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NurseReview.Org - Nursing Triage


Published on

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

Published in: Career, Health & Medicine

NurseReview.Org - Nursing Triage

  1. 1. Triage in Emergency Department Triage Waiting room Team leader
  2. 2. Definition of Triage <ul><li>Triage is the term derived from the French verb trier meaning to sort or to choose </li></ul><ul><li>It’s the process by which patients classified according to the type and urgency of their conditions to get the Right patient to the </li></ul><ul><li> Right place at the </li></ul><ul><li> Right time with the </li></ul><ul><li> Right care provider </li></ul>
  3. 3. Triage Categories <ul><li>Non disaster: To provide the best care for each individual patient. </li></ul><ul><li>Multi casualty/disaster: To provide the most effective care for the greatest number of patients. </li></ul>
  4. 4. Non disaster or E.D triage <ul><li>The primary objectives of an ED triage are to (ENA,1992, P. 1): </li></ul><ul><li>Identify patients requiring immediate care. </li></ul><ul><li>Determine the appropriate area for treatment </li></ul><ul><li>Facilitate patient flow through the ED and avoid unnecessary congestion. </li></ul>
  5. 5. 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.
  6. 6. Disaster <ul><li>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. </li></ul><ul><li>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 </li></ul>
  7. 7. Disaster <ul><li>The triage team </li></ul><ul><li>Triage of Victims </li></ul><ul><li>- first victims to arrive are frequently not </li></ul><ul><li>the most seriously injured. </li></ul><ul><li>Critical patients </li></ul><ul><li>Fatally Injured Patients </li></ul><ul><li>Non critical patients </li></ul><ul><li>Contaminated patients </li></ul>
  8. 8. Types of E.D. triage system <ul><li>Type 1: Traffic Director (Non Nurse). </li></ul><ul><li>Type 2: Spot Check </li></ul><ul><li>Type 3: Comprehensive </li></ul><ul><li>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. </li></ul><ul><li>Divide tasks among staff members, internal triage and external triage </li></ul>
  9. 9. Triage levels <ul><li>1- Resuscitation </li></ul><ul><li>2- Emergent </li></ul><ul><li>3- urgent </li></ul><ul><li>4- less urgent </li></ul><ul><li>5- Non urgent </li></ul><ul><li>The Canadian E.D. Triage and Acuity Scale </li></ul>
  10. 10. 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
  11. 11. TRIAGE LEVELS <ul><li>1- Resuscitation -- threat to life </li></ul><ul><li>Time to nurse assessment IMMEDIATE Time to physician assessment IMMEDIATE </li></ul><ul><li>Cardiac and respiratory arrest </li></ul><ul><li>Major trauma </li></ul><ul><li>Active seizure </li></ul><ul><li>Shock </li></ul><ul><li>Status Asthmatics </li></ul>
  12. 12. Triage levels <ul><li>2- Emergent </li></ul><ul><li>Potential threat to life,limb or function </li></ul><ul><li>Nurse Immediate , Physician < 15 minutes </li></ul><ul><li>Decreased level of consciousness </li></ul><ul><li>Severe respiratory distress </li></ul><ul><li>Chest pain with cardiac suspicion </li></ul><ul><li>Over dose (conscious) </li></ul><ul><li>Severe abdominal pain </li></ul><ul><li>G.I. Bleed with abnormal vital signs </li></ul><ul><li>Chemical exposure to eye </li></ul>
  13. 13. Triage levels <ul><li>3- Urgent </li></ul><ul><li>Condition with significant distress </li></ul><ul><li>Time Nurse < 20 min, physician < 30 min </li></ul><ul><li>Head injury without decrease of LOC but with vomiting </li></ul><ul><li>Mild to moderate respiratory distress </li></ul><ul><li>G.I. Bleed not actively bleed </li></ul><ul><li>Acute psychosis </li></ul>
