From The President’s Desk… Summer 2025

TRIAGE – Legal Nurse Pearls
by
Jennifer S. Wilson, RN, BS, CEN, CPEN

(Sources for this article are included in the Sidebar.)

Introduction

Triage is derived from the French word trier, which means to sort. It was originally used to describe the sorting of agricultural products. It is now used primarily in health care. Triage is the rapid evaluation process of patient acuity for the purpose of establishing the order and/or location in which the patient should be seen. The earliest documented systems designed to distribute health care among the wounded and sick date back to the military in the 18^th century. Napoleon’s chief surgeon recognized the need to categorize wounded soldiers promptly during battle. Injured soldiers were sorted by the severity of their injuries, ranging from those who were severely injured and not salvageable to those who needed immediate care to those who could safely wait. The goal was to return the soldiers to the battlefield as quickly as possible. It was deemed the original 3-level triage system of immediate, urgent, and non-urgent (1). It has since evolved, improving steadily and becoming more refined with each war and through the ongoing years and changes in healthcare (2).

This article will focus specifically on the emergency department (ED) triage algorithm, the Emergency Severity Index (ESI), which is a scientifically validated scoring or rating system. The Emergency Nurses Association (ENA) and the American College of Emergency Physicians (ACEP) promote the use of a standardized screening tool to improve patient care. The ESI is quick and includes standardized screening questions to prevent delays in patient care.

History of Triage Algorithms

The original ESI concept was established in 1998, by two emergency medicine physicians, Richard Wuerz and David Eitel. They formed a group of emergency department nurses, medical practitioners, managers, educators, and researchers, and instituted the ESI algorithm in 1999 (3). It has since been modified and produced in a number of handbooks. In 2012, the Agency for Healthcare Research and Quality (AHRQ) created a Version 4 Handbook, for use of ESI as a triage tool for emergency department care (4). And in 2020, the ENA published the Emergency Severity Index (ESI) Handbook Fifth Edition, Version 5 (5). The ENA handbook serves as a guide, and is best used in conjunction with a comprehensive educational program, along with instruction on institution-specific triage policies and protocols. Triage is most often performed by registered nurses, but can also be performed by other licensed healthcare professionals who have had training. The primary goal of the ESI algorithm is to quickly move the right patient to the right resources, at the right place and time, and is used to coordinate the care and staging of patients in ED waiting rooms via a tracking board or communication device.

There are many other triage algorithms, including the Australasian Triage Scale (ATS) (6), the Manchester Triage System (MTS) (7), and the Canadian Triage and Acuity Scale (CTAS) (8). A noted difference in these algorithms is the monitoring of time intervals for provider evaluation. The ESI system does not define expected time intervals for physician evaluation; however, the ATS scale used in Australia and New Zealand defines the maximum waiting time for medical assessment and treatment. The systems assign ATS1 to patients needing immediate care, and ATS5 to patients who are stable and can wait 120 minutes. The MTS is used in England and Scotland and establishes 5 time intervals:  Immediate, Very Urgent (2-10 minutes), Urgent (60 minutes), Standard (120 minutes), and Nonurgent (240 minutes). And lastly, the CTAS scale used in Canada, categorizes the urgency of care into 5 levels of acuity:  Resuscitation, Emergent (15 minutes), Urgent (30 minutes), Less Urgent (60 minutes), and Nonurgent (120 minutes).

Emergency Severity Index (ESI)

ESI is the most frequently used triage scale in the United States and when used appropriately, improves patient care and outcomes (9). The first question the triage nurse should ask is “does this patient need immediate life-saving interventions?” The assessment begins with an “across-the-room” assessment utilizing the AVPU acronym (alert, verbal, responsive to painful stimuli, or unresponsive):

• Is the patient alert, or is the patient unresponsive? If the patient is unresponsive or only responds to painful stimuli, evaluation is needed immediately and is deemed a level 1, needing immediate life-saving treatment.
• What is the patient’s color? Pale or grey, or nice and pink?
• How is the patient’s breathing efforts? Assessments include airway patency, pulse, cardiac rhythm and rate.
• Is the patient in a high-risk situation, confused, lethargic, disoriented, in severe pain, or one who could easily deteriorate or lose a limb or an organ.
• And lastly, should the patient be evaluated immediately or can the patient wait.

This quick decision making process requires experience and expertise, and experience does not always equal expertise. Some nurses under-triage and some over-triage. Under-triage increases patients’ risks for morbidity and mortality, whereas over-triage limits the resources available to sicker patients. One study involving over 100,000 ED patients, revealed that 22.2% (32,782) were over-triaged and 20.3% (29,996) were under-triaged (10). After assessing the need for immediate life-saving interventions, vital signs are obtained, and if these approach dangerous levels, a higher triage level is considered or assigned, following the established ESI flowsheets. Training, expertise, critical thinking, and excellent assessment skills are necessary components of accurate triage.

An important factor for triage nurses to be aware of, is that triage levels can be eclectic and change with the patient, but ONLY if the patient’s condition changes before they are taken from the waiting room. In this situation, the nurse should carefully document the reason(s) for changing the triage level and the resultant action taken (5). Accurate documentation not only improves patient care, but correct ESI levels inform hospital administration of patient acuity, staff and resource requirements, and bed requirements.

