You are not currently logged in. Please log in to CEUfast to enable the course progress and auto resume features.


Simple Triage and Rapid Treatment (START)

4.00 Contact Hours:
A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Authors:    Caitlinrae T. Montpetit (RN, BN) , Tosca R. Moore (RN, BSN)


This course prepares nurses to apply a specific triage system.


On completion of this educational activity, the learner will be able to:

  1. Discuss the different types of assessments:
    1. Rapid ABC Assessment
    2. Detailed Assessment
    3. Continual Assessment
  2. Discuss the Who, What, When, Where, Why, How and How Much elements of a triage interview
  3. Differentiate between the chief complaint and the actual needs of the patient
  4. Describe and assign the emergency severity index levels as outlined by the Emergency Nursing Association (ENA) official 5 level Emergency Severity Index (ESI) triage system.
  5. Apply ESI level to case studies

Triage Assessment

Assessment helps the patient care team to understand a situation, in order to identify the problem, the source of the problem, and the consequences of the problem. The purpose of an assessment is not to identify an intervention, but to find out whether an intervention is needed.

Triage Assessment, as stated by the Emergency Nurses Association (ENA), is about getting the right patient to the right place, at the right time, and to see the right provider (Gilboy et al 2012). The triage process must be done swiftly, yet competently and effectively. The process includes (ICRC, 2008):

  •   rapid ABC assessment,   
  •   patient identification,   
  •   chief complaint, and   
  •   nature of emergency.

The triage assessment must be done by a registered nurse as the scope of practice calls for an RN. A licensed practical nurse, nursing assistant or healthcare tech are not qualified to do the triage assessment (Bemis, 2007).

Triage systems were initiated by the military (started in France, WWI) in an effort to sort through soldiers that were injured into categories of life threatening or high risk injuries as opposed to those that could be treated in the field (Iserson and Moskop, 2007). Triage was further adapted by hospitals and transitioned into use by emergency departments (Rockwill, 2005).

The purpose of the Emergency Severity Index (ESI) Triage system in emergency departments today is to allow the triage nurse to effectively:

  •   determine which patients need to be seen first,   
  •   sort through the patients to get those that need to be seen emergently or immediately to the appropriate places, and   
  •   determine how long any one patient can wait to be seen (Gilboy et al).

The two main goals of the ESI Triage system are patient urgency and patient sorting. The ultimate intent is to meet standards of care by ensuring safety for patients and staff, meeting the patient needs at the appropriate level through standardization of practice with the appropriate use of resources (AHRQ, 2011).

The 4 Rs of Triage are Right patient, Right resources, Right place and Right time.

The Rapid ABC Assessment (ICRC, 2008)

Rpaid ABC Assessment

  •   ABC or CAB   
  •   Airway Patent   
  •   Breathing and Speaking   
  •   Circulation Cool Clammy
  1. Is the patients airway patent?
    1. The airway is patent when the speech is clear and no noise is associated with breathing.
    2. Is the patient able to speak in full sentences or broken one word responses?

Think about abnormal airway sounds, abnormal posture, abnormal breathing pattern

  1. Is the patients breathing effective?
    1. Breathing is effective when the skin color is normal, and respirations are easy and unlabored.
    2. Is the patient standing upright, sitting tripod in wheelchair or demonstrating dyspnea on exertion (DOE)?

Think about accessory muscles, cool, diaphoretic, cyanotic or dusky skin, Tachypnea, bradypnea or apneic periods. Note nasal flaring, expiratory grunting, and prolonged expiratory phase with use of pursed lips, diminished or absent breath sounds.

  1. Is the patients circulation effective?
    1. Circulation is effective when the skin is warm and dry, with radial pulses easily palpated.
    2. Does the skin feel cool, hot wet, dry?
    3. Is edema present?

Think about tachycardia, bradycardia, irregular pulse, pulseless, cool, hot, mottled, diaphoretic or flushed skin. Note pale mucous membranes or cyanotic nail beds. Evaluate for delayed capillary refill, diminished pulse quality, hypotension, muffled, distant, variable or adventitious heart tones, obvious bleeding.

Example: A patient enters the emergency room (ER) and states, I need to see a doctor. As the triage nurse approaches the patient, she is visually inspecting the patient from head to toe for an over-all presentation. Does the patient appear:

  •   sick,   
  •   weak,   
  •   short of breath (SOB),   
  •   clutching their chest,   
  •   holding an injury,   
  •   bleeding,   
  •   walking ok,   
  •   drooling or unable to handle secretions?

