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  • Comprehensive triage should take 2-5 minutes. Unfortunately pediatric and elderly patients take longer. Incomprehensive triage nurse takes VS, complete history and department specific screening questions, and then correctly triage them based on established acuity. This system bc it is time consuming is beginning to evolve into a 2 step triage. Intial nurse greets patient and if patient is stable they see second nurse for completion of triage.
  • Does this meet Level 1 or Level 2? How many resources will this take? Some facilities use the Ottowa ankle rules which determines whether or not the patient needs an xray. Almost always an xray. Crutch walking does not count as a resource. Most “ankles” are a 4 or 5. Tib/Fib fractures would be a level 3.
  • Does this meet Level 1 or 2? She needs life saving treatment immediately, most likely intubation. Her condition needs physician intervention immediately! VS out of normal range (RR>24, O2 sat<90%. LEVEL 1
  • Obviously not level 1 or 2. How many resources will this take? If the lump is the size of a golf ball, most likely will require I&D (1 resource).
  • Level 1 or 2? Possibly. Need to look at general “look” of patient. Needs a thorough OB assessment…clots, pads/hr, LMP, G/P. Could be spontaneous AB, ectopic pregnancy, or irregular menses. Almost all abd pains will be at least a 3 because of so many resources. Some will be level 2 depending on vital signs.
  • Level 1 or 2? Moderate distress…is there anything we can do in triage to help this patient? He is probably level 2. Resources? Xray, procedure, and conscious sedation (2 resources)
  • VS=normal. Resources=antibiotics, labs. Level 3. Need to assess for s/s of compartment syndrome (pain, parasthesia, pallor, pulselessness, paralysis, poikilothermia)
  • Pneumonia protocol…high risk? Level 1 if she required intubation-probably not. Level 2-only if her aloc was new onset or abnormal. Or if VS out of normal range. At least 2 resources. Talk about placement of patient and triage level are 2 different things.
  • Level 4. One resource. If this pt was 3 and screaming all about….would probably require conscious sedation and need to be level 3. Wound glue…level 5
  • Probably level 1…needs IVF immediately and possibly blood. If VS were a little better maybe level 2. R/F bleeding varices
  • 2 resources…level 3. Most post-op patients will be at least a level 3. Check VS…may need to up triage
  • Triage

    1. 1. TRIAGE <br />Mary Corcoran RN, BSN, MICN<br />
    2. 2. EMTALA: Emergency Medical Treatment and Labor Act<br />Requires a hospital to provide an appropriate medical screening exam to any person who comes to the emergency department and requests treatment or an examination for a medical condition. If the examination reveals an emergency medical condition, the hospital must also provide either necessary stabilizing treatment or appropriate transfer to another medical facility<br />
    3. 3. EMTALA<br /><ul><li>EMTALA regulations apply to anyone coming to a hospital seeking emergency medical services
    4. 4. EMTALA imposes financial penalties on physicians and hospitals
    5. 5. Additionally, the hospital, if found guilty of violating EMTALA regulations, can be excluded from participating in the Medicare program</li></li></ul><li>EMTALA<br />MEDICAL SCREENING EXAM<br /><ul><li>Most hospital policies state that only an Emergency Department MD or PA exam constitutes a Medical Screening Exam. Check with your supervisor
    6. 6. The triage process DOES NOT constitute a Medical Screening Exam.</li></li></ul><li>EMTALA<br /><ul><li>A person who presents anywhere on the hospital campus and requests emergency services, or who would appear to a reasonably prudent person to be in need of medical attention, must be handled under EMTALA
    7. 7. 250-yard rule: “Campus means the physical area immediately adjacent to the provider’s main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the HCFA regional office, to be part of the provider’s campus”.</li></li></ul><li>EMTALA<br />Questions for discussion<br /><ul><li>Does the triage nurse’s assessment constitute a Medical Screening Exam?
    8. 8. If a patient is lying on the sidewalk outside of the parking garage, is the emergency department required to evaluate and treat the person?
