Florida Hospital Florida Hospital DeLand DeLand

Triage Orientation Triage Orientation ClassClass

By Tammy Kirby, RN, BSNBy Tammy Kirby, RN, BSN

EVOLTION OF A TRIAGE EVOLTION OF A TRIAGE RN…RN…

Triage is derived from the french verb “trier” meaning to Triage is derived from the french verb “trier” meaning to “sort” or “choose”“sort” or “choose”

Comprehensive triage (Emergency Severity Index) is Comprehensive triage (Emergency Severity Index) is supported by ENA standards of Emergency Nursing Practice supported by ENA standards of Emergency Nursing Practice and is utilized at Florida Hospital DeLand. and is utilized at Florida Hospital DeLand.

You as the triage RN are sorting and classifying patients You as the triage RN are sorting and classifying patients according to their urgency of condition or the chief according to their urgency of condition or the chief complaint. complaint.

Roles of the triage RNRoles of the triage RN Make accurate, rapid triage decisions (may be based on an across-the-Make accurate, rapid triage decisions (may be based on an across-the-

room assessment)room assessment) Get patients with life-threatening emergencies back immediately and sort Get patients with life-threatening emergencies back immediately and sort

through the rest utilizing the Emergency Severity Index (ESI) triage processthrough the rest utilizing the Emergency Severity Index (ESI) triage process Be nice, especially under times of stress! Everyone is our customer and we Be nice, especially under times of stress! Everyone is our customer and we

want their business! Do unto others, even in times of high volumeswant their business! Do unto others, even in times of high volumes Answer questions appropriatelyAnswer questions appropriately Monitor the doorway and allow people back only after calling to make sure Monitor the doorway and allow people back only after calling to make sure

that it is okthat it is ok Quickly assess OB patients. If the patient is 20 weeks pregnant or more Quickly assess OB patients. If the patient is 20 weeks pregnant or more

and comes to the E.D with back or abdominal pain, call OB and send them and comes to the E.D with back or abdominal pain, call OB and send them upstairsupstairs

Perform initial interventions ex: icepack, dressings, blood glucose levels, Perform initial interventions ex: icepack, dressings, blood glucose levels, administer Tylenol/Motrin administer Tylenol/Motrin

Patient assessment and re-assessment if increased wait timesPatient assessment and re-assessment if increased wait times Perform actual triage process in a timely manner (most patients should Perform actual triage process in a timely manner (most patients should

take between 2-5 minutes).take between 2-5 minutes).

Roles Continued….Roles Continued…. Guide your techs. They are meant for Guide your techs. They are meant for

patient flow and assistance, cleaning patient flow and assistance, cleaning beds, greeting, rounding, and beds, greeting, rounding, and monitoring patients in the lobby. They monitoring patients in the lobby. They ARE NOT meant to stay with you in the ARE NOT meant to stay with you in the triage room and assist with vital signstriage room and assist with vital signs

Place basic orders. Ex: Urines, xrays, Place basic orders. Ex: Urines, xrays, Tylenol/Motrin. Remember to document Tylenol/Motrin. Remember to document in treatments that you collected a urine in treatments that you collected a urine

Many times you are the first Many times you are the first healthcare professional the patient healthcare professional the patient contacts and YOU represent the ENTIRE contacts and YOU represent the ENTIRE hospital at that pointhospital at that point

Provide patients with basic education in Provide patients with basic education in a positive and constructive manner. a positive and constructive manner. This can include basic health education This can include basic health education and illness or injury preventionand illness or injury prevention

Infection control: screen patients for Infection control: screen patients for potentially infectious diseases and potentially infectious diseases and provide appropriate isolation measuresprovide appropriate isolation measures

Always be sure to fill in as many fields as possible, even if it is ‘N/A’, Always be sure to fill in as many fields as possible, even if it is ‘N/A’, ‘Unknown’‘Unknown’

If they arrive via EMS, fill out the ‘EMS’ field and type in the unit numberIf they arrive via EMS, fill out the ‘EMS’ field and type in the unit number Be sure to review the allergiesBe sure to review the allergies The goal here is to try to triage a patient in 2-5 minutesThe goal here is to try to triage a patient in 2-5 minutes

