Emergency triage

1. Triage
This is the lecture No. 2
Source: Manual of emergency care
September
2011
1 Dr. Ahmad Tubaishat

2. Triage
The process of sorting patients as they present
to the ED for care.
Some cases need to be seen immediately, and
some can wait safely. Decision based on the
nurse assessment.
Goal: place right patient in the right place at the
right time for the right reason.
September
2011
2 Dr. Ahmad Tubaishat

3. Triage
Triage systems:
Three types identified, differ in:
- Triage severity rating system
- staffing
- degree of assessment and documentation
- extent to which triage staff initiate diagnostic
and therapeutic interventions.
September
2011
3 Dr. Ahmad Tubaishat

4. Triage
1- Type I:
Nonnurse, traffic director, receptionist greet pt,
establish presenting complaint, based on that
take a decision;
"sick" : taken to treatment area and seen
promptly or "not sick"
In this system doc is minimal: name &C/C
Risk: nonprofessional sort the case  serious
cases could unrecognized
September
2011
4 Dr. Ahmad Tubaishat

5. Triage
2- Type II:
RN or physician performs a spot check. Take a
quick look, limited information obtained, then
pt assigned into3 levels: emergent, urgent, or
nonurgent.
It is appropriate in low admissions rate hospital,
when no need for 24hr triage.
September
2011
5 Dr. Ahmad Tubaishat

6. Triage
3- Type III:
Comprehensive, advance
Experienced emergency nurse has a competency
based triage orientation process.
C/C , sub. and obj. data collected to support the
rating decision.
Initial findings documented in the record
September
2011
6 Dr. Ahmad Tubaishat

7. Triage
Two tired triage system:
Because of high load in some hospitals the system
adopted
First nurse: greet the pt, determine C/C, assess ABC,
decide if pt. need to be seen immediately or wait.
Immediate care: go to treatment room
Stable case: pt chart initiated by the first nurse,
document C/C then direct the patient to assessment
nurse
Second nurse: more detailed and focused evaluation,
initiate lab work and radiology according protocols.
September
2011
7 Dr. Ahmad Tubaishat

8. Triage
Triage severity rating system:
- Two level triage:
Sick: urgent care needed
not sick: no immediate care required.
September
2011
8 Dr. Ahmad Tubaishat

9. Triage
- Three level triage:
Sometimes Identified by colors: red yellow and
green or numbered 1-3:
- Emergent: immediate care, threat to life, limb,
organ.
e.g: cardiac arrest, major trauma, respiratory
failure.
Team response needed and reassessment is
continuous.
September
2011
9 Dr. Ahmad Tubaishat

10. Triage
- Urgent: prompt care, pt wait safely several
hours
E.g: abdominal pain, renal calculi
Reassessment needed q 30min
September
2011
10 Dr. Ahmad Tubaishat

11. Triage
-
- Nourgent: need to be seen , but not critical
and patient can wait safely
-
e.g: soar throat, rash, conjunctivitis
Reassessment needed q 1-2 hr.
Poor inter and intra rater reliability between the
3 level
September
2011
11 Dr. Ahmad Tubaishat

12. Triage
- Four level triage:
Breaking the emergent level into life threatening
and emergency
- Five level triage:
Range from level 1 most acute to level 5 acute
e.g: Manchester triage system:
September
2011
12 Dr. Ahmad Tubaishat

13. Triage
September
2011
13 Dr. Ahmad Tubaishat

14. Triage
The emergency severity index:
It is 5 level scale categories pt by severity and
resources
Severity: stability of vital function and potential
to threat
Resources: number of resources expected to
consume before discharge
September
2011
14 Dr. Ahmad Tubaishat

15. September
2011
15 Dr. Ahmad Tubaishat

16. Triage
The triage process:
Initial triage assessment should be within 5 min
of arrivals.
- Across the room assessment:
Begin when the nurse see the patient, based on
general appearance, decide wither immediate
care needed, pt taken directly to treatment
room
If stable, the triage process continue
September
2011
16 Dr. Ahmad Tubaishat

17. Triage
Observe:
Airway patency, RR, external bleeding, LOC,
pain, skin color, deformities, activity, clothing
Listen:
Abnormal airway sound, tone of voice, language
Smell:
Stool, urine, vomit, ketones, alcohol, infection,
chemicals
September
2011
17 Dr. Ahmad Tubaishat

18. Triage
- The triage interview:
Introduce ur self, ask for C/C, HPI, based on that
focused assessment of the problem and
measure V/S. level determined: either go
immediately to a room for treatment or to
waiting room.
Communication is important
September
2011
18 Dr. Ahmad Tubaishat

19. Triage
Information seek:
Who: pt demographics
What: C/C
Where: location of the problem & S/S
When: time of symptom onset
Why: precipitating factors
How: how symptom affect normal function and
how much
September
2011
19 Dr. Ahmad Tubaishat

20. Triage
- Triage V/S:
It is a controversial area
- Objective data:
Physical examination related to C/C only not system by system
or head to toe examination.
- Triage severity rating:
Based on C/C, subjective and objective data, triage nurse use
knowledge, experience and guidelines to assign severity
rating.
Undertriaged pt receive delayed care and risk deterioration.
Overtriaged divert resources.
September
2011
20 Dr. Ahmad Tubaishat

21. Triage
Safety and security
Factors that contribute to violence:
overcrowding, long waiting, violent gangs.
Measures should be taken: panic buttons,
restricted access doors, security cameras, police
officers
Monitor behavior
Triage nurse shouldn’t place themselves or
others at risk.
September
2011
21 Dr. Ahmad Tubaishat

22. Triage
Triage documentation:
Clear concise, support the assigned severity
rating.
Depend on the policy: usually there is area in
the chart for triage notes. SOPIE.
September
2011
22 Dr. Ahmad Tubaishat

23. Triage
Infection control:
Triage nurse should use STD infection control
precautions
Hand washing between pt.
It is an portal of entry for contagious diseases:
appropriate precautions
September
2011
23 Dr. Ahmad Tubaishat

24. Triage
Telephone triage:
Verbal interview and making assessment of the
health status of the caller by trained tel triage
nurse.
September
2011
24 Dr. Ahmad Tubaishat

25. Triage
Triage qualifications:
- RN, min 6 months of emergency experience
- formal triage education with supervised preceptorship
- ACLS cert
- Emergency nursing peds course
- trauma nursing course
- emergency nurse cert
- effective communications, flexible
- ability to use nursing process effectively
- role model and representative
- excellent decision making skills
September
2011
25 Dr. Ahmad Tubaishat

26. Triage
Patient assessment:
Component of the initial assessment
Primary assessment:
- A: Airway
- B: Breathing
- C: Circulation
- D: Disability, AVPU (alert, verbal, pain,
unresponsive)
- E: Exposure/ Environmental control
September
2011
26 Dr. Ahmad Tubaishat

27. Triage
Secondary assessment:
- F: Full set of vitals: Temp, Pulse, Respiration,
RR, o2 sat, weight
- G: Give comfort measures: PQRST for pain
- H: History (S& O: C/C , HPI, medical history,
meds, labs, family hx) and head to toe
assessment
- I: Inspect posterior surfaces
September
2011
27 Dr. Ahmad Tubaishat