TRIAGE

The best for the most with the least by the fewest.

HISTORYThe word triage, arising from the French trier meaning to sort has its origins in Latin.

DEFINITIONTriage is a brief clinical assessment that determines the time and sequence in which patients should be seen in the ED or, if in the field, the speed of transport and choice of hospital destination

PRIMARY OBJECTIVES Promptly identify patients requiring immediate, definitive careDetermine the appropriate area for treatmentFacilitate patient flow through the ED and avoid unnecessary congestion

Provide information and referrals to patients and familiesAllay patient and family anxietyEnhance favorable public perceptions of and experiences with emergency servicesPRIMARY OBJECTIVES

Triage is not only a necessity, but a major component of the Emergency Medical System

TYPES OF ED TRIAGE SYSTEMSVery diverseDeveloped according to the institutions and departments needsShould be tailored to meet the common goals of triage

TYPES OF ED TRIAGE SYSTEMS# of patients and severity of injuries < resourcesLife threatening injuries are treated first# of patients and severity of injuries > resourcesPatients with greatest chance of survival are treated first

TYPES OF ED TRIAGE SYSTEMSType I: Traffic Director-Triagemost basic typegreeting or traffic directing is performed by a non-professionalhow sick the patient looks determines classification as emergent or nonurgent

TYPES OF ED TRIAGE SYSTEMSType II: Spot-check Triagequick look systemRN or MD obtains info and limited subjective/objective data related to chief complaintemergent, urgent, delayed

Type III: Comprehensive Triagemost advanced system of triageassessment and prioritization performed by an experienced RNuse of sophisticated triage categoriesstandards followed for assessment, planning and interventionTYPES OF ED TRIAGE SYSTEMS

COMPREHENSIVE TRIAGE GOALSIdentification of patients with life-threatening problemsRegulation of patient flowEfficient use of resources and space

APPLICATIONSTRAUMADISASTERPREHOSPITAL OUTBREAKSEMERGENCY DEPARTMENT

START SYSTEMSimple Triage and Rapid Treatment Created in the 1980s by Hoag Hospital and the Newport beach CA Fire DepartmentAllows rapid assessment of victimsIt should not take more than 15 seconds/ patient

START SYSTEMClassification based on 3 categories:RespirationPerfusionMental status

Medical Screening ExaminationChief complaint - High acuity, high risk, true emergency Vital signs - Grossly abnormal Mental status - Evidence of abnormalities General appearance - Patient looks sick, patient's skin looks poorly perfused, patient shows signs of dehydration Ability to walk - Patients who cannot walk are at high risk for true emergency medical conditions.

METHODSThe majority of US Emergency Departments use 3-level triage:Emergent requires immediate evaluation & treatmentUrgentcan tolerate a period of time in the waiting roomNon-urgentminor illness/injury that can be treated within six hours

EmergentLife and limb threatening conditionsImmediate care within secondscardiac arrest, acute severe chest pain, massive vomiting of blood, sudden loss of consciousness, and major trauma with hypotensionReassessment is continuous

UrgentRequires prompt care but will not cause loss of limb or life if left untreated for hoursacute dyspnea, acute abdominal pain, acute chest pain, acute confusion, and severe pain. abdominal pain, high fever, acute back pain, serious extremity injuries, and large or high-risk lacerationsReassessment is every 30 minutes

Non-urgentDisorders are chronic, minor, or self-limiting. medication refill, acne, mild adult upper respiratory tract symptoms, mild sore throat, blood pressure check, and lumps and bumps. Keep in mind that no matter how minor, these patients may still require an MSE if they request treatment or evaluationReassessment is every 1 to 2 hours

Who should do triage?Early studies showed little difference in predicted outcomes of patients when physicians, as opposed to nurses, perform triageHowever, more recent studies suggest that experienced emergency medicine (EM) physicians and EM nurses actually may provide the best triage

PitfallsFailure to recognize and attend to a patient who complains of severe painFailure to recognize or acknowledge high-risk chief complaints Failure to take adequate vital signs

PitfallsFailure to adequately document the triage and/or MSE Failure to retriage patients initially assigned to the waiting room: Patients assigned to a waiting room should have vital signs retaken every 2 hours

CASESCase 1: A 36-year-old man presented to the ED with severe chest pain. His vital signs were blood pressure, 140/90 mm Hg; pulse, 120 beats per minute (bpm); respiration, 20 breaths per minute (bpm); and temperature, 99F. Although the patient's pulse was 120, his respiratory rate was normal, and he looked well.

Case 2: A 43-year-old man presented to the ED, complaining of a severe headache. The patient had normal vital signs except for a temperature of 39C. The ED was very busy and crowded.

Case 3: A 65-year-old man presented to the ED complaining of groin pain. He said the pain was severe and he did not feel well. His vital signs were blood pressure, 150/95 mm Hg; pulse, 108 bpm; respiration, 22 bpm; and temperature, 38C.

Case 4: A 55-year-old man presented to the ED complaining of abdominal pain. He stated that he thought his condition was secondary to eating too much greasy fast food too rapidly. His vital signs were blood pressure, 150/100 mm Hg; pulse, 100 bpm; respiration, 22 bpm; and temperature, 37C.

Case 5: A 22 year old female came in due to acute onset diarrhea. She had about 6 episodes and had severe epigastric pain. BP: 120/80, HR: 89 and RR: 23.

Case 5: A five year old female came in due to fever and chills of five days duration. HR: 110, RR: 30 and T: 40C. The patient had maculopapular rashes all over.

TRIAGE EXAMINATIONYEAR LEVEL VI2007

36/F fell from a ladder on outstretched hand with gross deformity, L forearm

40F, smokerCC: Vaginal bleeding VS: BP 80/50HR 90RR 24

55M, hypertensive, smokerCC: Chest pain VS: BP 90/50HR 90RR 24

56M, cookCC: difficulty of breathing VS: BP 130/80HR 90RR 28

58M, smokerCC: LLQ painVS: BP 120/80HR 100RR 24

19M, vendorhit-and-run victimunconscious VS: BP 130/80HR 90RR 24

22F, studentCC: R shoulder pain VS: BP 120/80HR 80RR 20

36M, non-smokerCC: low back pain VS: BP 130/80HR 88RR 22

44M, smokerCC: amputated index finger VS: BP 130/80HR 90RR 24

41M, smokerCC: foreign body sensation R eye VS: BP 130/80HR 90RR 24

56M, laborer, smokerCC: unconscious VS: BP 130/80HR 90RR 24

40M, carpenter, HPNCC: fall VS: BP 100/80HR 90RR 24

25M, studentCC: dog bite VS: BP 120/80HR 80RR 20

30M, bodybuilderCC: chest pain VS: BP 130/80HR 94RR 26

40M, smokerCC: electrocuted/fall VS: GCS 15BP 130/80HR 90RR 24

43M, smokerCC: numbness, lower extremities VS: BP 130/80HR 90RR 24

40M, smokerCC: epigastric pain VS: BP 140/80HR 92RR 20

12M, vendorCC: side-swiped by a truck VS: BP 120/80HR 90RR 24

40M, jockeyCC: fall VS: BP 130/80HR 90RR 24

QUESTIONS?The process we understand as triage was first described by Baron Dominique Jean-LarreyFirst systematic description in civilian medicine was from E. Richard Weinerman in Baltimore in 1964