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Triage and transport - Dr.Suresh Babu Chaduvula

This presentation on Triage and transport deals with how we should we deal with the patients who are attending the emergency department and to provide best treatment for the needy patients at appropriate time.
I hope this will be helpful to nurses, paramedics, graduate and under graduate students and emergency doctors and team.

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Triage and transport - Dr.Suresh Babu Chaduvula

  1. 1. Dr.Suresh Babu Chaduvula Professor Department of Obstetrics & Gynecology King Khalid University Abha, Saudi Arabia
  2. 2.  Triage is the term derived from the French verb trier meaning ‘to sort’ or ‘to choose’ It’s the process by which patients are 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
  3. 3.  To treat the patients in the order of their clinical urgency appropriately and timely
  4. 4.  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.
  5. 5.  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 requiring significant demand on resources.  The key to successful disaster management is to provide care to those who are in greatest need first. Correct triage is essential to accomplish this goal.
  6. 6. 1. Identify patients requiring immediate care. 2. Determine the appropriate area for treatment 3. Facilitate patient flow through the ED and avoid unnecessary congestion.
  7. 7. 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.
  8. 8.  Immediately accessible  Sign posted  Allow for patients examination  Privacy  Staff security  Fully equipped with Emergency equipment  Communication services
  9. 9.  Should be completed in 10 minutes  If it is going beyond 15 minutes call for additional nurse.  Accurate triage is key to the efficient operation  Effective triage – is based on knowledge, skills and attitude of the triage nurse.  Pediatric cases – record vital signs every 30 mts and others – 60 mts during reassessment.
  10. 10.  Triage is an essential function of EDs  Urgency refers to the need for time –critical intervention.  Patients who are not critical with low acuity categories –safe to wait for assessment and treatment but still require admission.
  11. 11. “The eye’s don’t see what the mind doesn’t know!”
  12. 12. 1. Rapidly identify patients with urgent life threatening conditions 2. Assess/ determine severity and acuity of the problem 3. Ensure that patients are treated in order of clinical emergency 4. Ensure that treatment is appropriate and timely 5. Allocate the patients appropriate and treatment area 6. Reevaluate who are in waiting area
  13. 13. 1. Streamlines patient flow 2. Reduces risk of further injury/ deterioration 3. Improves communication and public relations 4. Enhances team work 5. Identifies resource requirements 6. Establishes national benchmarks
  14. 14.  The triage team  Triage of Victims - first victims to arrive are frequently not the most seriously injured. They are 1. Critical patients 2. Fatally Injured Patients 3. Non critical patients 4. Contaminated patients
  15. 15.  Are divided into 5 levels or categories depending on following acuity determinants 1. Chief complaint 2. Brief triage history 3. Injury/ illness 4. General appearance 5. Vital signs The most urgent clinical feature that is identified will determine ALS category
  16. 16. Level 1- Resuscitation Level 2- Emergent Level 3- urgent Level 4- less urgent Level 5- Non urgent
  17. 17. 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
  18. 18. Potential threat to life, limb or function Nurse Immediate , Physician <10 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
  19. 19. Condition with significant distress Time Nurse < 15min, 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
  20. 20. Conditions with mild to moderate discomfort Time for Nurse assessment < 30 minutes Time for physician assessment < 1hour Head injury, alert, no vomiting Chest pain, no distress, no cardiac suspicion. Depression with no suicidal attempt
  21. 21. Conditions can be delayed, no distress Time for nurse 60 minutes Physician assessment more than 2h or 120 minutes  Minor trauma  Sore throat with temperature < 39 degree centigrade  Chronic medical illnesses.  Alcoholics
  22. 22.  An “across-the room” assessment  The triage history  The triage physical assessment  The triage decision
  23. 23. To identify obvious life threat conditions General appearance Air way Breathing Circulation Disability (neurogenic)
  24. 24. • The triage nurse must scan the area where patients enter the emergency door, even while interviewing other patient.
  25. 25.  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, tachypnea bradypnea, or apnea periods, retractions, use accessory muscles, nasal flaring, grunting, or audible wheezes
  26. 26.  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
  27. 27.  Extensive knowledge to emergency medical treatment  Adequate training and competent skills, language, terminology  Ability to use the critical thinker process  Good decision maker
  28. 28.  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.  Crowd control.  Telephone.  Communicate with team leader and seek feed back on decisions.
  29. 29.  Reassess the patient within 1-2hours of initial triage and continue to reassess 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.
  30. 30.  The last person in along line at triage may have a serious medical problem that requires immediate attention  Patient should wait no longer than 10 minutes for triage  If in doubt about a category, choose the higher acuity to avoid under triaging a patient
  31. 31.  With a trauma call involving a pregnant patient, you have two patients:  The woman  The unborn fetus  Any trauma to the woman has a direct effect on the fetus.
  32. 32.  Pregnant women may be the victims of:  Assaults  Motor vehicle crashes  Shootings  Domestic abuse  Pregnant women also have an increased risk of falls.
  33. 33.  Pregnant women have an increased amount of overall total blood volume and a 20% increase in heart rate.  May have a significant amount of blood loss before you will see signs of shock  Uterus is vulnerable to penetrating trauma and blunt injuries.
  34. 34.  When a pregnant woman is involved in a motor vehicle crash, severe hemorrhage may occur from injuries to the pregnant uterus.  Trauma is one of the leading causes of abruptio placenta.  Significant vaginal bleeding is common with severe abdominal pain.
  35. 35.  Cardiac arrest  Focus is the same as with other patients.  Perform CPR and provide transport.  Notify the receiving facility personnel that you are en route with a pregnant trauma patient in cardiac arrest.
  36. 36.  Follow these guidelines when treating a pregnant trauma patient:  Maintain an open airway.  Administer high-flow oxygen.  Ensure adequate ventilation.  Assess circulation.  Transport the patient on her left side.
  37. 37.  Some cultures may not permit a male health care provider to assess or examine a female patient.  Respect these differences and honor requests from the patient.  A competent, rational adult has the right to refuse all or any part of your assessment or care.
  38. 38.  The Golden Period is the time from injury to definitive care.  Treatment of shock and traumatic injuries should occur.  Aim to assess, stabilize, package, and begin transport within 10 minutes (“Platinum 10”).
  39. 39.  Rapid scan assists in determining transport priority.  High-priority patients include those with any of the following conditions:  Difficulty breathing  Poor general impression  Unresponsive with no gag or cough reflex
  40. 40.  High-priority patients (cont’d):  Severe chest pain  Pale skin or other signs of poor perfusion  Complicated childbirth  Uncontrolled bleeding
  41. 41.  High-priority patients (cont’d):  Responsive but unable to follow commands  Severe pain in any area of the body  Inability to move any part of the body
  42. 42.  Transport decisions should be made at this point, based on:  Patient’s condition  Availability of advanced care  Distance of transport
  43. 43.  Transport decision  Provide rapid transport for pregnant patients who:  Have significant bleeding and pain  Are hypertensive  Are having a seizure  Have an altered mental status
  44. 44.  Circulation  If there are signs of shock, control bleeding, give oxygen, and keep the patient warm.  Transport decision  If delivery is imminent, prepare to deliver at the scene.  If delivery is not imminent, prepare the patient for transport.
  45. 45. Thank You