"Who's next?" in a triage system



Unlike typical wait lines, where a “first-come, first-serve” process is standard, the order with which emergency center (EC) patients are seen and treated is determined by a triage system designed to rapidly identify and prioritize patients based on the severity of their illness or injury and their need for emergent therapy. By using key information, such as a patient’s age, signs and symptoms, past medical and surgical history, physical examination and vital signs (which may include heart rate, blood pressure, breathing rate, oxygen level and pain score), the triage system helps to determine the order and priority of emergency treatment.

Many ECs, including those at Texas Children’s Hospital locations, use a standardized, five-level triage system. Following a focused triage assessment and examination by a highly-skilled triage nurse, the patient is assigned a triage level, with the highest triage level reserved for those patients who need emergent and life-saving treatment. Overall, the EC patient’s wait time is not only determined by his/her own triage level, but also the triage level of all other patients in the EC. It’s important to remember triage is a dynamic process. Although a patient may be assigned a lower triage level on arrival, if his/her symptoms or vital signs worsen over the course of their EC visit, they will be reassessed and reassigned a new triage level.

Let’s go through a triage example.

Imagine three patients arrive in the EC at the same time. The first patient is Jasmine, a 3-month-old baby with a fever of 102.2°F for two days. The second patient is Carlos, a healthy 7 year old with fever of 104°F for four days. The third patient is Jennifer, a 12 year old who recently received chemotherapy for leukemia, but today has a fever of 101°F. After checking each patient’s vital signs, those for Jasmine and Carols are normal, but Jennifer’s, the third patient, are not. Her heart rate is very high and her blood pressure is very low. 

So, based on this information, which patient should be seen first, second and third?  Using the triage system as a guide, the order would be:




Although all of the patients are ill with fever, Jennifer’s past medical history (leukemia, chemotherapy) and abnormal vital signs prioritize her as needing immediate, life-saving medical treatment. Even though Carlos has been sicker longer and has a higher fever, Jasmine’s young age (and lack of 4 and 6 month vaccinations) plays an important role in determining her triage level, thereby placing her second in line.  Therefore, Carlos will be seen last, not because he isn’t sick, but, relative to Jennifer and Jasmine, he can safely wait the longest for medical evaluation and treatment.

At all three of Texas Children’s Emergency Centers, in the Texas Medical Center, West Campus and The Woodlands, your child’s health and comfort is very important to us! If a waiting period is expected, our trained triage and protocol nurses may utilize pre-established protocols or standardized orders to help improve your child’s symptoms (i.e., Tylenol for fever) or facilitate the evaluation of your child (i.e., X-rays for a broken bone). Additionally, they will oftentimes reassess your child’s vital signs, signs/symptoms, and response to therapy to ensure your child’s illness or injury is not worsening. However, if you ever feel your child is getting sicker (i.e., increased work of breathing, severe/unbearable pain, decreased responsiveness or difficult to awaken, seizure-like activity, etc.), please inform an EC staff member immediately.