Introduction
Triage is the process of sorting patients by severity of illness to ensure care is administered in a timely fashion according to each patient’s need. When specifically applied to the emergency department, “Emergency Department (ED) Triage” is used to quickly assess, risk-stratify, and manage incoming patients before their complete evaluation. A triage process allows systems to safely operate an influx of multiple patients with varying acuity levels in situations when clinical demand exceeds capacity. Formal triage systems have been employed since as early as the 19th century in warfare settings to effectively handle the growing amounts of field casualties [1].
Today, emergency triage can be generally separated into three distinct phases: prehospital triage, triage at the scene, and emergency department triage. Many different types of triage systems have been developed and implemented worldwide [2]. In this section, we will focus on emergency department triage and some of the most well-known triage systems globally.
Performing a Rapid Triage Assessment
The “rapid triage assessment” is essential to any triage system. Those performing the rapid triage assessment should have some clinical experience and a keen eye to quickly identify patients who need to be seen urgently. The goal of triage is to determine which patients need immediate attention, which patients can wait to be seen, and to manage large patient volumes safely. To accomplish this, one must gather pertinent history and physical exam findings quickly and efficiently.
Performing a Focused History
Obtaining a quick and focused history is of utmost importance during the rapid triage assessment. To summarize, providers must be able to get symptoms pertinent to the patient’s presentation, any relevant events leading to their presentation, and pertinent past medical history and allergies. One mnemonic that is useful and used by many for history-gathering is SAMPLE (as below) [3]:
The SAMPLE mnemonic is a structured method for gathering key clinical information during an emergency assessment. It serves as a framework for emergency medical personnel to obtain essential details quickly and efficiently, allowing them to prioritize care and decide on the best course of action. Each component of the mnemonic corresponds to a specific area of focus in history-gathering, which is vital for rapid triage in the emergency department or pre-hospital setting. Below is a more detailed breakdown of each element:
S – Signs & Symptoms
The first and most immediate part of the assessment focuses on the patient’s presenting signs and symptoms. These may include both subjective (what the patient describes) and objective (what the healthcare provider observes) data. For example, a patient may report chest pain, difficulty breathing, or nausea, while a provider might note abnormal vital signs or physical findings. It’s crucial to obtain a clear description of the symptoms, including onset, duration, intensity, and any factors that may have worsened or alleviated them. Understanding the signs and symptoms will help determine the severity of the condition and direct the urgency of intervention.
A – Allergies
Gathering information about any known allergies is vital in guiding treatment decisions, especially in emergencies where medications or interventions are required quickly. For example, if a patient has a known allergy to penicillin, it is essential to avoid using antibiotics in that class. Allergies to food, medications, environmental triggers, and latex should all be considered. In addition, healthcare providers should be mindful of potential allergic reactions that could complicate the management of the patient’s condition.
M – Medications
A comprehensive medication history helps identify substances that may impact the patient’s current clinical situation. This includes prescribed medications, over-the-counter drugs, supplements, and any recent changes to a medication regimen. For example, a patient taking blood thinners such as warfarin may require careful monitoring for signs of bleeding, while those on insulin may need their blood sugar levels closely monitored. Knowledge of recent changes, doses, and the possibility of drug interactions is crucial in the emergency setting.
P – Past Pertinent History
Past medical history (PMH) can provide essential context for understanding the patient’s current presentation. This includes chronic conditions such as diabetes, hypertension, or asthma, as well as previous hospitalizations, surgeries, or significant illnesses. Understanding a patient’s medical history helps healthcare providers anticipate complications and tailor their approach. For instance, if a patient with a history of seizures presents with altered mental status, healthcare providers will prioritize ruling out or treating seizure activity or postictal states.
L – Last Oral Intake
Knowing the last oral intake—what the patient has eaten or drunk—can provide valuable information about the patient’s condition, especially in cases of poisoning, drug overdoses, or gastrointestinal distress. For example, the timing of food or drink ingestion could suggest an issue with digestion or absorption, which may influence the choice of interventions. In cases of poisoning, knowing whether the patient ingested a toxic substance recently can impact the decision to administer activated charcoal or other antidotes. Additionally, the last oral intake can be crucial if the patient is scheduled for surgery or other procedures, as it helps assess the risk of aspiration or anesthesia complications.
