Cases & Commentaries

Emergent Triage Miss

Commentary By Debbie Travers, PhD, RN

The Case

A 42-year-old woman presented to a busy urban
emergency department (ED) and approached the triage nurse. The
patient told the triage nurse that she had "3 days of face and
tongue swelling." She also said that, in the previous 2 weeks, she
had two intensive care unit (ICU) admissions for similar complaints
and that she had required intubation in one of those instances.

The triage nurse documented that the patient was
"speaking in full sentences" and "swallowing secretions." The vital
signs at triage, including respiratory rate and oxygen saturation,
were normal. The triage nurse decided that this was "urgent" and
not "emergent," and therefore the patient was asked to wait in the
waiting room.

The patient sat in the waiting room for more than
2 hours before she was finally placed into a room in the ED. It was
another hour after that before a physician evaluated her. By that
time, her tongue and throat had swollen substantially, and she was
having difficulty breathing. She required emergency intubation, a
potentially dangerous and high-risk procedure, and aggressive
treatment with intravenous epinephrine, steroids, and

The patient was given a diagnosis of
angioedema—rapid swelling of the skin and tissues around the
mouth and throat. She was admitted to the ICU and had an
uncomplicated 5-day hospital stay. The patient experienced no major
long-term consequences.

The case was discussed in the departmental
quality conference. When asked why she did not bring the patient
into the ED more emergently, the triage nurse responded, "I didn't
think the patient was telling the truth about her recent

The Commentary

In a perfect world, all patients presenting to
the ED would be promptly evaluated by the ED caregiver. But that is
not the world we live in. Instead, all EDs must employ
triage: the process of categorizing patients according to
severity of illness to determine treatment priority—that is,
"to sort and assign the right patient to the right resources in the
right place at the right time."(1,2) The triage function is a key
component in keeping EDs safe, especially in the presence of ED
crowding. This case illustrates some of the challenges that triage
nurses face in differentiating patients who need treatment urgently
or emergently from patients who can safely wait to be seen.

Emergency Department Triage
Acuity Rating Systems

Triage is a critical step in the flow of patients
through the ED and is typically a high-volume and high-intensity
function. In most EDs, triage is performed by a nurse who evaluates
patients when they first arrive. As in this case, the triage
nurse's decisions directly affect the timeliness of care, and the
triage process has been linked to patient outcomes. For example,
under-triaged myocardial infarction patients in one study were
found to have delays in electrocardiogram acquisition and
reperfusion therapy.(3) In another study, differences in triage affected
rates of admission for varying degrees of illness.(4) To perform
triage most effectively, ED triage nurses should have a reliable,
valid method of identifying which patients need to be taken from
triage directly to the treatment area and which patients can safely

Standardized triage acuity scales are in use in
virtually all EDs in the United States to provide a method for
rating the urgency of patients' presenting conditions.
Historically, EDs in the United States used three-level or
four-level triage scales to divide patients by severity of illness.
A typical three-level acuity scale would have category labels such
as emergent, urgent, and non-urgent.(1)
Examples of each level are shown in Table 1. Researchers have
found a higher error rate with the largely subjective three-level
triage system than with newer triage acuity systems.(5-7) In addition,
with three-level scales, most patients are characterized in the
middle level, which provides poor discrimination of patients with
clinically distinct urgency.(6,8)

In recent years, there has been growing evidence
that five-level scales provide improved accuracy of triage acuity
decisions.(6,9-11) Such scales allow
stratification of patients into five clinically distinct categories
from level 1 (resuscitation) to level 5 (non-urgent).(12,13) Examples of
each level are shown in Table 2. There is no
consensus in the literature regarding the amount of time that
patients in each category can or do wait to be seen by a provider,
though some five-level triage systems have recommended "response"
times.(9,14) Five-level scales offer
more accuracy in classifying the urgency of ED patients'
conditions. Compared with three-level scales, the addition of two
additional triage strata provides three middle levels for patients
who don't need resuscitation but require more than minimal care and

In 2004, the American College of Emergency
Physicians (ACEP) and the Emergency Nurses Association (ENA) issued
a joint recommendation that EDs adopt a reliable, valid five-level
triage scale to support quality of patient care and move toward a
standard method for triage in US EDs.(2) While
no recent national data are available regarding the adoption of
five-level triage, there is a trend toward five-level triage as a
voluntary standard in the United States. In Canada and Australia,
five-level systems are the standard for ED acuity.(14,15) Several different five-level triage scales are
available, and adopting these could improve the accuracy of triage,
help better manage crowded EDs, and assist in understanding daily
ED operations.(2)

Many resources are available to assist EDs in
implementing a robust, valid, and workable five-level
triage.(13-15) Switching triage systems
represents a major change for ED staff, and change management
strategies can be employed to guide the process and foster adoption
of the new five-level system. Standardized case scenarios have been
found effective in educating triage nurses.(11,16,17) Triage audits are an effective way to monitor
triage post-implementation.(13)

Let's consider the case in question. While many
triage decisions hinge on generic issues like breathing and
circulation, it is often necessary to understand the underlying
disease process in order to triage effectively. Angioedema is a
rare but potentially life-threatening condition. Patients with
angioedema typically present to the ED with edema, most commonly of
the tongue, face, and neck. The edema can progress rapidly, leading
to airway obstruction.(18) Most patients with the
acute swelling of angioedema should receive prompt attention.

