4. Triage and Acuity Scale -- Category Definitions

Canadian Paediatric Triage and Acuity Scale:
Implementation Guidelines for Emergency Departments

The following lists of presenting complaints and case scenarios are not meant to be all-inclusive or absolute in their application. Triage personnel must use their experience and instincts to "up triage" priority, even if the patient does not fit exactly with the facts or definitions on the triage scale. In other words, if they look sick, they probably are. Conversely, provider's instincts should not be used to "down triage" or lower the triage level assignment, if the facts suggest a significant problem exists. To illustrate, if parents relate a history suggesting serious illness (e.g., respiratory difficulty, choking or cyanosis) but the patient currently looks well, triage nurses should assume the worst and allow subsequent caregivers to rule out life-threatening problems.

Level I -- Resuscitation

Time to medical care  IMMEDIATE

Level I refers to conditions that are threats to life or limb (or associated with imminent risk of deterioration) requiring immediate aggressive interventions. Level I conditions include the following.

1. Code or arrest: Patients with cardiac or pulmonary arrest (or imminent arrest)

2. Severe respiratory distress: There are many causes of respiratory distress, but benign causes can only be diagnosed by exclusion. Level I conditions include near-fatal asthma, airway obstruction by foreign body, infant bronchiolitis, intracranial events, pneumothorax, congestive heart failure, anaphylaxis and severe metabolic disturbances. Signs may include inability to speak, cyanosis, lethargy or confusion, tachycardia or bradycardia, and hypoxemia with O2 saturation <90%. These patients require rapid assessment of the ABCs and immediate physician intervention. Medications and equipment for management of respiratory and ventilatory failure, including intubation equipment, rapid sequence intubation drugs, bronchodilators, inotropes, and vasodilators must be immediately available.

3. Major trauma: Level I injuries include severe injury to any single body system or multiple system injury (injury severity score >12), head injury with GCS <10, severe burns >25% total body surface area (or with airway problems), chest or abdominal injury with altered mentation, tachycardia, bradycardia, hypotension, severe pain, or respiratory signs or symptoms.

4. Unconscious or unresponsive: CNS events, metabolic disturbances and intoxications or overdoses can all present with alteration of mental function, ranging from disorientation or confusion to complete unresponsiveness or seizures. Airway protection, supportive care and prompt assessment to determine the cause and necessary treatment are of critical importance. Hypoglycemia is a rapidly reversible problem that should be identified using rapid bedside screening tests.

5. Shock states: Conditions where there is an imbalance between oxygen supply (e.g., cardiogenic shock, pulmonary dysfunction, blood loss, disorders of oxygen affinity), oxygen demand (hyperdynamic states) or oxygen utilization (sepsis syndrome). In children, tachycardia is an early response, while bradycardia and hypotension occur late, signalling imminent cardiac arrest.

Typical Level I patients have one or more of the following findings.

  • Non responsive
  • Vital signs absent or unstable
  • Severe dehydration
  • Severe respiratory distress
  • Major burns
  • Septic shock
  • Anaphylaxis

Level II -- Emergent

Time to medical care <15 min

Level II refers to conditions that are a potential threat to life, limb or function, requiring rapid medical intervention or delegated acts. Level II conditions include the following.

1. Respiratory: Upper airway concerns may present with audible stridor as evidence of upper respiratory distress. Congenital vascular anomalies and foreign bodies may present with intermittent respiratory distress.

Lower airway concerns may present with audible wheezing, tachypnea, or cough, as evidence of lower respiratory distress. Dyspnea is subjective and may correlate poorly with lung function or deficits in oxygen uptake and pulmonary function. Depending on the patient's age, one may not be able to distinguish between asthma, congestive heart failure, pneumothorax, pneumonia, croup, epiglottitis, anaphylaxis, or a combination of problems. Rapid assessment of symptoms, vital signs and physical findings will facilitate early intervention for serious causes of dyspnea.

