Triage Protocols

1. Triage Protocols
TriageLogic 2015

2. Protocol Structure
• The structure of a protocol provides directions and supports- but
does not control- the nurse’s clinical decision process. The intent
of triage is not to diagnose but to identify health problems that
need medical evaluation. The triage process and use of a protocol
facilitates and appropriate plan of care using options ranging from
emergent to home care.

3. Activity Levels Within Protocols
• Protocols are structured to flow from the most emergent symptom
to the least urgent, i.e. 911 symptoms to home care. The
assessment questions are ordered so that emergent/urgent
symptoms are rules out as you progress through the protocol and
triage process.

4. Overview
• Each protocol has an overview or Disease Definition. Tis provides a
description of the particular protocol and a summary or key
clinical points. The overview may also contain elaboration of the
assessment parameters, as well as other clinical content for the
nurse to consider when choosing the correct protocol. Some also
contain information that is useful for the nurse to educate the
caller regarding their symptoms.
• BE SURE TO ALWAYS LOOK AT THE DEFINITION BEFORE CONTINUING
WITH YOUR TRIAGE.

5. Triage Assessment Questions
• Assessment questions provide structure to the assessment process
and prompt, through assessment of the presenting problem. The
questions are sequenced in order to distinguish the acuity level of
the presenting problem, and eliminate guesswork on the part of
the nurse. They also provide order and flow to the triage
assessment process
• FIND THE “INITIAL QUESTIONS” SECTION OF EACH PROTOCOL IN
TRIAGELOGIC

6. Dispositions
• A list of recommended action is organized within specific
disposition levels of the triage protocol. There are reasons to
choose each disposition listed in the protocol. These help to
accurately identify and determine the acuity of the problem and
the appropriate intervention based on the nursing assessment, i.e.
see provider within 24 hours or home care. It is important that the
reason for a disposition chosen be included in the nursing
assessment.

7. Care Advice
• Care advice to be given will be dependent on the disposition chose.
When you click on the correct disposition statement, the appropriate
care advice can be accessed from the disposition screen. Care advice in
some protocols can be individualized based on that patient’s symptoms,
age and acuity of symptoms. Care advice may differ depending on the
age of assessment information of that patient.
• For example: The care advice for vomiting is different for a breast fed
infant vs. and infant under 12mos of age. Only the information pertinent
to that specific child needs to be given and documented, Care advice
instructions give the caller/parent a plan to follow in lieu of or until a
provider is seen.

8. Receiving Incoming Calls

9. Continue With Your Assessment
• Choose protocols, determine disposition and give caller the
information provided. “Based on the information you have given
me regarding your child’s/ your symptoms, we would
recommend that… etc” Tell the caller the recommended
dispostion and give the care advice that pertains to them and the
severity of their symptoms as per the protocols chosen.

10. Continue With Your Assessment
• At the end of the call, wrap up the call by saying, “Have I
answered all of your questions?” or “Did you understand
everything I told you? If your symptom worsens, please call
back or seek medical attention.”
• This evaluated the nurse’s instruction and attempts to ensure that
the parent does not need to call back for further instruction in the
care advice that was already provided.

11. Examples of 911 Calls Are
1. Severe breathing problems
• Cessation of breathing
• Weak, slow breathing (almost ready to stop)
• Choking and unable to breathe or turning blue
2. Difficulty breathing as a part of reaction to medications, bee sting, foods (possible anaphylaxis)
3. Severe Bleeding
• Blood is pumping or spurting from the wound
• Blood is pouring out and cannot be stopped with direct pressure
4. Major neck injury (advise not to move child until EMS arrives)
5. Major open wound of chest or abdomen
6. Seizure or convulsion in process (has not stopped)
7. Coma or unconsciousness
8. Shock suspected

12. Emergency Calls and 911/ Cont.
9. Croup with severe stridor
10. Confusion now
11. Severe Weakness (not moving or can’t
walk)
12. Severe Burns
13. Choking- severe
14. Cyanosis widespread
15. New onset severe drooling, can’t swallow
16. Sever dehydration
17. Near drowning
18. Electrical shock or lightening strike
19. Suicidal Attempt, severe homicidal
20. Hypothermia <95 F due to cold exposure or
Hyperthermia >106 due to heat exposure
21. Meningococcal sepsis suspected
(puroura/petecchiae with fever)
22. Severe Trauma
Calls that, using your nursing judgment, may
require immediate CPR (cardiopulmonary
resuscitation).
These calls will be documented using the 911 symptoms guideline in TriageLogic.

