Triage in Emergency Department

TriageWaiting room

Team leader

Definition of Triage

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

It’s the process by which patients 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

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.

Non disaster or E.D triage

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

1. Identify patients requiring immediate care.

2. Determine the appropriate area for treatment

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

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.

Disaster• 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 if their needs place significant demands on resources.

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

Disaster

The triage teamTriage of Victims

- first victims to arrive are frequently not

the most seriously injured.Critical patientsFatally Injured PatientsNon critical patientsContaminated patients

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 who greets each patients on arrival, perform a primary survey and determine whether the patient is able to wait for further assessment by a second triage nurse.

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

Triage levels

1- Resuscitation

2- Emergent

3- urgent

4- less urgent

5- Non urgent

The Canadian E.D. Triage and Acuity Scale

Overview of three category triage acuity systemscategory acuity Recommended

reassessmentExamples

Class 1 EmergentImmediately life or limb threatening

continuous Cardiopulmonary arrest, severe respiratory distress, major burns, major trauma, massive uncontrolled bleeding

Coma, status epil..

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

Every 30 minutes

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

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

Every 1-2 hrs

Rash, chronic headache, sprains, cold symptoms

TRIAGE LEVELS1- 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

Triage levels2- Emergent

Potential threat to life,limb or function

Nurse Immediate , Physician <15 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

Triage levels

3- Urgent

Condition with significant distress

Time Nurse < 20 min, 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

Triage levels

4- Less urgent

Conditions with mild to moderate discomfort

Time for Nurse assessment <1h

Time for physician assessment < 1h

Head injury, alert, no vomiting

Chest pain, no distress, no cardiac susp.

Depression with no suicidal attempt

Triage levels

5- Non urgent

Conditions can be delayed, no distress

Time for nurse and Physician assessment more than 2h

• Minor trauma

• Sore throat with temp. < 39

Basic component of triage

• An “across-the room” assessment

• The triage history

• The triage physical assessment

• The triage decision

An “ across the room assessment”

To identify obvious life threat conditions

General appearance

Air wayBreathing

Circulation

Disability(neurogenic)

Across the door assessment•The triage nurse must scan the area where patients 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 doesn’t look right kindly but quickly interrupt any current interaction and go investigate.

Across the room assessment

• 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, tachypnic

bradypnea, or apnea periods, retractions, use accessory muscles, nasal flaring, grunting, or audible wheezes

Across the room assessment• CirculationAltered skin signs, pale, mottling, flushingUn controlled bleeding• Disability (neuro.)

LOC Interaction with environment Inability to recognize family members Unusual irritability

Response to pain or stimuliFlaccid or hyper active muscle tone

Characteristics of triage nurse

• Extensive knowledge to emergency medical treatment

• Adequate training and competent skills, language, terminology

• Ability to use the critical thinker process

• Good decision maker

Requirements of Triage nurse

• Be able to function well under stressful situations• Be able to make accurate assessments regarding patient

care • Have working knowledge of internal operations of

emergency department • Know interdepartmental policies • Be able to make rapid and sound decisions • Have firm convictions • Posses good communication skills• Be able to offer emotional support to others • Be able to think ahead

Cont. Requirements of Triage nurse

• Be able to supervise others • Be an on the spot teacher • Be able to control traffic flow • Posses good crisis intervention skills • Have a working knowledge if the prehospital care system • Be able to avoid conflict and loss of temper • Represent the hospital and emergency department to the

public • Assist in discharge planning • Be able to handle telephone triage • Be able to deal with patient communication problems

Qualifications of triage nurse

• Posses valid state registered nurse license• Be certified as mobile intensive care nurse • Be certified in basic life support • Have minimum of two years of critical care

nursing experience with at least six months of this being in the emergency department

• Have at least four training shifts in the triage position with senior triage nurse

• Have at least three evaluation shifts in the role of triage

Role of triage nurse

• 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.

Role of triage nurse

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

• Crowd control.

• Telephone.

• Communicate with team leader and seek feed back on decisions.

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 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.

•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