Triage in Emergency Department

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Triage in Emergency Department
Triage
Waiting room
Team leader
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Definition of Triage

• Triage is the term derived from the French verb
  trier meaning to sort or to choose
• Its 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

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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.

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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.

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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.
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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

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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

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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

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Triage levels

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

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Overview of three category triage acuity systems
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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

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Triage levels

• 2- Emergent
• Potential threat to life,limb or function
• Nurse Immediate , Physician lt15 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

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Triage levels

• 3- Urgent
• Condition with significant distress
• Time Nurse lt 20 min, physician lt 30 min
• Head injury without decrease of LOC but with
  vomiting
• Mild to moderate respiratory distress
• G.I. Bleed not actively bleed
• Acute psychosis

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Triage levels

• 4- Less urgent
• Conditions with mild to moderate discomfort
• Time for Nurse assessment lt1h
• Time for physician assessment lt 1h
• Head injury, alert, no vomiting
• Chest pain, no distress, no cardiac susp.
• Depression with no suicidal attempt

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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. lt 39

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Basic component of triage

• An across-the room assessment
• The triage history
• The triage physical assessment
• The triage decision

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An across the room assessment

• To identify obvious life threat conditions
• General appearance

Disability (neurogenic)
Air way
Circulation
Breathing
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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 doesnt look right kindly but
  quickly interrupt any current interaction and go
  investigate.

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Across the room assessment

• Air way
• Abnormal airway sounds, strider, 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 apnea periods, retractions, use
  accessory muscles, nasal flaring, grunting, or
  audible wheezes

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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

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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

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Requirements of Triage nurse

• Be able to function well under stressful
  situations
• Be able to make accurate assessments regarding
  patient care
• Have working knowledge of internal operations of
  emergency department
• Know interdepartmental policies
• Be able to make rapid and sound decisions
• Have firm convictions
• Posses good communication skills
• Be able to offer emotional support to others
• Be able to think ahead

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Cont. Requirements of Triage nurse

• Be able to supervise others
• Be an on the spot teacher
• Be able to control traffic flow
• Posses good crisis intervention skills
• Have a working knowledge if the prehospital care
  system
• Be able to avoid conflict and loss of temper
• Represent the hospital and emergency department
  to the public
• Assist in discharge planning
• Be able to handle telephone triage
• Be able to deal with patient communication
  problems

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Qualifications of triage nurse

• Posses valid state registered nurse license
• Be certified as mobile intensive care nurse
• Be certified in basic life support
• Have minimum of two years of critical care
  nursing experience with at least six months of
  this being in the emergency department
• Have at least four training shifts in the triage
  position with senior triage nurse
• Have at least three evaluation shifts in the role
  of triage

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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.

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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.

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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.

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• 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