Triage Level 5

7/29/2019 Triage Level 5

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TRIAGE AT

ST JOSEPHHEALTHCARE


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Provides efficient care utilizing triagemodules.

Provides training and understanding of

concepts of triage


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Developed by Eula Brown RN for Emergency Departmentuse.

Collaborators:Brenda Harris, Education Technology specialist

Patty Sturt RN, Clinical Educator


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picture


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Objectives

At the end of this program the end user will

be able to verbalize skills related to:

Understanding the basic concept of triageDefine 5 levels of triage acuity

Understand components of ED triage process

for all types of patients


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Objectives contd

Define components of triage 1.visual assessment

2.subjective assessment

3.Objective assessment 4.Define resources needed

5.Making the triage decision

Be aware of and incorporate situations regarding legal,abuse, documentation, customer service, hazardousmaterials, and cultural issues into the triage module.

To utilize patient scenerios with clinical end users for abetter understanding of triage


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MODULES PRESENTED

Module 1: Introduction

Module 2: Components of triage

Quick assessment

Subjective data

Objective data

Resources and special situations

Triage decisionModule 3: Examples of each level

Module 4: Triage Pearls


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Triage: French word meaning

to sort.

Developed and used originally by military

during World War I as a model for classifying

patients according to priority of care needed.

Used extensively during WWII

Emergency Departments nation-wide have

adopted and utilize some form of triage system

to use in classifying patients based on careneeded.


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The most common system is the

three level system.

Classification is defined as:

Emergent

Urgent or

Non-urgent.


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Throughout the later part of the 20th

century, this system has been shown to belacking in accuracy and not adequate for

the volume and needs of 21st century

EDs.


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Canada, Australia, and UK have each

developed different 5 level triage systems.

We in the US have been presented with

an Emergency Severity Index 5 level

triage system that has been shown to be

very effective in recognizing different

classifications of patients and identifyingresources needed to provide the most

efficient patient care.


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Two of the most significant factors differentiating theUS system from the others are:

The 5 level classification used by Canada and Australia aredefined by what are safe wait times for different levels

US ESI system recognizes and incorporates needed resourcesfor patient care into the classification system. The US systemdoes not consider safe wait times in determining a level ofclassification


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THE 5 levels are definedas follows:


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Critical: (1)

Conditions that require

immediate and aggressive

intervention


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Emergent: (2)

Conditions that represent

potential loss of life of limb if

interventions not done

promptly.


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Urgent: (3)

Interventions needed in the

emergency department fortimely return to health. HR and

RR within normal limits. Needs

two or more potential resources.


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Non-urgent: (4)

Conditions that will benefit

from being seen in the ED,

but may wait to be seen. One

resource needed.


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Minor: (5)

Conditions that may be seen

in clinic setting and/or have

no expectation of

deterioration. One to zero

resources needed.


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COMPONENTS OF THE

TRIAGE PROCESS:


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1. QUICK ASSESSMENT

2. SUBJECTIVE DATA

3. OBJECTIVE DATA4. RESOURCES

5. TRIAGE DECISION


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Quick assessment: This beginswhen the patient approaches triage.

Across the room assessment is based on

ABCD parameters of airway, breathing,

circulation, mental status/disability,This includes: distress noted, tachypnea,

bradypnea, wheezing, accessory muscles,

nasal flaring, altered skin color, stridor,pt unconscious, psychosis/hallucinations,

inability to recognize familiar people

uncontrolled bleeding


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** If, at anytime during the quick across

the room assessment, the patient

demonstrates a combination of the abovesymptoms that indicates an emergent or

critical situation , they are taken

immediately to an ED room andinterventions are started.

The triage acuity is critical or emergent.


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Subjective data: Triage

history

Chief complaint: this is what the patient

says is wrong (preferably in their own

words)


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Further subjective data:

Medical history: * AMPLE

*AMPLE =

A = al lergies, age of patientM= medications, dose, frequency, last dose

P= past medications, surgical, pregnancy or prenatalhistory

L= Most recent meal, tetanus, LMP, ETOH or drugingestion

E=Events sur rounding present i l lness or injur y,associated symptoms


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Subjective data contd:

pain

Level of pain using appropriate scale

Duration

Severity

Quality

Radiation

Location


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Objective data:

Focus assessment based on patients chief

complaint and initial presentation.

