Triage Lecture Dr F Mesa Gaerlan

TRIAGETRIAGE

The best for the most with the The best for the most with the least by the fewest.least by the fewest.

HISTORYHISTORY

The word “triage”, arising from the French “trier” meaning “to sort” has its origins in Latin.

DEFINITIONDEFINITION

Triage is a brief clinical assessment that Triage is a brief clinical assessment that determines the determines the time and sequencetime and sequence in which in which patients should be seen in the ED or, if in the patients should be seen in the ED or, if in the field, the field, the speed of transportspeed of transport and and choice of choice of hospital destinationhospital destination

PRIMARY OBJECTIVESPRIMARY OBJECTIVES

Promptly identify patients requiring Promptly identify patients requiring immediate, definitive careimmediate, definitive care

Determine the appropriate area for treatmentDetermine the appropriate area for treatment Facilitate patient flow through the ED and Facilitate patient flow through the ED and

avoid unnecessary congestionavoid unnecessary congestion

Provide information and referrals to patients Provide information and referrals to patients and familiesand families

Allay patient and family anxietyAllay patient and family anxiety Enhance favorable public perceptions of and Enhance favorable public perceptions of and

experiences with emergency servicesexperiences with emergency services

PRIMARY OBJECTIVES PRIMARY OBJECTIVES

Triage is not only a necessity, but Triage is not only a necessity, but a major component of the a major component of the Emergency Medical SystemEmergency Medical System

TYPES OF ED TRIAGE TYPES OF ED TRIAGE SYSTEMSSYSTEMS

Very diverseVery diverse Developed according to the institution’s and Developed according to the institution’s and

department’s needsdepartment’s needs Should be tailored to meet the common goals Should be tailored to meet the common goals

of triageof triage


# of patients and severity of injuries < # of patients and severity of injuries < resourcesresources Life threatening injuries are treated firstLife threatening injuries are treated first

# of patients and severity of injuries > # of patients and severity of injuries > resourcesresources Patients with greatest chance of survival are Patients with greatest chance of survival are

treated firsttreated first


Type I: Traffic Director-TriageType I: Traffic Director-Triage most basic typemost basic type greeting or traffic directing is performed by a non-greeting or traffic directing is performed by a non-

professionalprofessional how “sick” the patient looks determines how “sick” the patient looks determines

classification as emergent or nonurgentclassification as emergent or nonurgent


Type II: Spot-check TriageType II: Spot-check Triage ““quick look” systemquick look” system RN or MD obtains info and limited RN or MD obtains info and limited

subjective/objective data related to chief complaintsubjective/objective data related to chief complaint emergent, urgent, delayedemergent, urgent, delayed

Type III: Comprehensive TriageType III: Comprehensive Triage most advanced system of triagemost advanced system of triage assessment and prioritization performed by an assessment and prioritization performed by an

experienced RNexperienced RN use of sophisticated triage categoriesuse of sophisticated triage categories standards followed for assessment, planning and standards followed for assessment, planning and

interventionintervention


COMPREHENSIVE TRIAGE COMPREHENSIVE TRIAGE GOALSGOALS

Identification of patients with life-threatening Identification of patients with life-threatening problemsproblems

Regulation of patient flowRegulation of patient flow Efficient use of resources and spaceEfficient use of resources and space

APPLICATIONSAPPLICATIONS

TRAUMATRAUMA DISASTERDISASTER PREHOSPITAL PREHOSPITAL OUTBREAKSOUTBREAKS EMERGENCY DEPARTMENTEMERGENCY DEPARTMENT

START SYSTEMSTART SYSTEM

Simple Triage and Rapid Treatment Simple Triage and Rapid Treatment Created in the 1980”s by Hoag Hospital and Created in the 1980”s by Hoag Hospital and

the Newport beach CA Fire Departmentthe Newport beach CA Fire Department Allows rapid assessment of victimsAllows rapid assessment of victims It should not take more than 15 seconds/ It should not take more than 15 seconds/

patientpatient

START SYSTEMSTART SYSTEM

Classification based on 3 categories:Classification based on 3 categories: RespirationRespiration PerfusionPerfusion Mental statusMental status

Medical Screening ExaminationMedical Screening Examination

Chief complaintChief complaint - High acuity, high risk, true - High acuity, high risk, true emergency emergency

Vital signsVital signs - Grossly abnormal - Grossly abnormal Mental statusMental status - Evidence of abnormalities - Evidence of abnormalities General appearanceGeneral appearance - Patient looks sick, patient's - Patient looks sick, patient's

skin looks poorly perfused, patient shows signs of skin looks poorly perfused, patient shows signs of dehydration dehydration

Ability to walkAbility to walk - Patients who cannot walk are at - Patients who cannot walk are at high risk for true emergency medical conditions.high risk for true emergency medical conditions.

