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7/29/2019 Triage ( emergency department )
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Triage in Emergency Department
TriageWaiting
room
Team leader
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Definition of Triage
Triage is the term derived from the Frenchverb trier meaning to sort or to choose
Its the process by which patients classifiedaccording 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
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Triage Categories
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.
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Non disaster or E.D triage
The primary objectives of an ED triage are to:
1. Identify patients requiring immediate care.
2. Determine the appropriate area for treatment
3. Facilitate patient flow through the ED and
avoid unnecessary congestion.
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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.
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Disaster
Definition: an incident, either natural orhuman-made, that produces patients innumbers needing services beyond immediately
available resources.
The key to successful disaster management isto provide care to those who are in greatest
need first.
Correct triage is essential to accomplish thisgoal
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Disaster
The triage team
Triage of Victims
- first victims to arrive are frequently not
the most seriously injured.
Critical patients
Fatally Injured Patients
Non critical patients
Contaminated patients
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Types of E.D. triage system
Type 1: Traffic Director (Non Nurse). Type 2: Spot Check
Type 3: Comprehensive
Two-tiered systems: initial screening by RN whogreets each patients on arrival, perform a primarysurvey and determine whether the patient is able to
wait for further assessment by a second triage nurse.
Divide tasks among staff members, internal triageand external triage
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Triage levels
1- Resuscitation
2- Emergent
3- urgent
4- less urgent
5- Non urgentThe Canadian E.D. Triage and Acuity Scale
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TRIAGE LEVELSLevel 1 - Immediately Life-threatening or
Resuscitation:
Conditions requiring immediate assessment.
Includes:
Airway or severe respiratory compromise
Cardiac arrest.
Severe shock. Symptomatic cervical spine injury.
Multisystem trauma.
Altered level of consciousness (GCS < 10)..
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Triage levels Triage Level 2Imminently Life-threatening or
Emergent: Conditions requiring assessment within 10 to 15 minutes
Include:
Head injuries.
Severe trauma / Asthma / Allergy
Any pain greater than 7 on a scale of 10
GI bleed with unstable vital signs.
Abdominal pain in patients older than age 50.
Any neonate age 7 days or younger
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Triage levels Triage Level 3Potentially Life-threatening/Time
Critical or Urgent
Conditions requiring assessment within 30 minutes
Include: Alert head injury with vomiting.
Mild to moderate asthma / trauma
GI bleed with stable vital signs. Mild to moderate respiratory distress
Acute psychosis
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Triage levels Triage Level 4Potentially Life-
serious/Situational Urgency or Semi-urgent
Conditions requiring assessment within 1 hr.
Include:
Head injury without vomiting.
Minor trauma / allergy
Vomiting and diarrhea in patient older than age 2without evidence of dehydration.
Earache.
Chronic back pain
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Triage levels
Triage Level 5Less/Non-urgent
Conditions requiring assessment within 2 hours
Include: Minor trauma, not acute.
Sore throat.
Chronic abdominal pain.
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Color Coding
Red tags - (immediate) are used to label those
who cannot survive without immediate
treatment but who have a chance of survival.
Yellow tags - (observation) for those who
require observation (and possible later re-
triage). Their condition is stable for the
moment and, they are not in immediate danger
of death.
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Green tags - (wait) are reserved for the
"walking wounded" who will need medical
care at some point.
White tags - (dismiss) are given to those
with minor injuries for whom a doctor's careis not required.
Black tags - (expectant) are used for thedeceased and for those whose injuries are so
extensive that they will not be able to survive
given the care that is available.
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Basic component of triage
An across-the room assessment
The triage history
The triage physical assessment The triage decision
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An across the room assessment
To identify obvious life threat conditions
General appearance
Air way
Breathing
Circulation
Disability
(neurogenic)
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Across the room assessment
The triage nurse must scan the area wherepatients enter the emergency door, even while
interviewing other patient.
The triage antenna should be seeking clues to
problems in all people who enter the triage area
If any patient doesnt look right kindly butquickly interrupt any current interaction and go
investigate.
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Across the room assessment
Air wayAbnormal airway sounds, stridor, wheezing grunting
Unusual posture e.g.. Sniffing position, inability to
speak, drooling or inability to handle secretion
Breathing
Altered skin signs, cyanosis, dusky skin, tachypnic
bradypnea, or apnea periods, retractions, use
accessory muscles, nasal flaring, grunting, or
audible wheezes
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Across the room assessment Circulation
Altered skin signs, pale, mottling, flushingUncontrolled 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
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Characteristics of triage nurse
Extensive knowledge to emergency medicaltreatment
Adequate training and competent skills,
language, terminology Ability to use the critical thinker process
Good decision maker
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Importance of re triage
Reassess the patient within 1-2hours of initial
triage and continue to re assess on a regular
basis
Patients who may have presented withoutcardinal signs of severe illness may develop
them during long waits.
Patients who appear intoxicated actually mayhave life threatening problems such as DKA,
and should not be permitted to keep it off in the
waiting room.
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The last person in along line at triage may
have a serious medical problem that requires
immediate attention
Patient should wait no longer than 5 minutes
for triage
If in doubt about a category, choose the higher
acuity to avoid under triaging a patient