Focus assessment should be completedtaking into consideration the

illness/injuries the patient presents with.


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Think/consider: What is the worst

possible thing that could be wrong with

this patient?Vital Signs are included in a focus

assessment.

O2 sat is included in the objectiveassessment as needed

Objective Data contd


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Carefully consider all assessment data todetermine if the patient has a critical oremergent situation.

pallor

Indications of blood loss

degree of distress

Vital signsO2 sat

Objective data contd


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Objective data contd

The very young patients or very old have

unique considerations or physiological

changes that may place them at a higheracuity level.


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RESOURCES: Resources the triage nurse

believes the patient may need based on thetriage assessment

ED team (nurses, techs) patients requiring one or more initialnurses or technicians to stabilize, protect, prevent other harm, andeffectively care for patient

SITUATIONS REQUIRING EXTRA PERSONNEL: EXAMPLEAlzheimers patient requiring constant care.

Ancillary Resources:

LAB

X-RAY

CASE MANAGER

CT SCAN OR ULTRASOUND

RESPIRATORY THERAPY


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Resources the triage nurse believes the

patient may need based on the triage

assessment

Medical management: does the patient

need MD or can patient be seen by PAonly. Is the patient to be seen by private

MD.

EMTALA issues


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Resources contd

Crisis situations requiring additional

staff or chaplaincy services.

Legal issues (Management oradministrative resources)

Patients that require additional

placement or assistance with meetingdischarge home needs.


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Situations that require additional

Resources

Simple procedures (simple wound, IV

care, dressing)

Complex procedures (moderate sedation,complicated burn care, gastric lavage)


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Evaluating Resource needs and

examples:

Legal issues:

Illness/injury (chief complaint) that leads the

triage nurse to suspect abusive situation:

Example Abuse situations : patient states

was assaulted by boyfriend earlier today.

This would then involve police, abuse form,

and possible community resources.


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Examples legal issues:

Example: patient with right-sided Paralysis

presents from nursing home with multiple

bruising and skin tears to left side of body:

This would involve abuse form, notificationof house administrator

MVC/Trauma patients: police involvement,

community resource involvement, coroners

case, legal evidence collection.


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Special issues that may impact

triage assessment:

Trauma:

What happened?

When?Mechanism of injury: i.e. Four wheeler

accident, MVC (simple fender bender),

MVC rollover, MVC t-bone. Penetrating

trauma vs. blunt trauma


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Special issues contd

COBRA: EMTALA:

No patients can be questioned regarding

insurance/payment of emergencydepartment services without medical

screening first. (Medical screening: any

and all tests, examinations done by qualifiedpractioners to determine an emergent

condition)


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Patients should not be transferred from

another hospital without confirmation

that the accepting facility has the

capacity and resources to care for the

patient. The patient must have an

accepting physician


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Special issues contd

Cultural issues:

Language barriers: need for translator services

Customs of different religions or ethnic groups:coining for fever patients, IV/blood products

restrictions


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Crisis situations:

Patients with new onset mental illness

Patients presenting with intent to harmthemselves or others

Patients in medical distress with families

needing interventions to help copy

Patients presenting with disability thatimpairs communication and/or affects timely

treatment

Example: Aphasia


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HazMat/Environmental situations:

Specif ic agent if known?: chemical,

radiation, biological

Example: Hydrof luoric acid

When did the exposure occur?

What type of exposure:

Inhalationlungs

Dermal - burn to face, eyes, etc.

Resources must anticipate including decon!

Evaluating resource


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Evaluating resource

needs contd

Procedures:

Simple: Saline lock, simple wound, simple

laceration

Complex: procedural sedation, extensive

burn, gastric lavage


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Quickly analyze subjective,

objective data, and resources


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Triage decision:.

IS..

Based on above components

and utilizes the experienced

nurses decision making skills

T i b f i


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Triage can be confusing...


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The next slides are definitions

and pt examples of each level

or category:


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CRITICAL PATIENTS:

Level One - red


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ABCDs:

compromised in one or more areas.

CRITICAL: (1) - brought back to room

immediately with aggressive ED Team

interventions star ted.


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Cardiac arrest

Respiratory arrest

Does not respond to painful stimuli(*AVPU)

the level one patient has a new onset of

decreased AVPU


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EMERGENT PATIENTS:

Level Two - orange


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ABCDs:

Patients with potential compromise to life

or limb and/or chief complaint of

emergent nature

EMERGENT brought back to room

immediately with interventions started.