The nurse touches the patients hand and asks his/her name, and why the patient needs to see a doctor. Is the hand warm or cool or hot, dry or clammy? Can the patient tell you his name? Is his speech clear or slurred? Can the patient elaborate on his need to see a physician? Does the presentation match the complaint? Are they alone or with family?

By now, the nurse will have determined if the patient is alert and oriented times 4, short of breath, diaphoretic, circulation effective, and whether or not the complaint matches the presentation, or if what the patient genuine needs are different from what the patient complaints.

The chief complaint should be written as a "direct quote from the patient or significant other, stating the MAIN symptom that brought the patient to the ER for treatment (Bianco, 2006). If the patient gives you a monologue of complaints and symptoms, use only part of the whole quote. The chief complaint is usually 3-5 words, not always the first words of the patient. Some investigation may be needed to determine the reason the patient came to the ER.

It is the responsibility of the nurse to ensure that patient needs and patient complaints are met to the best of their ability; by, working with the doctor and the patient. The complaint and need may differ from each other.

The 10 most common reasons for an ER visit (English, 2012)

  1. Headaches   
  2. Foreign objects in the body   
  3. Skin infections   
  4. Back pain   
  5. Cuts and contusions   
  6. Upper respiratory infections   
  7. Sprains and broken bones   
  8. Toothaches   
  9. Abdominal Pain   
  10. Chest pains

The Detailed Assessment (ICRC, 2008)

The patients identity, chief complaint, and level of emergency or urgency are determined by the FIRST interview (Rapid ABC Assessment). The patients need for treatment cannot be prioritized based on only the patients chief complaint. The chief complaint is one aspect of the information required to meet the objectives of triage. A detailed assessment is started. Further detailed information is needed: the who, what, when, where, why and how now need to be assessed by the emergency room nurse (Bemis, 2007).

  •   Who: Identifies the patient by age, sex, culture, lifestyle,   
  •   What: Identifies the chief complaint that brought patient to ER   
  •   When: time the chief complaint started   
  •   Where: is the body part or system involved or associated with the chief complaint   
  •   Why: is the event or factors leading up to the ER visit   
  •   How: is normal function affected by the chief complaint   
  •   How much: severity of pain or dysfunction

Remember to get AMPLE History: (Bemis, 2007)

  • A =   allergies, age
  • M =  medications
  • P =  past history
  • L =  last meal, tetanus, menstrual period
  • E =  events of the illness or complaint

The Continual Assessment (ICRC, 2008)

The patient in the emergency department is in an ever changing state. The patient will improve with treatment or need further treatment to make improvements or prevent decompensation. The disposition is considered at the START. Will the patient be treated and discharged, admitted, transferred, or requires significant resources from the emergency room staff to stabilize? Patients need frequent reassessment for:

  •   response to treatments, such as, nebulizers, pain medications, nausea medications,   
  •   critical labs or critical drugs such as: elevated troponin, hypoglycemia, hyperglycemia, vital signs associated with critical drips (diltiazem, nitroglycerin (NTG), amiodarone).   
  •   in-put and out-put secondary to gastrointestinal (GI) bleed, urinary retention, nasogastric (NG) tube output, wound bleeding

Do not be surprised if the complaint changes from the time of presentation to ER or that the nurse changes the complaint, based on the patients real needs (Bemis, 2007). As an example: Patient complains of left shoulder pain and feeling weak, but his heart rate (HR) is 145 and, after getting an electrocardiogram (ECG), reflects new onset atrial fibrillation (A Fib).

Other things to consider:

  •   altered level of consciousness,   
  •   decreased Glasgow coma score,   
  •   decreased interaction with the environment,   
  •   inability to recognize familiar people,   
  •   unusual irritability,   
  •   decreased response to pain,   
  •   flaccid or hyperactive muscle tone,   
  •   unequal, nonreactive or misshapen pupils, or   
  •   seizure activity.

Emergency Severity Index (ESI)

ESI is a standardized triage system that is supported by both ENA, and ACEP (American College for Emergency Physicians), and provides validity and consistency of a rating system amongst medical institutions across the United States (Briggs & Grossman, 2006).