Yet, this case highlights some of the challenges
of triage and how using a three-level scale presents a dilemma for
triage nurses in overcrowded EDs. Put yourself in the place of that
nurse to see why. While the patient with tongue and facial swelling
has the potential for deterioration, at the time of triage
the patient had stable vital signs and was in no apparent
respiratory distress. The nurse may have found it difficult to
justify classifying the patient as emergent (level 1) since many
patients in this category typically have unstable vital signs
(e.g., low blood pressure or low oxygen saturation) and are in need
of resuscitation and attention within minutes. If beds are scarce
in a crowded ED, fellow staff members may disagree with a triage
nurse who places a patient with stable vital signs in the last open
bed. Research has shown that under-triage is more common with
three-level systems.(6) If a five-level triage
acuity system had been used to triage this patient, she clearly
would have been classified in level 2—the level used for all
patients with high-risk conditions, whether or not the patient has
stable vital signs.(12,13) Past medical history is an important parameter in
identifying some high-risk patients, such as this patient's history
of ICU admissions and intubation. Examples of high-risk conditions
that warrant a level 2 rating in a five-level triage system are
provided in Table 3.

The rationale in identifying high-risk patients
is that they have the potential for deterioration, as in
the case of the missed angioedema patient whose tongue and facial
swelling indicate a potential for airway compromise. A fundamental
principle in five-level triage systems is the understanding that,
while level 1 patients are clearly unstable and in need of
life-saving interventions, level 2 patients are at high risk and
need to be moved to the clinical area promptly for monitoring. (We
need to acknowledge, of course, that the triage nurse's skepticism
about this patient's clinical history may have prevented her from
triaging the patient correctly. Nevertheless, the history could
have increased the likelihood that the patient was seen in a timely
manner.) While no triage scale can overcome human error, they can
improve outcomes. Triage nurses are encouraged to err on the side
of over-triage if patients seem to be on the border between two
levels; this approach favors patient safety over resource

As ED crowding has worsened, many performance
improvement initiatives have focused on ED patient wait times, and
a common method is to stratify wait times by triage
levels.(19) With the focus on reducing wait times, especially
for the most acute patients, there is a potential to down-triage
patients during periods of peak ED crowding. For example, if
treatment areas are full and patients backed up in the waiting
room, triage nurses may be inclined to rate a borderline patient
level 3 (urgent) instead of level 2 (emergent). In this case, the
less acute rating wouldn't necessitate that a bed be cleared. The
patient would likely be sent to the waiting room. This phenomenon
of "triage drift" has been suggested in the literature but has not
been well studied.(4,20) This is only one of many
reasons for under-triaging patients, which can still happen even in
five-category triage systems.(3,16)

While the adoption of the five-category triage
system can improve triage accuracy, it is not the complete answer,
since many judgments remain subjective and thereby subject to
errors. A promising development is the use of computerized decision
support systems for triage. Dong and colleagues in Canada (4) created a standardized electronic triage tool based
on the five-level Canadian Triage and Acuity Scale (CTAS) and
demonstrated that the tool improved categorization of all levels,
and in particular improved under-triage of level 2 patients.

Take-Home Points

  • Triage is very challenging in the
    context of crowding, but it is critical to ED safety.
  • Five-level triage is associated with
    more accurate triage overall, and less under-triage.
  • Case studies are a key strategy for
    effective triage education.

Debbie Travers, PhD,
Assistant Professor, Health Care Systems & Emergency

School of Nursing
University of North Carolina at Chapel Hill


1. Triage: Meeting the
Challenge. Park Ridge, IL; Emergency Nurses Association: 1997.
ISBN: 9789992964712.

2. Fernandes CM, Tanabe
P, Bonalumi N, et al. Five-level triage: a report from the ACEP/ENA
Five-level Triage Task Force. J Emerg Nurs. 2005;31:39-50.
[go to PubMed]

3. Atzema CL, Austin PC,
Tu JV, Schull MJ. Emergency department triage of acute myocardial
infarction patients and the effect on outcomes. Ann Emerg Med.
2009;53:736-745. [go to

4. Dong SL, Bullard MJ,
Meurer DP, et al. Emergency triage: comparing a novel computer
triage program with standard triage. Acad Emerg Med.
2005;12:502-507. [go to PubMed]

