Triage in Emergency Department Triage Waiting room Team leader

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): 1.Identify patients requiring immediate care. 2.Determine the appropriate area for treatment 3.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

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

Overview of three category triage acuity systems categoryacuityRecommended reassessment Examples Class 1 Emergent Immediately life or limb threatening continuousCardiopulmonary arrest, severe respiratory distress, major burns, major trauma, massive uncontrolled bleeding Coma, status epil.. Class 2Urgent 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 3Non 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

Is patient dying ? Level II, III, IV, V Can patient wait ? How many resources ? YesNo Level I YesNo Level II EMERGENCYEMERGENCY SEVERITYSEVERITY INDEXINDEX Level III, IV, V ONE Level IV  TWO Level III NON Level V

What are resources ? ResourcesNot resources Labs HX and physical exam. ECG-X-rays C-T MRIPoint 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 Air way Breathing Circulation Disability (neurogenic)

Across the door assessment The triage nurse must scan the area where patients enter the emergency door, even while interviewing other patient.The triage nurse must scan the area where patients enter the emergency door, even while interviewing other patient. The triage should be seeking clues to problems in all people who enter the triage areaThe triage 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.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

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