13. Urgent Calls
• Difficulty Breathing (e.g. Choking, stopped
breathing, weak breathing, stridor, cyanisis, or
other signs of respiratory distress)
• Possible anaphylaxis (difficulty breathing or
swallowing following medication, bee sting, food,
or other possible allergen)
• Neurological symptom (e.g. Seizure, loss of
consciousness, syncope, hard to awaken,
confusion, altered mental status, stiff next)
• Poisoning, ingestion, drug overdose
• Foreign body-airway (choking) or swallowed
• Trauma
• Electric shock
• Near Drowning
• Heat Exhaustion or stroke
• Hypothermia (body temperature <95F)
• Psychosocial emergencies: sexual assault, domestic
violence, child abuse, and suicidal ideation)
• Asthma, wheexing or courp (with no mention of
difficulty breathing)
• Foreign body- ear, nose, vagina
• Bleeding (including blood in vomit or stool) (Exception-
bleeding stopped)
• Burns (other than sunburn)
• Bites (e.g. animal, snake, spider, marine animal, bee,
yellow jacket)
• Fever >105F (not caller’s statement of “high fever”)
• Infants >3 months
• Severe pain (especially abdomen, head, or chest
• Possible dehydration
• Purple rash (purple spots or dots

14. Non-Urgent Calls
• All others (cold, cough, etc.)- These are calls in which a
reasonable delay in call response is unlikely to result in a negative
outcome.

15. Communication With your Patients

16. Building Trust
• Be aware of your voice quality. How you say it is just as important
as what you say.
• Adjust the volume of your voice to the caller.
• Ask their name. It helps to personalize the call.
• Match your pace to the callers natural rate of speed.
• Be aware of word choices.
• Avoid the use of jargon and complex medical terminology.
• Enunciate and speak confidently

17. Say this, not that…
1. May I help you?/ Can I help you?
2. May I ask your name?
3. Can I ask you a question?
4. I am not sure about that.
1. How may I help you?/ I can help
you.
2. My name is Carol and your name
is?
3. I would like to ask you a few
questions that will help in…
4. I do not have an answer for you. I
will call your pediatrician and
he/she will call you right back.
Negative Statements Alternative Positive Statements

18. Effective Communication
• Be attentive
• Be accepting- convey to the caller this is a safe place to say
whatever needs to be said
• Show empathy
• Show respect
• Be genuine- honest, warm, and straighforward

19. The Nursing Process
• Identify the problem:
• Gather information- your assessment. Ask open ended questions.
Paraphrase (and repeat back to caller).
• Open your protocols to guide you to a disposition. Resist the urge
to diagnose- it is beyond our scope of nursing!
• Explore solutions: plan of action.
• Home Care and Teaching: most frequent disposition used.

20. Handling Parents of Newborns
• Parents of newborns are often anxious, exhausted, and sometimes
require additional support and education.
• Accepted call length times may be extended to allow for
additional teaching/listening/support.
• ALL calls for babies under the age of 3 months must be triaged,
even if the parent is only calling for information. The exception
would be if they are calling to page the MD for bilirubin or other
lab/test results but always ask if the child is stable.
• Always page the MD if the parent requests, or if you feel any
concern over the baby’s condition and/or the parent's ability to
cope with the situation.

21. Call Length Goals
• Intro/presenting Problem 30 seconds
• Gathering Demos 30 seconds
• Nursing Assessment 1-2 minutes
• Triage Using Guidelines 1-2 minutes
• Disposition Choice/ Referral if Needed 30 seconds
• Discussing Care Advice With Patients 1 minute
• Confirming Parent Understanding 30 seconds
• Confirming Plan of Action 30 seconds
• Documenting MD Page/ Medication
Doses/ Other Additional Homecare 1 minute
• Closing Call 30 seconds
Total: 7-9 Minutes

22. Medication Advice
• KNOW YOUR MEDICATIONS!
• Doses/ side effects/ cautions/ contradictions. Do a COMPLETE
health assessment before giving out any medication dose
(allergies/chronic health conditions/ past medical history/
surgical history/ medication taken on a daily basis etc…

23. Urgent Home Care with Follow-up
• Triage the patient using the appropriate protocol such as Asthma
attach, Croup guideline.
• If appropriate, use the “urgent home treatment with follow-up”
disposition.
• Advise the patient to use the appropriately prescribed rescue
medicine or home treatment recommended by protocol.
• Call them back within 30-60 minutes

24. Urgent Home Care With Follow-up cont.
• During the follow-up call the nurse should document in the additional notes
section id the pt’s symptoms have improved, worsened or stayed the same.
Based on the follow-up assesment the nurse should document what the new
plan of action will be. For example; Call 911, Go to ED/ UCC, PCP for referral,
Call PCP, or continue with homecare and call back if symptoms change or
worsen.
• Any additional care advice can be typed or the nurse may make reference to
the protocol and disposiotion that the care advice was taken from. For
example-”Care advice given as per asthma protocol (home care)”
• If the patient has developed any new symptoms since the original call/triage
was made a “New Note” must be opened, both previous (refer to first call) and
present symptoms and treatment should be documented and appropriate
protocols should be referenced.

25. Follow-Up Call for 911
• 911- Nurse will call back in 10 minutes to assure caregiver reached
EMS and offer assistance/comfort until EMS arrives

26. Post Orientation- What to Expect
• Weekly note review with feedback and review data sheet listing
strengths/ areas to improve and a plan for the upcoming week.
Approximately 3 months.
• 3 Months of Administrative QA following not review period
• Support from your director, manager, supervisor, coworkers,
charge nurse, and IS