    9. 9. If a homeless person comes to triage complaining of chronic back pain, is the emergency department required to evaluate and treat the person?</li></li></ul><li>What is Triage?<br />From the French verb “Trier” which means to “sort” or to “choose”<br />Began in the battlefield when they would prioritize wounded soldiers<br />1950’s and 60’s Medical staff with military background began to educate civilian staff on the concept of “triage”<br />As physician practice changed to an “office” based specialty system, and ER’s volume bean to increase<br />
    10. 10. 3 Common Triage Systems<br /> Traffic Director- simplest, non clinical employee greets patient and directs them to treatment area or wtg room based on initial impression- by 2002 obsolete<br />Spot-check triage- appropriate for low volume, ED. Registration greets patient and pages triage nurse. The RN performs basic assessment<br />Comprehensive triage- supported by ENA. Triage done by competent RN. The RN determines priority of care based on physical, developmental and psychosocial needs<br />
    11. 11. Triage Acuity <br />In 2003, 2 hospitals had EMT’s and RN’s complete triage’s on 5 scripted patients and then were asked same scenarios 6 weeks later and only 24% of participants assigned the same ratings both times<br />The goal is to develop a standardized acuity system in order for everyone to have the same understanding of each level assigned<br />
    12. 12. Trends Affecting ED Wait Times<br />The American Hospital Association (2002) revealed 90% of ED’s perceive they are operating over capacity.<br />The avg time to see ED physician in 2001 (49 min) which was an 11% increase over 1997<br />And increased to 56min in 2006<br />Factors contributing to increased ED volumes:-<br /> * decrease in ED’s, aging population, longer ED stays, inability to move admissions, increase in the uninsured, po0r access to primary care, nursing shortage<br />
    13. 13. The Interview<br />Introduce Yourself<br />Confirm the Patients Identity (IMPORTANT)<br />Obtain a Chief Complaint/Reason for visit<br />Gather Subjective & Objective Data<br />Including LMP, VS, Weight, History, Mechanism etc<br />Perform a rapid, concise, focused assessment, with quick primary and secondary survey<br />
    14. 14.
    15. 15. Pediatric Patients<br />Use the CIAMPEDS format to triage pediatric patients<br />C- Chief complaint- primary problem<br />I- Immunizations- UTD, NUTD<br />A- Allergies<br />M- Medications – Name, last dose, how much?<br />P- PMH<br /> Parents impression of child’s condition<br />E- Events surrounding illness/injury<br />D- Diet- bottles, ounces<br />D- diapers<br />S- Symptoms associated with illness, injury<br />
    16. 16. Pediatric Patient<br />Use Similar A-I Assessment criteria as adults<br />A- Airway; patency, positioning, audible sounds<br />B-Breathing; inc or dec WOB. AMU, nasal flaring<br />C-Circulation; color of skin, cap refill<br />D- Disability; activity level, response to environment<br />E-Exposure; identify underlying injuries<br />F- Fahrenheit<br />G- Get VS, including weight in kg<br />H- Head to Toe Assessment; quick related to cc<br />I- inspect the back and isolate; observe for hidden injuries, communicable illness<br />Be cognizant of legal issues related to abuse/neglect and the difference between adults and children<br />
    17. 17. OB Patients<br />Most OB patients can be transferred to L&D via wheelchair, Usually patients 20 weeks gestation and greater are evaluated in L&D or by OB physician.<br />EMERGENT OB-A patient with a “presenting part” must be delivered in ED. Prepare for delivery if patient is multigravida, completely dilated, had SROM, or c/o rectal pressure<br />Urgent OB- Patients in active labor- ( contractions 2 minutes apart lasting 60-90 sec, presence of “bloody show”, ROM<br />Non-urgent OB- Patients not in active labor- per hospital policy<br />Legal Considerations-Important to know who can transport patients to L& D<br />
    18. 18. Geriatric Population<br />Important points to remember when triaging geriatric patients:<br />Altered pain perception common<br />Delayed presentation common<br />Upper abdominal pain, an ill appearance, abnormal VS= RED FLAG<br />Consider etiology of falls<br />Consider elder abuse<br />Older patients are uniquely prone to delirium<br />
    19. 19. Psychiatric Patients<br />All patients exhibiting aggressive and/or agitated behavior are considered violent unless proven otherwise<br />Never turn your back on these patients<br />When speaking to psychiatric patient be simple, direct, clear and concise<br />Do not overlook physical injuries or illnesses in psychiatric patients<br />
    20. 20. What do you think?<br />40 y/o old female c/o epigastric pain, vomiting<br />50 y/o male with a ripping sensation in his chest?<br />23 y/o with RLQ pain and fever?<br />19 y/o post partum, hypotensive & fever?<br />2 y/o, vaccines NUTD, drooling & fever?<br />4 week old male, vomiting after every meal?<br />80 y/o with abdominal pain, vomiting bilious?<br />4 m old diff breathing, congestion- winter months?<br />