2. Asthma: Severe asthma is best confirmed using a combination of objective measures (e.g., FEV1, PEFR, O2 saturation) and clinical severity markers, including symptoms, vital signs and a history of previous severe episodes. The best measure of severity and guide to therapy is some form of spirometric testing. If the FEV1 or PEFR are <40% of predicted or of the previous best effort, the patient is considered severe and requires prompt treatment and close observation until signs of improvement. In children who are unable do spirometry, particularly those under age 6, clinical features and O2 saturation are used to estimate severity.

3. Altered mental state: Infectious, inflammatory, ischemic, traumatic, and metabolic disorders, as well as poisoning, adverse drug effects and dehydration can all affect sensorium, causing anything from minor cognitive deficits to agitation, lethargy, confusion, seizures, paralysis, and coma. Even subtle changes in mental status can be associated with serious life-threatening conditions. For example, in young children, irritability and poor feeding may reflect altered mentation due to serious bacterial infection or dehydration.

4. Head injury: Depending on severity and associated findings, head injuries may fit into one of several triage levels. More severe or high-risk patients require a rapid physician assessment to determine the requirements for airway protection, CAT scanning or neurosurgical intervention. These patients usually have an altered mental state (GCS <13). Severe headache, loss of consciousness, confusion, neck symptoms and nausea or vomiting can be expected. Details regarding the time of impact, mechanism of injury onset and severity of symptoms and changes over time are very important.

5. Severe trauma: These patients may have high-risk mechanisms and severe single system symptoms or multiple system involvement with less severe signs and symptoms in each (ISS >=9). Generally the physical assessment of these patients should reveal normal or nearly normal vital signs (abnormal vital signs suggest Level I). These patients may have moderate to severe pain and normal mental status, or meet the criteria outlined above for Level II head injuries.

6. Toxic or metabolic: Intentional overdose patients are unreliable historians. It is difficult to determine which agents have been ingested and the actual quantities. When more than one child is involved, weigh each child and calculate the severity of the ingestion assuming the worst-case scenario -- that one child ingested all of the agent(s). Consult a local poison control centre for up-to-date advice. These patients require early physician assessment or advice regarding the need for monitoring and toxicological screening, the use of modalities to limit absorption or enhance elimination, and the need for specific antidotes. Patients with any signs of toxicity (e.g., altered mental state, abnormal vital signs) should be seen very quickly (<5 min).

Metabolic problems can present with altered level of consciousness, vomiting, abnormal vital signs and a multitude of other symptoms. Children may seem disproportionately ill relative to the presenting complaints. A high index of suspicion, routine glucose and metabolic screening, and appropriate consultation is required for their management.

7. Raised intracranial pressure: Infections, hemorrhage, and blocked ventriculoperitoneal shunts can present with acute or subacute findings of raised intracranial pressure. In the presence of CNS changes, vomiting and lethargy should not be assumed to be due to gastrointestinal infections. Patients with major neurological deficits may require airway protection or emergent CT scanning to determine appropriate diagnosis and the need for neurosurgical intervention.

8. Circulatory compromise: Delayed capillary refill, tachycardia, decreased urine production and skin changes suggest poor tissue perfusion. Vomiting and diarrhea secondary to gastrointestinal infection are a common etiology. The signs of dehydration are not always reliable, particularly in younger patients. Hemorrhage in moderate trauma may be masked by a child's ability to maintain his or her blood pressure.

9. Limb or organ dysfunction: Traumatic amputations, open fractures and fractures with neuro-vascular deficits all require urgent management. Testicular pain, priapism or paraphimosis require urgent assessment and management. Penetrating eye injuries necessitate urgent referral.

10. Neonates: Infants <7 days may present with hyperbilirubinemia, undiagnosed congenital heart abnormalities, bowel obstruction, and sepsis. The signs of serious problems may be very subtle, such as minimal temperature abnormalities, feeding disturbance, or increased lethargy. Parental anxiety is often very high, and these patients should be brought into the ED treatment area and have prompt physician assessment or verbal review.

