TRIAGE LEVEL |
DEFINITION |
USUAL PRESENTATION |
SENTINEL DIAGNOSIS |
---|
Level 1 Resuscitation Time to physician IMMEDIATE |
▪ Conditions that are threats to life or limb (or imminent risk of deterioration) requiring immediate aggressive interventions |
▪ Respiratory failure, shock, coma, or cardiopulmonary arrest ▪ Requires continuous assessment and intervention to maintain physiological stability |
E.g., coma, seizures, moderate to severe respiratory distress, unconscious, major burns, trauma, significant bleeding, and cardiopulmonary arrest |
Level 2 Emergent Time to physician 15 min |
▪ Conditions that are a potential threat to life, limb, or function, requiring rapid medical intervention or delegated acts |
▪ Moderate to severe respiratory distress ▪ Altered level of consciousness ▪ Dehydration ▪ Requires comprehensive assessment and multiple interventions to prevent further deterioration ▪ Fever: age < 3 months and > 38.0°C |
E.g., sepsis, altered LOC, ingestion, asthma, seizure (postictal), DKA, child abuse, purpuric rash, fever, open fractures, violent patients, testicular pain, lacerations, or orthopedic injuries with neurovascular compromise, dental injury with avulsed permanent tooth |
Level 3 Urgent Time to physician 30 min |
▪ Conditions that could potentially progress to a serious problem requiring emergency intervention ▪ May be associated with significant discomfort or affecting ability to function at work or activities of daily living |
▪ Alert, oriented, well hydrated, minor alterations in vital signs ▪ Interventions include assessment and simple procedures ▪ Febrile child > 3 months with T > 38.5°C ▪ Mild respiratory distress ▪ Infant < 1 month |
E.g., simple burns, fractures, dental injuries, pneumonia without distress, history of seizure, suicidal ideation, ingestion requiring observation only, head trauma: alert/vomiting |
Level 4 Semi-urgent Time to physician 1 hour |
▪ Conditions that relate to patient age, distress, or potential for deterioration or complications ▪ Would benefit from intervention or reassurance within 1-2 hours |
▪ Vomiting/diarrhea and no dehydration age > 2 ▪ Simple lacerations/sprain/strains ▪ Alert with fever and simple complaints such as ear pain, sore throat, or nasal congestion ▪ Head trauma: no symptoms |
Level 5 Non-urgent Time to physician 2 hours |
▪ Conditions that may be acute but non-urgent, may be part of a chronic problem ± evidence of deterioration ▪ Investigation or interventions could be delayed/referred to other areas of the hospital or health care system |
▪ Afebrile, alert, oriented, well hydrated with normal vital signs ▪ Interventions not usually required other than assessment/discharge instruction ▪ Vomiting alone or diarrhea alone with no suspicion or signs of dehydration |
Source: Adapted from: Beveridge R, Clarke B, et al. Implementation guidelines for the Canadian ED Triage and Acuity Scale (CTAS). Retrieved from: http://www.caep.ca/002.policies/002-02.CTAS/CTAS-guidelines.htm. |