Triage Priority Levels
The general standard for emergency departments is to have five levels of priority: code, critical, urgent, nonurgent disabled, and ambulatory.
Code. The code level refers to someone who has suffered cardiac arrest outside of the hospital or someone whose vital signs crash within the emergency department. Resusdtation efforts are in progress. These cases do not go to triage. They go straight into the code or trauma room, where, usually, there is a team standing by. This category also includes people with gunshot or stab wounds with possible vital organ involvement and/or altered or absent vital signs.
Critical. The critical designation denotes a person with stable vital signs who is exhibiting symptoms or who gives a history that clearly delineates a life-threatening condition. This might be a patient with chest pain, shortness of breath, and profuse sweating (diaphoresis). This also would include people who have a history of vomiting blood, multiple traumas with head injury, or a gunshot or stab wound, as well as asthmatics, diabetics with low blood sugar or extremely high blood sugar, and the like. The triage nurse usually sees these people first and should hand them over immediately to the doctors. In some cases, the nurse can administer initial treatment under standing orders, such as oxygen or a dextrose (simple sugar) injection for the diabetic who is crashing from low blood sugar (hypoglycemia). No time should be wasted in treating these individuals.
Urgent. The urgent category, as usually described in hospital manuals, represents patients with serious conditions requiring medical intervention within two hours. More specifically, a doctor should see patients with an urgent need within one hour; these patients should never wait more than two hours. These are people with abdominal pain, high fever and/or productive cough, deep lacerations with bleeding under control, closed fractures with deformity, and so on. If the emergency department is so overwhelmed that the triage nurse can anticipate a longer wait, he or she has an obligation to monitor such a patient for changes in symptoms with vital sign measurement at least once every hour. Accepted standards of care also require that these persons be lying on a stretcher and not sitting in a chair.
Nonurgent disabled. The nonurgent disabled individuals, unable to walk or remain in a chair, are those for whom the triage nurse determines that up to a four-hour wait is clinically acceptable. The acceptable standards require that the triage nurse place these people on a stretcher for comfort and safety. Sometimes the disability relates to the presenting problem, such as a herniated disc causing severe low back pain. With others, the disability does not seem related, as with nursing home residents who arrive because their feeding stomach tube or bladder urine-draining tube has become dislodged. This creates a problem because most of those transferees do not need to be in an emergency room. A physician could easily replace the tubes at the nursing home.
Notwithstanding the practical considerations, the health-care reimbursement system provides nursing home operators with financial incentives for transferring their residents to occupy space in the hospital emergency department. This is especially incomprehensible since it would be a great deal less traumatic to the frail elderly to remain in their quiet, peaceful, familiar beds rather than having strangers uproot them to' the noisy, overcrowded emergency room. Nonetheless, the government would rather waste an extra three thousand tax dollars for the ambulance and hospital charges and prevent patients with real crises from having access to the emergency room bed. This is a defect in the health-care bureaucracy that indirectly kills people and causes the elderly to suffer mental anguish.
Ambulatory. Lastly, the ambulatory patients are those who do not need emergency care but are there anyway with colds, toothaches, headaches, bumps, bruises, abrasions, small lacerations, skin rashes, and so on. This usually makes up the majority of the waiting room population. This is why emergency departments need triage. The more progressive hospitals have a twenty-four hour walk-in clinic to relieve the burden of the emergency areas. However, the principle standard of any triage nurse is to err on the side of caution. Thus many people who would do well with the clinic will remain in the emergency department.
To conclude with regard to triage, it is important to ask the triage nurse, "What level of priority did you assign?" Then ask for the rationale. If he or she sends you to the walk-in clinic with abdominal pain, nausea, diarrhea, fever, and/or a severe headache following head trauma, you have a problem. You are supposed to be on a stretcher with an intravenous line and with a blood specimen drawn, tagged, and bagged for the laboratory. The triage nurse need not have the last word. You have a right to ask for the charge nurse or supervisor to reassess the situation and countermand the initial decision.