Emergency Severity Index (ESI) TriageEmergency Severity Index (ESI) Triage

Reliable and accurateReliable and accurate ConsistentConsistent Evidence basedEvidence based Different nurses will rate the same Different nurses will rate the same

patient the same way patient the same way The same nurse will rate the same The same nurse will rate the same

patient the same way over timepatient the same way over time Rapid way of sorting patients Rapid way of sorting patients

based on their needsbased on their needs The ESI Triage requires nurses to The ESI Triage requires nurses to

anticipate expected resources anticipate expected resources neededneeded

Benefits of ESI include impartial Benefits of ESI include impartial judgments of patients who do not judgments of patients who do not need to be seen in the main E.D, need to be seen in the main E.D, but may be seen in Fast Track or but may be seen in Fast Track or categorized as an ‘MSE’ and can categorized as an ‘MSE’ and can follow up with DeLand Family follow up with DeLand Family Health Source or their pcp Health Source or their pcp

ESI Algorithm and 4 decision pointsESI Algorithm and 4 decision points

1.1. Is the patient Is the patient dying?dying?

2.2. Is this a patient Is this a patient who shouldn’t wait?who shouldn’t wait?

3.3. How many How many resources will this resources will this patient need?patient need?

4.4. What are the What are the patients vital signs?patients vital signs?

ESI LevelsESI Levels

Level 1-Resuscitative -REDLevel 1-Resuscitative -RED

Level 2-Emergent –ORANGELevel 2-Emergent –ORANGE

Level 3-Urgent-YELLOWLevel 3-Urgent-YELLOW

Level 4-Less Urgent-GREENLevel 4-Less Urgent-GREEN

Level 5-Non Urgent-BLUELevel 5-Non Urgent-BLUE

****Levels are decided by the approximate Levels are decided by the approximate number of resources that the patient will number of resources that the patient will utilizeutilize

LevelLevel AcuityAcuity Treatment and Treatment and reassessment reassessment guideline (times)guideline (times)

ExamplesExamples

11 ResuscitativResuscitativee

ImmediateImmediate Cardiac arrestCardiac arrest

Active seizureActive seizure

AnaphylaxisAnaphylaxis

Open chest woundOpen chest wound

UnconsciousUnconscious

UnresponsiveUnresponsive

Uncontrolled hemorrhageUncontrolled hemorrhage

22 EmergentEmergent 5-15 minutes5-15 minutes Acute Chest painAcute Chest pain

Irregular pulse with Irregular pulse with symptomssymptoms

Major fx (ex femur)Major fx (ex femur)

SnakebitesSnakebites

Stroke Fever>3mos oldStroke Fever>3mos old

Psych w S.I/H.IPsych w S.I/H.I

33 UrgentUrgent Up to 2 hrsUp to 2 hrs Renal calculiRenal calculi

Abdominal painAbdominal pain

DislocationsDislocations

Vaginal bleedingVaginal bleeding

Persistent n/v/dPersistent n/v/d

44 Less UrgentLess Urgent Up to 3 hrsUp to 3 hrs UTI’s Sore throatUTI’s Sore throat

STD’s CoughSTD’s Cough

Abscess FeverAbscess Fever

Vaginal dischargeVaginal discharge

55 Non-UrgentNon-Urgent When bed When bed availableavailable

Suture removalSuture removal

RX refill Dental painRX refill Dental pain

Bruise Minor insect bites Bruise Minor insect bites

ER rechecksER rechecks

ES

I Level

Decision Point ADecision Point A

ES

I Level 1

•Is the patient dying?•Does the patient need immediate intervention?

ES

I Level 1

Decision Point BDecision Point B

Should the patient wait? Is this a high risk Should the patient wait? Is this a high risk situation?situation?

Is the patient in extreme pain or Is the patient in extreme pain or distress?distress?

ES

I Level 2

Decision Point BDecision Point B

ES

I Level 2

Decision point CDecision point C

ES

I Level

Decision Point CDecision Point C

If the answer to the first two steps If the answer to the first two steps are “no” then the triage nurse moves are “no” then the triage nurse moves on in the algorithmon in the algorithm

Decision Point C consists of the Decision Point C consists of the determination of resourcesdetermination of resources

Level 3 patients are predicted to use Level 3 patients are predicted to use 2 or more resources, level 4 patients 2 or more resources, level 4 patients require 1 resource, and level 5 require 1 resource, and level 5 patients require 0 resources.patients require 0 resources.