E – Events Leading to the Incident
Understanding the sequence of events that led to the current emergency is essential for diagnosing the cause and assessing the patient’s clinical needs. For example, was the patient involved in a motor vehicle accident, or did they experience a sudden onset of chest pain while exercising? Gathering this information helps to identify the mechanism of injury or the type of acute event, which could significantly alter the emergency management plan. It also provides insight into potential causes of the symptoms and any necessary preventive or therapeutic actions.
Purpose and Application of the SAMPLE Mnemonic in Rapid Triage
The SAMPLE mnemonic is a concise tool designed to quickly gather relevant historical information that can significantly impact clinical decision-making in the emergency department. This structured approach is particularly helpful in high-pressure environments where time is critical, such as during triage or when managing patients with complex or time-sensitive conditions.
The goal during history-gathering in an emergency is to obtain just enough, but not too much detail. Too much detail may delay treatment, while too little may result in missing critical information. For example, a lengthy review of a patient’s family history may be less pertinent in an acute situation compared to knowing their current medication list or the events leading to the emergency. The SAMPLE framework ensures that the provider gathers relevant information to make informed decisions about the next steps in care, whether that be immediate intervention, further diagnostics, or a more detailed secondary assessment.
The SAMPLE mnemonic is an effective tool for emergency practitioners to rapidly gather crucial information during triage and initial assessment. By focusing on the most important elements—signs and symptoms, allergies, medications, past medical history, last oral intake, and events leading up to the incident—providers can prioritize interventions, anticipate potential complications, and provide optimal care in emergency settings.
Performing a Focused Physical Exam
After performing a focused history, it is important to use the information gathered to guide your focused physical exam. For example, a patient presenting with the chief complaint of sore throat should receive an expedited examination of the head, ears, mouth, and neck. The rest of the physical exam should be deferred unless the patient has another complaint that is not covered by these sections. The purpose of the focused physical exam is to look for “red flag” exam findings that would warrant more immediate attention and intervention, such as the peritonitic abdomen in the patient presenting with abdominal pain, oropharyngeal swelling in the patient presenting with shortness of breath and rash, left-sided flaccidity in the patient presenting with sudden onset weakness and tingling, and other concerning findings [4].
Vital Signs and Objective Data
There are clues to key providers about how sick their patients are. One of the most important clues is a patient’s set of vitals; therefore, it is exceedingly important to obtain a full set of vitals for all patients arriving at the emergency department. Vitals at either extreme of the spectrum are equally important, and grossly abnormal vitals should prompt a more expedited triage and shorter waiting times. Other clues that help identify sick patients include the level of pain, duration of symptoms, level of consciousness, and mechanism of injury. Suppose someone is determined to be in distress at any point during the triage process. In that case, they must be brought to a designated patient care area for immediate ED provider attention. In the paragraphs below, we will discuss this further regarding adult populations.
Heart Rate
Bradycardia is a heart rate of less than 60 bpm, while tachycardia is a heart rate of more than 100 bpm [5]. If a patient is experiencing associated hypotension with an abnormal heart rate, then it is obvious that they are sick. However, there are other key questions that you may ask in the physical exam to elucidate further a patient’s severity of illness regarding an abnormal heart rate. For example, experiencing associated chest pain, palpitations, extreme fatigue or weakness, altered mental status, shortness of breath, or nausea can be signs that the abnormal heart rate is due to a concerning underlying pathology in the patient. Tachycardia can be indicative of infection, dysrhythmia, acute blood loss, and toxin exposure amongst other etiologies. It is also important to ask about medication use in these patients as this can be your first sign of an accidental (or intentional) chronotropic medication overdose – such as with beta-blockers, calcium channel blockers, and other medications that need to be seen by a medical provider quickly.
Blood Pressure
Hypotension is defined as a blood pressure less than 90/60 mmHg, while hypertension is defined as more than 140/90 mmHg [5]. With hypotension, it is important to first quickly assess if a patient is experiencing a decreased mental status and level of alertness in order to determine if any immediate interventions are needed – if so, this patient is definitely sick and cannot wait for care. Next, it is important to assess for possible causes of hypotension and severe illness, such as septic, hemorrhagic, neurogenic, and anaphylactic shock. For hypertension, it is important to assess for signs that could indicate end-organ failure, such as chest pain, shortness of breath, and focal neurologic deficits. Patients exhibiting the above symptoms should be evaluated sooner rather than later.
