Introduction
The Emergency Department (ED) is a critical point of access for children needing medical care, from general EDs to specialized pediatric EDs. With a significant and increasing number of pediatric ED visits each year, a robust and reliable triage system is essential to ensure timely and appropriate care.
This guide provides emergency department providers with practical information on implementing effective pediatric triage, with the end goal of “right patient, right provider, right care, right time.”
I. Understanding triage
Definition
Triage: Derived from the French word “trier” (to sort), triage is the process of rapidly assessing patients to determine the severity of their condition, assign an acuity level, and anticipate the resources needed for their care.
Historical context
Triage was originally used in military settings to prioritize care for the wounded. Triage principles were introduced into civilian EDs in the 1960s, and ongoing refinement has led to standardized triage systems designed for efficiency and optimal patient outcomes.
II. The importance of a standardized system
A standardized triage system, such as a five-level system, is crucial for consistent, safe, and efficient pediatric care.
Core functions of a standardized triage system
- Prioritizing patient care: Ensures the sickest or most injured patients are seen first.
- Efficient resource allocation: Helps allocate staff, equipment, and other resources effectively.
- Benchmarking & quality improvement: Standardized data support comparisons and highlight areas for improvement.
- Data sharing & surveillance: Facilitates national-level data collection and tracking of ED visit trends.
A five-level triage system supports consistent acuity assignment, better communication, and safer throughput in busy EDs.
III. The Emergency Severity Index (ESI): A five-level triage system
The American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA) recommend using a reliable, valid five-level triage system such as the Emergency Severity Index (ESI) for pediatric patients. The ESI is a well-validated tool that integrates both patient acuity and resource utilization.
Key features of the ESI
- Five acuity levels: Patients are assigned to Levels 1–5, with Level 1 being most critical and Level 5 least urgent.
- Algorithm-based approach: Triage nurses follow a specific algorithm to determine acuity.
- Focus on acuity & resources: Considers both severity of condition and anticipated resource use.
- Nursing judgement: Clinical judgement heavily guides Levels 1 and 2; for Levels 3–5, nurses predict necessary resources (labs, imaging, procedures) to guide disposition.
How the ESI works
Initial assessment: A & B questions
- A – Immediate life-saving intervention? If yes → ESI Level 1.
- B – High-risk or imminently unstable? If yes → ESI Level 2. Use pediatric-specific high-risk conditions as a guide.
Pediatric high-risk conditions (ESI Level 2 guidance)
- Hematology/oncology patient with fever
- Shunt patient with headache, nausea/vomiting, and/or fever
- Diabetic with altered mental status, with or without nausea/vomiting
- Bleeding disorder with significant trauma
- Ocular exposure
- Postoperative tonsillectomy and adenoidectomy bleed
- Suicidal ideation or attempt
- Gastrostomy or gastrojejunal tube out and unable to place Foley in stoma in triage
- Smoke inhalation or carbon monoxide exposure
- Open fracture or altered neurovascular status with deformity
- Abdominal pain with peritoneal signs
- Sickle cell patient with fever or pain
- Cardiac patient with change in normal saturation and/or increased O2 needs
- Infants ≤ 60 days with fever or hypothermia (≤ 36 °C or ≥ 38 °C, rectal, by history or in ED)
- Eye injury with significant pain
- Scrotal pain
- Apparent life-threatening event with history of cyanosis
- Ingestions (excluding foreign body)—consult ED physician
- Cervical spine immobilized and on backboard
- Abdominal trauma with significant abdominal pain
- Permanent tooth available for reimplantation
Resource assessment (for less acute patients)
If the patient is not ESI Level 1 or 2, the nurse estimates the number of resources the patient is likely to require (ESI Levels 3–5). Only estimate up to two resources.
Examples of common triage resources used when assigning ESI Levels 3–5.
Simple
procedure (1 resource): e.g., laceration repair
or Foley catheter.
Complex procedure (2 resources):
e.g., procedural sedation.
Benefits of the ESI
- Improved interrater reliability: Multiple studies show good agreement between nurses using ESI.
- Accurate resource prediction: Supports efficient resource allocation and throughput planning.
- Pediatric-specific updates: ESI Version 4 (2012) includes a dedicated pediatric triage chapter and more pediatric case scenarios.
IV. Key pediatric triage considerations
Effective pediatric triage requires understanding the unique physiological and developmental factors that shape children’s responses to illness and injury.