    21. 21. Recommended by the ENA (Emergency Nurses Association) and ACEP (American College of Emergency Physicians)<br />ESI 5 level Triage System <br />
    22. 22. Introduction<br />Level 1- Resuscitation 0 minutes<br />Level 2- Emergency 10 min<br />Level 3- Urgent 30 minutes<br />Level 4- Semi urgent 60 minutes<br />Level 5- Non-urgent 120 minutes<br />
    23. 23. Level<br />1<br />Requires Life Saving Intervention?<br />Yes<br />No<br />High Risk Situation<br />Or<br />Confused/Lethargic/ Disoriented<br />Or <br />Severe pain/Distress<br />Level<br />2<br />Yes<br />How Many Resources are Needed?<br />None One Many<br />yes<br />Level <br />3<br />Dangerous Vital Signs?<br />Level<br />4<br />Level <br />5<br />No<br />
    24. 24. Emergency Severity Index (ESI) <br /><ul><li>Acuity assessment
    25. 25. Airway, breathing, circulation
    26. 26. Potential for life, organ or limb threat
    27. 27. How soon the patient needs to be seen
    28. 28. Expected resource assessment
    29. 29. Number of resources, as estimated by the triage nurse, that a patient is expected to consume in order for a disposition decision to be reached</li></li></ul><li>ESI<br /><ul><li>Five explicitly defined categories
    30. 30. Mutually exclusive
    31. 31. Allows for rapid sorting
    32. 32. Differs from a complete assessment
    33. 33. Gather sufficient information to assign an ESI level
    34. 34. Quick sorting</li></li></ul><li>ESI<br /><ul><li>Requirements to maintain the validity and reliability of the instrument
    35. 35. Experienced emergency department nurse at triage
    36. 36. Education of each RN prior to implementation</li></li></ul><li> Patient dying?<br /> 1<br />A<br />yes<br />no<br /> Can not wait?<br />B<br />yes<br />no<br /> How many resources?<br /> none one many<br />C<br /> 2<br />Vital signs<br />D<br /> 5<br /> 4<br />consider<br />no<br /> 3<br />
    37. 37. Yes<br />Is this patient dying? A<br />1<br />No<br />
    38. 38. Decision Point A<br />Is This patient Dying? <br />Does this patient require immediate life-saving intervention?<br /><ul><li>Airway
    39. 39. Obstructed or partially obstructed
    40. 40. Unable to protect their own airway
    41. 41. Breathing
    42. 42. Apneic
    43. 43. Intubated pre-hospital
    44. 44. Severe respiratory distress
    45. 45. SpO2 less than 90%</li></li></ul><li>Decision Point A<br />Does this patient require immediate life-saving intervention?<br /><ul><li>Circulation
    46. 46. Pulseless, or concerned about rate, rhythm or quality?
    47. 47. Drugs
    48. 48. Hemodynamic interventions
    49. 49. Immediate IV medications to correct hemodynamic instability</li></li></ul><li>Decision Point A<br /><ul><li>Does this patient have an acute mental status change that requires immediate life-saving intervention?
    50. 50. Examples:
    51. 51. Hypoglycemia needs glucose
    52. 52. Heroin overdose needs Narcan
    53. 53. Subarachnoid bleed needs airway protection</li></li></ul><li>What are life Saving Interventions?<br /><ul><li>Airway and Breathing
    54. 54. Intubation
    55. 55. -Surgical airway
    56. 56. -CPAP, BiPAP
    57. 57. -Bag valve mask ventilation
    58. 58. Defibrillation
    59. 59. External Pacing
    60. 60. Chest needle decompression
    61. 61. Significant IV fluid resuscitation
    62. 62. Blood administration
    63. 63. IV medications
    64. 64. vasopressors
    65. 65. Control of major bleeding</li></ul>Resuscitation <br />Hemodynamics<br />
    66. 66. What are NOT life saving interventions?<br />ECG<br />Laboratory studies<br />Oxygen<br />Monitor<br />IV access<br />ASA<br />Nitroglycerine<br />Pain medications<br />Antibiotics<br />Heparin<br />Diagnostic Tests <br />Medications<br />
    67. 67. No<br />Yes<br />Can not wait? B<br />No<br />2<br />
    68. 68. High risk situation?<br />or<br />Confused/lethargic/disoriented?<br />or<br />Severe pain/distress?<br />B<br />Yes<br />2<br />No<br />
    69. 69. Decision point B<br />Can this Person Safely Wait to be Seen?<br /><ul><li>Determination is made on a brief interview, gross observations, “sixth sense”
    70. 70. Does not require a full set of vital signs
    71. 71. Unsafe for the patient to wait
    72. 72. Suggestive of a condition that could easily deteriorate
    73. 73. Symptoms of a condition where treatment is time sensitive
    74. 74. Potential major life or organ threat</li></li></ul><li>Examples of “high risk” patients<br /><ul><li>Episode of chest pain, denies other symptoms, known cardiac history
    75. 75. Rule out PE
    76. 76. Newborn with a fever
    77. 77. Rule out ectopic pregnancy
    78. 78. Neutropenia with a fever
    79. 79. Suicidal/homicidal
    80. 80. New Onset Confusion in elderly
    81. 81. Adolescent found confused and disoriented
    82. 82. Patients in SEVERE pain
    83. 83. Sexual Assault Patient</li></li></ul><li>Decision point Bis this person in severe pain or distress?<br /><ul><li>Is this patient currently in pain?
