1. TRIAGE IN ER
Aline Akiki
MSN, HCMQ

2. TRIAGE IN ER
The number of patients seeking care in emergency departments (EDs) is increasing, while the number of EDs continues to decrease.
Triage is the process of sorting patients as they present to the ED for care
The triage encounter take no more than 2 to 5 minutes

3. TRIAGE IN ER
The triage nurse must quickly identify those patients who need to be seen immediately and those patients who are safe to wait for care.
This important decision needs to be based on a brief patient assessment that enables the triage nurse to assign an acuity rating.

4. Goal of Triage The overall goal of triage is to place:
The right patient in
The right place at
The right time for
The right reason

5. Role
The triage nurse should have rapid access or be in view of the registration and waiting areas at all times.
Greets client and family in a warm empathetic manner.
Performs brief visual assessments.
Documents the assessment.
Triages clients into priority groups using appropriate guidelines.
Transports client to treatment area when necessary.
Gives report to the treatment nurse or emergency physician, documents who report was given to and returns to the triage area.
Keeps patients/families aware of delays.
Reassesses waiting clients as necessary.
Instructs clients to notify triage nurse of any change in condition

6. Canadian Triage and Acuity Scale (CTAS)
All Canadian EDs use this five-level acuity rating system.
The system mandates that every patient presenting for care should be at least visually assessed within 10 minutes of presentation.
For each triage level there is a list of presenting complaints or conditions.
The ED RN assigns acuity based on chief complaint and a focused subjective and objective assessment.

7. The triage assessment The triage assessment:
Chief complaint: patient’s statement of the problem
Validation and assessment of chief complaint:
Subjective: Onset/Course/Duration
When did it start (be exact with time)? What were you doing when it started?
How long did it last?
Does it come and go?
Is it still present?
Where is the problem? Describe character and severity if painful (Pain scale).
Radiation?
Aggravating or alleviating factors?
If pain is or was present: Character and intensity (pain scale) to be documented.
Previous history of same? If yes, what was the diagnosis?
Objective: this part of the triage assessment may be deferred to the treatment area if the patient requires rapid access to care / interventions (Level I, II, III).
Physical appearance - color, skin, activities
Degree of distress: severe distress; NAD (no acute distress)
Emotional response: anxious, indifferent
Complete Vital Signs if time allows or necessary for assignment of triage level (Level III, IV, V).
Physical assessment
Additional Information:
Allergies
Medications:
List by name, if available
List by category if patient doesn’t know name: B/P, heart, stomach, nerve

8. Triage & Acuity Scale Category Definitions
Five levels of triage acuity scales 1-Resuscitation: immediately to be seen 2- Emergent (to be seen in 1-14 minutes) 3- Urgent (to be seen minutes) 4- Less urgent (to be seen 1-2 hours) 5- Non-urgent (to be seen 2-24 hours)

9. Triage & Acuity Scale Category Definitions
Level I Resuscitation
Conditions that are threats to life or limb (or imminent risk of deterioration) requiring immediate aggressive interventions.
e.g.
Code/arrest, Major trauma, Shock states, Severe Respiratory Distress, Unconscious

10. Triage & Acuity Scale Category Definitions
Level II Emergent
Conditions that are a potential threat to life limb or function, requiring rapid medical intervention or delegated acts.
e.g.
Altered mental state: Infectious, inflammatory, ischemic, traumatic, poisoning, drug effects, metabolic disorders, dehydration …can all affect sensorium from simple cognitive deficits to agitation, lethargy, confusion, seizures, paralysis, coma.
Severe trauma

11. Triage & Acuity Scale Category Definitions
Level III Urgent
Conditions that could potentially progress to a serious problem requiring emergency intervention. May be associated with significant discomfort or affecting ability to function at work or activities of daily living.
Time to physician £ 30 min.
Moderate trauma: Patients with fractures or dislocations or sprains with severe pain (8-10/10).
GI Bleed: Upper or lower GI bleed, not actively bleeding, with normal vital signs

12. Triage & Acuity Scale Category Definitions
Level IV Less Urgent (Semi urgent)
Conditions that related to patient age, distress, or potential for deterioration or complications would benefit from intervention or reassurance within 1-2 hours
E.g.
Corneal Foreign body: If pain is mild or moderate (4-7/10), Minor fractures, Minor head injury, alert (GCS 15)

13. Triage & Acuity Scale Category Definitions
Level V Non Urgent
Conditions that may be acute but non-urgent as well as conditions which may be part of a chronic problem with or without evidence of deterioration.
The investigation or interventions for some of these illnesses or injuries could be delayed or even referred to other areas of the hospital or health care system.
e.g.
Minor trauma: contusions, abrasions, minor lacerations (not requiring closure by any means,
Sore throat, URI (viral illnesses, with normal vital signs or low grade fever )

14. Overview of the Emergency Severity Index

15. The Emergency Severity Index (ESI)
The Emergency Severity Index (ESI) is a simple to use, five-level triage algorithm that categorizes emergency department patients by evaluating both patient acuity and resource needs. If a patient does not meet high acuity level criteria (ESI level 1 or 2), the triage nurse then evaluates expected resource needs to help determine a triage level (ESI level 3, 4, or 5)

16. the ESI algorithm

17. The Emergency Severity Index (ESI)
The algorithm uses four decision points
(A, B, C, and D) to sort patients into one of the
five triage levels.
four key questions:
A. Does this patient require immediate life-saving
intervention?
B. Is this a patient who shouldn't wait?
C. How many resources will this patient need?
D. What are the patient's vital signs

18. Decision Point A Does this patient require immediate life-saving
intervention?
1- Immediate life-saving intervention required: airway, emergency medications, or other hemodynamic interventions (IV, supplemental O2, monitor, ECG or labs DO NOT count); and/or any of the following clinical conditions: intubated, apneic, pulseless, severe respiratory distress, SPO2<90, acute mental status changes, or unresponsive.
2- Unresponsiveness is defined as a patient that is either:
(1) nonverbal and not following commands (acutely); or
(2) requires noxious stimulus (P or U on AVPU) scale.

