Emergency Department Triage System
ByJamal Wahadneh Rn MPH and
Ms Aida Salahat RnAl-Makassaed Emergency department
Objectives
• Define Triage• Define Triage system• Identify different systems• Describe emergency severity index• Function of triage system
History of Triage
• Definition
• Origin
• Informal triage
Goals of Triage
• Primary
• Secondary
Category of triage
• In hospital triage
• Multi casualty disaster triage
Types of triage methods
• Three level
• Four level
• Five level
Function of triage
• Identify life-threatening conditions and determine acuity level of each patient
Reassessment in triage
• Level 1 =Continuous• Level 2 = every 15 min• Level 3 = every 60 min• Level 4 = every 60 to 90 min• Level 5 = every 2 hours
Five level system
• Origin of 5 level
• Identify different levels
Emergency Severity Index
• Definition
• Advantages
• disadvantages
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 Not resources• Labs • HX and physical exam.
• ECG-X-rays C-T MRI •Point of care testing
• IV Fluids /hydration • Saline or Hep lock
• IV /IM Medication • PO. Medication
• Specialty consult • Simple wound care (dressing check /recheck) crutches ,splints,slings.
• Simple procedure
• Complex procedure
Key concepts
• Acuity level change
• Choose higher acuity when in doubt
Basic triage components
• Across the room assessment
• Triage history
• Physical assessment
• Triage decision
Key concept
• Discontinue assessment and transport the patient immediately to the treatment area if immediate care is needed. Do not delay treatment to finish the assessment
Triage process
• Establish priorities
• Scientific method
• Importance of time
Nursing process in triage
• Assessment time
• Vital signs
• Pain scale
• Nursing diagnosis
Key Concept
• Never assume the accident caused the presenting condition. The presenting condition may have caused the accident.
Interview methods
• Open ended• Close ended• Communication style• Use of five sense• attitude
How do I triage?
• Across the room• General appearance• Abcd• Subjective and objective (AMPLE)• Focused assessment• Pains scale (Pqrst)
Triage decision
• Step1- visual• Step 2- chief complaints• Step3- focused assessment• Step 4- pose hypothesis• Step 5- determine acuity• Step 6- reassess the acuity
Remember That:
Effective triage gets the patient • To the right place.• At the right time.• With the right care provider.
Questions