Triage ( emergency department )

7/29/2019 Triage ( emergency department )

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Triage in Emergency Department

TriageWaiting

room

Team leader


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Definition of Triage

Triage is the term derived from the Frenchverb trier meaning to sort or to choose

Its the process by which patients classifiedaccording 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:

1. Identify patients requiring immediate care.

2. Determine the appropriate area for treatment

3. 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 orhuman-made, that produces patients innumbers needing services beyond immediately

available resources.

The key to successful disaster management isto provide care to those who are in greatest

need first.

Correct triage is essential to accomplish thisgoal


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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 whogreets each patients on arrival, perform a primarysurvey and determine whether the patient is able to

wait for further assessment by a second triage nurse.

Divide tasks among staff members, internal triageand external triage


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Triage levels

1- Resuscitation

2- Emergent

3- urgent

4- less urgent

5- Non urgentThe Canadian E.D. Triage and Acuity Scale


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TRIAGE LEVELSLevel 1 - Immediately Life-threatening or

Resuscitation:

Conditions requiring immediate assessment.

Includes:

Airway or severe respiratory compromise

Cardiac arrest.

Severe shock. Symptomatic cervical spine injury.

Multisystem trauma.

Altered level of consciousness (GCS < 10)..


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Triage levels Triage Level 2Imminently Life-threatening or

Emergent: Conditions requiring assessment within 10 to 15 minutes

Include:

Head injuries.

Severe trauma / Asthma / Allergy

Any pain greater than 7 on a scale of 10

GI bleed with unstable vital signs.

Abdominal pain in patients older than age 50.

Any neonate age 7 days or younger


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Triage levels Triage Level 3Potentially Life-threatening/Time

Critical or Urgent

Conditions requiring assessment within 30 minutes

Include: Alert head injury with vomiting.

Mild to moderate asthma / trauma

GI bleed with stable vital signs. Mild to moderate respiratory distress

Acute psychosis


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Triage levels Triage Level 4Potentially Life-

serious/Situational Urgency or Semi-urgent

Conditions requiring assessment within 1 hr.

Include:

Head injury without vomiting.

Minor trauma / allergy

Vomiting and diarrhea in patient older than age 2without evidence of dehydration.

Earache.

Chronic back pain


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Triage levels

Triage Level 5Less/Non-urgent

Conditions requiring assessment within 2 hours

Include: Minor trauma, not acute.

Sore throat.

Chronic abdominal pain.


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Color Coding

Red tags - (immediate) are used to label those

who cannot survive without immediate

treatment but who have a chance of survival.

Yellow tags - (observation) for those who

require observation (and possible later re-

triage). Their condition is stable for the

moment and, they are not in immediate danger

of death.


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Green tags - (wait) are reserved for the

"walking wounded" who will need medical

care at some point.

White tags - (dismiss) are given to those

with minor injuries for whom a doctor's careis not required.

Black tags - (expectant) are used for thedeceased and for those whose injuries are so

extensive that they will not be able to survive

given the care that is available.


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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

Air way

Breathing

Circulation

Disability

(neurogenic)


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Across the room assessment

The triage nurse must scan the area wherepatients 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 butquickly interrupt any current interaction and go

investigate.


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Across the room assessment

Air wayAbnormal 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 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, flushingUncontrolled 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 medicaltreatment

Adequate training and competent skills,

language, terminology Ability to use the critical thinker process

Good decision maker


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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 withoutcardinal signs of severe illness may develop

them during long waits.

Patients who appear intoxicated actually mayhave 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

Triage ( emergency department )

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