Emergency Department Triage System
Emergency Severity Index (ESI) - 5-Level Triage System
ESI Level 1 - Resuscitation (Immediate)
Definition: Patient requires immediate life-saving intervention
- Cardiac arrest / Respiratory arrest
- Severe respiratory distress with cyanosis
- Active hemorrhage with hemodynamic instability
- Unresponsive or obtunded (GCS 8 or less)
- Anaphylaxis with airway compromise
- Severe trauma with unstable vital signs
Response: Immediate physician presence, activate trauma/code team as indicated
Target door-to-provider: 0 minutes
ESI Level 2 - Emergent (High Risk)
Definition: High-risk situation or severe pain/distress
- Chest pain with cardiac risk factors
- Stroke symptoms (FAST positive) - Activate stroke protocol
- Severe abdominal pain with peritoneal signs
- Altered mental status (GCS 9-13)
- High-risk mechanism of injury
- Active suicidal ideation with plan
- Severe pain (8-10/10) requiring immediate intervention
- Immunocompromised with fever greater than 38.5C
Response: Bedside RN assessment, physician evaluation within 10 minutes
Target door-to-provider: 10 minutes or less
ESI Level 3 - Urgent
Definition: Requires multiple resources but stable vital signs
Resource Prediction: Labs, imaging, IV fluids, specialty consultation
- Moderate abdominal pain, stable vitals
- Moderate to severe dehydration
- Complex lacerations requiring suturing
- Extremity injuries with deformity
- Acute psychiatric presentation (not actively suicidal)
- Fever with stable vital signs in adults
Target door-to-provider: 30 minutes or less
ESI Level 4 - Less Urgent
Definition: Requires one resource
- Simple laceration
- Urinary symptoms requiring UA only
- Minor orthopedic injury needing X-ray only
- Medication refill with stable chronic condition
Target door-to-provider: 60 minutes or less
ESI Level 5 - Non-Urgent
Definition: Requires no resources
- Minor complaints appropriate for clinic/urgent care
- Prescription refills
- Chronic stable complaints
Target door-to-provider: 120 minutes or less
Critical Assessment Parameters
Primary Survey (ABCDE)
| Component | Assessment | Immediate Interventions |
|---|---|---|
| A - Airway | Patent? Obstructed? Protected? | Head tilt-chin lift, jaw thrust, suction, OPA/NPA, intubation |
| B - Breathing | Rate, depth, SpO2, breath sounds, work of breathing | Supplemental O2, BVM, needle decompression if tension pneumothorax |
| C - Circulation | Pulse quality/rate, BP, skin color/temp, cap refill, active bleeding | IV access, fluid resuscitation, direct pressure, tourniquet PRN |
| D - Disability | GCS, pupils, blood glucose, gross motor/sensory | Glucose if hypoglycemic, C-spine precautions |
| E - Exposure | Complete examination, temperature | Remove clothing, prevent hypothermia, log roll |
Time-Critical Diagnoses
STEMI Protocol
- Recognition: Chest pain plus ST elevation 1mm or greater in 2 contiguous leads or new LBBB
- Target: Door-to-balloon 90 minutes or less (if PCI available), Door-to-needle 30 minutes or less (if fibrinolysis)
- Immediate actions:
- 12-lead ECG within 10 minutes of arrival
- Aspirin 325mg chewed (if no contraindication)
- Activate cardiac catheterization lab
- IV access, continuous cardiac monitoring
Stroke Protocol (Code Stroke)
- Recognition: FAST positive (Face droop, Arm weakness, Speech difficulty, Time to call)
- Target: Door-to-CT 25 minutes or less, Door-to-needle 60 minutes or less for tPA eligibility
- Immediate actions:
- Notify stroke team immediately
- Establish time of symptom onset (Last Known Well)
- Obtain STAT non-contrast head CT
- Check blood glucose, INR/PT, PTT
- NIH Stroke Scale assessment
Sepsis Protocol (Sepsis-3 Criteria)
- Recognition: Suspected infection plus qSOFA 2 or greater (RR 22+, altered mentation, SBP 100 or less)
- SEP-1 Bundle (Hour-1):
- Measure lactate level
- Obtain blood cultures before antibiotics
- Administer broad-spectrum antibiotics
- Begin 30 mL/kg crystalloid for hypotension or lactate 4 mmol/L or greater
Pediatric Triage Considerations
Pediatric Assessment Triangle (PAT)
- Appearance: Tone, interactiveness, consolability, look/gaze, speech/cry (TICLS)
- Work of Breathing: Abnormal sounds, positioning, retractions, nasal flaring
- Circulation to Skin: Pallor, mottling, cyanosis
Age-Specific Vital Sign Parameters
| Age | Heart Rate | Respiratory Rate | Systolic BP (min) |
|---|---|---|---|
| Newborn | 100-160 | 30-60 | 60 |
| Infant (1-12 mo) | 100-160 | 24-40 | 70 |
| Toddler (1-3 yr) | 90-150 | 22-30 | 70 + (age x 2) |
| Preschool (3-6 yr) | 80-140 | 20-26 | 70 + (age x 2) |
| School Age (6-12 yr) | 70-120 | 18-24 | 70 + (age x 2) |
| Adolescent (12+ yr) | 60-100 | 12-20 | 90 |
Mass Casualty Incident (MCI) Triage - START System
Simple Triage And Rapid Treatment (START) for multiple casualty events
| Category | Tag Color | Criteria | Priority |
|---|---|---|---|
| Immediate | RED | Life-threatening, salvageable with immediate intervention | 1st |
| Delayed | YELLOW | Serious but can wait 4-6 hours for treatment | 2nd |
| Minor | GREEN | Walking wounded, can wait hours to days | 3rd |
| Deceased/Expectant | BLACK | Not breathing after airway opening, or injuries incompatible with survival | Last/None |