5. Gill JM, Reese CL 4th,
Diamond JJ. Disagreement among health care professionals about the
urgent care needs of emergency department patients. Ann Emerg Med.
1996;28:474-479. [go to PubMed]

6. Travers DA, Waller AE,
Bowling JM, Flowers D, Tintinalli J. Five-level triage system more
effective than three-level in tertiary emergency department. J
Emerg Nurs. 2002;28:395-400. [go to PubMed]

7. Wuerz RC, Fernandes
CMB, Alarcon J. Inconsistency of emergency department triage. Ann
Emerg Med. 1998;32:431-435. [go to PubMed]

8. McCaig LF, Burt CW.
National Hospital Ambulatory Medical Care Survey: 2003 Emergency
Department Summary. Advance data from Vital and Health Statistics;
No. 358. Hyattsville, MD; National Center for Health Statistics;
2005. [Available at]

9. Beveridge R, Ducharme
J, Janes L, Beaulieu S, Walter S. Reliability of the Canadian
emergency department triage and acuity scale: inter-rater
agreement. Ann Emerg Med. 1999;32:155-159. [go to

10. Jelinek GA, Little
M. Inter-rater reliability of the National Triage Scale: over
11,500 simulated occasions of triage. Emerg Med. 1996;8:226-230.
[Available at]

11. Wuerz RC, Milne LW,
Eitel DR, Travers D, Gilboy N. Reliability and validity of a new
five-level triage instrument. Acad Emerg Med. 2000;7:236-242
[go to

12. Bullard MJ, Unger B,
Spence J, Grafstein; CTAS National Working Group. Revisions to the
Canadian Emergency Department Triage and Acuity Scale (CTAS) adult
guidelines. CJEM. 2008;10:136-151. [go to

13. Gilboy N, Tanabe P,
Travers DA, Rosenau AM, Eitel DR. Emergency Severity Index, Version
4: Implementation Handbook. Rockville, MD: Agency for Healthcare
Research and Quality; 2005. AHRQ Publication No. 05-0046-2.
[Available at]

14. Australian College
for Emergency Medicine. Policy on the Australasian Triage Scale.

15. Canadian Association
of Emergency Physicians. Implementation Guidelines for the Canadian
ED Triage and Acuity Scale (CTAS). [Available at]

16. Travers DA, Waller
AE, Katznelson J, Agans R. Reliability and validity of the
emergency severity index for pediatric triage. Acad Emerg Med.
2009;16:843-849. [go to

17. Manos D, Petrie DA,
Beveridge RC, Walter S, Ducharme J. Inter-observer agreement using
the Canadian Emergency Department Triage and Acuity Scale. CJEM.
2002;4:16-22. [go to

18. Shores CG.
Angioedema in the upper airway. In: Tintinalli HE, Kelen GD,
Stapczynski S. Tintinalli's Emergency Medicine: A Comprehensive
Study Guide, 6e. Columbus, OH: McGraw-Hill; 2004;chap 243. ISBN:
9780070653511. [Available at]

19. Horwitz LI, Green J,
Bradley EH. US emergency department performance on wait time and
length of visit. Ann Emerg Med. 2010;55:133-141. [go to

20. Jímenez JG,
Murray MH, Beveridge R, et al. Implementation of the Canadian
Emergency Department Triage and Acuity Scale (CTAS) in the
principality of Andorra: can triage parameters serve as emergency
department quality indicators? CJEM. 2003;5:315-322. [go to


Table 1. Examples of Three-Level Triage
Acuity Scales.

  Triage Level 1 Triage Level 2 Triage Level 3

life or limb threat

Urgent, semi-urgent


Timeframe for being seen by a


Require prompt care but
will not suffer loss of life or limb if left untreated several

Require evaluation and
treatment but time not a critical factor

Examples Severe respiratory distress, anaphylaxis, cardiac
chest pain

Abdominal pain;
fractures; asthma, mild distress

Rash, urinary tract
infection, sprains


Table 2. Examples of Five-Level Triage Acuity

  Triage Level 1 Triage Level 2 Triage Level 3 Triage Level 4 Triage Level 5


Emergent, emergency,
very urgent


Semi-urgent, less

Non-urgent, stable


Cardiopulmonary arrest,
anaphylaxis, active seizures

Cardiac chest pain,
fever in immunocompromised patient, respiratory distress

Abdominal pain,
fractures, dehydration

Urinary tract
infection; ankle sprain; laceration, simple (requiring sutures)

Rash, small lacerations
(no sutures needed)


Table 3.
Examples of High-Risk Conditions (Level 2).

• Fever in immunocompromised patient
• Suspected cardiac chest pain
• Suicidal
• Gastrointestinal bleeding
Asthma in significant
respiratory distress

• Sudden onset of
severe headache with no past history of headaches, neurological