Decision point DDecision point D

ES

I Level

Decision Point DDecision Point D

What Are the Patients Vital What Are the Patients Vital Signs? Signs? – Heart RateHeart Rate– RespirationsRespirations– Blood PressureBlood Pressure– Pulse OxPulse Ox– TemperatureTemperature

ES

I Level

Tem

pera

ture

*Note: Pediatric Fever *Note: Pediatric Fever CriteriaCriteria

AgeAge TemperatureTemperature ESI LevelESI Level

0-28 days0-28 days >100.4>100.4 22

1-3 months1-3 months >100.4>100.4 Consider 2Consider 2

3-36 months3-36 months >102.2>102.2 Consider 3Consider 3

Ordering Tylenol/Motrin…Ordering Tylenol/Motrin… You can do it!!!!!!!!!!!!!!You can do it!!!!!!!!!!!!!! Get an accurate height and weight on Get an accurate height and weight on

the childthe child If the patient is 6 months or older, ask if If the patient is 6 months or older, ask if

the parents medicated them at home, if the parents medicated them at home, if Motrin was given, give Tylenol in triage Motrin was given, give Tylenol in triage etc.etc.

If the patient is less than 6 months, give If the patient is less than 6 months, give Tylenol only!!!!! If the parents gave Tylenol only!!!!! If the parents gave Tylenol at home, call a physician and Tylenol at home, call a physician and possibly possibly obtain an order for Motrinobtain an order for Motrin

If it is an adult, call physician and give If it is an adult, call physician and give fever control medication as orderedfever control medication as ordered

Place the order in the computerPlace the order in the computer Go in to MAWGo in to MAW Scan the patient’s bandScan the patient’s band Scan the medication, adjust the dose Scan the medication, adjust the dose

and administer medand administer med Document in triage note how much was Document in triage note how much was

givengiven

Examples of Level 3Examples of Level 3

Stable Abdominal painsStable Abdominal pains Flank PainFlank Pain Dislocations (with a palpable pulse)Dislocations (with a palpable pulse) Vaginal Bleeding (VSS)Vaginal Bleeding (VSS) Persistent n/v/dPersistent n/v/d Psychiatric disorders without suicidal Psychiatric disorders without suicidal

or homicidal ideationor homicidal ideation

Examples of Level 4Examples of Level 4

Repeat HCG levels Repeat HCG levels with no other with no other complaints.complaints.

Possible strep Possible strep throatthroat

Foreign body in Foreign body in nose, ear, or eyenose, ear, or eye

STD check. No pain STD check. No pain or bleeding presentor bleeding present

Examples of Level 5=MSEExamples of Level 5=MSE

Standard prescription refillStandard prescription refill Superficial AbrasionSuperficial Abrasion Dental painDental pain Poison Ivy or Poison OakPoison Ivy or Poison Oak Suture removal (unless placed here)Suture removal (unless placed here) Sore Throat (no difficulty swallowing)Sore Throat (no difficulty swallowing) Sinus pain (without headache or Sinus pain (without headache or

fever)fever)

MSE Out Guidelines: Greater than 5 years old, less than 64 MSE Out Guidelines: Greater than 5 years old, less than 64 years oldyears old

PAIN….PAIN….

It can be used to upgrade a patient to the next, It can be used to upgrade a patient to the next,

higher acuity levelhigher acuity level. . All patients who have a pain All patients who have a pain rating of 7/10 or greater should be rating of 7/10 or greater should be considered considered for meeting a higher acuity level. However, follow your gut feeling and use your common sense

Ex: Ex: An elderly patient fell and may have fractured a hip. An elderly patient fell and may have fractured a hip. They arrive via private car with family and is in severe pain They arrive via private car with family and is in severe pain (10/10) and diaphoretic. Vital signs are stable. The patient (10/10) and diaphoretic. Vital signs are stable. The patient would typically be placed as a level 3, but do to pain level would typically be placed as a level 3, but do to pain level and symptoms, they may be placed as a level 2. and symptoms, they may be placed as a level 2.

SepsisSepsis They Key is EARLY detection and recognition.They Key is EARLY detection and recognition. Sepsis can lead to SIRS (Systemic Inflammatory Response Sepsis can lead to SIRS (Systemic Inflammatory Response

Syndrome), organ dysfunction, and ultimately end in death if Syndrome), organ dysfunction, and ultimately end in death if not detected ASAP!not detected ASAP!

Delayed treatment of patients with severe infection is Delayed treatment of patients with severe infection is associated with high mortality rates and increased costs for associated with high mortality rates and increased costs for hospitals.hospitals.

These patients need IV fluid resuscitation and antibiotic These patients need IV fluid resuscitation and antibiotic therapy ASAP.therapy ASAP.

SEPSIS-KEEP IT IN MIND!!!!SEPSIS-KEEP IT IN MIND!!!!Does the patient have any of the three following??????Does the patient have any of the three following??????

****Suspected infection?****Suspected infection?****Temp >100.4 or <96.5?****Temp >100.4 or <96.5?****HR >90?****HR >90?****RR > 20?****RR > 20?****Any altered mental status?****Any altered mental status?****02 Sat < 90%?****02 Sat < 90%?****SBP<90?****SBP<90?