  14. 14. Triage levels <ul><li>4- Less urgent </li></ul><ul><li>Conditions with mild to moderate discomfort </li></ul><ul><li>Time for Nurse assessment < 1h </li></ul><ul><li>Time for physician assessment < 1h </li></ul><ul><li>Head injury, alert, no vomiting </li></ul><ul><li>Chest pain, no distress, no cardiac susp. </li></ul><ul><li>Depression with no suicidal attempt </li></ul>
  15. 15. Triage levels <ul><li>5- Non urgent </li></ul><ul><li>Conditions can be delayed, no distress </li></ul><ul><li>Time for nurse and Physician assessment more than 2h </li></ul><ul><li>Minor trauma </li></ul><ul><li>Sore throat with temp. < 39 </li></ul>
  16. 16. Basic component of triage <ul><li>An “across-the room” assessment </li></ul><ul><li>The triage history </li></ul><ul><li>The triage physical assessment </li></ul><ul><li>The triage decision </li></ul>
  17. 17. An “ across the room assessment” <ul><li>To identify obvious life threat conditions </li></ul><ul><li>General appearance </li></ul>Air way Breathing Circulation Disability (neurogenic)
  18. 18. Across the door assessment <ul><li>The triage nurse must scan the area where patients enter the emergency door, even while interviewing other patient. </li></ul><ul><li>The triage antenna should be seeking clues to problems in all people who enter the triage area </li></ul><ul><li>If any patient doesn’t look right kindly but quickly interrupt any current interaction and go investigate. </li></ul>
  19. 19. Across the room assessment <ul><li>Air way </li></ul><ul><li>Abnormal airway sounds, strider, wheezing grunting </li></ul><ul><li>Unusual posture e.g.. Sniffing position, inability to speak, drooling or inability to handle secretion </li></ul><ul><li>Breathing </li></ul><ul><li>Altered skin signs, cyanosis, dusky skin, tachypnic </li></ul><ul><li>bradypnea, or apnea periods, retractions, use accessory muscles, nasal flaring, grunting, or audible wheezes </li></ul>
  20. 20. Across the room assessment <ul><li>Circulation </li></ul><ul><li>Altered skin signs, pale, mottling, flushing </li></ul><ul><li>Un controlled bleeding </li></ul><ul><li>Disability (neuro.) </li></ul><ul><li> LOC </li></ul><ul><li> Interaction with environment </li></ul><ul><li> Inability to recognize family members </li></ul><ul><li> Unusual irritability </li></ul><ul><li>Response to pain or stimuli </li></ul><ul><li>Flaccid or hyper active muscle tone </li></ul>
  21. 21. Characteristics of triage nurse <ul><li>Extensive knowledge to emergency medical treatment </li></ul><ul><li>Adequate training and competent skills,language, terminology </li></ul><ul><li>Ability to use the critical thinker process </li></ul><ul><li>Good decision maker </li></ul>
  22. 22. Role of triage nurse <ul><li>Greet patients and identify your self. </li></ul><ul><li>Maintain privacy and confidentiality </li></ul><ul><li>Visualize all incoming patients even while interviewing others. </li></ul><ul><li>Maintain good communication between triage and treatment area </li></ul><ul><li>maintain excellent communication with waiting area. </li></ul><ul><li>Use all resources to maintain high standard of care. </li></ul>
  23. 23. Role of triage nurse <ul><li>Teaching ----- use of thermometer, first aid ??? avoid lecturing. </li></ul><ul><li>Crowd control. </li></ul><ul><li>Telephone. </li></ul><ul><li>Communicate with team leader and seek feed back on decisions. </li></ul>
  24. 24. Importance of re triage <ul><li>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. </li></ul><ul><li>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. </li></ul>
  25. 25. <ul><li>The last person in along line at triage may have a serious medical problem that requires immediate attention </li></ul><ul><li>Patient should wait no longer than 5 minutes for triage </li></ul>If in doubt about a category, choose the higher acuity to avoid under triaging a patient