1. Triage Hospitalist Night Float Curriculum Lucile Packard Children’s Hospital, Stanford Written by Becky Blankenburg, MD, MPH and Erin Augustine, MD

2. Objectives 1.To refine your own system for triaging pages and phone calls at night. 2.To identify ways of proactively improving your triage abilities. 3.To elucidate key details when receiving medical information over the phone.

3. Case 1 You are the intern on-call and simultaneously receive the following 5 pages. How do you prioritize them? What do you do? 1.“Josh has bad abdominal pain.” 2.“Sophia’s mom just arrived from work and would like to hear how she is doing.” 3.“Dr. Smith (Zach’s private physician) just called and is upset that you didn’t start him on Ceftriaxone. He would like a call back immediately.” 4.“Molly [12 with pre-B cell ALL just admitted with fever and neutropenia] has a blood pressure that’s 70/30.” 5.“Alex is breathing harder. Would like to start Albuterol.”

4. Triage Definition: “A process for sorting injured [or sick] people into groups based on their need for or likely benefit from immediate medical treatment. Triage is used in hospital emergency rooms, on battlefields and disaster sites, [and at night] when limited medical resources must be allocated.” - American Heritage Dictionary

5. Triage Derived from the French word trier, meaning “to sort” First used by the chief surgeon of Napoleon’s army (Dominique-Jean Larrey) in the early 19 th century First published report of civilian ED triage in 1966

6. General Principles to Improve Ability to Triage on the Wards What do you do? How can you help others improve their ability to triage?

7. General Principles to Improve Ability to Triage on the Wards Get good sign-out Check on sicker patients at beginning of shift Anticipate how patients will get sicker and what you will do in response Know your resources ahead of time (physicians in-hospital (and outside), nurses, respiratory therapists, etc) Look/ask for trends –Trends in vitals, trends in pain, etc

8. General Principles to Improve Ability to Triage on the Wards cont Communicate delays/concerns to your attending –Some delays can lead to poor patient outcomes (and your attendings can be helpful mobilizing resources, if they know) Communicate delays to families and nurses (when possible) –Most people are remarkably understanding if they just have appropriate expectations

9. Case 2 You are the senior on-call and take the following phone advice call from a patient’s parent. What do you do? “Eva has been vomiting.”

10. Phone Triage – Calls from Parents Goals: Answer simple medical questions. Advise disposition for a patient (e.g., if needs to be seen immediately or can wait to be seen). May not be necessary to diagnose.

11. Phone Triage – Calls from Parents: Patient’s Medical History Helpful medical information to know and document: Call Back Number Name of Parent History of Present Illness Past Medical History (also review on-line, if available) Medications Allergies to Medications

12. Mental Status Vitals –Temperature, pulse, respiratory rate Respiratory –Respiratory rate, retractions Abdomen GU Skin –Rashes Phone Triage – Calls from Parents: Physical Exams Over the Phone

13. Phone Triage – Calls from Parents: Management Options 1.Where to Triage a.911 b.ED immediately c.Urgent Care d.PCP next day/in a few days e.Call family same day/next day to follow-up 2.Prescriptions a.Can call in simple prescriptions 3.Review routine return precautions a.Signs/symptoms for the parents to be aware of and return to medical attention if present 4.Document your call (in Cerner at LPCH)

14. Phone Triage – Outside Providers: Communicate Patient Information Name, Age, Weight Current Medical Condition Pertinent Past Medical History and Medications Allergies Vital Signs (Including BP & O 2 Sat) Pertinent Physical Exam Findings  Mental Status  Airway Status  Perfusion Assessment Interventions Performed & Response to Therapy Condition Updates Send Copies of Notes, Labs, Imaging Studies

15. Phone Triage – Outside Providers: Communicate Recommendations Providing Advice Is Recommended Evaluation  Labs  Imaging Management  Airway Management  Oxygen  Intubation  IV Placement  Medication Administration Transportation

16. Transport Considerations Local Resources  Staff Availability & Training  Equipment  Medications Distance of Transport Transport Availability Road Conditions & Weather

17. Transportation Options Basic Life Support (BLS) Advanced Life Support (ALS) Critical Care Neonatal Air  Helicopter  Fixed-Wing Airplane

18. Basic Life Support Transport Team  EMT-Basic Capabilities  Administer Oxygen  Administer IV Fluids  Immobilize  Administer Limited Selection of Medications  Albuterol, EpiPen, Oral Glucose Recommended if  Stable Patient  Immediate Transport Necessary (“Load & Go”)

19. Advanced Life Support Transport Team  EMT-Paramedic Capabilities  Intubate  Obtain IV Access  Administer Oral & IV Medications Recommended if  Life-Threatening Condition  Altered Consciousness  Respiratory Distress

20. Critical Care Transport Team  EMT or Special Care Transport Paramedic  Critical Care Transport Nurse(s)  +/- Respiratory Therapist  +/- Physician Capabilities  Cardiac Monitoring  Vasoactive Medication Administration  Ventilatory Support

21. Air Transport Recommended if  Long Distances  Poor Road Conditions or Weather  Patient Requires Immediate Intervention  Intracranial Hemorrhage

22. Air Transport Special Considerations Unable to “pull over” to work on patient Noise prohibits auscultation Pneumothorax  Low pressure at high altitude may lead to pneumothorax expansion.  Helicopter transport is acceptable because it flies at sea level.  Fixed-wing airplane transport is only acceptable if the cabin is pressurized to sea level.  Best to avoid high altitude for 6 weeks after pneumothorax resolution.

23. Take Home Points 1.Take proactive steps to aid you in triaging pages and phone calls at night. 2.Focus on key details when receiving medical information from a lay person via phone. 3.It is best for your patient’s outcome to help advise his/her work-up and treatment as soon as the outside provider calls you.

24. References Schmitt BD, Thompson DA. Triage Documentation: Setting a Best Practice. http://www.answerstat.com/articles/5/42.html, 2005.http://www.answerstat.com/articles/5/42.html Thompson T, Stanford K, Dick R, Graham J. Triage Assessment in Pediatric Emergency Departments: A National Survey. Ped Em Care, 26(8):544-548, 2010. American College of Surgeons Committee on Trauma, American College of Emergency Physicians, National Association of EMS Physicians, Pediatric Equipment Guidelines Committee-Emergency Medical Services for Children (EMSC) Partnership for Children Stakeholder Group and American Academy of Pediatrics. Policy Statement – Equipment for Ambulances. Pediatrics. 2009. 124:e166-71. Orr RA, Felmet KA, Han Y, McCloskey KA, Dragotta MA, Bills DM, Kuch BA, Watson RS. Pediatric specialized transport teams are associated with improved outcomes. Pediatrics. 2009. 124:40-8. Sirbaugh PE, Leswing V. Prehospital Pediatrics. UpToDate. 2011. Baumann MH. Pneumothorax and Air Travel: Lessions Learned From a Bag of Chips. Chest. 2009. 136:655-6.