    84. 84. Pain intensity rating
    85. 85. Chief complaint
    86. 86. PMH, medications
    87. 87. VS, physical assessment findings
    88. 88. Assign ESI level 2 if and only if
    89. 89. Self-reported 7/10 or greater
    90. 90. AND
    91. 91. RN cannot intervene and they require immediate intervention
    92. 92. Do you want to give your last bed to this patient?</li></li></ul><li>Examples of Level 2 Severe pain<br /><ul><li>Kidney stone
    93. 93. Burn victim
    94. 94. Oncology patients
    95. 95. Possible dislocated shoulder
    96. 96. ? Compartment syndrome</li></li></ul><li>Decision Point C<br />How Many Resources will this patient require?<br /><ul><li>Determined by the experienced ED RN at triage
    97. 97. Based on the standard of care
    98. 98. Independent of type of hospital, location, physician on duty, acuity of the department</li></li></ul><li> How many different resources are needed?<br /> None One 2 or more<br />C<br /> Vital signs <br />5<br />4<br />3<br />
    99. 99. Mean Resources Used Per Triage Category<br /> Mean # of resources used<br /> ESI Triage Level<br />
    100. 100. Resources: Count number of different types of resources, not individual tests or x-rays (ex: CBC, electrolytes, and coags equal one resource; CBC plus chest x-ray equal two resources.<br />
    101. 101. ESI Level 5<br /><ul><li>No resources
    102. 102. Examples:
    103. 103. Healthy 10 year old with “poison ivy”
    104. 104. Healthy 52 year old who ran out of his blood pressure medicine yesterday
    105. 105. 22 year old, involved in a car accident 2 days ago, wants to be checked. Nothing hurts.
    106. 106. 46 year old with a cold</li></li></ul><li>ESI Level 4<br /><ul><li>Stable, can safely wait hours to be seen
    107. 107. Care by mid-level providers in fast track or express care setting
    108. 108. Requires a physical exam and one resource</li></li></ul><li>ESI Level 4<br /><ul><li>Examples:
    109. 109. Healthy 19 year old with sore throat and fever.
    110. 110. Healthy 29 year old with a UTI, denies vaginal discharge.
    111. 111. Healthy 43 year old with stubbed toe who states “I think I broke it!”.
