Applying CTASSelected Complaints Require Greater Knowledge of Second Order Modifiers

Module 4

Version 2.5, 2012CTAS National Working Group

© Canadian Association of Emergency Physicians

Module 4 - Objectives Define Second Order Modifiers Understand that most apply to both adults &

Paediatrics Focus on those relevant to single or special

complaints Recognize triage pitfalls Place triage in a rural context Apply CTAS learning to case scenarios

Definition 2nd Order Modifiers are specific to a limited

number of complaints and:may be required to supplement 1st Order

Modifiers to ensure the patient is assigned an appropriate acuity score or

may be an absolute requirement to assign a triage score for patients with certain complaints where 1st Order Modifiers are either irrelevant or totally inadequate to assign acuity.

Level 1 - Presentations Cardiac arrest (non traumatic) Cardiac arrest (traumatic) Respiratory arrest Seizure (actively seizing) Violent/homicidal behaviour (imminent

harm to self or others or specific plans)

Level 2 - Presentations Chemical exposure, eye Palpitations/irregular heart beat (history of

documented lethal) Syncope/presyncope (no prodromal

symptoms) Burn (>25% BSA) Frostbite/cold injury (cold pulseless limb) Amputation (traumatic amputation of a digit)

Level 3 - Presentations Vertigo (positional, no other neuro

symptoms) Extremity injury (tight cast with

neurovascular symptoms) Blood and body fluid exposure (low risk

exposure) Major trauma – blunt (prolonged spinal

immobilization)

Level 4 - Presentations Unilateral reddened hot limb (localized

inflammation) Laceration/puncture (sutures required) Blood in stool/melena (rectal bleeding

small amount) Sexual assault (≥12 hours, no injury)

Level 5 - Presentations

Nasal congestion / hay fever Imaging tests Exposure to communicable disease Loss of hearing (gradual loss)

Other Specific 2nd Order Modifiers Environmental Late Pregnancy Mental Health

Environmental Exposures Low temperatures can indicate acuity level

CEDIS complaints: Hypothermia or Near Drowning

Temperature CTAS Level

<32C 2

32 - 35C 3

>35C, no frostbite, normal VS

4

Late Pregnancy ModifierCEDIS Presenting

ComplaintSecond Order Modifier CTAS

levelPregnancy issues > 20 weeks

Presenting fetal parts, prolapsed cord 1

Vaginal bleeding 3rd trimester 1

Active labor (contractions ≤2 min) 2

No fetal movement / no fetal heart tones 2

Headache +/- edema+/- abdominal pain +/- hypertension

2

Post delivery 2

Active labor (contractions >2 min) 3

Possible leaking amniotic fluid 3

Case example 24 year old female Presents with diffuse intermittent, crampy,

abdominal pain, which started last night and has progressively worsened. The pains are now coming < every 2 minutes.

Reports pain to be 10/10 at its worst. Has an attack of pain at triage and is in obvious acute distress.

Admits LMP was more than 8 months ago. RR 21, HR 92, BP 140/96

Mental HealthCEDIS Presenting

ComplaintSecond Order Modifier CTAS

LevelDepression / Suicidal / Deliberate self harm

Attempted suicide or clear plan 2Active suicidal intent 2Uncertain flight or safety risk 2Suicidal ideation, no plan 3Depressed, no suicidal ideation 4

Anxiety / Situational crisis

Severe anxiety / agitation 2Uncertain flight or safety risk 2Moderate anxiety / agitation 3Mild anxiety / agitation 4

Hallucinations / Delusions

Acute psychosis 2Severe anxiety / agitation 2

Uncertain flight or safety risk 2Moderate anxiety / agitation or with paranoia 3Mild agitation, stable 4Mild anxiety / agitation, chronic hallucinations 5

Mental HealthCEDIS Presenting

ComplaintSecond Order Modifier CTAS

LevelInsomnia Acute 4

Chronic 5

Violent / Homicidal behaviour

Imminent harm to self or others or specific plans 1

Uncertain flight or safety risk 2

Violent / homicidal ideation, no plan 3

Social problem Abuse physical, mental, high emotional stress 3

Unable to cope 4

Chronic, non urgent condition 5

Bizarre behaviour Uncontrolled 1

Uncertain flight or safety risk 2

Controlled 3

Harmless behaviour 4

Chronic, non urgent condition 5

Mental Health DefinitionsSuicidal Term Definition

Suicide attempt Self injurious behavior with a non fatal outcome accompanied by evidence (explicit or implicit) that the person attempted to die.

Suicide intent Subjective expectation and desire for self-destructive act that would end in death.

Suicidal ideation Thought of serving as an agent of one’s own death, may vary in seriousness depending on specificity of plans and degree of suicidal intent.