Physiologic and developmental considerations
- Body surface area: Children have relatively larger body surface area, increasing susceptibility to heat and fluid loss.
- Thermoregulation in neonates: Neonates have poor thermoregulation and can become hypothermic quickly—minimize exposure during assessment.
- Subtle signs of illness: Critically ill neonates and young children may present with hypothermia, poor feeding, or irritability rather than overt signs.
- Heart rate dependence: Cardiac output in neonates and young children is primarily heart-rate dependent; bradycardia or severe tachycardia is dangerous. Hypotension is a late finding.
- Accurate weight: Obtain weight in kilograms for dosing, using validated tools when needed.
- Portability: Be prepared to assess critically ill children who are carried into the ED.
Psychosocial and safety considerations
- Caregiver input: Listen carefully to caregivers’ descriptions of baseline behavior and current changes.
- Abuse risk factors: Note socioeconomic stressors, substance use, mental illness, and chronic illness/disability; always question whether injuries match developmental stage.
- Mental health concerns: Recognize the increasing prevalence of mental health issues and suicidality, regardless of the primary complaint.
II. The pediatric triage process: Step-by-step
The pediatric triage process is fundamental in determining severity of illness or injury and immediate needs. It should be conducted efficiently, ideally within 3–5 minutes.
A. Initial rapid assessment using the Pediatric Assessment Triangle (PAT)
Purpose: Rapidly determine whether the child appears “sick” or “not sick” in the first moments of interaction.
Method: Hands-off observation of three components.
- Appearance: Alertness, interaction, consolability, gaze, and speech/cry, supported by the TICLS mnemonic.
- Work of breathing: Abnormal sounds (snoring, grunting, wheezing) and signs such as positioning, retractions, nasal flaring.
- Circulation to the skin: Pallor, mottling, cyanosis, and bleeding (expose in a warm environment).
Result: Use PAT findings to determine overall urgency of care.
TICLS mnemonic for appearance
- Tone: Moves spontaneously; sits or stands as age appropriate.
- Interactivity: Interacts with people, environment, and objects.
- Consolability: Stops crying with comfort from caregiver.
- Look/gaze: Tracks objects; makes eye contact.
- Speech/cry: Age-appropriate speech or strong cry.
B. Primary survey (ABCDE)
Purpose: Systematically identify and address life-threatening conditions.
Method: Conduct in the following order:
- Airway: Assess patency, obstruction, and compromise.
- Breathing: Assess rate, effort, and breath sounds.
- Circulation: Heart rate, blood pressure, pulses, capillary refill, perfusion.
- Disability: Level of consciousness and neurologic status.
- Exposure: Check for hypothermia, hyperthermia, rashes, signs of trauma or abuse.
Triage red flags
Airway
- Apnea
- Stridor
- Hoarse voice/cry
- Drooling
- Choking
- Gurgling
- Sniffing position
- Hypoxemia
Breathing
- Increased work of breathing
- Retractions
- Grunting
- Nasal flaring
- Seesaw respirations
- Head bobbing
- Adventitious breath sounds
- Tripod positioning
Circulation
- Tachycardia or bradycardia
- Hypotension
- Capillary refill > 3 sec or < 1 sec
- Decreased pulses or bounding pulses
- Cyanosis or mottling
- Uncontrolled bleeding
Disability
- Altered level of consciousness
- Inconsolable crying
- Abnormal pupillary reaction
- Hypoglycemia
Exposure
- Hypothermia
- Hyperthermia > 105.1 °F
- Rash (petechial, purpura)
- Signs of abuse
C. Secondary survey (CIAMPEDS & focused assessment)
Purpose: Gather pertinent history and perform a focused physical assessment based on the presentation.
Method:
- CIAMPEDS history: Use the CIAMPEDS mnemonic to obtain a systematic history. Interview adolescents separately for mental health or sexual complaints when needed.
- Focused physical assessment: Examine affected systems/areas based on chief complaint.
- Pain assessment: Use developmentally appropriate pain scales.
CIAMPEDS mnemonic
- C – Chief complaint
- I – Immunizations / isolation: Include need for isolation.
- A – Allergies: Food, medications, dyes, latex, blood.
- M – Medications: Current medications.
- P – Past medical history
- E – Events: Surrounding illness or injury.
- D – Diet / diapers: PO
intake and urine output.
