Triage a Patient by ESI Acuity

Triage is the ED front door. Triage is the assessment that takes a new arrival, records what is wrong with them and how sick they look, and assigns an ESI acuity — the Emergency Severity Index, a 5-level scale where 1 (Resuscitation) is the most urgent and 5 (Minor) the least. The acuity is what decides who is seen first, so getting it right and getting it fast is the whole job.

Who / when: the ED triage nurse assesses every patient as they arrive — whether they walked in, came by ambulance, were referred, or were brought by the police. We will follow Grace Okoro, a triage nurse, taking in a man who has arrived short of breath.

1. Triage nurse — open Emergency → Triage. The “Triage Assessment” form opens, and the Awaiting Triage panel on the side shows who is already waiting.
2. Triage nurse — on Presentation, search for the patient by name or UHID. Set the arrival mode (Walk-in, Ambulance, Referral or Police) and the time of arrival, and type the presenting complaint. If a Manchester discriminator fits (e.g. “Acutely short of breath”), pick it, and set the pain score 0–10.
3. Triage nurse — on Vital Signs, record temperature, HR, BP, SpO₂, RR, GCS and blood glucose. Toggle Infection Risk Flag if the patient should be isolated pending review.
4. Triage nurse — on Acuity, choose the ESI level (1–5) that matches how sick the patient is, then press “Assign & Route”. The patient drops onto the boards as a live visit.

Caution

If you set ESI 1, the screen warns you that the resus team is paged the moment you route the patient. Use it for the truly immediate cases — cardiac arrest, airway compromise, major trauma — and head to Run a Resuscitation.

Tip

A patient who gets better or worse while waiting can be re-graded without re-triaging from scratch — reassessment keeps the original triage and records the new acuity with fresh vitals, so the board always reflects how sick they are right now.

What happens next

Routing opens one clinical encounter for the visit and captures the ED attendance fee automatically, so charting, orders and billing all attach to the same record. The patient now appears on the Bed & Zone Board in the Waiting zone, on the Tracking wallboard under Triage, and on the Disposition worklist as Pending. From here the team gives them a zone and a bay, starts treatment, and works toward a decision.

Follow the trail

• Next: Run a Resuscitation
• Related: Work the Bed and Zone Board · Fast-Track a Minor Injury · for ambulance arrivals see the Ambulance journey · for booked patients see Check In an Appointment Into an Encounter