Triage in Emergency Triage in Emergency DepartmentDepartment

BYBY

Mohammad abuadas, RN, MScMohammad abuadas, RN, MSc

Triage

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Team leader

OBJECTIVESOBJECTIVES

At the end of this lecture the students will be able At the end of this lecture the students will be able to:to:

1- State the definition of word “triage”.1- State the definition of word “triage”. 2- Identify the triage categories.2- Identify the triage categories. 2- Review triage levels.2- Review triage levels. 3- Understand (across the room assessment).3- Understand (across the room assessment). 4- Identify the characteristics of triage nurse.4- Identify the characteristics of triage nurse. 5- Describe the roles of triage nurse.5- Describe the roles of triage nurse. 6- Understand the importance of re triage.6- Understand the importance of re triage.

First UnitFirst Unit Assess & Secure the SceneAssess & Secure the Scene Establish Areas as Outlined in the SchematicEstablish Areas as Outlined in the Schematic Communicate & Communicate &

Direct Incoming UnitsDirect Incoming Units Requests Additional Requests Additional

ResourcesResources Notify HospitalsNotify Hospitals Establish Triage Establish Triage

Unit CoordinatorUnit Coordinator

Definition of triageDefinition of triage

Triage is the term derived from the French Triage is the term derived from the French verb trier meaning to sort or to chooseverb trier meaning to sort or to choose

It’s the process by which patients classified It’s the process by which patients classified according to the type and urgency of their according to the type and urgency of their conditions to get the conditions to get the Right patientRight patient to the to the

Right placeRight place at the at the

Right timeRight time with the with the

Right careRight care provider provider

Triage categoriesTriage categories

Non disaster: To provide the best care for Non disaster: To provide the best care for each individual patient.each individual patient.

Multi casualty/disaster: To provide the Multi casualty/disaster: To provide the most effective care for the greatest most effective care for the greatest number of patients.number of patients.

Non disaster or E.D triageNon disaster or E.D triage

The primary objectives of an ED triage are The primary objectives of an ED triage are to (ENA,1992, P. 1):to (ENA,1992, P. 1):

1.1. Identify patients requiring immediate Identify patients requiring immediate care.care.

2.2. Determine the appropriate area for Determine the appropriate area for treatmenttreatment

3.3. Facilitate patient flow through the ED and Facilitate patient flow through the ED and avoid unnecessary congestion.avoid unnecessary congestion.

4. Provide continued assessment and 4. Provide continued assessment and reassessment of arriving and waiting reassessment of arriving and waiting patients.patients.

5. Provide information and referrals to 5. Provide information and referrals to patients and families.patients and families.

6. Allay patient and family anxiety and 6. Allay patient and family anxiety and enhance public relations.enhance public relations.

DisasterDisaster

Definition: an incident, either natural or human-Definition: an incident, either natural or human-made, that produces patients in numbers needing made, that produces patients in numbers needing services beyond immediately available resources. services beyond immediately available resources. May involve a large no. of patients or a small no. of May involve a large no. of patients or a small no. of patients if their needs place significant demands patients if their needs place significant demands on resources.on resources.

The key to successful disaster management is to The key to successful disaster management is to provide care to those who are in greatest need first provide care to those who are in greatest need first and just as importantly, not provide care to to and just as importantly, not provide care to to those who have little or no chance of survival. those who have little or no chance of survival. Correct triage is essential to accomplish this goalCorrect triage is essential to accomplish this goal

DisasterDisaster

The triage teamThe triage team Triage of VictimsTriage of Victims

- first victims to arrive are frequently - first victims to arrive are frequently notnot

the most seriously injured.the most seriously injured. Critical patientsCritical patients Fatally Injured PatientsFatally Injured Patients Non critical patientsNon critical patients Contaminated patientsContaminated patients

Types of E.D. triage systemTypes of E.D. triage system

Type 1: Traffic Director (Non Nurse).Type 1: Traffic Director (Non Nurse). Type 2: Spot CheckType 2: Spot Check Type 3: ComprehensiveType 3: Comprehensive

Two-tiered systems: initial screening by RN Two-tiered systems: initial screening by RN who greets each patients on arrival, perform a who greets each patients on arrival, perform a primary survey and determine whether the primary survey and determine whether the patient is able to wait for further assessment patient is able to wait for further assessment by a second triage nurse.by a second triage nurse.