Uncertain flight or safety risk

Patients threatening violence towards themselves or others; patients exhibiting uncontrolled anger, restlessness, paranoia, or hallucinatory behavior; or patients unable or unwilling to cooperate with suicide risk assessment and who pose a flight risk. Need close observation based on site resources.(If family member willing to observe & both parties agree ‘hospital-assigned’ close observation may not be required.)

Case example 18 year old female Found in closed garage with car engine

running Alert, but will not establish eye contact Will not answer questions, but is

cooperative RR 22, HR 102, BP 118/76, Temp 36.6°C

Mental Health DefinitionsAnxiety / Agitation Definition

Severe anxiety / agitation Extreme unease, apprehension or worry with signs of excessive circulating catecholamines; or dangerously agitated and uncooperative and does not calm down when asked

Moderate anxiety / agitation Clear unease, apprehension, or worry, but no obvious tachycardia or tremulousness; or signs of agitation, and does not consistently obey commands (e.g. will sit or calm down when asked, but soon becomes restless and agitated again

Mild anxiety / agitation Mild unease, apprehension or worry, but can be reassured; or restless but cooperative; obeys commands.

Mental Health DefinitionsHallucination / Delusion

Definition

Acute psychosis May present with extreme self neglect, disordered or racing thoughts or both, speech pattern impairments, impaired reality testing with ‘lack of insight’, may be responding to hallucinatory or delusional thoughts or both, which may be accompanied by hostility.

Paranoia Delusions of a persecutory nature - being followed, poisoned, or harmed in some way. Ideas of reference - the belief that people are talking about you. May be accompanied by extreme fear, agitation or hostility.

Chronic hallucinations Known history of hallucinations with no recent change in nature, and/or frequency, or in patient’s level of distress related to them.

Chronic, non-urgent condition

Patient is well known to the ED and triage nurse with a recurrent complaint that has either been fully dealt with, or patient is just looking for food, warmth or temporary shelter.

Mental Health DefinitionsBizarre Behaviour Definition

Uncontrolled Bizarre, disoriented or irrational behaviour, not controlled by verbal communication and reasoning, and placing the patient or others in imminent physical danger

Controlled Bizarre, irrational behaviour that is viewed as threatening but controllable through verbal support and reasoning; patient is accompanied by a friend or family member.

Harmless behavior Bizarre or eccentric behaviour (usually of long standing with no recent change from patient’s norm) that is of no threat to the patient or others and requires no acute intervention.

Psychosocial ModifiersComplaint 2nd order modifier CTAS level

Concern for patient’s welfare

Conflict or unstable situation 1

Risk of flight or ongoing abuse 2

Suspected physical or sexual assault 3

History/signs of abuse or maltreatment 4

Paediatric disruptive behavior

Uncertain flight or safety risk/family distress 2

Acute difficulties with others/environment 3

Persistent problematic behavior 4

Chronic, unchanged behavior 5

Examples of Triage Pitfalls1. Not recognizing hemodynamic compromise in children with reasons to

be hypovolemic/or hypotentsive2. Not appreciating the dangers of complaints in the perineal region or

limb complaints of pain or swelling (especially deep space infections)3. Not recognizing the possibility that a mental health presentation can

be as acute or dangerous as a medical or surgical one4. Not considering new onset bizarre behaviour an acute medical

problem (ie acute delerium)5. Not assessing neurovascular status of distal limb in patients

presenting with limb pain or injury6. Letting negative feelings about a patient influence the acuity score

assigned7. Mistaking patient fears (“I can’t breath”; “I’m going to die”) without

physiologic findings, as being simple anxiety

CTAS Implementation in Rural Hospitals

Characteristics: ED physicians may not be on-site Protocol for ambulances to call ahead when

patients are Level 1 and 2. Nursing staff can initiate resuscitation. Physician-directed care provided in person, by

telephone, or by medical directivesExtracted from: CAEP and SRPC Position Statement-Rural Implementation of CTAS; CJEM JCMU 2003; 5(2):104-107

CTAS in Rural Hospitals CTAS Level 5 patients may be deferred to another

time or place if:1) Patient is 6 months of age or older2) Vital signs are deemed satisfactory by the nurse and

temperature is 35 - 38.5°C (38.3°C for age >60 years)3) No clinical indication requiring physician attention4) Where the nurse is unsure, telephone consultation with the

physician, has determined that the problem is non urgent5) Appropriate hospital policies and medical directives are in

place6) There is agreement between medical and nursing staff to

accept the processExtracted from: CAEP and SRPC Position Statement-Rural Implementation of CTAS; CJEM JCMU 2003; 5(2):104-107

and revised 2006 & posted at (http://srpc.ca/librarydocs/revCtas.pdf)

Cases for Discussion

Case 1 28 year old female 8 weeks pregnant Moderate vaginal bleeding No respiratory distress HR 92, Temp 37°C, BP 102/60 Abdominal pain (moderate 5/10)

Case 2 A 16 year old male collapsed at a track

and field event with what was reported as seizure activity.

At triage he is alert and orientated. RR 22/min, HR 62/min. He reports a similar event occurred a

week ago. He has a history of seizures.