METHODSMETHODS

The majority of US Emergency Departments use 3-level triage: Emergent– requires immediate evaluation &

treatment Urgent–can tolerate a period of time in the waiting

room Non-urgent–minor illness/injury that can be

treated within six hours

EmergentEmergent

Life and limb threatening conditionsLife and limb threatening conditions Immediate care within secondsImmediate care within seconds cardiac arrest, acute severe chest pain, massive cardiac arrest, acute severe chest pain, massive

vomiting of blood, sudden loss of vomiting of blood, sudden loss of consciousness, and major trauma with consciousness, and major trauma with hypotensionhypotension

Reassessment is continuousReassessment is continuous

UrgentUrgent

Requires prompt care but will not cause loss of Requires prompt care but will not cause loss of limb or life if left untreated for hourslimb or life if left untreated for hours

acute dyspnea, acute abdominal pain, acute acute dyspnea, acute abdominal pain, acute chest pain, acute confusion, and severe pain. chest pain, acute confusion, and severe pain.

abdominal pain, high fever, acute back pain, abdominal pain, high fever, acute back pain, serious extremity injuries, and large or high-serious extremity injuries, and large or high-risk lacerationsrisk lacerations

Reassessment is every 30 minutes Reassessment is every 30 minutes

Non-urgentNon-urgent

Disorders are chronic, minor, or self-limiting. Disorders are chronic, minor, or self-limiting. medication refill, acne, mild adult upper medication refill, acne, mild adult upper

respiratory tract symptoms, mild sore throat, respiratory tract symptoms, mild sore throat, blood pressure check, and lumps and bumps. blood pressure check, and lumps and bumps. Keep in mind that no matter how minor, these Keep in mind that no matter how minor, these patients may still require an MSE if they patients may still require an MSE if they request treatment or evaluationrequest treatment or evaluation

Reassessment is every 1 to 2 hoursReassessment is every 1 to 2 hours

Who should do triage?Who should do triage?

Early studies showed little difference in Early studies showed little difference in predicted outcomes of patients when predicted outcomes of patients when physicians, as opposed to nurses, perform physicians, as opposed to nurses, perform triagetriage

However, more recent studies suggest that However, more recent studies suggest that experienced emergency medicine (EM) experienced emergency medicine (EM) physicians and EM nurses actually may physicians and EM nurses actually may provide the best triage provide the best triage

PitfallsPitfalls Failure to recognize and attend to a patient Failure to recognize and attend to a patient

who complains of severe painwho complains of severe pain Failure to recognize or acknowledge high-risk Failure to recognize or acknowledge high-risk

chief complaints chief complaints Failure to take adequate vital signs Failure to take adequate vital signs

PitfallsPitfalls Failure to adequately document the triage Failure to adequately document the triage

and/or MSE and/or MSE Failure to retriage patients initially assigned to Failure to retriage patients initially assigned to

the waiting room: Patients assigned to a the waiting room: Patients assigned to a waiting room should have vital signs retaken waiting room should have vital signs retaken every 2 hoursevery 2 hours

CASESCASES

Case 1: A 36-year-old man presented Case 1: A 36-year-old man presented to the ED with severe chest pain. His to the ED with severe chest pain. His vital signs were blood pressure, vital signs were blood pressure, 140/90 mm Hg; pulse, 120 beats per 140/90 mm Hg; pulse, 120 beats per minute (bpm); respiration, 20 breaths minute (bpm); respiration, 20 breaths per minute (bpm); and temperature, per minute (bpm); and temperature, 99°F. Although the patient's pulse was 99°F. Although the patient's pulse was 120, his respiratory rate was normal, 120, his respiratory rate was normal, and he looked well. and he looked well.

Case 2: A 43-year-old man presented to the Case 2: A 43-year-old man presented to the ED, complaining of a severe headache. The ED, complaining of a severe headache. The patient had normal vital signs except for a patient had normal vital signs except for a temperature of 39°C. The ED was very busy temperature of 39°C. The ED was very busy and crowded. and crowded.

Case 3: A 65-year-old man Case 3: A 65-year-old man presented to the ED presented to the ED complaining of groin pain. complaining of groin pain. He said the pain was He said the pain was severe and he did not feel severe and he did not feel well. His vital signs were well. His vital signs were blood pressure, 150/95 mm blood pressure, 150/95 mm Hg; pulse, 108 bpm; Hg; pulse, 108 bpm; respiration, 22 bpm; and respiration, 22 bpm; and temperature, 38°C. temperature, 38°C.