11. Eye pain (with pain score 8­10/10): Chemical exposures (acid or alkali) cause severe pain. These patients should receive topical analgesics and have eye irrigation according to local guidelines (15 minutes for acid and 30 minutes for alkali). Prolonged irrigation may be necessary to bring the pH into an acceptable range. In situations where the physician assessment may be delayed, the treatment protocol should be implemented without a physician order. Penetrating injuries, corneal foreign bodies and solar keratitis benefit from topical analgesics. Successful relief of pain may allow physician assessment to be delayed in such cases. If pain is not controlled the diagnosis should be reconsidered.

12. Anaphylaxis: Patients with severe allergic reactions can deteriorate rapidly. Those with a history of asthma are at particularly high risk of death. Problems should be suspected if there are any respiratory symptoms or complaints of tightness in the throat. These patients may receive epinephrine and other medications (e.g., benadryl) by protocol, and have slightly longer delays to physician assessment, particularly if there is a prior history of this problem, with an uncomplicated course. True anaphylaxis involves multiple body systems: CNS (altered mental state to seizure or coma), CVS (hypotension or tachycardia, vascular collapse or shock), respiratory (wheeze, cyanosis, cough), skin (urticaria, itch with any type of non-purpuric rash), GI (vomiting, abdominal pain, diarrhea), renal. The history of time of exposure and type of agent relative to the time of onset of symptoms are important to determine the cause and for future follow-up or discharge advice.

13. Vaginal bleeding or acute pelvic lower abdominal pain: Patients with vaginal bleeding and or acute lower abdominal pain, with altered vital signs, should be assessed for the possibility of ectopic or other serious problems associated with pregnancy.

14. Serious infections: Patients with bacterial infections or sepsis syndrome usually appear unwell and will have an abnormality in one or more physical signs (e.g., mental state, vital signs, O2 saturation). Sepsis and meningitis in children can present with variable findings dependent on age and extent of disease. Purpuric skin rashes, non-blanching spots and petechiae may be associated with meningitis.

Ask about fever, chills and rigors (uncontrollable shaking episodes sometimes associated with teeth chattering or bed rocking). In a neonate, temperature instability may be an indication of sepsis.

Infants less than 3 months old with a temperature of <36°C or >38°C and a history of abnormal behaviour or abnormal examination are at higher risk of sepsis than older infants. Infants more than 3 months old with fever and a toxic appearance should be rapidly assessed and treatment initiated.

Immune-suppressed and asplenic children may develop septic shock rapidly with minimal elevations of temperature and minimal findings.

15. Diabetes: Medical alert bracelets, history from others, physical assessment, vital signs, bedside glucose testing are all useful for identifying diabetics with hyper- or hypoglycemia. Diaphoresis or altered mental state are typical of hypoglycemia. Altered mental state, blurred vision, fever, vomiting, abnormal pulse and respirations (rapid and deep) are more typical of elevated blood sugar, with or without diabetic ketoacidosis.

16. Headache: This presenting complaint appears in multiple triage levels. There are significant concerns about delays in diagnosing "CNS catastrophes" (subarachnoid, epidural, subdural, meningitis or encephalitis), which may have several overlapping features with migraine. For patients with migraine it is important to institute abortive therapy, with non-opiate agents, to relieve unnecessary pain and suffering and shorten ED length of stay. The key to diagnosis and risk stratification is primarily based on an accurate history of onset, family history, course, duration, associated symptoms and prior history of similar episodes. It is important to establish what is meant by "sudden" pain. Intracranial catastrophes are usually associated with maximal intensity at onset. Gradual-onset headaches are not always benign but they are rarely catastrophic.

17. Acute psychosis or extreme agitation: These patients may be suffering from metabolic disturbances, poisoning or other organic problems. If the acute psychosis or agitation is part of a known ongoing psychiatric illness, the patient will benefit from early intervention with antipsychotics, sedatives (chemical restraint) or, if necessary, physical restraints. History from family, friends, witnesses, caregivers and other health care providers (e.g., community physicians, nurses or EMTs), in addition to vital signs and physical assessment, will facilitate identification of patients at medical risk, particularly those with hypoglycemia, overdose or CNS events.

18. Child abuse, neglect or assault: These patients are at ongoing risk of injury. They have special needs relating to their mental well being. There are specific requirements for the collection of samples for evidence, or the activation of local protocols for the use of assault teams and community services. Shaken infants may present as afebrile with altered level of consciousness.