ESI permits the RN to have a means for quick, effective and accurate sorting of patients, which begins as soon as the nurse sees the patient. This allows the nurse to identify patients who are in immediate need of life saving interventions or those who are less critical (Trimarchi, 2012). This further allows the emergency room physician to have a guideline for determination of thresholds for diversions or natural disaster events.

ESI levels 3-5 are determined by the number of resources utilized. Resources include:

  • ECG,
  • IV access,
  • labs,
  • x-rays, CT scan, or ultrasound,
  • IV fluid therapy, IV meds, IM meds,
  • nebulizer meds,
  • specialty consultations (social work, GI, Cardiac, Psychiatry, Surgery, )
  • procedures (laceration repair, foley catheter insertions, Incision, Drainage, )
  • Conscious Sedation,
  • Airway management.

Count the different type of resources, not the individual tests. (i.e. all labs count as one resource, all x-rays count as one resource) (Eitel et al, 2001). Prediction of number of resources utilized is initiated immediately, starting with the first encounter of the patient by the triage nurse (Trimarchi, 2012). The triage nurse will use information obtained from the subjective and objective aspects of the triage assessment, the patients medical history, medications, age and gender.

The very young (< 3 months) and the very old (>75yrs) may increase the patients ESI category up a level simply based on their age and complaint (i.e. fever, elevated heart rate, sob, dehydration) (AHRQ, 2011). Co-morbidities may increase the patients ESI category up a level (Gilboy et al). These co-morbidities may be: smoker, ETOH abuse, drug abuse, immunosuppressed, HTN, sedentary life style. If a person presents looking age 85, but is age 70, he/she may very well be the age 85 health wise.

All child bearing age females are considered pregnant until proven otherwise.

Chest pain is considered cardiac in nature until ruled out.

Level 5: Requires no resources and may be a Nurse only visit.


  • upper respiratory Infection (treated on complaint only),
  • medication refill,
  • blood pressure check,
  • point of care testing (such as pregnancy testing, blood glucose check)
  • oral (PO) meds,
  • simple wound care (dressings, recheck),
  • bladder scan.

Level 4: One resource

Level 3: Two or more resources

Level 2: Does NOT require immediate lifesaving intervention, but is CRITICAL for recovery of the patient and would place the patient on a high risk status.

Level 1: REQUIRES immediate LIFE SAVING intervention

  • CPR (chest compressions, ambu)
  • Emergency Airway Access needed (intubation, vent)
  • Artificial Ventilation required (absent or diminished breath sounds, ambu, ventilator, bipap)
  • Electrical therapy (defibrillation, cardio version, external pacer)
  • Hemodynamic instability (controlling active bleeding, blood transfusion, orthostatic vitals with a significant change of BP>10mmhg systolic or >100 in heart rate, hypoglycemia, aortic aneurism, Traumatic events, MVA, near drowning.
  • Cardiac Arrhythmia
  • Medications: Narcan, D-50, Dopamine, Adenosine, Atropine, Levophed, Cardizem, Amiodarone, Vasopressin, Nitroglycerin,

Determining between level 1 and 2:

  • Is it a high risk situation or a life threatening situation
  • Severe pain versus traumatic injury
  • Chest pain versus acute MI
  • New onset confusion, AMS versus lethargy, ETOH, hypoglycemia
  • Suicidal ideation, homicidal ideation versus anxiety, panic

The patients ESI level may change from the triage time to time of disposition (Briggs & Grossman, 2006). It may increase or decreased depending upon the outcome of the diagnosis and what is revealed during the exam as the nurse and doctor work together to determine the patients needs. The patient may different aspects to different healthcare team member as the patient recalls or is prompted to provide additional information.

Regardless of the ESI level, depending on a patient's specific medical condition, the emergency room physician will admit the patient to the hospital, discharge the patient home or transfer the patient to a more appropriate medical facility (Gilboy et al). Remember, demographics, living arrangements, ability to pay for medications, primary care physician (PCP), must also be considered for final disposition.

ANY high risk situation can rapidly develop into a life threatening situation which requires lifesaving intervention, thereby upgrading a level 2 to a level 1.

