediatric patients here, we were concerned that the ESI would not be reliable or valid in that population."

Researchers at Maine Medical set out to assess the tool’s validity when used to assess acuity levels in children. "Our paper is the first to evaluate the ESI specifically in pediatric patients," says Strout. "Like other EDs, we were unsure if the tool would work in pediatric patients. Our study showed that the tool is safe and effective to use with both adult and pediatric patients."1

According to a 2003 survey done by the National Center for Health Statistics, 20% of U.S. EDs now are using a five-level system. "I hope that our work will help EDs that were holding off, to decide to go ahead and make the change," says Strout. "I think that many EDs will be moving forward with the switch." The primary benefit for ESI in the pediatric patient is less undertriage, which results in safer care, according to Trish Murray, RN, BN, CEN, ED nurse manager at Houlton (ME) Regional Hospital. The Houlton ED is implementing the ESI in adult and pediatric patients.

"In the three-level system, criteria for emergent, urgent, and nonurgent were so subjective and left too much to that gut feeling,’" she says. The ESI uses a systematic approach to consider all of the symptoms and vital signs to determine an appropriate triage category, while still taking into account your gut feeling," says Murray.

Two-hour inservices were done in groups of five or six nurses. The nurses were given an overview of ESI and looked at 40 cases including several pediatric cases such as fever, toxic ingestion, and dehydration, followed by completion of a competency test. Close attention was paid to vital signs and how these affected the ESI triage level, says Murray.

"Some triage models don’t look at vital signs, but this is an important piece of the triage nursing assessment, especially in neonates, infants, and toddlers," she says. "You might have a perfectly healthy appearing 2-week-old infant in front of you, but a fever makes them a high-risk situation." This patient would be classified as ESI Level 5 if there was no fever, but is classified as Level 2 due to the presence of fever, she explains.

Similarly, a child with a vague respiratory illness might not initially be an apparent high-risk situation, but when you look at their respiratory rate, temperature, and oxygen saturation, it can prompt you to assign a higher triage level, says Murray.

"Based on the case studies done in our ED, I think that we are more likely to overtriage with the ESI," she says. "That means that when that one child surprises you with a diagnosis you’d never expect, you’re safer in your triage process."


  1. Baumann MR, Strout TD. Evaluation of the emergency severity index (version 3) triage algorithm in pediatric patients. Acad Emerg Med 2005; 12:219-224.


For more information on the use of the Emergency Severity Index in pediatric patients, contact:

  • Trish Murray, RN, BN, CEN, Nurse Manager, Emergency Department, Houlton (ME) Regional Hospital. Telephone: (207) 532-9471. E-mail:
  • Tania D. Strout, RN, BSN, Research Nurse, Department of Emergency Medicine, Maine Medical Center, Portland. Telephone: (207) 662-7049. E-mail: