ENA Triage Guidelines


The Emergency Nurses Association (ENA), an organization dedicated to patient safety and emergency nursing standards, teaches triage practices and procedures to nurses around the world. The standards and practices discussed here come from the The Victorian Department of Human Services, which developed its triage guidelines in association with the ENA of Victoria (Australia) and based on ENA position papers.

Primary Triage

Primary triage consists of three basic categories of decision. "Expected" triage refers a patient to a doctor based on an obvious problem, while "over triage" patients receive treatment at a higher priority levels than their condition may suggest, and "under triage" patients receive categorization at a lower level than indicated by their symptoms.

Collecting Data

During primary triage, nurses base their decisions on both objective and subjective information. Objective factors include a "first glance" primary survey and an assessment of physiological issues such as breathing, circulation, level of consciousness, pain, mental or sensory problems, and whether the patient faces additional illness or injury.
Subjective factors include the patient's account of his ailment, symptoms, cause of the problem, health risks, medical history and when the problem started. The nurse must also make sure this information is communicated to other health professionals or interested parties.

Other Responsibilities

Triage nurses must know more than how to save patients. A nurse that meets ENA standards should also know how to provide secondary services once primary triage has taken place. If, for example, a patient experiences an unexpected crisis, the nurse must step in to aid the patient while securing his permission, explaining the situation to him clearly and politely, and following approved policies and procedures. The ENA also requires nurses to provide a safe, supportive, properly equipped medical environment for triage patients.

Discrepancies Between Scales

According to the Agency for Healthcare Research and Quality, the actual scales and systems used to assess triage worldwide lack a uniform approach. A triage scale might consist of anywhere from two to five categories with labels such as "Urgent," "Non-Urgent," or "Resuscitation," and different health organizations tend to use whatever scale they prefer. The ENA urges the adoption of a universal five-level scale for all triage cases. The Merriam-Webster Dictionary defines triage as the grouping of patients according to the urgency of their medical needs. Triage occurs on battlefields, at disaster sites, and in hospital emergency rooms where doctors and nurses must allocate their time and resources as efficiently as possible for those who need it most.