----IF YOU ANSWERED ‘YES’ to 2 or more of the above, suspect SEPSIS!IF YOU ANSWERED ‘YES’ to 2 or more of the above, suspect SEPSIS!--Also, place a mask on patients with an active cough to prevent the spread of --Also, place a mask on patients with an active cough to prevent the spread of

infection!infection!--Encourage hand washing!--Encourage hand washing!

Sepsis continued….Sepsis continued….

As the triage RN, it is As the triage RN, it is youryour responsibility to triage these patients responsibility to triage these patients appropriately and get them to the appropriately and get them to the back as fast as possible. If there are back as fast as possible. If there are no beds and there is a protocol RN, no beds and there is a protocol RN, notify them to get the patient back to notify them to get the patient back to expedite the ‘Sepsis/Infection’ expedite the ‘Sepsis/Infection’ protocol. protocol.

CHEST PAINCHEST PAIN Patients 30 years old or older that Patients 30 years old or older that

present to triage with chest pain present to triage with chest pain are always a level 2.are always a level 2.

It is your responsibility as the It is your responsibility as the triage RN to obtain an ekg within triage RN to obtain an ekg within 10 minutes10 minutes

If there are beds available, send If there are beds available, send the patient straight back and the patient straight back and open the triage note. Notify the open the triage note. Notify the charge RN you are sending them charge RN you are sending them back.back.

If there are no beds available, If there are no beds available, place an order for the EKG in place an order for the EKG in triage and have a tech take a triage and have a tech take a sticker to the back for physician sticker to the back for physician review. Finish triage process.review. Finish triage process.

Worth RepeatingWorth Repeating

1. Does the Patient Require 1. Does the Patient Require Immediate Life saving Immediate Life saving interventions? interventions?

2. Is this a patient who 2. Is this a patient who shouldn’t wait?shouldn’t wait?

3. How many resources will this 3. How many resources will this patient need?patient need?

4. What are the patient’s vital 4. What are the patient’s vital signs?signs?

ES

I Level

Examples-Lets ChatExamples-Lets Chat

3 Month old presents with fever, vomiting x 2 this a.m, and cough. No 3 Month old presents with fever, vomiting x 2 this a.m, and cough. No diarrhea. Mom states baby is usually healthy but has not been eating. diarrhea. Mom states baby is usually healthy but has not been eating. Mother does not own a thermometer, but states pt ‘feels hot’. Baby is Mother does not own a thermometer, but states pt ‘feels hot’. Baby is listless, skin hot, sunken fontanel. All vitals with exception to temperature listless, skin hot, sunken fontanel. All vitals with exception to temperature are wnl.are wnl.

40 yr old male is brought in by his son. Pt states he fell 10 feet off a ladder 40 yr old male is brought in by his son. Pt states he fell 10 feet off a ladder and landed on his side. States R hip and R upper arm pain. Denies loc/neck and landed on his side. States R hip and R upper arm pain. Denies loc/neck pain. Pt pale, diaphoretic, mildly distressed. pain. Pt pale, diaphoretic, mildly distressed.

23 yr old presents with R sided dental pain x 1 week. States unable to get 23 yr old presents with R sided dental pain x 1 week. States unable to get a dental appointment due to lack of insurance. VSS. No other complaints, a dental appointment due to lack of insurance. VSS. No other complaints, no facial swelling. no facial swelling.

15 yr old male presents with sudden onset R testicular pain and swelling. 15 yr old male presents with sudden onset R testicular pain and swelling. Denies trauma. States ‘some’ discharge and ‘some’ pain w urination. Pt in Denies trauma. States ‘some’ discharge and ‘some’ pain w urination. Pt in obvious distress. VSS. obvious distress. VSS.

Triage Pointers and Documentation…Triage Pointers and Documentation…

If you don’t know….ask! Call the FT doc/nurse. Call the charge If you don’t know….ask! Call the FT doc/nurse. Call the charge nurse….utilize your co-workersnurse….utilize your co-workers

When documenting, use direct quotations from the patient When documenting, use direct quotations from the patient It is ok to administer weight-based Tylenol/Motrin. Place order in It is ok to administer weight-based Tylenol/Motrin. Place order in

computer, scan the patient, scan the medication, administer, and computer, scan the patient, scan the medication, administer, and chart in the triage note chart in the triage note

