Do you have 5-level triage yet? New advice offered
If your ED hasn’t switched to a five-level triage system yet, there’s no time like the present, according to a report from the joint five-level triage task force of the American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA). The task force recommends that EDs switch to the Canadian Triage & Acuity Scale (CTAS) or Emergency Severity Index (ESI) scale.
"At this time, these are the five-level systems with the best data," says Paula Tanabe, PhD, RN, co-chair of the ACEP/ENA task force.1
The most recent available statistics, from a 2001 survey of EDs, show only 3% of EDs using a five-level system.2 "This number has dramatically increased and will continue to do so in the future," says Christopher Fernandes, MD, FACEP, co-chair of the ACEP/ENA task force and professor and chief of emergency medicine at Hamilton Health Sciences/McMaster University, Hamilton, Ontario, Canada. "All EDs should look at moving to either CTAS or ESI in order to capture better triage data."
To decide which scale to use, EDs should consider ease of use and staff satisfaction with both scales, says Fernandes. "ED nurses should look at the mechanics of both scales, available either on the web or through the papers published," he recommends. "Nurses are a key component of the implementation process when the chosen scale is brought into the ED."
If you switch to the ESI system, be aware that the scale’s Level 1 and pediatric fever criteria recently were revised based on new research, says Tanabe. She recommends educating staff using the recently published ESI Implementation Manual.
ED committee choose ESI scale
At Northwest Community Hospital in Arlington Heights, IL, a committee formed of ED charge nurses, nurse practitioners, and physician assistants developed the triage flow process, equipment list revisions, and educational materials, says Barbara Weintraub, RN, MPH, MSN, coordinator of pediatric emergency services.
"The process was spearheaded by ED nurses, chiefly the ED clinical nurse specialist and myself," she explains. "We chose the ESI scale, as we felt it was better validated and easier to use in a very busy ED such as ours."
All members of the committee then acted as trainers for the rest of the ED staff at several mandatory educational sessions. Food, games, and prizes were offered to make the three-hour sessions more appealing, with themes such as "South of the Border," and "Elvis Lives.’’ After each session, all staff who worked triage were precepted by one of the committee members for four to eight hours. "We have also had ongoing quality improvement, as well as some remediation," says Weintraub.
The percentages of each triage level assigned were tracked and compared with the expected percentages from the ESI research, she explains. "When they started to drop with time, we had each triage person fill out an ESI validation sheet, which took them through the algorithm so they could show why they chose the level they did," Weintraub says. "Then, the original group of trainers evaluated these sheets and sent comments back to staff who had not properly utilized the algorithm."
References
- Fernandes CMB, Tanabe P, Gilboy N, et al. Five-level triage: A report from the ACEP/ENA Five-level Triage Task Force. J Emerg Nurs 2005; 31:39-50.
- MacLean S. 2001 ENA National Benchmark Guide: Emergency Departments. Des Plaines (IL): Emergency Nurses Association; 2002.
Sources/Resources
For more information on five-level triage, contact:
- Christopher Fernandes, MD, FACEP, Professor and Chief of Emergency Medicine, Hamilton Health Sciences/McMaster McMaster University, 1200 Main St. W., Hamilton, Ontario, Canada L8N 3Z5. Phone: (905) 527-4322. E-mail: [email protected].
- Paula Tanabe, PhD, RN, Research Assistant Professor, Department of Emergency Medicine, Northwestern University, Feinberg School of Medicine, 259 E. Erie, Suite 100, Chicago, IL 60611. Telephone: (312) 926-6483. E-mail: [email protected].
- Barbara Weintraub, RN, MPH, MSN, Emergency Services, Northwest Community Hospital, 800 W. Central Road, Arlington Heights, IL 60005. Telephone: (847) 618-5432. Fax: (847) 618-4169. E-mail: [email protected].
- Implementation guidelines for the Canadian Triage & Acuity Scale (CTAS) scale are available on the Canadian Association of Emergency Physicians web site (www.caep.ca). Click on "Policies & Guidelines" and "CTAS." Or to obtain CTAS teaching materials by mail, contact Michael Murray, MD, Chair, National CTAS Working Group, Suite 104, 1785 Alta Vista, Ottawa, Ontario, Canada K1G 3Y6. Phone: (800) 463-1158 or (613) 523-3343. Fax: (613) 523-0190. E-mail: [email protected].
- The Rockville, MD-based Agency for Healthcare Research and Quality (AHRQ) has developed a set of two DVDs titled Emergency Severity Index, Version 4: Everything You Need To Know and an accompanying, newly revised Implementation Handbook to assess nurses’ competency after training. To order the DVD or download the implementation handbook at no charge, go to the AHRQ web site (www.ahrq.gov/research/esi.) Or to obtain up to three free copies of the handbook, contact the AHRQ Publications Clearinghouse at (800) 358-9295 or send an e-mail request to [email protected]. For additional information about ESI, contact the research team from the ACEP/ENA task force at [email protected].
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