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Examples Level 2

Sudden onset speech deficits or motor

weakness indicative of acute stroke

Active chest pain suspicious for CADImmunocompromised patient with fever

Suicidal patient with a plan

I nfant < 4 mo of age with temp >100.4rectal


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Abdominal pain or back pain with

indicators of hypovolemic shock

Noticeable respiratory distress (i .e.Retractions and O2 Sat


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Patient with auditory hallucinations

Chemical splash to eye

Sudden partial or full loss of vision

I ndicators of neurovascular compromise

in an injured extremity

Acute lethargy/decreased Level of

consciousness:


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Acute sickle cell pain cr isis

I ndicators of ineffective cardiac

outputFebri le seizure


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URGENT PATIENTS:

Level 3 (yellow)


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ABCDS

Compromise may occur, but less likely


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Vital signs

HR and RR are not above normalparameters

O2sat is not less than 92%Blood pressure is not at a dangerouslevel.

Pain scale: Generally


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Will need to be seen after critical and

emergent patients.

Obtain additional subjective, objectivedata as needed to determine if the patient

is urgent.


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Examples Level 3

C/O of flank pain with pain level = or < 8

and history of kidney stones

Cough and fever

Vaginal bleeding with mild-moderate

discomfort and no indicators of

hypovolemiaExtremity injury with indicators of

possible fracture or dislocation


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Cellulitis without indicators of septic

shock or severe sepsis

= or > 65 y.o. with abdominal painVomiting and diarrhea in child with no

indicators or poor perfusion


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Headache with: GCS = 15, no

motor/sensory deficits, no history of

trauma, mild-mod pain

Croup

Abdominal pain with fever with no

indicators peritonitis


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Pediatric pt with fever and no indicators

of meningitis, meningococcemia, sepsis,

febrile seizure, or decreased perfusion.Laceration that definitely requires suture

repair


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Non-urgent: Level 4 (green)

ABCDs : Compromise not likely


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Patients seen after above three

levels.

Stable patients requiring one

resource.


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Examples level 4:

Foreign body sensation in eye with no

history of trauma, no visual changes and

mild pain

Vaginal itching and burning

Extremity injury with no indicators of

fracture or dislocation


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Non-productive cough with no or

minimal pain and no fever

Dysuria with no indicators ofpyelonephritis and no or minimal fever

Minor laceration with no sutures

required (may require steri-strips)


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Back pain with no indicators of

neurological compromise and no

significant mechanism of injury (i.e.

rollover MVC vs. twisted while

bending)

Rash for multiple days with no indicators

of respiratory distress or cellulitis


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Minor: Level 5 (blue)

ABCDs : No compromise


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Progression of i l lness/injury: l ittle to no

change from onset

Vital signs: stablePain scale:


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Resources: no resources needed.

Stable patients: could be seen in clinic or

office setting. Requires no or minimumresources.


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Examples level 5:

Request for prescription refill with no

symptoms or complaints

Superficial abrasionRequest for tetanus shot

Request for allergy shot

Suture removal with well healed woundand no indications of infection


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Triage Pearls

Triage guidelines should never replace goodnursing judgment.

Always validate what you think you heard.

Patients sometimes tell you what they think youwant to hear.

All female patients of childbearing age needLMP documented

New onset confusion: consider sepsis orhypoglycemia


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Patients who are a threat to themselves orothers must be suspect for higher level ofclassification

Many older patients may dismisscomplaints as normal for their age.However symptoms in the elderlypopulation may not always be age related.

Always think of the worst situation andtriage accordingly. It is better to triage upthan under triage.


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Maintain customer service attitude or callfor help as needed

Protect yourselfnever go to the end and

down the hill to retrieve a patient.call forhelp

Always pay attention to parents/caregiverssubjective data.

Females always need gynologicalassessment with GI problem


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Do not ignore the frequent flyers! They too canhave real disease.

Communication is more difficult with the very oldand very young. Therefore you need to take more

time with these patients.Bradycardia is an ominous sign in a child

More resources = may equal higher acuity!

Triage is a challenge to all nurses.but you can

do it!

BEYOND TRIAGE


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BEYOND TRIAGE.

Documents

Triage Level 5