High risk situations: (AHRQ, 2011)

NEUROLOGICAL Acute mental changes such as loss of consciousness, meningitis, history of multiple CVAs, acute onset ischemic stroke, < 2hrs, severe headache with change in mental status, head injuries especially with anticoagulation therapy.
ABDOMEN Gastro intestinal Bleed, abdominal pain in the elderly or the very young, abdominal pain or vaginal bleeding in pregnant females, mesenteric ischemia, ectopic pregnancy, appendicitis, galls stones, duct obstruction (cholelithiasis versus cholecysititis), diverticulitis versus diverticulosis, pancreatitis, small bowel obstruction, perforated ulcer.
CARDIAC Chest pain, acute coronary syndrome, history of angioplasty with chest pain, Cardiac Arrhythmia.
RESPIRATORY Acute respiratory distress, Shortness of breath (SOB), upper airway distress, pneumothorax, toxic, smoke inhalation, facial burns, allergies
GENITOURINARY Acute renal failure, or urinary retention, testicular torsion, anuria, polyuria, urethra obstruction, priapism, kidney stones with obstruction
GYNECOLOGICAL Ectopic pregnancy, spontaneous abortion, placenta previa, abruptio placenta, imminent delivery, gestational hypertension, gestational diabetes, sexual assault
MENTAL HEALTH Suicidal or homicidal ideation, combative, hostile, hysterical
GENERAL Immuno-compromised, oncology patients, transplant patients, hyper, hypoglycemic, DKA, Electrolyte disturbances, chemotherapy patients with a fever.
OCULAR Eye trauma, sudden partial or full loss of vision, floaters, pain, or chemical exposures
TRAUMA MVA with or without loss of consciousness, Burns, Bleeding, Active Arterial Bleeding, Compromised Neurovascular function in an extremity, Amputations (complete or partial), acceleration or deceleration injuries, Fractures (hip, pelvis, femur) Trauma may fall under level 1 or level 2, depending on the severity of the injury or extent of the injury.
ENVIRONMENTAL OR TOXICOLOGICAL EMERGENCIES Intentional Overdose of medication or substances, especially with Suicidal Ideation, Accidental Overdose of medication, ETOH, , Poisonous Snake Bites, Exposure to Organophosphates, Chemical spills, allergic reactions

Estimating Burn Size

The Rule of Nines helps the nurse to quickly estimate the size of a burn. This method divides the body's surface area into percentages.

Estimating burn size in an adult

  • The front and back of the head and neck equal 9% of the body's surface area.
  • The front and back of each arm and hand equal 9% of the body's surface area.
  • The chest equals 9% and the stomach equals 9% of the body's surface area.
  • The upper back equals 9% and the lower back equals 9% of the body's surface area.
  • The front and back of each leg and foot equal 18% of the body's surface area.
  • The groin area equals 1% of the body's surface area.

Estimating burn size in babies and young children

  • The front and back of the head and neck are 21% of the body's surface area.
  • The front and back of each arm and hand are 10% of the body's surface area.
  • The chest and stomach are 13% of the body's surface area.
  • The back is 13% of the body's surface area.
  • The buttocks are 5% of the body's surface area.
  • The front and back of each leg and foot are 13.5% of the body's surface area.
  • The groin area is 1% of the body's surface area.

The "rule of palm" is another way to estimate the size of a burn. The palm of the person who is burned (not fingers or wrist area) is about 1% of the body. Use the person's palm to measure the body surface area burned.

Danger Zone Vitals (Bemis, 2007)
Age Heart Rate Respiratory Rate SaO2
≤ 3 months ≥ 180 ≥ 50 ≤ 92%
3 months to 3 years ≥ 160 ≥ 40 ≤ 92%
3-8 years ≥ 140 ≥ 30 ≤ 92%
≥ 8 years ≥ 100 ≥ 10 ≤ 92%
≥ 18 years ≥ 100 ≥ 10 ≤ 90%