Case 4: A 55-year-old man Case 4: A 55-year-old man presented to the ED presented to the ED complaining of abdominal complaining of abdominal pain. He stated that he pain. He stated that he thought his condition was thought his condition was secondary to eating too secondary to eating too much greasy fast food too much greasy fast food too rapidly. His vital signs rapidly. His vital signs were blood pressure, were blood pressure, 150/100 mm Hg; pulse, 150/100 mm Hg; pulse, 100 bpm; respiration, 22 100 bpm; respiration, 22 bpm; and temperature, bpm; and temperature, 37°C. 37°C.

Case 5: A 22 year old Case 5: A 22 year old female came in due to acute female came in due to acute onset diarrhea. She had onset diarrhea. She had about 6 episodes and had about 6 episodes and had severe epigastric pain. BP: severe epigastric pain. BP: 120/80, HR: 89 and RR: 23.120/80, HR: 89 and RR: 23.

Case 5: A five year old Case 5: A five year old female came in due to fever female came in due to fever and chills of five days and chills of five days duration. HR: 110, RR: 30 duration. HR: 110, RR: 30 and T: 40and T: 40°C. The patient °C. The patient had maculopapular rashes had maculopapular rashes all over.all over.

TRIAGE TRIAGE EXAMINATIONEXAMINATION

YEAR LEVEL VIYEAR LEVEL VI

20072007

36/F 36/F fell from a ladder on fell from a ladder on outstretched handoutstretched handwith gross deformity, with gross deformity, L forearmL forearm

40F, smoker40F, smoker

CC: Vaginal CC: Vaginal bleeding bleeding

VS: VS: BP 80/50BP 80/50

HR 90HR 90

RR 24 RR 24

55M, hypertensive, 55M, hypertensive, smokersmoker

CC: Chest pain CC: Chest pain

VS: VS: BP 90/50BP 90/50

HR 90HR 90

RR 24 RR 24

56M, cook56M, cook

CC: difficulty of CC: difficulty of breathing breathing

VS: VS: BP 130/80BP 130/80

HR 90HR 90

RR 28 RR 28

58M, smoker58M, smoker

CC: LLQ painCC: LLQ pain

VS: VS: BP 120/80BP 120/80

HR 100HR 100

RR 24 RR 24

19M, vendor19M, vendor

hit-and-run victimhit-and-run victim

unconscious unconscious

VS: VS: BP 130/80BP 130/80

HR 90HR 90

RR 24 RR 24

22F, student22F, student

CC: R shoulder pain CC: R shoulder pain

VS: VS: BP 120/80BP 120/80

HR 80HR 80

RR 20 RR 20

36M, non-smoker36M, non-smoker

CC: low back pain CC: low back pain

VS: VS: BP 130/80BP 130/80

HR 88HR 88

RR 22 RR 22


CC: amputated CC: amputated index finger index finger

VS: VS: BP 130/80BP 130/80

HR 90HR 90

RR 24 RR 24


CC: foreign body CC: foreign body sensation R eye sensation R eye

VS: VS: BP 130/80BP 130/80

HR 90HR 90

RR 24 RR 24

56M, laborer, 56M, laborer, smokersmoker

CC: unconscious CC: unconscious

VS: VS: BP 130/80BP 130/80

HR 90HR 90

RR 24 RR 24

40M, carpenter, 40M, carpenter, HPNHPN

CC: fall CC: fall

VS: VS: BP 100/80BP 100/80

HR 90HR 90

RR 24 RR 24

25M, student25M, student

CC: dog bite CC: dog bite

VS: VS: BP 120/80BP 120/80

HR 80HR 80

RR 20 RR 20

30M, bodybuilder30M, bodybuilder

CC: chest pain CC: chest pain

VS: VS: BP 130/80BP 130/80

HR 94HR 94

RR 26 RR 26


CC: electrocuted/fall CC: electrocuted/fall

VS: VS: GCS 15GCS 15

BP 130/80BP 130/80

HR 90HR 90

RR 24 RR 24


CC: numbness, CC: numbness, lower extremities lower extremities

VS: VS: BP 130/80BP 130/80

HR 90HR 90

RR 24 RR 24


CC: epigastric pain CC: epigastric pain

VS: VS: BP 140/80BP 140/80

HR 92HR 92

RR 20 RR 20

12M, vendor12M, vendor

CC: side-swiped by CC: side-swiped by a truck a truck

VS: VS: BP 120/80BP 120/80

HR 90HR 90

RR 24 RR 24

40M, jockey40M, jockey

CC: fall CC: fall

VS: VS: BP 130/80BP 130/80

HR 90HR 90

RR 24 RR 24

QUESTIONS?QUESTIONS?

The process we understand as triage was first described by Baron Dominique Jean-Larrey

First systematic description in civilian medicine was from E. Richard Weinerman in Baltimore in 1964

Documents

Triage Lecture Dr F Mesa Gaerlan