Place C-collar on acute neck pain patients. Remove rings on Place C-collar on acute neck pain patients. Remove rings on arm/wrist fx patients. Place masks on patients that are possibly arm/wrist fx patients. Place masks on patients that are possibly leukopenic or have flu-like symptoms leukopenic or have flu-like symptoms

If you do an EKG, order it in Power orders and mark it as If you do an EKG, order it in Power orders and mark it as ‘complete’ when done‘complete’ when done

It is ok to place basic orders in triage. Ex: urinalysis, DOA, It is ok to place basic orders in triage. Ex: urinalysis, DOA, pregnancy tests (Provider order), EKG, Tylenol/Motrin. Anything pregnancy tests (Provider order), EKG, Tylenol/Motrin. Anything you can do to expedite patient movement through the E.D, DO IT!!you can do to expedite patient movement through the E.D, DO IT!!

Heights and weights on EVERYONE! Heights and weights on EVERYONE!

Triage Pointers and Documentation Triage Pointers and Documentation cont..cont..

Document as if the next time you see the chart will be in court.Document as if the next time you see the chart will be in court. Do not assume anything. Document objective observations Do not assume anything. Document objective observations Document sufficient information to justify your triage decision. Document sufficient information to justify your triage decision.

May document this in ‘Special comments’ in I view if more room is May document this in ‘Special comments’ in I view if more room is needed needed

REASSESSMENT OF PATIENTS- If there is no bed available and the REASSESSMENT OF PATIENTS- If there is no bed available and the patient has to wait, those patients assigned to a Level 3 should be patient has to wait, those patients assigned to a Level 3 should be reassessed every hour. Non urgent patient may be reassessed reassessed every hour. Non urgent patient may be reassessed every 1-2 hours (‘Making the Right Decision: A triage Curriculum every 1-2 hours (‘Making the Right Decision: A triage Curriculum by ENA). by ENA).

Be sure to review all allergies and make an allergy bracelet with Be sure to review all allergies and make an allergy bracelet with ALL allergies written on it!ALL allergies written on it!

If pt has a dialysis shunt or a mastectomy, please place the pink If pt has a dialysis shunt or a mastectomy, please place the pink bracelet in triage indicating that this arm cannot be used for bp’s, bracelet in triage indicating that this arm cannot be used for bp’s, blood draws etc. blood draws etc.

Triage Pointers and Documentation Triage Pointers and Documentation cont..cont..

If a pregnant female arrives, If a pregnant female arrives, is complaining of abdominal is complaining of abdominal pain, back pain, or possible pain, back pain, or possible fetal demise, and is 20 fetal demise, and is 20 weeks or further along, call weeks or further along, call birthcare. Speak with the birthcare. Speak with the charge nurse and come to a charge nurse and come to a decision together. Typically, decision together. Typically, they should be seen they should be seen upstairs first. If they come upstairs first. If they come to the E.D with other to the E.D with other symptoms such as cough, symptoms such as cough, congestion, headache with congestion, headache with stable vitals etc, they stable vitals etc, they should be seen in the E.D. should be seen in the E.D.

Psychiatric/Suicidal patientsPsychiatric/Suicidal patients Not all psychiatric patients need to be a level 2. Patients are Not all psychiatric patients need to be a level 2. Patients are

made a level 2 only if they are suicidal, homicidal, or are acutely made a level 2 only if they are suicidal, homicidal, or are acutely psychotic and acting out.psychotic and acting out.

If they are S.I/H.I, call charge RN after triaging patient for bed If they are S.I/H.I, call charge RN after triaging patient for bed assignment. When you or your tech brings them back, get them in assignment. When you or your tech brings them back, get them in a gown and notify primary RN so that security may be notified for a gown and notify primary RN so that security may be notified for belongings search. If no bed is available, give patient urine cup belongings search. If no bed is available, give patient urine cup and utilize protocol process if availableand utilize protocol process if available

If a reliable person is with the suicidal patient they may wait a If a reliable person is with the suicidal patient they may wait a

FEW MINUTES until bed or protocol room is opened up for patient FEW MINUTES until bed or protocol room is opened up for patient

If patient is there for detox, vital signs are stable, and they ARE If patient is there for detox, vital signs are stable, and they ARE NOT suicidal, they are a Level 3 and may wait if necessaryNOT suicidal, they are a Level 3 and may wait if necessary

Left without being seenLeft without being seen If a patient states they want to leave, encourage them to If a patient states they want to leave, encourage them to

stay. Find out their reasoning for wanting to leave.stay. Find out their reasoning for wanting to leave.