ESI ALGORITHMS

The ENA Emergency Severity Index Handbook Fifth Edition, contains a detailed algorithm for ESI Triage, which includes the following immediate assessments:

LEGAL NURSE CONSULTANT PEARLS FOR REVIEW
When reviewing cases that involve care in an emergency department, legal nurses need to look at the many complexities of triage and the hospital system. Triage is not black and white. It is not an easy process. At any given time, multiple patients may arrive in the waiting room at the same time. Triage nurses needs to look beyond what the patient wrote or said as to the reason they want to be seen. They must ask critical, important questions as to the real reason the patient is there, and determine quickly who gets evaluated first. When reviewing ED cases, legal nurses may look for the following:

• Did the triage nurse quickly determine what is normal and abnormal for the patient – are the symptoms new or have they been present for months?
• Did the triage nurse utilize resources appropriately when indicated, such as call supervisors for additional assistance when needed?
• Did the ED have policies and procedures in place for performing regular, timed reassessments, and did the triage nurse follow the policies and procedures?
• Did the ED have policies in place for direct bedding and ways of communicating to all staff, quickly and effectively when there was an influx of patients?
• What were the hospital’s training guidelines for triage personnel?
• What was the experience level of the triage nurse?
• What is the scheduling process for the ED, are the staff working 12-hour shifts? (Not recommended by the ENA for triage nurses.)
• What ancillary assistance is available in the waiting room? Is there a technician, paramedic or another nurse?
• Who is responsible for transferring patients from the waiting room to the exam room?
• Was there support from nursing supervisors when there was a large influx of patients in the waiting room? Did they help with finding beds for the patients?
• Were labs, imaging, ECG, etc. performed in a timely manner, and did the timing follow hospital protocols? Were the test results reviewed in a timely manner?
• Who does the patient see when they first arrive in the ED? If it is registration, does a triage nurse have full view of the area, in order to perform the across-the-room assessment?

Conclusion

Some EDs have a provider in the triage room with the nurse performing a quick assessment and entering orders. If time allows, some providers may even evaluate and discharge patients directly from the waiting room. Every ED is different. When reviewing cases involving ED admission, legal nurses must determine what policies and procedures were in place at the time of a claimed event, if the policies were followed, and if established triage protocols and algorithms were in place. These are just some of the many questions that need to be asked when reviewing cases involving triage, triage nurses, or emergency department flow.

(Sources for this article are included in the Side Bar.)

Author: Jennifer S. Wilson, RN, BS, CEN, CPEN
Greater Orlando AALNC Chapter, Director at Large
President: J W Legal Nurse Associates
Email: jennifer@legalnurseassoc.com; www.legalnurseassoc.com   
Contact: 603-289-7438

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CHAPTER MEMBER HIGHLIGHT

JENELLE LEA, MBA, BSN, RN, CEN, GFN-C, SANE-A

Jenelle Lea is a nurse, entrepreneur and avid traveler. She is an actively practicing nurse in the ICU, ER, and Forensic Examiner roles.  She has over 31 years of experience as a registered nurse and holds multiple specialty certifications, including Emergency Nursing, Legal Nursing, and Forensics. Her clinical nursing experience includes Intensive Care, Forensics, Emergency Department, and Critical Care Transport. For many years Jenelle managed a large ambulance company and is familiar with Emergency Medical Systems.

Jenelle is the principal founder of SEAL Consulting, a legal nurse consulting practice. She formed SEAL Consulting in 2020 after completing an 18-month ABA approved Legal Nurse Consulting course through the University of California, Riverside. Professionally, Jenelle is an active participant in the American Association of Legal Nurse Consultants, the Emergency Nurses Association, The Academy of Forensic Nursing, and the International Association of Forensic Nurses, holding multiple board member positions through the years.
As a legal nurse consultant, Jenelle enjoys collaborating with both plaintiff and defense attorneys on interesting medical-legal cases within civil and criminal law. Jenelle has been a member of the Greater Orlando Chapter of AALNC since 2022, and is currently serving as a Director at Large. When she is not working, Jenelle is usually planning her next trip!

You can reach her by email at Jenelle@SEALconsulting.com, by phone at 760-522-6222, or through her website SEALconsulting.com

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ABOUT THE GREATER ORLANDO CHAPTER OF AALNC

The American Association of Legal Nurse Consultants (AALNC) was founded in 1989, as a not for profit membership organization dedicated to the professional enhancement and growth of registered nurses practicing in the specialty of legal nurse consulting. Chapter development quickly followed. The Orlando community was rich with nurses already practicing in the field of legal nursing. This group of committed professionals quickly became members of the new national organization and recognized the need for a local chapter. The Greater Orlando Chapter of AALNC, founded in 1990, was the second chapter formed under the new national organization. The Chapter was begun in support of AALNC’s mission, by providing networking opportunities, mentoring and support to nurses through professional development and education – a mission that continues today.

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MEET THE 2025 GREATER ORLANDO CHAPTER OFFICERS & DIRECTORS

President:  Robin Axtell, BSN, RN, LNCC
President Elect:  Michelle Gaines, MNA, RN, CRNA
Immediate Past President:  Tory Palivoda, BS, RN, LNCC
Secretary:  Patty Mitchell, BSN, RN, CLNC
Treasurer:  Jillian Talento, BSN, RN, CEN, LNCC
DAL:  Pamela Borello, BSN, RN, CNOR, CNAMB, CSSM(e)
DAL:  Jill Campbell, BSN, RN, CPTC
DAL:  Christine Dorman, DNP, APRN, ACNP-BC, CCRN
DAL:  Jenelle Lea, MBA, BSN, RN, CEN, GFN-C
DAL:  Lori Mollman, MBA, BSN, RN