- S – Symptoms: Associated with illness or injury.
D. Vital signs assessment
Purpose: Identify physiological distress and gauge severity of illness.
Method: Assess respiratory rate, heart rate, blood pressure (when indicated), temperature, and oxygen saturation, using appropriately sized equipment.
High-risk vital signs
| Age | Respiratory rate (RR) | Heart rate (HR) | Additional concerns |
|---|---|---|---|
| < 6 months | > 60 | > 180 | Oxygen saturation < 92% |
| 6–12 months | > 50 | > 160 | Capillary refill < 1 second or > 3 seconds |
| 1–2 years | > 40 | > 160 | |
| 2–8 years | > 30 | > 140 | |
| > 8 years | > 20 | > 100 | |
| All ages | – | – | Hypothermia or hyperthermia |
Always interpret vital signs in the context of the child’s overall clinical picture.
Important considerations in interpreting vital signs
- Clinical context: A single abnormal value does not automatically indicate high risk; integrate history, appearance, and exam.
- Fever: Fever increases heart rate; a typical response is about a 10% rise in baseline heart rate per degree Celsius. Consider higher acuity for tachycardia without fever or outside the expected range for fever.
- Trends: Serial vital signs are more informative than a single set.
- Age-appropriate equipment: Use correct cuff size and probes for reliable readings.
- Temperature abnormalities: Pay particular attention to hypothermia or hyperthermia in immunocompromised patients and neonates.
E. Triage decision, interventions, and acuity assignment
Purpose: Synthesize all information and determine appropriate triage interventions and acuity level.
Method:
- Synthesize data: Integrate PAT, primary survey, secondary survey, and vital signs.
- Initiate protocols: Apply nurse-led protocols, standing orders, or clinical pathways as defined in department policy (e.g., analgesia, antipyretics, NPO status, ice packs, basic splints, EKGs, simple wound care, x-ray orders).
- Isolation needs: Identify and implement appropriate isolation measures early.
- Assign acuity: Use your facility’s triage system (e.g., ESI) to determine priority and location of care.
III. Triage documentation and reassessment
Documentation
- Record acuity and chief complaint: Document triage level, chief complaint, and key subjective and objective findings.
- Record interventions: Clearly chart all triage interventions.
- Weight in kilograms: Document weight in kilograms to support safe medication dosing.
Reassessment
- Waiting room monitoring: Reassess patients in the waiting area, especially during crowding.
- Monitor progression: Track changes in illness/injury and response to triage interventions.
- Re-examination plan: Implement structured reassessment based on department resources and patient flow. Remember that assessment is a nursing function and cannot be delegated to unlicensed support staff.
IV. EMTALA compliance
EMTALA (Emergency Medical Treatment and Active Labor Act) requirements shape the legal and ethical framework for ED triage.
- Understand EMTALA: Be familiar with institutional policies and the core legal expectations.
- Medical screening examination (MSE): Ensure all patients receive an MSE to determine whether an emergency medical condition (EMC) exists, regardless of ability to pay or legal status.
- Stabilizing treatment: If an EMC is identified, provide stabilizing care within hospital capabilities.
- Appropriate transfer: If the facility cannot fully stabilize, arrange transfer to a higher level of care in an EMTALA-compliant manner.
- Policy adherence: Follow institutional EMTALA policies and procedures consistently.
V. Trends in triage and improving throughput
Quality indicators in ED settings aim to improve efficiency, reduce left-without-being-seen (LWBS) rates, and enhance patient safety. The following strategies can optimize pediatric ED throughput.
- Pivot roles: Use a pivot process for rapid assessment of identifiers, chief complaint, and vital signs at the first point of contact.
- Split flow: Expedite care of the sickest patients and speed nonurgent flow by performing immediate initial assessment during registration.
- Immediate bedding: Direct patients to an available bed immediately after registration/screening to reduce time to provider; complete full triage at bedside.
- Provider in triage: Place a frontline provider in the intake/triage area to initiate protocols, order tests, and treat/discharge lower acuity patients from the waiting area when appropriate.
Conclusion
Pediatric triage requires a specialized skillset and a comprehensive understanding of child-specific physiologic and psychosocial considerations. By implementing a standardized, evidence-based approach such as the Emergency Severity Index and focusing on efficient assessment and resource allocation, ED providers can optimize care for children presenting to the emergency department.