If they leave even after speaking with them, make a note in If they leave even after speaking with them, make a note in Iview ‘special comments’ and do an Incident Report. On the Iview ‘special comments’ and do an Incident Report. On the incident report, you should choose the section ‘Behavioral’ incident report, you should choose the section ‘Behavioral’ and ‘LWBS’. Also in the report, indicate the time they and ‘LWBS’. Also in the report, indicate the time they arrived and the time they left.arrived and the time they left.

It is your responsibility to place that patient in check out It is your responsibility to place that patient in check out and to do the appropriate documentation and to do the appropriate documentation INCLUDINGINCLUDING the the FCT. Ask registration to remove that patient from checkout.FCT. Ask registration to remove that patient from checkout.

Florida Hospital DeLand’s PolicyFlorida Hospital DeLand’s Policy

‘‘The primary goal of triage is to identify patients who require immediate The primary goal of triage is to identify patients who require immediate treatment for life-threatening conditions. The second goal of triage is to treatment for life-threatening conditions. The second goal of triage is to sort or prioritize patients according to the identified acuity’.sort or prioritize patients according to the identified acuity’.

Procedure:Procedure:

1. The triage RN will collect data and follow the algorithm of the 1. The triage RN will collect data and follow the algorithm of the Emergency Severity Index (ESI) to make a triage decision, moving from Emergency Severity Index (ESI) to make a triage decision, moving from one ESI decision point to the next.one ESI decision point to the next.

2. Triage includes four basic components:2. Triage includes four basic components:

*A quick look assessment*A quick look assessment

*Triage history (very brief)*Triage history (very brief)

*Triage physical assessment (brief)*Triage physical assessment (brief)

*Triage decision (not so brief;)*Triage decision (not so brief;)

3. The triage RN will evaluate the patient condition and potential for 3. The triage RN will evaluate the patient condition and potential for deterioration based upon data collected and by use of the ESI tool. These deterioration based upon data collected and by use of the ESI tool. These are as follows…..are as follows…..

………………..ContinuedContinued

*Is the patient dying?*Is the patient dying?

*Is this a patient who shouldn’t wait? Why?*Is this a patient who shouldn’t wait? Why?

*How many resources should this patient need? What are *How many resources should this patient need? What are considered considered

resources?resources?

*What are the patient’s vital signs?*What are the patient’s vital signs?

4. Based upon the above collected data, E.D patients will be 4. Based upon the above collected data, E.D patients will be classified using the five level triage system and will be categorized classified using the five level triage system and will be categorized as one of the following: Resuscitative, Emergent, Urgent, Less-as one of the following: Resuscitative, Emergent, Urgent, Less-Urgent, or Non-Urgent.Urgent, or Non-Urgent.

5. Patient’s location for treatment will also be assigned by the 5. Patient’s location for treatment will also be assigned by the triage RN as either Main side or Minor Care.triage RN as either Main side or Minor Care.

EMTALAEMTALA Emergency Medical Treatment and Active Labor Act-Emergency Medical Treatment and Active Labor Act- States that a hospital States that a hospital

that receives Medicare benefits must do the following:that receives Medicare benefits must do the following:

- Provide a Medical Screening Exam to all patients who present on - Provide a Medical Screening Exam to all patients who present on hospital hospital

premises regardless of ability to pay. premises regardless of ability to pay.

- Provide stabilizing care- patients must not be at risk of - Provide stabilizing care- patients must not be at risk of deterioration from, deterioration from,

during, or following transfer or dischargeduring, or following transfer or discharge

- May NOT transfer patients who are potentially unstable if the - May NOT transfer patients who are potentially unstable if the hospital hashospital has

the capabilities on sitethe capabilities on site

- Maintain an on-call system to be able to provide services required - Maintain an on-call system to be able to provide services required to stabilizeto stabilize

patientspatients

- Provide patients with transfers that are medically necessitated- Provide patients with transfers that are medically necessitated

(Quick Reference to Triage, second edition. Valerie G.A. Grossman)(Quick Reference to Triage, second edition. Valerie G.A. Grossman)

Violence in triageViolence in triage Violence is a reality in the hospital setting. Put safety first!Violence is a reality in the hospital setting. Put safety first!

Healthcare workers are 16 more times likely to be injured in Healthcare workers are 16 more times likely to be injured in the workplace than any other types or workers. the workplace than any other types or workers. (Making the right (Making the right decision: A triage curriculum)decision: A triage curriculum)

50% of all hospital assaults are reported in the ED 50% of all hospital assaults are reported in the ED (Stultz, 1994). (Stultz, 1994).

