A matter of life and death: Triage and hospital emergency rooms

One of the most challenging tasks confronting busy hospital emergency rooms (ERs) is deciding who needs attention from a doctor most urgently. When patients come in the ER front door, they’re first seen by a triage nurse, who has a critical role in prioritizing care.

Triage is a medical term that means assigning degrees of urgency to patients based on their conditions. It’s not so important when an ER isn’t busy and physicians are available to see new patients immediately. That’s usually not the case, though. For crowded ERs, proper triage can mean the difference between life and death.

Some hospitals have started to use artificial intelligence to improve human efforts in making triage decisions for COVID-19 patients. One health system of 11 hospitals has trained 80 triage nurses to use consistent call scripts and guidelines to make triage decisions.

As a former hospital administrator, I welcome this kind of innovation. Scripts, guidelines, policies, procedures, and algorithms (step by step guides or flowcharts that guide health care) can go a long way toward improving the quality of care that’s being delivered to patients.

Around 2000, two emergency physicians developed one of the most widely-used algorithms in ER triage. It’s called the Emergency Severity Index (ESI). The goal of inventing ESI was to introduce a measure of objectivity and consistency into what had always been a triage system that was subjective and varied from hospital to hospital.

Currently, the ESI triage system is divided into five categories and focuses on four decisions that must be may for every emergency room patient:

• Is the patient in a life or death situation that requires immediate care and intervention?

• Is this a patient who shouldn’t wait for care?

• How many resources (staff, equipment, and supplies) will the patient require for treatment?

• What are the patient’s vital signs?


A patient with an ESI of 1 is someone who needs immediate life-saving intervention. In other words, this is the biggest emergency in the ER.


When the triage nurse assigns a patient an ESI of 2, it’s a patient who’s: (1) in a high-risk situation; (2) presenting with confusion, lethargy, or disorientation—these are often the earliest signs of a serious problem; or (3) in severe pain or distress.


Vital signs help guide a triage nurse’s decisions. Three values are important in assigning an ESI score. Triage nurses look for “danger zone” vital signs in the categories of heart rates, respiratory rates, and oxygen saturation.

For heart rate, a danger zone in a patient is:

• Less than three months old: greater than 180 beats per minute.

• 3 months old to 3 years old: greater than 160 beats per minute.

• 3–8 years old: greater than 140 beats per minute.

• Over 8 years old: greater than 100 beats per minute.

For respiratory rate, a danger zone in a patient is:

• Less than three months old: greater than 50 breaths per minute.

• 3 months old to 3 years old: greater than 40 breaths per minute.

• 3–8 years old: greater than 30 breaths per minute.

• Over 8 years old: greater than 20 breaths per minute.

For oxygen saturation, a danger zone in a patient is:

• Less than 92% for all ages.

When a patient has one or more of these vital signs in the danger zone, the triage nurse should consider assigning an ESI of 2.

Triage medical malpractice

Triage nursing is one of the most essential functions in an emergency room. How a patient is triaged makes the difference between getting essential care versus getting sidelined in the waiting room.

When a triage nurse makes a mistake, it can set a patient on the wrong track and led to tragic, irreversible consequences. That’s what happened to a client of ours who sought immediate medical treatment at a Houston-area hospital for suspected stroke symptoms.

The patient’s wife called 911 because she thought that he was having a stroke because he had a sudden onset of right-sided weakness and facial drop, accompanied by difficulty speaking. You can hear his slurred speech as plain as day in the 911 recording.

When he got to the hospital, the ER triage nurse assigned him an ESI of 3. That mistake led to him being stuck in the waiting room for three hours before being reassessed. At that point, his condition had deteriorated significantly, and the nurse recognized that he was having a stroke. The resulting delay in treatment left him with a permanent brain injury.

Things would have been different if the triage nurse had made a correct ESI assignment, for sure. But there were also other opportunities for the ER nursing staff to make things right. For instance, it was inappropriate to wait three hours before reassessing this patient.

If you’ve been seriously injured because of poor ER care, then contact a skilled, top-rated Houston, Texas medical malpractice lawyer for help in evaluating your potential case.

Robert Painter
Article by

Robert Painter

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm Medical Malpractice Attorneys in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him for a free consultation and strategy session by calling 281-580-8800 or emailing him right now.