Triage in Emergency Department BY Mohammad abuadas, RN, MSc Triage Waiting room Team leader

OBJECTIVES At the end of this lecture the students will be able to: 1- State the definition of word “triage”. 2- Identify the triage categories. 2- Review triage levels. 3- Understand (across the room assessment). 4- Identify the characteristics of triage nurse. 5- Describe the roles of triage nurse. 6- Understand the importance of re triage.

First Unit Assess & Secure the Scene Establish Areas as Outlined in the Schematic Communicate & Direct Incoming Units Requests Additional Resources Notify Hospitals Establish Triage Unit Coordinator Relate to your students what the radio transmission of the first arriving unit might be in your jurisdiction. “Paramedic 203 to dispatch. We have a collision involving two buses. We are requesting three Medical Strike Teams with Rescue. Have the first team begin Triage and the second team establish the Treatment Area at the 7-Eleven parking lot. The third team should stage in the Kindercare Lot.” “Advise EMRC of the incident and that we could be transporting approximately 60 patients. Ask them to begin a call-down. We will contact them for hospital status.”

Definition of triage Triage is the term derived from the French verb trier meaning to sort or to choose It’s the process by which patients classified according to the type and urgency of their conditions to get the Right patient to the Right place at the Right time with the Right care provider

Triage categories Non disaster: To provide the best care for each individual patient. Multi casualty/disaster: To provide the most effective care for the greatest number of patients.

Non disaster or E.D triage The primary objectives of an ED triage are to (ENA,1992, P. 1): Identify patients requiring immediate care. Determine the appropriate area for treatment Facilitate patient flow through the ED and avoid unnecessary congestion.

4. Provide continued assessment and reassessment of arriving and waiting patients. 5. Provide information and referrals to patients and families. 6. Allay patient and family anxiety and enhance public relations.

Disaster Definition: an incident, either natural or human-made, that produces patients in numbers needing services beyond immediately available resources. May involve a large no. of patients or a small no. of patients if their needs place significant demands on resources. The key to successful disaster management is to provide care to those who are in greatest need first and just as importantly, not provide care to to those who have little or no chance of survival. Correct triage is essential to accomplish this goal

Disaster The triage team Triage of Victims - first victims to arrive are frequently not the most seriously injured. Critical patients Fatally Injured Patients Non critical patients Contaminated patients

Types of E.D. triage system Type 1: Traffic Director (Non Nurse). Type 2: Spot Check Type 3: Comprehensive Two-tiered systems: initial screening by RN who greets each patients on arrival, perform a primary survey and determine whether the patient is able to wait for further assessment by a second triage nurse. Divide tasks among staff members, internal triage and external triage

Triage levels 1- Resuscitation 2- Emergent 3- urgent 4- less urgent 5- Non urgent The Canadian E.D. Triage and Acuity Scale

Recommended reassessment Overview of three category triage acuity systems category acuity Recommended reassessment Examples Class 1 Emergent Immediately life or limb threatening continuous Cardiopulmonary arrest, severe respiratory distress, major burns, major trauma, massive uncontrolled bleeding Coma, status epil.. Class 2 Urgent Requires prompt care, but will not cause loss of life or limb if left untreated for several hours. Every 30 minutes Abdominal pain, non cardiac cp, multiple fractures, lacerations, renal calculi, Class 3 Non urgent And treatment but time is not a critical factor Every 1-2 hrs Rash, chronic headache, sprains, cold symptoms

TRIAGE LEVELS 1- Resuscitation -- threat to life Time to nurse assessment IMMEDIATE Time to physician assessment IMMEDIATE Cardiac and respiratory arrest Major trauma Active seizure Shock Status Asthmatics

Triage levels 2- 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- Urgent Condition with significant distress Time Nurse < 20 min, physician < 30 min Head 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 urgent Conditions with mild to moderate discomfort Time for Nurse assessment <1h Time for physician assessment < 1h Head injury, alert, no vomiting Chest pain, no distress, no cardiac susp. Depression with no suicidal attempt