    112. 112. Healthy 12 year old with a minor thumb laceration</li></li></ul><li>ESI Level 3<br /><ul><li>30-40 % of patients in the ED
    113. 113. Require in-depth evaluation
    114. 114. Long length of stay
    115. 115. Before assigning a patient to ESI Level 3 the nurse must consider the patients vital signs</li></li></ul><li>ESI Level 3,4, and 5 examples<br /><ul><li>ESI Level 3</li></ul> -Fractured ankle<br /> -Abdominal pain<br /> -Most migraines<br /><ul><li>ESI Level 4</li></ul> -Sprained ankle, toe<br /> -Abscess<br /><ul><li>ESI Level 5</li></ul> -Toothache<br />
    116. 116. Decision point D<br />What are the patients vital signs?<br /><ul><li>Consider the vital signs</li></ul>Are they outside the acceptable parameters for age?<br />If unacceptable considerup-triage to ESI Level 2<br />
    117. 117. Danger zone vitals?<br /> HR RR SaO2<br /><3 m >180 >50 <92% <br />3m-3y >160 >40 <92%<br />3-8y >140 >30 <92%<br />>8y >100 >20 <92%<br />Level <br />3<br />
    118. 118. Pediatric Fever Criteria<br /><ul><li>1 to 28 days of age: assign at least ESI 2 if temp >38.0C (100.4F)
    119. 119. 1 to 3 months of age: consider assigning ESI 2 if temp >38.0c (100.4F)
    120. 120. 3 months to 3 years of age: consider assigning ESI 3 if: temp >36.0C (102.2F), or incomplete immunizations, or no obvious source of fever</li></li></ul><li>Lets Practice<br />
    121. 121. Pediatric Sprained Ankle<br /><ul><li>An eight year old is brought to triage because of an injured right ankle. The child tripped over a ball while playing soccer. The ankle hurts with ambulation and you notice edema over the medial aspect of the ankle. His mother tells you the child is healthy, takes no medications and has no allergies. VS WNL.</li></li></ul><li>Respiratory Distress<br /><ul><li>Paramedics arrive with a 42 y/o morbidly obese female who called EMS with a CC of SOB. On arrival the paramedics found her sitting upright, working hard at breathing with a respiratory rate of 48 and a room air SPO2 of 84%. They are unable to obtain any further history. </li></li></ul><li>Lump…<br />“I have a lump on my back” reports a 28 year old healthy male. Upon further questioning he tells you the lump looks like a huge, large pimple. He reports no drainage or fever.<br />No PMH or meds.<br />His vital signs are:<br />BP 118/74, T 98.8, HR 72, RR 16<br />
    122. 122. Vaginal Bleeding/ Abdominal Pain<br />23 y/o female presents to triage with a CC of moderate vaginal bleeding and generalized abdominal cramping (5/10) for 2 hours. Her LMP was 8 weeks ago. She is G1P0. Her skin is warm and dry.<br />Her vital signs are:<br />BP 110/80, T 98.6, HR 84, RR 20<br />
    123. 123. Shoulder<br /><ul><li>A 45 y/o male is brought to triage by his friend who states the patient injured his left shoulder while playing football. The patient has a gross deformity to his shoulder with neuro deficits to the left arm. He is unable to move his arm, complains of excruciating pain (20/10 when asked), and is diaphoretic.</li></li></ul><li>Bite<br />Mom brings her 4 y/o son to triage with a CC of a red arm. The patient was bitten by the family dog about 3 days ago. The child is cranky. His right arm is reddened, with edema to a large area surrounding the dog bite.<br />His vital signs are:<br />T 99.5, HR 120, RR 24<br />
    124. 124. PNA<br />A 70 year old male arrives by ambulance from a nursing home. The nursing home reports a non-productive cough since he choked on his lunch today. His baseline mental status is unchanged, although he is normally confused. Skin is warm and moist.<br />His vital signs are:<br />BP 135/80, T 100.2, HR 94, RR 20,<br />SpO2 94% on RA<br />
    125. 125. Laceration<br />A tearful 5 year old is carried in by her father who reports is daughter was trying to help set the dinner table and broke a glass. You notice a 3 cm laceration on her left hand. The bleeding is controlled. No history, allergies or meds.<br />Her vital signs are:<br />BP 98/64, T 97.8, HR 108, RR 24<br />
    126. 126. Hematemesis<br /><ul><li>EMS arrives with a 49 year old male with a history of cirrhosis and hepatitis C. His wife called 911 when he started vomiting bright red blood. On arrival he is pale, diaphoretic and has a BP of 92/78, HR 130, RR 28.</li></li></ul><li>Wound<br />19 y/o male states he had an appy last week. Wound is red, opened up, and yellow pus is oozing out. No other medical history. No meds.<br />101.8, HR=98<br />
    127. 127. Trauma<br />Notified by EMS you are receiving an 8 y/o female hit by a bus. Witnesses state she was thrown across the street. <br />VS= HR=148, RR=36, BP=70/palp, O2 sat=91%.<br />
    128. 128. What if they Leave?<br />LWBS<br />Pts who are LWBS (Left Without Being Seen), are more common in high volume ER’s <br />Most patients are frustrated with the long wait times<br />Discuss the LWBS policy with your specific facilities<br />
    129. 129. Triage Nurse Qualifications<br />Triage Nurses are the Gate Keepers to the ER, if they Over-triage they can use up vital beds in the ER, if they Under-triage they can delay vital care<br />Triage Nurses must be knowledgeable, experience, temperament, and qualifications necessary to function in a high stress roll<br />Most facilities require at least 6mo- 1year of ER experience before allowing nurses to triage<br />
    130. 130. Questions?<br />