Factors that lead to violence are long waits, staff shortages, Factors that lead to violence are long waits, staff shortages, overcrowding, availability of drugs and potential hostages, overcrowding, availability of drugs and potential hostages, easy access, and presence of patients with etoh and drug easy access, and presence of patients with etoh and drug problemsproblems

Violence is associated with low tolerance for frustration, Violence is associated with low tolerance for frustration, problems with authority, limited resources, and poor coping problems with authority, limited resources, and poor coping skillsskills

Indicators of Impending ViolenceIndicators of Impending Violence

Patient CharacteristicPatient Characteristic

Appearance Appearance -- Piercing starePiercing stare

- Narrow, glaring eyes- Narrow, glaring eyes

- Red face- Red face

- Fearful or angry expression- Fearful or angry expression

- Perspiring heavily- Perspiring heavily

Demeaner Demeaner - Talking rapidly- Talking rapidly

- Repeating the same thing over and over- Repeating the same thing over and over

- Chanting or singing- Chanting or singing

- Interacting in a euphoric or grandiose manner - Interacting in a euphoric or grandiose manner

- Admitting to hearing voices- Admitting to hearing voices

- Using a loud voice, yelling, or screaming- Using a loud voice, yelling, or screaming

- Using profanity, making threatening or aggressive - Using profanity, making threatening or aggressive statementsstatements

- Pacing, fidgeting, rocking- Pacing, fidgeting, rocking

- Pounding fists or carrying a weapon- Pounding fists or carrying a weapon

What if What if youyou encounter a Violent patient in encounter a Violent patient in triage?triage?

Get Help!!! Do not attempt to subdue Get Help!!! Do not attempt to subdue a violent patient by yourself!!a violent patient by yourself!!

Call ext 5555 and call a code grayCall ext 5555 and call a code gray Try to get out of the triage room if Try to get out of the triage room if

possiblepossible Worst case scenario, push the blue Worst case scenario, push the blue

code buttoncode button Yell for assistance!Yell for assistance!

Cultural DiversityCultural Diversity

According to the U.S Census bureau statistics (2000), the United States is According to the U.S Census bureau statistics (2000), the United States is now the most ethnically diverse country in the worldnow the most ethnically diverse country in the world

Understanding and accepting another person’s cultural beliefs are Understanding and accepting another person’s cultural beliefs are essential for providing quality care in the E.D.essential for providing quality care in the E.D.

JCAHO requires assessment of cultural, spiritual, and religious needs for JCAHO requires assessment of cultural, spiritual, and religious needs for every patientevery patient

In the E.D we must be aware that cultural diversity can play a significant In the E.D we must be aware that cultural diversity can play a significant role in the perception of healthcare and the health care providerrole in the perception of healthcare and the health care provider

Language barrier: Language barrier: Often the first source of cultural conflict and Often the first source of cultural conflict and misunderstanding between the triage RN and patient. misunderstanding between the triage RN and patient. Do your best to Do your best to obtain a translatorobtain a translator

Many patients will bring their own translators. You may use them in a Many patients will bring their own translators. You may use them in a pinch, but it is not ideal pinch, but it is not ideal

Minors in triageMinors in triage If a patient is under the age of 18 and unaccompanied by an adult, you, as If a patient is under the age of 18 and unaccompanied by an adult, you, as

the triage nurse, must make an attempt to reach their legal guardian. Make the triage nurse, must make an attempt to reach their legal guardian. Make a note in the triage commentsa note in the triage comments

If a patient is an unaccompanied minor, a pregnant female, and at the If a patient is an unaccompanied minor, a pregnant female, and at the hospital for pregnancy-related issues, no consent is neededhospital for pregnancy-related issues, no consent is needed

If this same patient presents to the E.D for non-pregnancy related issue (i.e If this same patient presents to the E.D for non-pregnancy related issue (i.e cough, sore throat, laceration etc), you must attempt to obtain consent from cough, sore throat, laceration etc), you must attempt to obtain consent from a legal guardiana legal guardian

Married minor does not need consentMarried minor does not need consent If an unaccompanied minor presents in an emergent situation, implied If an unaccompanied minor presents in an emergent situation, implied

consent is assumedconsent is assumed Even if a minor is here for a non-life threatening emergency and you cannot Even if a minor is here for a non-life threatening emergency and you cannot

reach a guardian, you may not refuse to care for the patientreach a guardian, you may not refuse to care for the patient

Minors cont….Minors cont….

