Triage in the Triage in the Emergency DepartmentEmergency Department

Triage in Emergency Department

Triage

Waiting room

Team leader

Triage• A French verb means “To Sort – To choose”• Medically:– The process of applying medical priority to patients to do

the most for the most

• Practically, it is a subspecialty of emergency nursing that requires specific comprehensive educational preparation

• Means RAPID evaluation of patients to determine level of ACUITY or PRIORITY of care

Triage

• Chief complaints• General appearance• ABCD• Environment• Limited history• Co-morbidities

• It is the process which places the right patient in the right place at the right time to receive the right care.

• Accurate triage allow the nurse to do the greatest good for the greatest number of afflicted .

1- Gathering information at point of triage .2- Perform initial assessment ( assessment sheet ) at point

of triage .

• The goal of triage process :to gather sufficient data for determining acuity, identify immediate needs, and establish a rapport with the patient and family.

• Triage process should be completed within 5 minutes.

Is a process of prioritizing patients based on the severity of their

condition.

Triage is the first step in the patient pathway in the Emergency

Department; It aims to:

Ensure that patients are treated in the order of their clinical urgency

Ensure that treatment is appropriately and timely

Allocate the patient to the most appropriate assessment and treatment area

Gather information that facilitates the description of the departmental case mix

There are well validated and reliable five level

triage systems that have become the standard

in different countries:

Evidence support use of 5 level triage scale

LevelsLevels CountriesCountries SystemSystem1. Resuscitation

2. Emergency

3. Urgent

4. Semi-urgent

5. Nonurgent

New Zeland

Australian Triage Scale (ATS)

1. Resuscitation

2. Emergency

3. Urgent

4. Less urgent

5. Non urgent

Canada

Canadian Triage and Acuity Scale (CTAS)

1. Immediate (red)

2. Very Urgent (green

3. Urgent (yellow)

4. Standard (green)

5. Non urgent (blue)

UK

Manchester

Resuscitation immediatelyCat 1Cat 1

Emergency < 10 minCat 2Cat 2

Urgent < 30 minCat 3Cat 3

Semi urgent < 60 minCat 4Cat 4

Non urgent < 120 minCat 5Cat 5

Time to treatment for triage Time to treatment for triage categories:categories:

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 Asthmaticus

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- UrgentCondition with significant distressTime Nurse < 20 min, physician < 30 minHead 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 urgentConditions with mild to moderate discomfortTime for Nurse assessment <1h Time for physician assessment < 1hHead injury, alert, no vomitingChest pain, no distress, no cardiac susp.Depression with no suicidal attempt

Triage levels5- Non urgentConditions can be delayed, no distressTime for nurse and Physician assessment

more than 2h• Minor trauma• Sore throat with temp. < 39

Key Concepts in Triage

• Acuity level might change

• Never assume accident has always caused the present condition. It may be the reverse

• Choose higher acuity level when in doubt

• Discontinue assessment and transfer the patient immediately to treatment area if immediate care is needed

Basic components of Triage System

An “ across the room assessment”

To identify obvious life threat conditionsGeneral appearance

Air way

Breathing

Circulation

Disability(neurogenic)

Across the door assessment

•To 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.

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

Re-assessment in Triage

• Level 1 = continuous• Level 2 = every 15 minutes• Level 3 = every 60 minutes• Level 4 = every 60 – 90 minutes• Level 5 = every 2 hours