Emergency Department Triage Protocols

Policy O Each patient presenting to the Emergency Department, either ambulatory or transferred by emergency medical personnel, shall be prioritized and categorized utilizing the 5 Level Emergency Severity Index (ESI) Instrument. O Triaging is not equivalent to a medical screening examination. O Triaging merely determines the “order” in which patients will be seen, not the presence or absence of an emergency medical condition.

Purpose O The Registered Nurse in the ED may initiate the following protocols for patients requiring immediate intervention or to expedite patient treatment. O It is understood that protocols initiated by a Registered Nurse require documentation on the patient record. O Implementation of protocols is contingent on communication between the nurse and physician!

Special Instructions O A. All patients presenting to the Emergency Department requesting services, will be seen by a Qualified Medical Personnel, regardless of ability to pay. O Questions regarding ability to pay or insurance information are not to be obtained at triage.

Special Instructions O B. Ambulatory patients will have a brief assessment performed by the Triage Nurse utilizing subjective and objective data. O Those patients presenting via ambulance entrance will have an assessment performed at the bedside by an RN.

Special Instructions O C. Information to identify the patient and to initiate the ED record, will be obtained from family or the patient while the initial assessment and/or treatment is begun.

Special Instructions O D. Patients will be categorized using ESI level 1-5, by evaluating patient acuity and resources needed. O Acuity is determined by stability of vital functions and potential for life, limb, or organ threat. O Resources needed are defined as the number of resources a patient is expected to consume in order for a disposition decision to be reached.

ESI Levels O Level I O A medical condition manifesting itself by symptoms of sufficient severity that they require immediate life-saving interventions. O These patients are critically ill and require immediate physician evaluation ad interventions.

ESI Levels O Level II O A medical condition that is a high risk situation, newly confused, lethargic or disoriented or in sever pain or distress. O A high risk patient is one whose condition could easily deteriorate or a patient who presents with symptoms suggestive of a condition requiring time sensitive treatment

ESI Levels O Level III O A patient predicted to require two or more resources

ESI Levels O Level IV O A patient predicted to require one resource

ESI Levels O Level V O A patient predicted to require no resources O NOTE: The patient may be re-categorized at any time as changes in condition necessitates.

Designated Room Usage O All rooms have O2 and Cardiac Monitors and therefore can be versatile at any time patient treatment warrants O Isolation rooms will be used for infectious disease requiring negative pressure O Exam 20 and 40 will be utilized for patients who are suicidal or a safety risk O Forensic Room for sexual assault victims or child molestation O Trauma 1, 2,3, and Pediatric Trauma for unstable chest pain or obvious distress, anaphylactic reactions, moderate trauma, GI bleed that is unstable, Overdoses, Major Trauma or CPR or an Imminent Delivery

Procedures O In order to facilitate patient flow in the department, the triage orders outlined below can be initiated immediately after the patient has been assessed during triage. O If, however, the current workload at triage prohibits them being initiated by the triage nurse, they can be started as soon as the patient gets placed in a room. O Implementation of these orders is contingent on communication between the nurse and physician.

Notify MD ASAP O Critically ill patients O Unconscious patients O Patients with unstable vital signs

IV Access O Patients with a Triage ESI level of 1, 2 or 3 may have intravenous access inserted. O Blood samples should be obtained a part of the access procedure to avoid additional discomfort or possible lost opportunity to obtain specimens. O The blood tubes collected will be labeled and then held in an appropriately secured area until orders for testing are made or the patient is released from the ED.

Temperatures O Pediatric patients less than 3 months of age, who present with a chief complaint of fever, or head injury (even if no fever at triage) MUST have the initial examination done by a physician.

Temperatures O Rectal temperatures will be obtained on the following types of patients O Children under the age of 1 year old having complaints of fever or any related infectious process O Patients with a fever greater than 102 O Unconscious patients O Any patient PRN as ordered by the physician

Elevated Temperatures O Remove any excessive clothing, blankets, etc. O Undress and gown loosely O Ask the physician for antipyretic for temperatures greater than 101 degrees (unless the patient had fever at home, received an antipyretic and fever is reducing) O **always ask the dosage that was given at home** O Encourage cooling liquids po (fluid challenges, popsicles, etc.) to help bring the patient’s temperature down.