Triage levels 5- Non urgent Conditions can be delayed, no distress Time for nurse and Physician assessment more than 2h Minor trauma Sore throat with temp. < 39

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

E S I M R G N C Y E V R I T Y N D E X Is patient dying ? Yes No Level I Level II, III, IV, V Can patient wait ? Yes No Level III, IV, V Level II How many resources ? TWO Level III ONE Level IV NON Level 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

Basic component of triage An “across-the room” assessment The triage history The triage physical assessment The triage decision

An “ across the room assessment” To identify obvious life threat conditions General appearance Disability (neurogenic) Air way Circulation Breathing

Across the door assessment The triage nurse must 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.

Across the room assessment Air way Abnormal airway sounds, stridor, wheezing grunting Unusual posture e.g.. Sniffing position, inability to speak, drooling or inability to handle secretion Breathing Altered skin signs, cyanosis, dusky skin, tachypnic, bradypnea, or apneic periods, retractions, use accessory muscles, nasal flaring, grunting,or audible wheezes

Across the room assessment Circulation Altered skin signs, pale, mottling, flushing Un controlled bleeding Disability (neuro.) LOC Interaction with environment Inability to recognize family members Unusual irritability Response to pain or stimuli Flaccid or hyper active muscle tone

Characteristics of triage nurse Extensive knowledge to emergency medical treatment Adequate training and competent skills, language, terminology Ability to use the critical thinker process Good decision maker

Role of triage nurse Greet patients and identify your self. Maintain privacy and confidentiality Visualize all incoming patients even while interviewing others. Maintain good communication between triage and treatment area maintain excellent communication with waiting area. Use all resources to maintain high standard of care.

Role of triage nurse Teaching ----- use of thermometer, first aid ??? avoid lecturing. Crowd control. Telephone. Communicate with team leader and seek feed back on decisions.

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

Maryland Department of Transportation MIEMSS HOSP NOTIFIED Triage Tag Maryland Emergency Medical Services TRIAGE TAG A V P U Inflated at _______________ PASG Gauge Tourniquet @ _______ Extremity Splint Gross Decon. Final Decon. Maryland Department of Transportation Patient Information Triage Status Chief Complaint Transportation Peel - off Bar Codes Transport Record Vital Signs History Treatment

Patient Information Section During MCIs this information is not always obtainable. Information is not a priority, can be added throughout triage, treatment, transportation, and hospital reception phases.

Triage Status Section Universal color coding system Space provided for four individual evaluations Initial assessment - apply tag for priority assignment Secondary reassessment (in treatment area) Blank - can be used in the treatment area or during transportation Hospital Once the tag is applied to the patient. refer to the tag NOT the ribbon to determine priority.

Chief Complaint Section Major obvious injuries or illness can be circled Indicate injuries on the human figure Additional information is added on the comments line

Transportation Line The transporting unit notes it’s agency information, destination facility, and the time the patient physically arrives at destination facility

Transportation Record Section Detachable by tear-off ticket and as a peel-off label Used to document patients removed from the scene to a hospital or other facility Transportation record label can be fixed to the transportation tactical worksheet - make certain unit, priority, and destination is marked and initialed Point Out “Initials” Area, Priority, Hospital, & Unit Note Log-in Sheet is Different from Transportation Tactical Worksheet Initial notified box after the hospital has been notified of the patient HOSP NOTIFIED

R - P - M Vital Signs Section In START Order R - P - M In START Order In RPM format described by S.T.A.R.T. -Respiration -Pulse -Mental Status

Medical History Section Information can be obtained anytime during the incident Information can be obtained from Medic Alert identification devices Relevant medical history & medications

Treatment Record Section Documents treatment sequence and progress Quick documentation of common treatments Space provided for additional treatments and remarks Spaces provided for time treatment actions are taken and for provider initials Graphic is on the next slide Stress importance of documenting time

Treatment Record Layout

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