Triage This is the lecture No. 2 Source: Manual of emergency care September 20111Dr. Ahmad...

Triage

This is the lecture No. 2Source: Manual of emergency care

September 20111 Dr. Ahmad Tubaishat

Triage

The process of sorting patients as they present to the ED for care.

Some cases need to be seen immediately, and some can wait safely. Decision based on the nurse assessment.

Goal: place right patient in the right place at the right time for the right reason.


TriageTriage systems:

Three types identified, differ in:

-Triage severity rating system -staffing

-degree of assessment and documentation -extent to which triage staff initiate diagnostic

and therapeutic interventions.


Triage1 -Type I:

Nonnurse, traffic director, receptionist greet pt, establish presenting complaint, based on that

take a decision ;

"sick" : taken to treatment area and seen promptly or "not sick"

In this system doc is minimal: name &C/CRisk: nonprofessional sort the case serious cases could unrecognized


Triage2 -Type II:

RN or physician performs a spot check. Take a quick look, limited information obtained, then pt assigned into3 levels: emergent, urgent, or nonurgent.

It is appropriate in low admissions rate hospital, when no need for 24hr triage.


Triage3 -Type III:

Comprehensive, advanceExperienced emergency nurse has a competency based triage orientation process.

C/C , sub. and obj. data collected to support the rating decision.

Initial findings documented in the record


TriageTwo tired triage system:

Because of high load in some hospitals the system adoptedFirst nurse: greet the pt, determine C/C, assess ABC, decide if pt. need to be seen immediately or wait.

Immediate care: go to treatment roomStable case: pt chart initiated by the first nurse, document C/C then direct the patient to assessment nurseSecond nurse: more detailed and focused evaluation, initiate lab work and radiology according protocols.


TriageTriage severity rating system:

-Two level triage:

Sick: urgent care needednot sick: no immediate care required.


Triage -Three level triage:

Sometimes Identified by colors: red yellow and green or numbered 1-3:

-Emergent: immediate care, threat to life, limb, organ.

e.g: cardiac arrest, major trauma, respiratory failure.

Team response needed and reassessment is continuous.


Triage -Urgent: prompt care, pt wait safely several

hoursE.g: abdominal pain, renal calculiReassessment needed q 30min


Triage- -Nourgent: need to be seen , but not critical

and patient can wait safely-e.g: soar throat, rash, conjunctivitis

Reassessment needed q 1-2 hr.

Poor inter and intra rater reliability between the 3 level


Triage -Four level triage :

Breaking the emergent level into life threatening and emergency

-Five level triage :

Range from level 1 most acute to level 5 acutee.g: Manchester triage system:


Triage


TriageThe emergency severity index:

It is 5 level scale categories pt by severity and resourcesSeverity: stability of vital function and potential to threatResources: number of resources expected to consume before discharge


TriageThe triage process:

Initial triage assessment should be within 5 min of arrivals.

-Across the room assessment:

Begin when the nurse see the patient, based on general appearance, decide wither immediate care needed, pt taken directly to treatment roomIf stable, the triage process continue


TriageObserve:

Airway patency, RR, external bleeding, LOC, pain, skin color, deformities, activity, clothingListen:

Abnormal airway sound, tone of voice, languageSmell:

Stool, urine, vomit, ketones, alcohol, infection, chemicals


Triage -The triage interview:

Introduce ur self, ask for C/C, HPI, based on that focused assessment of the problem and measure V/S. level determined: either go immediately to a room for treatment or to waiting room.

Communication is important


TriageInformation seek:

Who: pt demographicsWhat: C/CWhere: location of the problem & S/SWhen: time of symptom onsetWhy: precipitating factorsHow: how symptom affect normal function and how much


Triage -Triage V/S:

It is a controversial area

-Objective data:Physical examination related to C/C only not system by system or head to toe examination.

-Triage severity rating :Based on C/C, subjective and objective data, triage nurse use knowledge, experience and guidelines to assign severity rating.

Undertriaged pt receive delayed care and risk deterioration. Overtriaged divert resources.


TriageSafety and securityFactors that contribute to violence: overcrowding, long waiting, violent gangs.

Measures should be taken: panic buttons, restricted access doors, security cameras, police officersMonitor behavior

Triage nurse shouldn’t place themselves or others at risk.


TriageTriage documentation:

Clear concise, support the assigned severity rating.

Depend on the policy: usually there is area in the chart for triage notes. SOPIE.


TriageInfection control:

Triage nurse should use STD infection control precautionsHand washing between pt.

It is an portal of entry for contagious diseases: appropriate precautions


TriageTelephone triage:

Verbal interview and making assessment of the health status of the caller by trained tel triage nurse.


TriageTriage qualifications:

-RN, min 6 months of emergency experience -formal triage education with supervised preceptorship

-ACLS cert -Emergency nursing peds course

-trauma nursing course -emergency nurse cert

-effective communications, flexible -ability to use nursing process effectively

-role model and representative -excellent decision making skills


TriagePatient assessment:

Component of the initial assessmentPrimary assessment:

-A: Airway -B: Breathing -C: Circulation

-D: Disability, AVPU (alert, verbal, pain, unresponsive)

-E: Exposure/ Environmental control


TriageSecondary assessment:

-F: Full set of vitals: Temp, Pulse, Respiration, RR, o2 sat, weight

-G: Give comfort measures: PQRST for pain -H: History (S& O: C/C , HPI, medical history,

meds, labs, family hx) and head to toe assessment

-I: Inspect posterior surfaces


Triage This is the lecture No. 2 Source: Manual of emergency care September 20111Dr. Ahmad...

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