Case Studies

  1. A 48 yr. old male comes to the ER with a complaint of feeling anxious and panicky. His vitals are as follows: Temperature (temp) 97.3 F Respirations (RR) 22, Heart Rate (HR) 78, Blood Pressure (BP) 127/72, Pain rated 0 out of 10 (0/10), 98% room air oxygen saturation (RA SaO2). States he has felt anxious for the past week and does not know why. Feels panicky and paranoid that someone is out to get him. Further into the evaluation, you discover he has been hearing voices which tell him to cut himself. He denies feeling suicidal or homicidal, denies use of ETOH or Street Drugs, but you discover he has been taking more than prescribed doses of Percocet. States he has not been sleeping or eating well and cries a lot for no reason and gets angry easily. However, you smell ETOH on him and he is not walking steadily.
    • ESI level 2: Patient may not be suicidal or homicidal at this time, but he is at risk to harm himself due to hearing voices which are telling him to harm himself. He will be committed for psychiatric evaluation due to this and will require a 1:1 sitter. Psychiatric labs need to be ordered, psychiatric consult placed, and patient will be medically cleared for inpatient psychiatric evaluation.
  2. A 69 yr. old male presents with a complaint of chronic nausea, which has not been relieved by a change in medication (Zofran po) by his PCP, over the past several weeks. Vitals: Temp 97.2F, RR 16, HR 72, BP 165/76, Pain rated at 1/10 pain, 99% RA SaO2. Initial work up involves IV access, labs, IV medications and fluids. The patients sister arrives to visit the patient and informs the RN that the patient has increasingly isolated himself from friends and family members. She states when she goes over to visit in the evening, the patient is sitting in a chair in a room with the lights off. Patient use to frequently ride his motorcycle everywhere and was considered to be the jokester of the family.
    • ESI level 3: initially due to labs and medication, fluids. Once the depression information is gleaned from the patient and family member, a psychiatric commitment is initiated and psychiatric consult placed. Patient is admitted into an inpatient psychiatric unit. Increasing patient to an ESI level 2.
  3. 84 year old male presents with diffuse abdominal pain for the past week. Vital Signs Temp 97.2F, RR 16, HR 63, BP 184/77, Pain rated 9/10 pain, 98% RA SaO2. He has had intermittent pain which is sharp for the past two weeks, with it evolving to constant pain since yesterday. He has no nausea, vomiting or diarrhea, chills, fever but has had sweats. His last bowel movement was 8 days ago and it was small and hard.
    • ESI level 3. Patient will be worked up for abdominal pain, to include labs, x-rays, medications. Most likely he has constipation. He will need IV access and will receive pain meds and fluids. If a small bowel obstruction or perforated colon were identified, the ESI level would increase to 2
  4. 82 year old male presents with a history of dementia and frequent falls. He has a 4 cm laceration and swelling to the back of his head. There is a skin tear to his right forearm. His vital signs are Temp 97.4, RR 14, HR 67, BP 172/94, Pain rated 0/10 pain, 96% RA SaO2. He is not on a blood anticoagulant. He is at base line for his orientation. He has had 3 falls in three days.
    • ESI level 3, although the patient has hit his head, he is not on a blood anticoagulant and is at his baseline for mentation. A CT of the head will be ordered as a precaution to rule out a bleed. Wound care is provided to the skin tears, staples or durabond to the laceration. If the patient had an intracranial bleed, the ESI level would increase to 2.
  5. A 43 year old male presents with a complaint of intermittent mid sternal chest discomfort for the past month. He had similar chest discomfort this morning, which has since resolved. Complained of nausea, but no vomiting, has no chills, fever or sweats. No cough. He is a smoker. He is oriented X 4, respirations are even, non- labored, no SOB. Does not appear to be in any distress. Able to answer questions appropriately and without distress. Chest discomfort is reproducible.
    • ESI level 2: The patient would be considered high risk because he has a history of chest pain for the past month. Patient is also a smoker, which should be considered as a significant risk for a cardiac ischemic event. Remember Acute Myocardial Infarction (AMI) is often accompanied or preceded by the waxing and waning symptoms. ECG, labs, IV access, aspirin PO, O2 and CXR is immediately necessary.
  6. A 22 year old female presents to the ER with nausea, vomiting, moderate sore throat, chills, fevers. She is SOB, drooling and her skin is hot to touch. States she was fine until all of sudden I felt so sick. Vital Signs are Temp 102.5 F, RR 18, HR 72, BP 145/79, 95% RA SaO2, 3/10 pain.
    • ESI level 2, possibly 1 if intubated. High risk for epiglottitis. As this is a life threatening condition characterized by edema of the vocal cords. Onset is usually very rapid with a fever which is >101.3F accompanied by lethargy, anorexia and sore throat. The mouth drooling is an ominous sign. Often you will see them with an exhausted facial expression. There is no cough. Remember these patients are going to be high risk for obstruction and may need rapid access of airway, IV access, labs, possible intubation, neck x-rays, blood cultures, ABG, if intubated or O2 SaO2 <90%.
  7. >A 76 year old male was brought into the ER by his family because they found him on the floor in his bathroom. The fall was not witnessed. The toilet bowl was filled with maroon colored stool. Vital signs Temp 98.2, BP 70/30, RR 40, HR 128, RA O2 SaO2 89%. Patient states he has a history of A Fib and is on a blood anticoagulant to thin his blood.
