Emergency Nursing Foundations and Triage
Triage is a sorting decision, not a diagnosis
At the door you answer two questions: how sick is this patient right now, and how many resources will this patient consume? The Emergency Severity Index (ESI) is the most widely examined five-level system. ESI 1 means resuscitation. ESI 2 means high risk, new confusion, severe pain or distress, or a patient who simply cannot wait. ESI 3 means two or more resources with stable vital signs, ESI 4 means one resource, and ESI 5 means none. The teaching point that decides most marks is this: ESI 2 is a risk judgement, not a resource count - a patient with normal vital signs and chest pain radiating to the jaw is ESI 2 before anything is ordered.
The primary survey runs ABCDE: airway with cervical spine protection, breathing, circulation with haemorrhage control, disability (Glasgow Coma Scale, pupils, capillary glucose), and exposure with environmental control. The secondary survey - full history and head-to-toe examination - begins only after the primary survey is complete and resuscitation has started.
Predictable traps: assigning a level from a diagnosis rather than a presentation ('migraine equals ESI 4'); treating triage as a one-off event when it is dynamic and must be repeated as the waiting room changes; accepting 'danger zone' vital signs because the patient looks calm; and applying departmental triage during a mass casualty incident. Under START, ordinary priorities are suspended: colour is assigned by ability to walk, respiratory rate, perfusion and mental status, and the objective becomes the greatest good for the greatest number.
Rule of thumb: ask 'could this patient deteriorate within the next 60 minutes?' If yes, the patient is not a 3.