Divide tasks among staff members, internal Divide tasks among staff members, internal triage and external triagetriage and external triage

Triage levelsTriage levels

1- Resuscitation1- Resuscitation

2- Emergent2- Emergent

3- urgent3- urgent

4- less urgent4- less urgent

5- Non urgent5- Non urgent

The Canadian E.D. Triage and Acuity ScaleThe Canadian E.D. Triage and Acuity Scale

Overview of three category triage acuity systemscategorycategory acuityacuity Recommended Recommended

reassessmentreassessmentExamplesExamples

Class 1Class 1 EmergentEmergentImmediately life or limb Immediately life or limb threateningthreatening

continuouscontinuous Cardiopulmonary Cardiopulmonary arrest, severe arrest, severe respiratory distress, respiratory distress, major burns, major major burns, major trauma, massive trauma, massive uncontrolled uncontrolled bleedingbleeding

Coma, status epil..Coma, status epil..

Class 2Class 2 UrgentUrgentRequires prompt care, Requires prompt care, but will not cause loss of but will not cause loss of life or limb if left untreated life or limb if left untreated for several hours.for several hours.

Every 30 Every 30 minutesminutes

Abdominal pain, non Abdominal pain, non cardiac cp, multiple cardiac cp, multiple fractures, lacerations, fractures, lacerations, renal calculi, renal calculi,

Class 3Class 3 Non urgentNon urgentAnd treatment but time is And treatment but time is not a critical factornot a critical factor

Every 1-2 Every 1-2 hrshrs

Rash, chronic Rash, chronic headache, sprains, headache, sprains, cold symptomscold symptoms

TRIAGE LEVELSTRIAGE LEVELS

1- Resuscitation1- Resuscitation -- threat to life -- threat to life

Time to nurse assessment Time to nurse assessment IMMEDIATEIMMEDIATE Time to physician assessment Time to physician assessment

IMMEDIATEIMMEDIATE Cardiac and respiratory arrestCardiac and respiratory arrest Major traumaMajor trauma Active seizureActive seizure ShockShock Status AsthmaticsStatus Asthmatics

Triage levelsTriage levels2- Emergent2- Emergent

Potential threat to life, limb or functionPotential threat to life, limb or function

Nurse Immediate , Physician Nurse Immediate , Physician <<15 minutes15 minutes Decreased level of consciousnessDecreased level of consciousness Severe respiratory distressSevere respiratory distress Chest pain with cardiac suspicionChest pain with cardiac suspicion Over dose (conscious)Over dose (conscious) Severe abdominal painSevere abdominal pain G.I. Bleed with abnormal vital signsG.I. Bleed with abnormal vital signs Chemical exposure to eyeChemical exposure to eye

Triage levelsTriage levels

3- Urgent3- Urgent

Condition with significant distressCondition with significant distress

TimeTime Nurse Nurse < 20 min, physician < 30 < 20 min, physician < 30 minmin

Head injury without decrease of LOC but Head injury without decrease of LOC but with vomitingwith vomiting

Mild to moderate respiratory distressMild to moderate respiratory distress G.I. Bleed not actively bleedG.I. Bleed not actively bleed Acute psychosisAcute psychosis

Triage levelsTriage levels

4- Less urgent4- Less urgent

Conditions with mild to moderate Conditions with mild to moderate discomfortdiscomfort

Time for Nurse assessment Time for Nurse assessment <<1h 1h

Time for physician assessment Time for physician assessment < 1h< 1h

Head injury, alert, no vomitingHead injury, alert, no vomiting

Chest pain, no distress, no cardiac susp.Chest pain, no distress, no cardiac susp.