    • ESI level 1. Vital signs are indicating patient is compensating for his blood loss which means he may be in hemorrhagic shock secondary to a gastrointestinal bleed. Patient is most likely taking Coumadin for the A-Fib. He will need IV access, (2 large bore), fluid resuscitation, blood and medications.
  8. A 65 year old cachectic, female, nursing home patient was brought to the ER because her feeding tube fell out. She has been living at the nursing home since suffering from a massive CVA and is at base line mentally which is semi-comatose, responding to tactile painful stimuli.
    • ESI level 4. The patient is at her baseline mentation wise. All she needs is to have the feeding tube reinserted. There is no acute change in her condition. Once the tube is replaced, she will be transferred back to the nursing home.
  9. A 29 year old female presents at the ER after stepping on a rusty nail. Last tetanus is unknown.
    • ESI level 4. Patient is receiving an IM shot and will require to be observed for any reaction from the shot.
  10. A 72 year old male patient is wheeled into the ER with a history of COPD and has respirations that are even, but labored. Patient states I cant breathe and I feel so hot. His RA SaO2 is 84%.
    • ESI level 1. Patient will require life- saving airway management. His SaO2 is low and he is getting exhausted. The other vital signs are immaterial at this point as this patient should be immediately taken to the ER where the other vitals can be gotten while establishing airway patency. Once in the ER, ECG, labs, 2 large bore IV sites, O2, CXR will be done. He might be turned around with bi-pap or if he deteriorates, may be intubated. Regardless, the patient is receiving lifesaving interventions. If the patient is placed on O2 and immediately recovers, and does not require bi-pap or intubation, he could remain at a level 2.
  11. A 26 year old female walks into the ER requesting to go to detox again. She states she has been clean for several months but she started shooting heroin for the past two weeks because my boyfriend and I broke up. She denies Suicidal or homicidal ideation. Patient appears calm and is cooperative with the triage process. Her vital signs are within normal limits and she denies pain. She does not smell of ETOH, is ambulating normally and is conversing in a normal manner, with no slurred speech,
    • ESI level 4. This patient will require assistance in finding a detox program. Social work or Psychiatry will need to be consulted to assist in this and once placement has been found, she will be discharged from the emergency room. However, should the psychiatric department or social work department require labs, she would be elevated to ESI level 3 (two or more resources: labs and consult).
  12. A 36 year old male presents to the emergency room with a complaint of right lower quad abdominal (abd) pain which he has had all day since he woke up this morning. His pain level is 5/10 and he states it is worse when he eats; he has nausea, vomiting and has no appetite. Patient is holding his abdomen in a guarded position, skin is warm, dry. His vital signs are as follows: Temp 97.5 f, RR 16, HR 72, BP 130/54, 98% RA SaO2, 5/10 pain
    • ESI level 3. Patient will require labs and if he presents as an acute appendicitis, he will not be able to be placed in the waiting room. Signs and symptoms of acute appendicitis will include: mild to moderate RLQ pain, anorexia, nausea, vomiting, low grade fever, muscle rigidity and LLQ pressure that intensifies the RLQ pain. If the appendix ruptures, he would become an ESI level 2.
  • Two hours later, the complaints remain the same, but his HR is now 115, his pain level has increased and he is sweaty.
    • ESI level 2. Patients elevated HR coupled by all of these symptoms indicates he may have appendicitis and becomes high risk for surgical emergency.
  1. A four year old child is brought into the emergency room by her mother. I just turned my back for a minute to answer my phone cried the mother. The child was pulled out of the family pool by a neighbor. Mouth to mouth resuscitation was administered and the child is breathing on her own, but remains unresponsive. Vital Signs are: Temp 97.6, RR 28, HR 126, BP 80/65, 90% RA SaO2 and has been placed on a non- re-breather mask and SaO2 have increased to 96%.
    • ESI level 1. This child continues to be unresponsive. The patient will require lifesaving interventions to protect the airway, breathing and circulation. Patient needs IV access, 2 large bore IV sites, labs, x-rays, ABGs, possible intubation.
  2. A 23 year old male presents to the emergency room stating I accidently ate some shrimp dip and I am allergic to shrimp. I felt like my throat was closing up and I used my epinephrine pen. Vital Signs: Temp 98.6, HR 110, B/P 126/65, RR 20, RA SaO2 98%. No respiratory distress noted, bilateral lungs sounds are clear. Patient states he feels ok now but I was told if I ever used my epinephrine pen I should come into the emergency room to be checked out.
    • ESI level 2. Patient is having an allergic response to eating shrimp. Because he has used his epinephrine pen, he is going to require additional observation, medications, close monitoring. He should still get IV access, telemetry monitoring, X-rays, O2 if SaO2 are compromised. Possible for intubation, which increases him to an ESI level 1.
  3. A 40 year old female is brought into the triage area with nausea and is vomiting continuously. Her son who has brought her in, states his mother has been vomiting all day and now it is yellow stuff. He confirms that she has not taken her insulin and she has not been able to keep any food or fluids down. Vital signs: HR 125, BP 140, HR 78, RR 24. The accucheck machine registers her blood sugar as high.
