NurseReview.Org - Nursing Triage

Triage in Emergency Department Triage Waiting room Team leader

Definition of Triage
Triage is the term derived from the French verb trier meaning to sort or to choose
It’s the process by which patients classified according to the type and urgency of their conditions to get the Right patient to the
Right place at the
Right time with the
Right care provider

Triage Categories
Non disaster: To provide the best care for each individual patient.
Multi casualty/disaster: To provide the most effective care for the greatest number of patients.

Non disaster or E.D triage
The primary objectives of an ED triage are to (ENA,1992, P. 1):
Identify patients requiring immediate care.
Determine the appropriate area for treatment
Facilitate patient flow through the ED and avoid unnecessary congestion.

4. Provide continued assessment and reassessment of arriving and waiting patients. 5. Provide information and referrals to patients and families. 6. Allay patient and family anxiety and enhance public relations.

Disaster
Definition: an incident, either natural or human-made, that produces patients in numbers needing services beyond immediately available resources. May involve a large no. of patients or a small no. of patients if their needs place significant demands on resources.
The key to successful disaster management is to provide care to those who are in greatest need first and just as importantly, not provide care to to those who have little or no chance of survival. Correct triage is essential to accomplish this goal

Disaster
The triage team
Triage of Victims
- first victims to arrive are frequently not
the most seriously injured.
Critical patients
Fatally Injured Patients
Non critical patients
Contaminated patients

Types of E.D. triage system
Type 1: Traffic Director (Non Nurse).
Type 2: Spot Check
Type 3: Comprehensive
Two-tiered systems: intial screening by RN who greets each patients on arrival, perform a primary survey and determine whether the patient is able to wait for further assessment by a second triage nurse.
Divide tasks among staff members, internal triage and external triage

Triage levels
1- Resuscitation
2- Emergent
3- urgent
4- less urgent
5- Non urgent
The Canadian E.D. Triage and Acuity Scale

Overview of three category triage acuity systems Rash, chronic headache, sprains, cold symptoms Every 1-2 hrs Non urgent And treatment but time is not a critical factor Class 3 Abdominal pain, non cardiac cp, multiple fractures, lacerations, renal calculi, Every 30 minutes Urgent Requires prompt care, but will not cause loss of life or limb if left untreated for several hours. Class 2 Cardiopulmonary arrest, severe respiratory distress, major burns, major trauma, massive uncontrolled bleeding Coma, status epil.. continuous Emergent Immediately life or limb threatening Class 1 Examples Recommended reassessment acuity category

TRIAGE LEVELS
1- Resuscitation -- threat to life
Time to nurse assessment IMMEDIATE Time to physician assessment IMMEDIATE
Cardiac and respiratory arrest
Major trauma
Active seizure
Shock
Status Asthmatics

Triage levels
2- Emergent
Potential threat to life,limb or function
Nurse Immediate , Physician < 15 minutes
Decreased level of consciousness
Severe respiratory distress
Chest pain with cardiac suspicion
Over dose (conscious)
Severe abdominal pain
G.I. Bleed with abnormal vital signs
Chemical exposure to eye

Triage levels
3- Urgent
Condition with significant distress
Time Nurse < 20 min, physician < 30 min
Head injury without decrease of LOC but with vomiting
Mild to moderate respiratory distress
G.I. Bleed not actively bleed
Acute psychosis

Triage levels
4- Less urgent
Conditions with mild to moderate discomfort
Time for Nurse assessment < 1h
Time for physician assessment < 1h
Head injury, alert, no vomiting
Chest pain, no distress, no cardiac susp.
Depression with no suicidal attempt

Triage levels
5- Non urgent
Conditions can be delayed, no distress
Time for nurse and Physician assessment more than 2h
Minor trauma
Sore throat with temp. < 39

Basic component of triage
An “across-the room” assessment
The triage history
The triage physical assessment
The triage decision

An “ across the room assessment”
To identify obvious life threat conditions
General appearance
Air way Breathing Circulation Disability (neurogenic)

Across the door assessment
The triage nurse must scan the area where patients enter the emergency door, even while interviewing other patient.
The triage antenna should be seeking clues to problems in all people who enter the triage area
If any patient doesn’t look right kindly but quickly interrupt any current interaction and go investigate.

Across the room assessment
Air way
Abnormal airway sounds, strider, wheezing grunting
Unusual posture e.g.. Sniffing position, inability to speak, drooling or inability to handle secretion
Breathing
Altered skin signs, cyanosis, dusky skin, tachypnic
bradypnea, or apnea periods, retractions, use accessory muscles, nasal flaring, grunting, or audible wheezes

Across the room assessment
Circulation
Altered skin signs, pale, mottling, flushing
Un controlled bleeding
Disability (neuro.)
LOC
Interaction with environment
Inability to recognize family members
Unusual irritability
Response to pain or stimuli
Flaccid or hyper active muscle tone

Characteristics of triage nurse
Extensive knowledge to emergency medical treatment
Adequate training and competent skills,language, terminology
Ability to use the critical thinker process
Good decision maker

Role of triage nurse
Greet patients and identify your self.
Maintain privacy and confidentiality
Visualize all incoming patients even while interviewing others.
Maintain good communication between triage and treatment area
maintain excellent communication with waiting area.
Use all resources to maintain high standard of care.

Role of triage nurse
Teaching ----- use of thermometer, first aid ??? avoid lecturing.
Crowd control.
Telephone.
Communicate with team leader and seek feed back on decisions.

Importance of re triage
Reassess the patient within 1-2hours of initial triage and continue to re assess on a regular basis, patients who may have presented without cardinal signs of severe illness may develop them during long waits.
Patients who appear intoxicated actually may have life threatening problems such as DKA, and should not be permitted to keep it off in the waiting room.

The last person in along line at triage may have a serious medical problem that requires immediate attention
Patient should wait no longer than 5 minutes for triage
If in doubt about a category, choose the higher acuity to avoid under triaging a patient

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NurseReview.Org - Nursing Triage

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