Respiratory Rate
Tachypnea is defined as a respiratory rate above 20 bpm, while bradypnea is defined as a respiratory rate below 12 bpm [5]. Apnea is the total absence of breathing. Bradypnea and apnea can be seen in many conditions, including traumatic brain injury and heroin overdose. Tachypnea is seen in many conditions, including asthma exacerbation and conditions causing metabolic derangement, such as diabetic ketoacidosis. If a patient is not breathing or experiencing decreased oxygen saturation along with abnormal respirations, then it is obvious they are sick. However, for those cases that are less obvious, it is important to observe the patient’s work of breathing with their respirations. Those who appear to have a significantly increased respiratory effort, are becoming tired, or are experiencing shallow respirations will need medical evaluation and care sooner rather than later. Their fatiguing respiratory effort will eventually lead to respiratory failure and hypoxia. Those with stories concerning an underlying process that could quickly compromise respiratory function should also be prioritized. For example, a patient who presents with a story suspicious of intracranial hemorrhage who appears sleepy and only moans in response to questions is at high risk for respiratory decompensation.
Oxygen Saturation
Hypoxia is defined as an oxygen saturation below 92% [5]. While different patients can tolerate various oxygen saturation levels depending on their smoking status, history of lung disease, and other past medical history, it is important to assess the work of breathing and level of alertness in patients with low readings. Patients who appear to have increased work of breathing, decreased respirations, or decreased level of alertness are at risk for respiratory decompensation. These patients should be evaluated and treated sooner rather than later.
Temperature
Hypothermia is defined as a temperature below 35 C. In contrast, hyperthermia is defined as a temperature above 38 C [5]. Hypothermic patients must be rewarmed depending on the degree of hypothermia (this will be discussed in later chapters). It is important to determine the reason for their hypothermia – such as sepsis, submersion injury, and prolonged cold exposure. There are many reasons for hyperthermia, including but not limited to infection, prolonged heat exposure, and certain types of medication overdose. The hyperthermic patient must be physically cooled and given antipyretics or other medications depending on the cause of their hyperthermia. These are all causes for concern and immediate interventions.
Pain
The severity and location of pain can also help identify patients who need prompt attention. Patients in severe pain will need immediate attention and medications to alleviate their pain. The location of pain can also be a clue to a patient’s severity of illness. For example, chest pain radiating to the back could represent an aortic dissection, right lower quadrant abdominal pain could represent appendicitis, and headache with neck stiffness could represent bacterial meningitis. Patients with concerning pain severity and location should be prioritized [6].
Duration and Mechanism
The duration of symptoms can also be a clue to a patient’s severity of illness. In general, acute complaints, or complaints that occur with a sudden or recent onset, should raise higher suspicion for serious etiologies than a chronic complaint that has been occurring without change for weeks to months [6]. A patient’s mechanism of injury is also important to consider; for example, a person who has fallen from a significant height or has been involved in a high-speed accident should be evaluated quickly as well.
Level of Consciousness
Level of consciousness exists on a spectrum, from those who are unresponsive to those who are completely awake and alert. Unresponsive patients should receive immediate attention and interventions, including chest compressions if they are without a pulse and intubation. Lethargic patients and those experiencing quickly decreasing levels of alertness should also be prioritized. Those sleepy or confused should be seen urgently, while those fully awake and alert may wait to be seen if they are without other concerning signs/symptoms [6].
Triage is a complex process involving several components, and it can be challenging. Triage providers play a crucial role in ensuring the efficiency and safety of the ED. They must quickly and accurately assess a patient’s severity of illness to determine how long different patients can safely wait for care. It is essential that they do not focus on diagnosing the patient’s condition during triage, as this can delay the process. Such delays can compromise care for all patients, allowing seriously ill individuals to go unnoticed for extended periods while their condition worsens. Remember that a comprehensive history, examination, diagnostic work-up, and treatment will occur once the patient is admitted to a care area.
Triage Systems
Triage is a complex process that needs to be done expediently, especially when facing large patient volumes. Fortunately, many triage systems have been developed to help guide providers in quickly and accurately risk-stratifying patients during the rapid triage assessment. We will discuss some of the most popular and widely used triage systems, such as the Manchester Triage System and the Emergency Severity Index.