Medical protocols should allow early referral to mental health services, crisis intervention and specialized services. These patients require a safe and caring environment.

19. Severe pain (pain scales): When a patient claims to have a pain of 8­10/10 and does not appear to be in distress, or does not appear to have any condition you expect to cause intense pain, it is helpful to ask what their most painful previous experience had been. The first pain anyone has is by definition a 10/10. If they have had a broken bone or severe injury, and their current pain is being compared with one of these entities, this may help you to decide which triage level is appropriate. Younger children are more difficult to assess and require the use of facial analog scales and experience. Children thought to have severe pain (but who are unable to score or rate their pain) should be treated as though they have 8­10/10. Medical directives should be developed to allow triage nurses to alleviate pain promptly. Physical interventions are also effective for alleviation of pain (splinting, ice, elevation).

Level III -- Urgent

Time to medical care <30 min

Level III conditions are often associated with significant discomfort and the inability to work or carry out activities of daily living. Level III patients may deteriorate and require emergency intervention. This is the most critical triage category for assessment, reassessment and reassignment. The vital signs may be slightly abnormal or at the limits of normal. Level III conditions include the following.

1. Moderate asthma: Moderate asthma causes frequent cough, night awakening, or mild to moderate shortness of breath on exertion. Objective evidence may include oxygen desaturation (<92%­94%) with reduced forced expiratory volumes and peak expiratory flow rates (40%­60% of predicted or previous best). Medication history and previous attack patterns (intubations, ICU admissions and frequent hospitalization) can help identify high-risk individuals. It is unwise to assign low triage levels to asthmatics who present with increasing respiratory symptoms. These patients should be placed in an area where they can be observed and re-evaluated, and the patient or family should be advised to report deterioration to the emergency staff. Spirometric measurements (FEV or PEFR) should be performed on patients over age 5 who have come to the ED because of increasing respiratory symptoms. Medical directives should be in place to allow bronchodilator therapy at the earliest appropriate time.

2. Moderate respiratory distress: Patients with pneumonia, bronchiolitis or croup may complain of, or appear to be, short of breath. An assessment of vital signs and other symptoms helps decide the need for urgent investigation or treatment. Objective measures such as oxygen saturation are helpful, particularly if wheezing is present.

3. Altered mental state: Post-ictal patients with a known seizure disorder or new onset but brief seizure (<5 minutes) should be considered Level III if they are alert, breathing normally, protecting their airway (normal gag) and have normal vital signs. Overdose patients should be considered Level III if they have stable vital signs and are not at risk of deterioration. Patients with intracranial shunts who have altered mentation require specific investigation.

4. Head injury: Level III head injury patients may have had a high-risk mechanism, but should be alert (GCS 14 or 15) with only moderate pain (<8/10), nausea or vomiting. These patients should be upgraded to Level II if they are deteriorating or appear unwell.

5. Moderate trauma: Patients with fractures often have significant pain; however, rapid nursing intervention with splinting and analgesics may make a Level III triage designation reasonable. Small joint dislocations with only moderate pain (<8/10) may be considered Level III but, in general, large joint dislocations should be reduced promptly, so physician assessment should occur in <30 minutes. All Level III patients are stable, with normal or near normal vital signs.

6. Volume depletion: Examples of Level III volume depletion include vaginal bleeding with normal vital signs, resolved post-tonsillectomy bleeding with normal vital signs, and diarrhea or vomiting with normal vital signs. Note, however, that dehydration and serious infections are sometimes subtle in very young children, and vital signs may be normal. Patients with Level III volume depletion should be reassessed within 30 minutes.

7. Abdominal pain: Constipation often causes moderate pain, but appendicitis in the older child and intussusception in the younger patient must be considered. Children with post-traumatic abdominal pain must be assessed for significant injury.

8. Acute psychosis and suicidal ideation: Level III psychiatric patients include those who are not agitated but who might be a threat to themselves or others. These patients may be emotional, but are cooperative and not violent. They should be placed in a safe, caring environment, and triage staff should determine whether an overdose or suicide attempt has occurred.