Depression with no suicidal attemptDepression with no suicidal attempt

Triage levelsTriage levels

5- Non urgent5- Non urgent

Conditions can be delayed, no distressConditions can be delayed, no distress

Time for nurse and Physician assessment Time for nurse and Physician assessment more than 2hmore than 2h

Minor traumaMinor trauma Sore throat with temp. < 39Sore throat with temp. < 39

Reassessment in triageReassessment in triage

Level 1 =ContinuousLevel 1 =Continuous Level 2 = every 15 minLevel 2 = every 15 min Level 3 = every 60 minLevel 3 = every 60 min Level 4 = every 60 to 90 minLevel 4 = every 60 to 90 min Level 5 = every 2 hoursLevel 5 = every 2 hours

Is patient dying ?

Level II, III, IV, V

Can patient wait ?

How many resources ?

Yes No

Level I

Yes No

Level II

EMERGENCY

SEVERITY

INDEX

Level III, IV, V

ONELevel IV

TWOLevel III

NONLevel V

What are resources ?Resources Resources Not resourcesNot resources LabsLabs HX and physical exam. HX and physical exam.

ECG-X-rays C-T MRIECG-X-rays C-T MRI Point of care testing Point of care testing

IV Fluids /hydration IV Fluids /hydration Saline or Hep lock Saline or Hep lock

IV /IM Medication IV /IM Medication PO. MedicationPO. Medication

Specialty consult Specialty consult Simple wound care Simple wound care (dressing check /recheck) (dressing check /recheck) crutches ,splints,slings. crutches ,splints,slings.

Simple procedure Simple procedure

Complex procedure Complex procedure

Basic component of triageBasic component of triage

An “across-the room” assessmentAn “across-the room” assessment The triage historyThe triage history The triage physical assessmentThe triage physical assessment The triage decisionThe triage decision

An “ across the room assessment”An “ across the room assessment”

To identify obvious life threat conditionsTo identify obvious life threat conditions

General appearanceGeneral appearance

Air wayBreathing

Circulation

Disability(neurogenic)

Across the door assessmentAcross the door assessmentThe triage nurse must scan the area The triage nurse must scan the area where patients enter the emergency door, where patients enter the emergency door, even while interviewing other patient.even while interviewing other patient.The triage antenna should be seeking The triage antenna should be seeking clues to problems in all people who enter clues to problems in all people who enter the triage areathe triage areaIf any patient doesn’t look right kindly but If any patient doesn’t look right kindly but quickly interrupt any current interaction quickly interrupt any current interaction and go investigate.and go investigate.

Across the room assessmentAcross the room assessment Air wayAir way

Abnormal airway sounds, stridor, wheezing gruntingAbnormal airway sounds, stridor, wheezing grunting

Unusual posture e.g.. Sniffing position, inability to Unusual posture e.g.. Sniffing position, inability to speak, drooling or inability to handle secretionspeak, drooling or inability to handle secretion

BreathingBreathing

Altered skin signs, cyanosis, dusky skin, Altered skin signs, cyanosis, dusky skin, tachypnic, bradypnea, or apneic periods, tachypnic, bradypnea, or apneic periods, retractions, use accessory muscles, nasal flaring, retractions, use accessory muscles, nasal flaring, grunting,or audible wheezesgrunting,or audible wheezes

Across the room assessmentAcross the room assessment CirculationCirculationAltered skin signs, pale, mottling, flushingAltered skin signs, pale, mottling, flushingUn controlled bleedingUn controlled bleeding Disability (neuro.)Disability (neuro.)

LOCLOC Interaction with environmentInteraction with environment Inability to recognize family membersInability to recognize family members Unusual irritabilityUnusual irritability

Response to pain or stimuliResponse to pain or stimuliFlaccid or hyper active muscle toneFlaccid or hyper active muscle tone

Characteristics of triage nurseCharacteristics of triage nurse

Extensive knowledge to emergency Extensive knowledge to emergency medical treatmentmedical treatment

Adequate training and competent skills, Adequate training and competent skills, language, terminologylanguage, terminology

Ability to use the critical thinker processAbility to use the critical thinker process Good decision makerGood decision maker

Role of triage nurseRole of triage nurse

Greet patients and identify your self.Greet patients and identify your self. Maintain privacy and confidentialityMaintain privacy and confidentiality Visualize all incoming patients even while Visualize all incoming patients even while

interviewing others.interviewing others. Maintain good communication between triage Maintain good communication between triage

and treatment areaand treatment area maintain excellent communication with waiting maintain excellent communication with waiting

area.area. Use all resources to maintain high standard of Use all resources to maintain high standard of

care.care.