Case 3 23 year old chemical worker was splashed in the

face by an exploding liquid Complaining of burning pain (7/10) to face and

right eye No respiratory distress or oropharyngeal

complaints RR 18, HR 96, BP 140/88, O2 Sat 96%

Case 4 16 year old male brought in by police after being

rescued while threatening to jump off a balcony Has a previous history of a suicide attempt Has a history of manic depression and is on

lithium He is being restrained by police on arrival and is

uncooperative Hard to obtain vital signs, but appears stable Unknown whether has ingested drugs, but none

found at the scene

Case 5 17 year old female Itchy all over Lips are swollen but no throat tightness Is anxious but no respiratory difficulty Peanut allergy, has epi pen but hasn’t used it Arms and neck covered in red, whealed rash Previous admission to ICU with anaphylaxis RR 22, HR 98, BP 132/86, O2 Sat 97%

Case 6 43 year old homeless lady is brought in by police due to

complaints that she was wandering in and out of traffic. Obviously restless and asking when she can leave, but

will calm down and respond appropriately when asked questions. She then fidgets and will start to get up to leave if left alone. Denies suicidal ideation.

Is unkempt and warmly dressed for the autumn season RR 18, HR 92, BP 130/80, Temp 37.1°C Agrees to sit with volunteer when food offered and police

promise to collect her belongings and bring them to the ED, but still becomes easily restless

Case 7 A 14 year old female has self-inflicted superficial

lacerations to both wrists. Her teacher reports that the girl was found sitting on the floor in a school bathroom.

The patient is very quiet and does not make eye contact with you. She is co-operative but slow to respond to questions. She states she “cannot go on”. She denies taking any pills.

RR 18, HR 72, BP 122/68

Case 8 A 10 year old boy is brought to the ED by

the police accompanied by a school counselor. He is verbally abusive, loud, restless, and agitated. He is requiring physical restraint. His parents have been notified. The counselor reports a history of conduct disorder.

Case 9 A mother brings her 2 year old son to the ED.

She states while bathing her son she noticed his penis was swollen and the foreskin was retracted proximally. When she tried to clean the penis he cried with pain and refused to let her touch him. The swelling has increased significantly and her son is in pain.

The boy is restless and clinging on to his mother.

RR 30, HR 128

Case 10

An 8 year old girl presents after a fall off her bike approximately one hour ago.

She has moderate (7/10) pain and avulsion of an upper incisor.

Father has the tooth in a glass of milk. RR 20, HR 100

Case 11 A 4 year old presents with parents

following seizure at home. He has had 3 in the past, all associated with fever.

Parents state he was well until bedtime, developed a fever, had a one minute generalized tonic seizure which was identical to past events.

He looks well and is running around. RR 24, HR 100, Temp 39°C.

A mother brings her 6 year old son to triage. He may have been poked in the right eye by another child at the playground and there might be something in the eye.

On arrival child is alert and responds to the triage nurse.

His right eye is slightly swollen and tearing. Mother keeps a tissue over the eye as the boy complains the light causes pain.

Case 12

15 year old male presents asking to see a doctor but is reluctant to say why. He finally indicates he has groin pain (3/10) which he thinks was due to an injury. He also indicates he has recently run away from home and is living on the street

Denies any other symptoms and when asked if someone hurt him he avoids answering

No past medical history and denies drug abuse RR 19, HR 76, BP 118/76, GCS 15, O2 Sat 98%

Case 13

Case 14 A 5 year old girl arrives by ambulance

actively seizing (tonic-clonic) for the past 1 hour.

The patient has a known history of a seizure disorder. Ativan was given rectally by the caregivers at home.

She is unresponsive, pale and breathing irregularly.

Case 15 A 3 year old ingested an unknown amount

of his grandmother’s digitalis approximately 1 hour ago. His mother called Poison Information Centre who told her to take the child to the nearest emergency.

The child is alert, nauseated, and has vomited once.

RR 24, HR 80

Questions?

References 1. Bullard MJ, Unger B, Spence J, Grafstein E, the CTAS National Working

Group. Revisions to the Canadian Emergency Department Triage andAcuity Scale (CTAS) adult guidelines. CJEM 2008;10:136-42.

2. Grafstein E, Bullard MJ, Warren D, Unger B, the CTAS National WorkingGroup. Revision of the Canadian Emergency Department InformationSystem (CEDIS) presenting complaint list version 1.1. CJEM 2008;10:151-61.

3. Warren DW, Jarvis A, LeBlanc L, Gravel J, the CTAS National WorkingGroup. Revisions to the Canadian Emergency Department Triage andAcuity Scale Paediatric guidelines (PaedCTAS). CJEM 2008;10:224-32

Go to the website below and view CTAS & CEDIS webpageshttp://www.caep.ca/template.asp?id=F59D1B40C1AE4FBD842B6D536D21BB6C