9. Moderate pain (4­7/10): Patients with minor problems but moderate pain should have nursing intervention (e.g., ice, splints), a protocol to institute analgesics or early access to verbal physician assessment.

Level IV -- Less Urgent

Time to medical care <60 min

Conditions that may be related to the patient's age or level of distress, and that have a potential for deterioration or the development of complications. These patients benefit from reassurance and intervention within 1 to 2 hours. Level IV conditions include the following.

1. URI symptoms: Patients with upper airway congestion, cough, aches, fever or sore throat frequently present to the ED. Unfortunately, patients with strep throat, mono, peritonsillar abscess, epiglottitis, pneumonia or other serious illnesses cannot always be identified in routine or quick-look assessments. Flu-like illnesses with generalized symptoms can be serious for patients who have significant underlying health problems, or are very young. Because some serious bacterial infections can present with symptoms that appear to be the "flu," these patients may require Level III care. If there are significant respiratory signs or symptoms, perform an O2 saturation and if <95%, upgrade triage level.

2. Head injury: Level IV head injury patients are those with a minor head injury; they are alert, have no vomiting, no neck symptoms and have normal vital signs. They may require a brief period of observation, depending on the time of injury in relation to their presentation to the ED. The age of the patient and the type of care and support they will receive at home may also influence the triage, the disposition decision, or observation period.

3. Vomiting and diarrhea, with no signs of dehydration: Risk of dehydration increases when vomiting and diarrhea are both present. Simple viral gastroenteritis does not usually cause serious problems in most children. Signs of dehydration vary by age. Young children may have behaviour or mental status changes that can range from simple fussiness, to being very lethargic or even unconscious. Clues found in vital signs: dry mucous membranes, decreased tears, decreased urine output and skin turgor. Questions should include: how many times the patient has vomited, whether it occurred only when eating or drinking, and time of the last episode (exact times are best). The same is true for diarrhea. If there have been <5 loose bowel movements per day, then dehydration or electrolyte imbalances are unlikely. In children with >10 bms/d (with or without blood) more serious causes should be considered. Patients with >=10 episodes of vomiting in the previous 24 hours or >5 bms/d for 2 or more days should be upgraded to a level II or III, depending on the assessment of hydration. Vomiting can be a sign of other problems (e.g., CNS abnormalities, cardiac disease, drug effects, diabetes). These possibilities must be considered.

4. Minor trauma: Patients with minor fractures, sprains, contusions, abrasions or lacerations that require investigation or intervention are categorized as Level IV. They have normal vital signs and mild pain (1­3/10).

5. Abdominal pain: Patients with a history of acute pain of mild intensity (1­3/10) are triaged as Level IV. Vital signs should be normal, and the patient should not be in acute distress. Constipation can cause very severe pain and can be confused with more serious problems. Start by assuming the worst, and ensure there are sufficient clinical or investigative data to exclude potentially severe but treatable problems (e.g., appendicitis). The severity of the pain is not a reliable means of excluding these problems.

6. Headache: Headaches that are not sudden, not severe, not migraine and have no associated high-risk features (see Levels II and III) can be categorized as Level IV. Infections (e.g., sinusitis, URI) or flu-like illnesses may be the cause of these headaches.

7. Earache: Otitis media and externa can cause moderate (4­7/10) to severe (8­10/10) pain. These patients should receive analgesics as part of nursing protocol and intervention. If the patient has severe pain or is in acute distress, the triage level should be III, or there should be an order for analgesics. Triage staff should judge how soon physician assessment should occur. Determining the cause of ear pain and implementing appropriate treatment and reassessment is important.

8. Chest pain: Children usually present with chest pain associated with minor trauma or infectious processes. These patients should have no acute distress, no shortness of breath and normal vital signs. Patients with underlying lung or cardiac disease (e.g., cystic fibrosis, collagen vascular disease) should be triaged according to their history of disease and findings.