‘‘Most states allow pregnant women of any age to Most states allow pregnant women of any age to consent to treatment. Emancipated minors (i.e., consent to treatment. Emancipated minors (i.e., individuals below the age of consent who are self-individuals below the age of consent who are self-supporting and recognized in a legal capacity as supporting and recognized in a legal capacity as an adult) are also recognized in most states. an adult) are also recognized in most states. Consent for other minors must come from a legal Consent for other minors must come from a legal guardian unless the physician determines the guardian unless the physician determines the patient requires emergency treatment to prevent patient requires emergency treatment to prevent significant morbidity of loss of life.’ (Making the significant morbidity of loss of life.’ (Making the Right Decision: A triage curriculumRight Decision: A triage curriculum, 2001), 2001)

Disaster TriageDisaster Triage

A disaster is defined as a natural or A disaster is defined as a natural or manmade situation that produces manmade situation that produces patients who need services in patients who need services in numbers that extend beyond numbers that extend beyond immediately available resources immediately available resources (Making the Right Decision: A Triage Curriculum, 2001)(Making the Right Decision: A Triage Curriculum, 2001)

Examples of Disasters..Examples of Disasters.. HurricanesHurricanes TornadoesTornadoes FloodsFloods EarthquakesEarthquakes LandslidesLandslides Bus, train, or plane crashesBus, train, or plane crashes FiresFires Collapsed buildingsCollapsed buildings BombsBombs Hazardous material spillsHazardous material spills

Disaster continued….Disaster continued….

The key to successful disaster management is to The key to successful disaster management is to provide care for those in greatest need without provide care for those in greatest need without depleting resources on those with little or no depleting resources on those with little or no chance of survival. Appropriate triage is crucial chance of survival. Appropriate triage is crucial to this endeavor. Each facility must have a to this endeavor. Each facility must have a disaster or emergency preparedness plan in place disaster or emergency preparedness plan in place (JCAHO, 1998)(JCAHO, 1998)

**At Florida Hospital DeLand, it is required that E.D **At Florida Hospital DeLand, it is required that E.D staff sign up for ‘A shift’ (during the storm) or ‘B staff sign up for ‘A shift’ (during the storm) or ‘B shift’ (after the storm)shift’ (after the storm)

Emergency TriageEmergency Triage The System Florida Hospital DeLand uses is The System Florida Hospital DeLand uses is

the START system: Simple Triage And Rapid the START system: Simple Triage And Rapid Treatment. This is initial triage only used for Treatment. This is initial triage only used for quick assessment and sorting of the injured. quick assessment and sorting of the injured. If the patient is not tagged at the scene, FHD If the patient is not tagged at the scene, FHD uses the ‘Hospital Emergency Medical Tag’, uses the ‘Hospital Emergency Medical Tag’, which works in conjunction with the field which works in conjunction with the field tags. These are located in the E.D storage tags. These are located in the E.D storage area in the ‘Disaster box’area in the ‘Disaster box’

Categories:Categories:1. 1. ImmediateImmediate- Compromised airway, - Compromised airway, Respiratory rate >30 per minute, decreased Respiratory rate >30 per minute, decreased perfusion, or decreased mental status. perfusion, or decreased mental status. Should receive treatment in 30 minutes.Should receive treatment in 30 minutes.

Emergency Triage Cont….Emergency Triage Cont….

2. 2. Delayed- Delayed- Non-ambulatory patients who do not fit Non-ambulatory patients who do not fit immediate criteria, C-spine patients who do not fit immediate criteria, C-spine patients who do not fit immediate criteria. Delayed patients should receive immediate criteria. Delayed patients should receive treatment within 2 hours.treatment within 2 hours.

3. 3. Minor- Minor- Ambulatory patients. Need basic first aid. Ambulatory patients. Need basic first aid. Their care can be delayed for hours if necessary.Their care can be delayed for hours if necessary.

4. 4. Deceased- Deceased- 44thth priority according to START. Patients priority according to START. Patients without a pulse or respirations, these patients have already without a pulse or respirations, these patients have already expired. They should be moved to appropriate designated expired. They should be moved to appropriate designated area.area.

Questions? Questions? Comments? Comments? Concerns?Concerns?

ReferencesReferences

Emergency Severity Index, Version 4: Implementation Emergency Severity Index, Version 4: Implementation Handbook. Nicki Gilboy et. al., 2005Handbook. Nicki Gilboy et. al., 2005

Making the Right Decision: A triage curriculum 2Making the Right Decision: A triage curriculum 2ndnd edition. edition. Emergency Nurses Association, 2001Emergency Nurses Association, 2001

Quick Reference to Triage, Second Edition. Valerie G.A Quick Reference to Triage, Second Edition. Valerie G.A Grossman, 2003Grossman, 2003

Its TOUR TIME////Its TOUR TIME////