    • ESI level 2. Patient may be considered a candidate for diabetic ketoacidosis. Her HR and RR are elevated; the blood glucose is shown as high. She will require IV access, ECG, x-rays, O2, fluids, medications. If the patient is placed on an insulin drip, the ESI level increases to level 1.
  4. A 40 year male comes in on the memorial day holiday with the complaint of my tooth is killing me. He states he will not be able to see his dentist until sometime next week because I cant call to make an appointment until tomorrow and I dont know when I can get in. He states he began to have the toothache yesterday with it getting worse today. Pain is 10/10 and is continuous, aches with sharp, intermittent pain. There is no facial swelling. The tooth is sensitive to cold temperature. Vital signs: Temp 99.9 F, HR 88, RR 12, BP 125/71, he denies nausea, vomiting, chills and sweating.
    • ESI level 5. No resources would be required. Patient will receive prescriptions for oral antibiotics or pain medications. If the patient is given an IM shot in the emergency room for pain or antibiotics, he would be elevated to ESI level 4.
  5. A 79 year old male is brought to the ER with severe abdominal pain which started about 30 minutes prior to arrival. He rates the pain as 15+/10 he states the pain radiates to his back and it feels like someone is ripping me in half He has a history of HTN. He is diaphoretic and tachycardic. Vitals: HR 129 BP 80/62 RR 22 RA SPO2 94%.
    • ESI level 1. Patient is presenting with signs of shock: hypotensive, tachycardic, decreased peripheral perfusion. He has a history of hypertension. He has signs and symptoms which could be pointed to an Abdominal Aortic Aneurysm (AAA). He will require IV access (2 large bore), labs, x-ray, CT of abdomen and pelvis, fluid resuscitation, pain medication, and ECG.
  6. A 76 year old male wants to see a doctor because he is no longer able to cut his toenails. The only medical history he has is COPD and HTN. He is not a diabetic. Vital signs are with in normal limits.
    • ESI level 5. He requires no resources. He requires only a brief exam and an outpatient referral to a podiatrist. If a podiatry consult is placed, he would be elevated to ESI level 4.
  7. A 23 Year old pregnant female is brought in by EMS for sudden onset of a headache. She is 28 weeks pregnant. She has no other medical problems. Per EMS, she vomited about 5 minutes prior to arrival. Her vital signs are with in normal limits. Upon arrival, patient is unresponsive to tactile or verbal stimuli. She is moaning and grimacing.
    • ESI level 2. Think about rule out cerebral hemorrhage. Sudden onset headache, nausea, vomiting and is unresponsive to tactile or verbal stimuli. A CT scan will have to be done emergently. She may have to be intubated to protect her airway, thereby elevated her to an ESI level 1.
  8. A 79 year old female arrives at the ER with her right arm in a sling. She states she was walking out to get her mail when she tripped on an uneven sidewalk and fell onto her right side. She denies hitting her head or losing consciousness. She has a positive radial pulse in the right arm, there is some deformity noted. She is unable to hold anything in her right hand. Her pain level 5/10. All other vitals are with in normal limits. The pain is sharp, constant.
    • ESI level 3. Patient will require two or more resources. She will require x-rays and possibly a cast or splint and possibly an orthopedic consult. She will most likely require IM pain medication to control her pain. But it is not high risk; therefore she would not require a level 2.
  9. A 53 year old male comes to the ER holding his left hand with his right hand and states I was working on my horse trailer, trying to connect the trailer to the truck when I dropped the hitch and it landed on my hand Patient has a crushing injury to his 2nd and 3rd fingers on the left hand, the nail is off on the 3rd finger.
    • ESI level 3. Patient most likely has a crushing injury. He will require x-rays, pain medication, orthopedic consult and splints. If the extremity is pulseless, the ESI level increases to level 2.
  10. A 37 year male comes to the ER stating, I was putting water in my radiator on the car and it blew up in my face patient presents with 2nd degree burns to his torso and 1st degree to his neck and jaw. He has singed nose hairs and eyebrows.
    • ESI level 2. Patient is presenting with 1st and 2nd degree burns. Although his airway is intact, he does have singed eye brows. Rule of 9s will be used to determine severity of burns. He is going to require large bore IV access, labs, sterile gauze and normal saline to the burn area, monitor for airway patency, admission to burn unit, pain meds, and antibiotics.
  11. A 67 year old male presents to the ER with slurred speech and carrying a mason glass jar with a snake in it. He states he was drinking with his buddies when he saw a snake in the driveway. He was trying to catch it when it bit him on the right hand. One of his sons caught the snake, which has turned out to be a water moccasin his neuro assessment indicates his right hand is reddened, swollen and streaks are going up his right hand, arm.
    • ESI level 2. Patient has been bitten by a poisonous snake. He is going to require IV access, neuro checks Q30 minutes, antivenin (CroFab) and placement in an ICU for observation.
  12. A 79 year old male is brought to the ER from the nursing home after a fall. He stood up in his wheelchair without assistance and attempted to walk. He stumbled and fell onto his left side and did not hit his head or lose consciousness. There are no injuries present and vitals are with in normal limits.
    • ESI level 5. Patient does not require any resources other than examination to ensure no injuries are present.