9. Depression: Patients who complain of suicidal thoughts or have made gestures but do not seem agitated can be categorized as Level IV. They should have normal vital signs. Suicidal risk and the possibility of overdose is difficult to define accurately. Caregivers should show empathy. These patients should have a responsible person with them, be placed in a quiet and secure area if possible, and be reassessed periodically. They should also be evaluated for their potential for suicide.

10. Mild acute pain (scale 1­3/10): Minor injuries or musculoskeletal problems accompanied by mild pain are triaged as Level IV.

Level V -- Non Urgent

Time to medical care <120 min

Level V conditions may be acute but non-urgent, or may be part of a chronic problem (with or without evidence of deterioration). Investigation or interventions for some of these illnesses or injuries can be delayed or referred to other areas of the hospital or health care system. Level V conditions include the following.

1. URI, sore throat: These patients have minor complaints (e.g., typical viral illness), normal vital signs, and no respiratory symptoms or compromise.

2. Minor cutaneous problems: Minor trauma problems such as contusions, abrasions, lacerations (not requiring closure by any means), suture removal and sunburn are typical Level V conditions. Skin conditions can include eczema, warts, lice or simple rash. Nursing interventions, cleansing, immunization status and minor analgesics are all expectations of patients in this category.

3. Abdominal pain: Mild pain (1­3/10) that is chronic or recurring, with normal vital signs, is a presentation typical of Level V patients. Some patients complain of more severe pain, but it may be difficult to justify higher triage assignment. Consider the context in which these patients present and take efforts not to be judgemental. Their symptoms may be very challenging and frustrating for both the care provider and the patient. Extended waiting periods should lead to reassessment or upgrading of triage level.

4. Vomiting alone, diarrhea alone: These patients have no signs of dehydration, and normal mental status and vital signs.

5. Psychiatric or psychosocial: These patients may seem to have minor or insignificant problems. They may have presented to the ED because they are frustrated by a lack of availability of other health care options that are community specific, or they may even be simply unaware of what other options are available. Having an open mind and being sensitive to socioeconomic and cultural issues will allow the provider the opportunity to evaluate the level of care needed and the risk of harm to self or others. Although these patients have normal vital signs, they may have chronic or recurring depression, trouble coping, school difficulties, or behavioural problems. Some chronic but more serious psychiatric disturbances or behaviour disorders for which there is no evidence of deterioration or change cannot usually be fully evaluated in triage.

Patients difficult to categorize

If it is difficult to assign a triage level because the patient doesn't seem to fit any of the categories, the provider should discuss the case with a colleague or make a judgement based on experience or instinct. When deciding triage level, the fundamental principle is this: patients should be treated as though they were close friends or family members. Patients who have a similar "administrative presentation" such as "recheck" or for "tests" or "booked procedures" are not all the same in terms of their need for care or the amount of resources required. Patients with the same clinical symptoms or complaint, such as vomiting, head injury, asthma, can be assigned to one of several triage levels. The level should be based on the available investigation and treatment guidelines, care maps and critical pathways.

Scheduled revisits

Patients returning for dressing changes, cast checks, rechecks of medical conditions (e.g., limp, hydration, jaundice, abdominal pain, headache, asthma) are diverse in terms of their requirements for care, resources required and needs with respect to time to intervention. Some EDs do scheduled procedures and, based on the community and system capabilities, this may be the best possible option. Even though they may be elective and sometimes not very urgent, it is not usual to operate a system that would allow long delays to intervention. Designated fast track or procedure areas for these patients may only be local management issues that are not relevant to triage as a system of prioritization. If triage assignment is used to group patients based on resource need and timeliness to care, then most patients would be Level V with a very low expectation of admission. All patients should be triaged, because there are very real differences in those who have scheduled tests (e.g., ultrasound of the abdomen or pelvis, CT of the head, bone scan). The patient's condition may have changed from when the test was arranged, or the recheck may be because symptoms have worsened or changed. To assume that all revisits, rechecks, scheduled tests or procedures are the same triage priority or resource consumption is dangerous and does nothing to monitor the appropriateness of system utilization.

Pearl of wisdom: If patients look sick and you are not sure, triage them as Level I or II.

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