Manchester Triage System
One of the most well-known and globally used triage systems is the Manchester Triage System (MTS). It was developed in the UK and is widely used worldwide. This triage system helps ensure patient safety by defining the maximum time each patient can wait before being seen and treated. The MTS contains flowcharts for various presenting complaints that help to distinguish the severity of illness based on key “discriminators” (signs and symptoms) [7]. Each level of severity is assigned a different color. Red indicates immediate evaluation, while blue indicates non-urgent evaluation (can wait up to 240 minutes). Flowcharts are available for various chief complaints in adult and pediatric patients. The MTS (Figure) for the adult chief complaint of “chest pain” is discussed below [8].
RED: Immediate/Life-Threatening
The red category signifies the highest level of urgency, where the situation is life-threatening and requires immediate medical intervention. The maximum waiting time is 0 minutes, indicating that the patient must receive attention without delay. Correlating examples for chest pain in this category include airway compromise, inadequate breathing, or shock. These conditions are critical as they can lead to rapid deterioration or death if not addressed promptly. Immediate treatment might involve airway management, advanced resuscitation, or stabilization of vital signs.
ORANGE: Emergent/Could Become Life-Threatening
The orange category represents conditions that are not immediately life-threatening but could escalate to critical levels if left untreated. The maximum waiting time in this category is 10 minutes, emphasizing the need for swift medical evaluation and intervention. Examples of chest pain scenarios in this category include severe pain, cardiac pain, acute shortness of breath, or abnormal pulse. These symptoms often indicate serious underlying issues such as myocardial infarction, severe arrhythmias, or pulmonary embolism, all of which require urgent diagnostic and therapeutic measures to prevent deterioration.
YELLOW: Urgent/Not Life-Threatening
In the yellow category, conditions are urgent but not immediately life-threatening. The maximum waiting time is 60 minutes, providing a moderate window for assessment and treatment. Correlating examples for chest pain include pleuritic pain, persistent vomiting, history of cardiac disease, or moderate pain. These symptoms may point to less severe causes, such as musculoskeletal issues, gastroesophageal reflux, or pleurisy. However, the history of cardiac disease suggests a need for careful evaluation to rule out more serious conditions.
GREEN: Semi-Urgent/Not Life-Threatening
The green category involves semi-urgent conditions where the likelihood of life-threatening complications is low. Patients in this category can wait up to 120 minutes for treatment. Examples include vomiting, mild pain, or recent problems. Chest pain in this category is typically associated with benign causes, such as anxiety, mild gastrointestinal issues, or a musculoskeletal strain. While these cases are not critical, timely assessment ensures patient comfort and prevents unnecessary progression of symptoms.
BLUE: Non-Urgent/Needs Treatment When Time Permits
The blue category is for non-urgent conditions that require treatment only when time permits. The maximum waiting time is 240 minutes, as these cases are unlikely to escalate to a critical level. Examples include other complaints that may not even directly relate to chest pain or are minor in nature. These could involve mild discomfort or non-specific symptoms that do not pose any immediate threat to the patient’s health. Such cases can be safely managed without priority over more urgent categories.
Emergency Severity Index
Much like the Manchester Triage System, the Emergency Severity Index triage system (developed in the USA) is also globally known and used. It stratifies patients into five levels: level 1, the most urgent, and level 5, the least urgent. It also helps to determine what resources are necessary to move a patient toward disposition. It is based on four key decision points: does the patient require life-saving interventions (Step A), are they in a high-risk situation (Step B), how many resources do they need (Step C), and what are their vitals (Step D)? The ESI Triage Algorithm, types of resources, and level of urgency, along with examples, are discussed below [9].
Step-by-Step ESI Triage Algorithm
Step A: The first question asks whether the patient requires immediate, life-saving interventions. If the answer is “Yes,” the patient is classified as Level 1, indicating the highest level of urgency. If “No,” the triage proceeds to Step B.
Step B: This step evaluates whether the patient is in a high-risk situation, is lethargic, confused, or in severe pain. A “Yes” response classifies the patient as Level 2, while a “No” response advances the process to Step C.
Step C: At this stage, the need for medical resources is assessed. If the patient requires only one resource, they are categorized as Level 4. If multiple resources are needed, they may qualify for a higher urgency level, prompting a review in Step D.
Step D: This step determines whether the patient exhibits “danger zone” vital signs, such as abnormal heart rate, respiratory rate, or oxygen saturation. A “Yes” response results in a Level 2 classification, while “No” leads to a Level 3 classification.
Types of Resources Defined by ESI
Resources play a critical role in the ESI system, as they help determine patient levels during Step C. Common resource types include:
- Diagnostic Tools: Labs, EKG/ECG, X-rays, CT scans, MRI, or ultrasounds.