In conclusion, by completing a brief focused assessment, it allows the triage nurse to sort patients into five categories based on the patients need and acuity level. It allows the nurse to quickly and effectively determine which patients must be seen immediately and which patients can wait to be seen.

Having a standardized triage system that is accepted nation-wide allows for emergency departments across the United States to be able to function on the same page, so to speak. This permits nurses from emergency department to emergency department to be able to communicate the patients acuity level with a few simple words (Reiter & Scarletta, 2008). It doesnt take the place of a nurse to nurse report for details, but does allow the receiving nurse to get a mental picture of how complicated the patient may be.


Agency for Healthcare Research and Quality (AHRQ). Emergency Severity Index, Version 4 U.S. Department of Human & Health Services 30 June 2011

American College of Emergency Physicians Foundation (ACEPF). About emergencies: When Should I go to the Emergency Department. Retrieved 29 May 2012 from (Visit Source).

Bemis, P. Emergency Nursing Bible, 4th Edition, 2007.

Bianco, C. How Emergency Rooms Work. retrieved 29 May 2012 from (Visit Source).

Briggs, J and Grossman, V. Emergency Nursing 5-tier Triage Protocols, 2006. Philadelphia, Lippincott, Williams & Wilkins.

Eitel, D, Gilboy, N, Tanabe, P, and Travers, D. Making the Right Decision: A Triage Curriculum, 2nd Edition. Emergency Nurses Association 2001.

English, M., 10 Most Common Reasons for an ER Visit Retrieved 29 May 2012 from (Visit Source).

Gilboy, N., Tanabe, P., Travers, D., Rosenau, A. and Eitel, D. Emergency Severity Index, Version 4: Implementation Handbook. AHRQ publication no. 05-0046-2. 2012.

ICRC, Guidelines for Assessment in Emergencies, International Federation of Red Cross and Red Crescent Societies (ICRC), March 2008.

Iserson, K and Moskop, J., Triage in Medicine, Part I: Concept, History and Types March, 2007.

Reiter, M. and Scaletta, T., On Your Mark, Get Set, Triage Emergency Physicians Monthly, The Independent Voice for Emergency Physicians, August 31, 2008.

Rockwill, M., Agency for Healthcare Research and Quality. May, 2005.

Trimarchi. M., 10 Injury Treatment Priorities at the Emergency Room. retrieved 01 June 2012 from (Visit Source).

This course is applicable for the following professions:

Advanced Registered Nurse Practitioner (ARNP), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Registered Nurse (RN)


CPD: Practice Effectively, Critical Care / Emergency Care

Last Updated: