Triage

Hospitalist Night Float CurriculumLucile Packard Children’s Hospital, StanfordWritten by Becky Blankenburg, MD, MPH

and Erin Augustine, MD

Objectives

1. To refine your own system for triaging pages and phone calls at night.

2. To identify ways of proactively improving your triage abilities.

3. To elucidate key details when receiving medical information over the phone.

Case 1You are the intern on-call and simultaneously receive

the following 5 pages. How do you prioritize them? What do you do?

1. “Josh has bad abdominal pain.”2. “Sophia’s mom just arrived from work and would

like to hear how she is doing.”3. “Dr. Smith (Zach’s private physician) just called

and is upset that you didn’t start him on Ceftriaxone. He would like a call back immediately.”

4. “Molly [12 with pre-B cell ALL just admitted with fever and neutropenia] has a blood pressure that’s 70/30.”

5. “Alex is breathing harder. Would like to start Albuterol.”

Triage

Definition:• “A process for sorting injured [or sick]

people into groups based on their need for or likely benefit from immediate medical treatment. Triage is used in hospital emergency rooms, on battlefields and disaster sites, [and at night] when limited medical resources must be allocated.”

- American Heritage Dictionary

Triage

• Derived from the French word trier, meaning “to sort”

• First used by the chief surgeon of Napoleon’s army (Dominique-Jean Larrey) in the early 19th century

• First published report of civilian ED triage in 1966

General Principles to Improve Ability to Triage on the Wards

• What do you do?• How can you help others improve

their ability to triage?

General Principles to Improve Ability to Triage on the Wards

• Get good sign-out• Check on sicker patients at beginning of

shift• Anticipate how patients will get sicker

and what you will do in response• Know your resources ahead of time

(physicians in-hospital (and outside), nurses, respiratory therapists, etc)

• Look/ask for trends– Trends in vitals, trends in pain, etc

General Principles to Improve Ability to Triage on the Wards

cont• Communicate delays/concerns to your

attending– Some delays can lead to poor patient

outcomes (and your attendings can be helpful mobilizing resources, if they know)

• Communicate delays to families and nurses (when possible) – Most people are remarkably

understanding if they just have appropriate expectations

Case 2

You are the senior on-call and take the following phone advice call from a patient’s parent. What do you do?

• “Eva has been vomiting.”

Phone Triage – Calls from Parents

Goals: • Answer simple medical questions.• Advise disposition for a patient

(e.g., if needs to be seen immediately or can wait to be seen).

• May not be necessary to diagnose.

Phone Triage – Calls from Parents: Patient’s Medical

HistoryHelpful medical information to know and

document:• Call Back Number• Name of Parent• History of Present Illness• Past Medical History (also review on-line, if

available)• Medications• Allergies to Medications

• Mental Status• Vitals

– Temperature, pulse, respiratory rate

• Respiratory– Respiratory rate, retractions

• Abdomen• GU• Skin

– Rashes

Phone Triage – Calls from Parents:

Physical Exams Over the Phone

Phone Triage – Calls from Parents:

Management Options1. Where to Triage

a. 911b. ED immediatelyc. Urgent Cared. PCP next day/in a few dayse. Call family same day/next day to follow-up

2. Prescriptionsa. Can call in simple prescriptions

3. Review routine return precautionsa. Signs/symptoms for the parents to be

aware of and return to medical attention if present

4. Document your call (in Cerner at LPCH)

Phone Triage – Outside Providers: Communicate Patient Information

• Name, Age, Weight• Current Medical Condition• Pertinent Past Medical History and Medications• Allergies• Vital Signs (Including BP & O2 Sat) • Pertinent Physical Exam Findings

Mental Status Airway Status Perfusion Assessment

• Interventions Performed & Response to Therapy • Condition Updates• Send Copies of Notes, Labs, Imaging Studies

Phone Triage – Outside Providers: Communicate Recommendations

• Providing Advice Is Recommended• Evaluation

Labs Imaging

• Management Airway Management

Oxygen Intubation

IV Placement Medication Administration

• Transportation

Transport Considerations

• Local Resources Staff Availability & Training Equipment Medications

• Distance of Transport• Transport Availability • Road Conditions & Weather

Transportation Options

• Basic Life Support (BLS) • Advanced Life Support (ALS) • Critical Care• Neonatal • Air

Helicopter Fixed-Wing Airplane

Basic Life Support Transport• Team

EMT-Basic

• Capabilities Administer Oxygen Administer IV Fluids Immobilize Administer Limited Selection of Medications

Albuterol, EpiPen, Oral Glucose

• Recommended if Stable Patient Immediate Transport Necessary (“Load &

Go”)

Advanced Life Support Transport• Team

EMT-Paramedic

• Capabilities Intubate Obtain IV Access Administer Oral & IV Medications

• Recommended if Life-Threatening Condition Altered Consciousness Respiratory Distress

Critical Care Transport

• Team EMT or Special Care Transport Paramedic Critical Care Transport Nurse(s) +/- Respiratory Therapist +/- Physician

• Capabilities Cardiac Monitoring Vasoactive Medication Administration Ventilatory Support

Air Transport

• Recommended if Long Distances Poor Road Conditions or Weather Patient Requires Immediate

Intervention Intracranial Hemorrhage

Air Transport Special Considerations

• Unable to “pull over” to work on patient• Noise prohibits auscultation• Pneumothorax

Low pressure at high altitude may lead to pneumothorax expansion.

Helicopter transport is acceptable because it flies at sea level.

Fixed-wing airplane transport is only acceptable if the cabin is pressurized to sea level.

Best to avoid high altitude for 6 weeks after pneumothorax resolution.

Take Home Points

1. Take proactive steps to aid you in triaging pages and phone calls at night.

2. Focus on key details when receiving medical information from a lay person via phone.

3. It is best for your patient’s outcome to help advise his/her work-up and treatment as soon as the outside provider calls you.

References

• Schmitt BD, Thompson DA. Triage Documentation: Setting a Best Practice. http://www.answerstat.com/articles/5/42.html, 2005.

• Thompson T, Stanford K, Dick R, Graham J. Triage Assessment in Pediatric Emergency Departments: A National Survey. Ped Em Care, 26(8):544-548, 2010.

• American College of Surgeons Committee on Trauma, American College of Emergency Physicians, National Association of EMS Physicians, Pediatric Equipment Guidelines Committee-Emergency Medical Services for Children (EMSC) Partnership for Children Stakeholder Group and American Academy of Pediatrics. Policy Statement – Equipment for Ambulances. Pediatrics. 2009. 124:e166-71.

• Orr RA, Felmet KA, Han Y, McCloskey KA, Dragotta MA, Bills DM, Kuch BA, Watson RS. Pediatric specialized transport teams are associated with improved outcomes. Pediatrics. 2009. 124:40-8.

• Sirbaugh PE, Leswing V. Prehospital Pediatrics. UpToDate. 2011. • Baumann MH.  Pneumothorax and Air Travel:  Lessions Learned From

a Bag of Chips.  Chest.  2009.  136:655-6.