Weights O All patients under the age of 18 must have weight taken and documented in kilograms, on the triage record. O Estimated weights must be documented on anyone older than 18 years of age, on the triage record. O All patients to receive weight based medications, need an actual weight taken and documented on the record.

OB Patients O All pregnant patients greater than 12 weeks gestation will have Fetal Heart Tones (FHT’s) assessed, no matter that patient’s chief complaint.

Pediatrics O Under 3 months of age with a c/o fever or head injury, must have initial examination done by a physician O Any child under 2 years old with trauma, head injury or sustaining a fall MUST have an initial examination done by a physician O All pediatric molestations MUST be treated by a physician

Chest pain greater than 25 years old O Order O Portable chest x-ray O STAT EKG/ Obtain an old EKG and hand deliver to the physician for immediate STEMI determination O CBC O Troponin O PT O BMP O O2, Cardiac Monitor, Post Rhythm Strip on the chart O Saline Lock O Continuous Pulse Oximeter O Obtain a second EKG in 5 minutes if active chest pain

Greater than 50 years old O Obtain an EKG for O Chest pain O Dizziness O Syncope O Dyspnea O Arm pain O Weakness O Neck or Jaw pain O Back pain O Abdominal pain in women

Greater than 80 years old Obtain and EKG for Chest pain Dizziness Syncope Dyspnea Arm pain Weakness Neck or Jaw pain Back pain Abdominal pain in women Nausea or vomiting

Possible TIA or CVA O Refer to the stroke protocol

Trauma O Call the physician to the bedside O Type and screen (hold) O CBC O Hepatic Function Panel O PT O PTT UA with Culture Reflex O Alcohol O Rapid Drug Screen O BMP O Undress the patient completely O O2, Cardiac Monitor, Post Rhythm Strip on chart O Saline lock (one or two accordingly) O Continuous pulse oximeter

Shortness of Breath/ Respiratory Distress O Notify MD ASAP if in distress O Place on cardiac monitor, obtain rhythm strip and record on chart O Obtain a baseline air pulse oximeter, unless the patient is in respiratory distress. O Place the patient on oxygen at 2 lpm via nasal cannula, or as indicated to keep the patient’s pulse oximeter greater than 93 % O Start a saline lock and draw blood for, but not necessarily order the following: CBC, Basic Chemistry. O EKG O Portable chest x-ray

Abdominal Pain/ Flank Pain Female (child bearing age) O CBC O Hepatic Function Panel O Lipase O HCG urine O BMP O UA with Culture Reflex O Saline Lock O Obtain catheter urine if no urine is available within 30 minutes

Abdominal Pain/ Flank Pain Males O CBC O Hepatic Function Panel O Lipase O BMP O UA with Culture Reflex O Saline Lock O Obtain catheter urine if no urine available within 30 minutes

Sepsis O Portable chest x-ray O STAT EKG/ obtain old EKG O CBC O Lactic Acid O Hepatic Function Panel O BMP O 2 blood cultures from different sites O UA with Culture Reflex O O2, Cardiac Monitor, Post Rhythm Strip on Chart O Saline Lock O Continuous Pulse Oximeter

Psychiatric/ Overdose O Undress the patient totally and remove all clothing and belongings from the room O STAT EKG/ Obtain old EKG O Alcohol O Hepatic Function Panel O CBC O Rapid Drug Screen O BMP O Suicide Precautions O O2, Cardiac Monitor, Post Rhythm Strip on Chart O Saline Lock O Continuous Pulse Oximeter

GI Bleed O STAT EKG and obtain old EKG O Type and Screen (on hold) O CBC O Hepatic Function Panel O PT O BMP O O2, Cardiac Monitor and Post Rhythm Strip on Chart O Saline Lock (one or two accordingly) O Hemoccult

Seizures O CBC O UA with Culture Reflex O BMP O Seizure Precautions O Continuous Pulse Oximeter O Saline Lock O O2

