Emergency Department Triage

Two patients arrive simultaneously — chest pain and a twisted ankle. The triage nurse's classification determines who waits and who gets a bed. That system has specific rules the NCLEX tests.

Emergency department triage uses the Emergency Severity Index (ESI), a five-level system that sorts patients by acuity and predicted resource needs. ESI Level 1 is immediate and life-threatening (cardiac arrest, active hemorrhage with hemodynamic compromise, severe respiratory distress requiring intubation) — these patients bypass the waiting room entirely. ESI Level 2 is emergent with high-risk situations: chest pain, stroke symptoms, altered mental status, or severe pain. These clients should not wait to be seen. ESI Level 3 requires two or more resources (labs, imaging, IV fluids) but vital signs are stable. ESI Levels 4 and 5 need one resource or none — a laceration needing sutures or a prescription refill. The triage nurse performs a rapid, focused assessment: chief complaint, a brief visual survey (work of breathing, skin color, mental status), and vital signs when indicated. Triage is NOT a full assessment — it is a screening tool to assign urgency. Reassessment is critical: a Level 3 patient whose pain escalates or vitals destabilize must be re-triaged upward. The triage nurse documents but does not diagnose; the goal is to identify who needs immediate intervention versus who can safely wait.

Key Distinctions

Don't confuse ED triage (ESI — 5 levels based on acuity and resources) with disaster triage (START — 4 color categories based on survival likelihood with mass casualties). ESI is used in daily ED operations; START is activated only when casualties overwhelm capacity. Students often rank ESI by diagnosis rather than presentation — a diabetic requesting an insulin refill (ESI 5) is not the same acuity as a diabetic with altered consciousness (ESI 2).

Clinical Pearl

ESI asks two questions in order: 'Will this patient die without immediate intervention?' then 'How many resources will this patient need?' Mortality first, resources second.