- Treatment: IV fluids, IV/IM/nebulized medications, and specialist consultations.
- Procedures: Simple procedures, such as laceration repair or Foley catheter insertion, are counted as one resource. Complex procedures, including conscious sedation, fracture reduction, and intubation, may require additional considerations.
Points according to required resources;
- 1 point for Labs (e.g., blood tests), EKG/ECG or X-rays, or Advanced Imaging (e.g., CT, MRI, or ultrasound).
- 1 point for IV fluids.
- 1 point for IV, IM, or nebulized medications.
- 1 point for a Specialist consultation.
- 1 point for a Simple procedure, such as laceration repair or Foley catheter placement.
- 2 points for a Complex procedure, such as conscious sedation, fracture reduction, or intubation.
These resource definitions allow triage staff to assess patient needs objectively. A higher number of resources often correlates with a more urgent ESI level.
ESI Levels and Their Corresponding Urgency
The ESI system categorizes patients into five levels of urgency based on their condition and resource needs:
- Level 1 (Immediate): Patients need immediate attention due to life-threatening conditions like cardiac arrest.
- Level 2 (Emergent): These patients are at high risk of rapid deterioration, such as those experiencing an asthma attack.
- Level 3 (Urgent, Multiple Resources): Patients with conditions requiring multiple resources, like abdominal pain, fall into this category.
- Level 4 (Stable, One Resource): These patients need only one resource, such as laceration repair.
- Level 5 (Stable, No Resources): Patients with stable conditions requiring no resources, such as a prescription refill, are classified here.
Advanced Triage
Once you are comfortable with the above basic triage concepts, you can familiarize yourself with advanced triage considerations, such as ordering an initial diagnostic work-up and treatments.
Ordering an Initial Diagnostic Work-Up and Other Orders
As soon as a patient is determined to be sick or unstable, your priority should be to place them in a patient care area as quickly as possible for medical attention. You can then place initial orders, which should be directed toward stabilizing them. Placing IVs early and facilitating early medication/fluid administration can be life-saving measures. Be sure to ask these patients (or their loved ones) early in their evaluation regarding their wishes for cardiopulmonary resuscitation (CPR) and intubation. Once a patient is stable, or if they’re already stable, you can use their pertinent history and physical exam findings to guide your initial diagnostic imaging and labs. Consider your most likely diagnoses and “can’t miss diagnoses” when placing these initial orders [10].
Author
Priya Arumuganathan
Priya Arumuganathan, MD is a third year Emergency Medicine resident at West Virginia University. After residency, she will be completing a Global Emergency Medicine Fellowship at the University of Pennsylvania. During residency, Priya served as a Chief Resident and was very active in teaching core EM content, ultrasound skills, and procedural basics to medical students and new residents. Her rural background and training at several critical access hospitals have helped her build a foundation for working in low-resource environments, and she has been able to translate these skills to her global work. Her academic interests include EM education & training in low-resource environments, telemedicine, and rural health.
Scott Walker Findley
Dr. Findley is an associate professor with the WVU Department of Emergency Medicine. He splits time between the larger WVU academic centers and outlying rural emergency departments, spending most of his clinical time in single coverage facilities. After recognizing the challenges inherent in rural emergency medicine (EM), he designed and developed the WVU Division of Rural EM. Dr. Findley secured a federal telemedicine grant to expand telemedicine services in WV critical access hospitals, an institutional HOPE grant to assess per-birth needs in rural emergency departments, assisted with a rural specific response to COVID – 19, secured a position as medical director and advisor for Adventure WV, successfully launched a multisite rural EM rotation for residents, facilitated rural rotations for medical students, and oversaw the integration of rural EM lectures and simulated cases into the resident curriculum. In addition to remaining academically connected, Dr. Findley works closely with the WVU Emergency Department Divisions of ultrasound, EMS and Education to bring resources into the community sites and rural areas. Dr. Findley also sits on the national American College of Emergency Physicians (ACEP) Rural Emergency Medicine’s Task Force. He has taken an active role in research with local and national presentations as well as publishing in academic journals. Although these opportunities have been rewarding, Dr. Findley believes nothing teaches you more, maintains drive and sharpens focus better than pulling shifts and seeing patients and he plans to continue working the majority of his clinical hours in smaller departments.
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Reviewed and Edited By
Arif Alper Cevik, MD, FEMAT, FIFEM
Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.