Syncope / Dizziness O STAT EKG and obtain and old EKG O CBC O Troponin O If older than 25 years of age HCG serum qualitative in females of child bearing age O FSBS O BMP O O2, Cardiac Monitor and post Rhythm Strip on Chart O Saline Lock O Continuous Pulse Oximeter

Vaginal Bleed - Pregnant O ABO Cell and RH Panel O CBC O BMP O HCG Quant O UA with Culture Reflex O Saline Lock O NPO

Vaginal Bleed – Not Pregnant O HCG Qualitative O CBC BMP

Sore Throat O Strep Reflex

STD - Male O UA with Culture Reflex O GC/Chlamydia swab at bedside O Swabs available in the room

STD - Females O HCG urine O Set up for Pelvic Exam with appropriate tubes O GC/Chlamydia swab at bedside O Trichomonas swab at bedside O UA with Culture Reflex O Obtain catheter urine if no urine is available within 30 minutes

Hypoglycemia O CBC O BMP O UA with Culture Reflex O FSBS O Saline Lock

Hyperglycemia O CBC O Acetone O BMP O UA with Culture Reflex O FSBS O Saline Lock

Eyes O Remove contact lenses if has not already been done O Obtain visual acuity on all patient that present with any type of eye complaint with glasses or lenses in O Ask physician for 2 drops of Tetracaine into the affected eye(s) when pain or photophobia present, no allergy, bleeding or obvious open globe rupture O If chemical injury, instill Normal Saline irrigation to the affected eye(s).

Burns O Apply cool, moist, sterile compresses to small burns to address the patient’s pain relief until the doctor can assess the patient. AVOID ICE O Keep the extremity moderately elevated if possible. O In the case of severe discomfort or patient has sustained more than 5% of body surface area (for example ½ of the arm or ½ of the leg), consider starting saline lock in order to be able to give IV pain medication as soon as the physician has seen the patient

Extremities O When assessing complaints involving extremities, palpate and assess one joint proximal and distal to the injury for pulse and discoloration O Remove all potentially constrictive clothing and/or jewelry from the involved extremity. O Apply ice, but not directly to the skin, x20 minutes then off for 20 minutes. Keep replenishing the ice packs until the patient is dispositioned. O Keep the extremity elevated. O Consider splinting the extremity when there is obvious deformity to address the patient’s pain/comfort issues O Ask the physician for pain medication O For any injuries in which there is obvious deformity, place a saline lock in order to be able to administer IV pain medication as soon as the physician sees the patient. NPO if surgical candidate. O Have the patient mark on the skin with a marker, areas in which they are experiencing pain.

Extremities O Indications to order x-rays O Painful with history of trauma O Swelling, deformity or bruising secondary to trauma O Point tenderness secondary to trauma O Crush injuries O To rule out foreign body O Pain, swelling and/or redness, without history of trauma

Extremities O The following x-rays are to be ordered as indicated: O Shoulder O Humerus O Elbow O Wrist O Hand/wrist (when having pain proximal to the MP joint) O Fingers (when pain is distal to the MP joint, specify which finger is to be x-rayed) O Knee O Lower Leg (Tibia/Fibula)(when pain is localized over the medial malleolus) O Lower leg and Ankle (when the patient is experiencing any pain in the lower leg and the ankle) O Ankle (when pain is localized over the lateral malleolus) O Foot (when pain is proximal to the metatarsal) O Toes (when pain is distal to the metatarsal) O Hip/AP Pelvic Order 1 view CXR for obvious fracture, (i.e. shortening and/or external rotation of the lower extremity

Extremities – care of amputated parts O Rinse with room temperature 0.9 % sterile Normal Saline to remove gross contamination O Wrap the part in sterile gauze, which has been moistened with room temperature 0.9% sterile Normal Saline and place it in a sealable plastic bag, then into an emesis basin and then place the basin on (NOT IN) ice.

References O Please refer to the following policies and training for complete information O Triage ES O Surge Capacity ES O Ambulance Diversion AD 4-4 O Emergency Severity Index Triage Training