19. the patient requires an immediate lifesaving intervention??
Does this patient have a patent airway?
Is the patient breathing?
Does the patient have a pulse?
Is the nurse concerned about the pulse rate, rhythm, and quality?
Was this patient intubated pre-hospital because of concerns about the patient's ability to maintain a patent airway, spontaneously breathe,
or maintain oxygen saturation?
Is the nurse concerned about this patient's ability to deliver adequate oxygen to the tissues?
Does the patient require an immediate medication, or other hemodynamic intervention such as volume replacement or blood?
Does the patient meet any of the following criteria: already intubated, apneic, pulseless, severe respiratory distress, SpO2 < 90 percent, acute mental status changes, or unresponsive?
Questions to evaluate If the patient needs lifesaving interventions

20. Decision Point A
The triage nurse must also assess the patient's level of responsiveness.
The ESI algorithm uses the AVPU (alert, verbal, pain, unresponsive) scale

21. Decision Point A:
Level-1 patients are critically ill and require immediate physician evaluation and interventions.
Each patient with chest pain must be evaluated
within the context of the level-1 criteria
Example
Cardiac arrest, Respiratory arrest, Severe respiratory distress, SpO2 < 90, Critically injured trauma patient who presents, unresponsive, Overdose with a respiratory rate of 6, Severe respiratory distress with agonal or gasping type respirations, Severe bradycardia or tachycardia with signs of hypoperfusion, Hypotension with signs of hypoperfusion, Trauma patient who requires immediate crystalloid and colloid resuscitation, Chest pain, pale, diaphoretic, blood pressure70/palp., Weak and dizzy, heart rate = 30, Anaphylactic shock

22. Decision Point B: Should the Patient Wait?
high-risk patient is one whose condition could easily deteriorate or who presents with symptoms suggestive of a condition requiring time-sensitive treatment.
E.g severe headache evoking subarchnoid hemorrage

23. Decision Point B: Should the Patient Wait?
Severe pain/distress is determined by clinical observation and/or patient rating of greater than or equal to 7 on 0-10 pain scale.
Intervention
ESI level-2 patients need vital signs and a comprehensive nursing assessment but not necessarily at triage.
Placement in the treatment areais a priority and should not be delayed to finish obtaining vital signs or asking additional questions.

24. Decision Point C: Resource Needs
C. How many resources will this patient need?
Resources: Count the number of different types of resources, not the individual
Tests or x-rays (examples: CBC, electrolytes and coags equals one resource; CBCplus chest x-ray equals two resources).

25. Decision Point C: Resource Needs
This decision point again requires the triage nurse to draw from past experiences in caring for similar emergency department patients.

26. Decision Point C: Resource Needs
ESI level 3 patients present with a chief complaint that requires an in-depth evaluation.
An example is patients with abdominal pain.
They often require a more in-depth evaluation but are felt to be stable in the short term, and certainly may have a longer length of stay in the ED
ESI level 4 and ESI level 5 make up between 20 percent and 35
percent of ED volume, perhaps even more in a community with poor primary care access.

27. Decision Point C: Resource Needs
Before assigning a patient to ESI level 3, the nurse needs to look at the patient’s vital signs and decide whether they are outside the accepted parameters for age and are felt by the nurse to be meaningful.
If the vital signs are outside accepted parameters, the triage nurse should consider upgrading the triage level to ESI level 2.
The vital signs used are pulse, respiratory rate, and oxygen saturation and, for any child under age, body temperature.

28. Decision Point C: Resource Needs
Ankle injury Healthy, 19-year-old female who twisted her ankle playing soccer. Edema at lateral malleolus, hurts to bear weight. ESI Resources = 1 Ankle x-ray
Urinary tract infection symptoms
Healthy, 29-year-old female with UTI symptoms appears well, afebrile, denies vaginal discharge
ESI Resources = 1
Exam Urine & urine culture

29. Case discussion
45-year-old male involved in a motor vehicle crash immediately prior to arrival. Unable to remember the events, moderately severe headache.
Level 2. At high-risk for a traumatic brain injury and possible epidural hematoma.
52-year-old male with sudden onset of slurred speech level 2. High risk for acute stroke

30. Case studies
EMS presents to the ED with an 18-year-old female with a suspected medication overdose. Her college roommates found her lethargic and “not acting right,” so they called 911. The patient has a history of depression. On exam, you notice multiple superficial lacerations to both wrists. Her respiratory rate is 10, and her SpO2 on room air is 86 percent. ESI level 1: Requires immediate lifesaving intervention. The patient’s respiratory rate, oxygen saturation, and inability to protect her own airway indicate the need for immediate endotracheal intubation

31. Resources http://caep.ca/resources/ctas/implementation-guidelines
Emergency Severity Index (ESI). A Triage Tool for Emergency Department Care. Version 4. Implementation Handbook Edition