Role of triage nurseRole of triage nurse

Teaching ----- use of thermometer, first Teaching ----- use of thermometer, first aid ??? avoid lecturing.aid ??? avoid lecturing.

Crowd control.Crowd control. Telephone.Telephone. Communicate with team leader and Communicate with team leader and

seek feed back on decisions.seek feed back on decisions.

Importance of re triageImportance of re triage Reassess the patient within 1-2hours of Reassess the patient within 1-2hours of

initial triage and continue to re assess on a initial triage and continue to re assess on a regular basis, patients who may have regular basis, patients who may have presented without cardinal signs of severe presented without cardinal signs of severe illness may develop them during long waits.illness may develop them during long waits.

Patients who appear intoxicated actually Patients who appear intoxicated actually may have life threatening problems such as may have life threatening problems such as DKA, and should not be permitted to keep it DKA, and should not be permitted to keep it off in the waiting room.off in the waiting room.

•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

Triage Triage TagTag

Patient InformationPatient Information

Triage StatusTriage Status

Chief ComplaintChief Complaint

TransportationTransportation

Peel - off Bar CodesPeel - off Bar Codes

Transport RecordTransport Record

Vital Signs Vital Signs

HistoryHistory

TreatmentTreatment

MIEMSS

HOSP NOTIFIED Maryland Emergency Medical Services

TRIAGE TAG

A V P U

A V P U

A V P U

Inflated at _______________PASG

Gauge

Tourniquet @ _______

Extremity Splint

Gross Decon. Final Decon.

Maryland Department of Transportation

Patient Information SectionPatient Information Section

During MCIs this information is not During MCIs this information is not always obtainable.always obtainable.

Information is not a priority, can be added Information is not a priority, can be added throughout triage, treatment, throughout triage, treatment, transportation, and hospital reception transportation, and hospital reception phases. phases.

Triage Status SectionTriage Status Section

Universal color coding systemUniversal color coding system Space provided for four individual evaluationsSpace provided for four individual evaluations

Initial assessment - apply tag for priority assignmentInitial assessment - apply tag for priority assignment Secondary reassessment (in treatment area)Secondary reassessment (in treatment area) Blank - can be used in the treatment area or during Blank - can be used in the treatment area or during

transportationtransportation Hospital Hospital

Chief Complaint SectionChief Complaint Section

Major obvious injuries or illness can be Major obvious injuries or illness can be circledcircled

Indicate injuries on the human figureIndicate injuries on the human figure Additional information is added on the Additional information is added on the

comments linecomments line

Transportation Line Transportation Line

The The transporting unittransporting unit notes it’s agency notes it’s agency information, destination facility, and the information, destination facility, and the time the patient physically arrives at time the patient physically arrives at destination facilitydestination facility

Transportation Record SectionTransportation Record Section Detachable by tear-off ticket and as a Detachable by tear-off ticket and as a

peel-off labelpeel-off label Used to document patients removed from Used to document patients removed from

the scene to a hospital or other facilitythe scene to a hospital or other facility Transportation record label can be fixed Transportation record label can be fixed

to the transportation tactical worksheet - to the transportation tactical worksheet - make certain unit, priority, and destination make certain unit, priority, and destination is marked and initialed is marked and initialed

HOSP NOTIFIED

Vital Signs SectionVital Signs Section

In START Order

R - P - M

Medical History SectionMedical History Section

Information can be obtained anytime Information can be obtained anytime during the incidentduring the incident

Information can be obtained from Medic Information can be obtained from Medic Alert identification devicesAlert identification devices

Relevant medical history & medicationsRelevant medical history & medications

Treatment Record SectionTreatment Record Section

Documents treatment sequence and Documents treatment sequence and progressprogress

Quick documentation of common Quick documentation of common treatmentstreatments

Space provided for additional treatments Space provided for additional treatments and remarksand remarks

Spaces provided for time treatment actions Spaces provided for time treatment actions are taken and for provider initials are taken and for provider initials

Treatment Record LayoutTreatment Record Layout