Consept of TriageOleh : Rudi Hamarno

Definition

Triage is a process that sort of patient as base of life threating .

History : Napoleon Bonaparte (War I)

PRINCIPLES OF TRIAGEPRINCIPLES OF TRIAGE

1. Triage should be immediate & timely

2. Asses should be adequate & accurate

3. Decisions are made based on assess .

4. Provide interv accord to acuity condition

5. Patient satisfaction is achieved

6. Complete of documention

TRIAGE CLASSIFICATIONTRIAGE CLASSIFICATION

3 Categories 3 Categories

Original form of triage:Original form of triage:

1.1. Highest priorityHighest priority

2.2. Second prioritySecond priority

3.3. Lowest priorityLowest priority

This very general This very general suffered from lack of suffered from lack of specificity & too much specificity & too much subjectivity subjectivity

4 Category Triage

1. Highest priority (immediate, Class 1,

severe & emergent.)

2. High priority (secondary, Class 2,

moderate & urgent.)

3. Low priority (delayed, Class 3, mild & non

urgent.)

4. Deceased (probable death & Class 4/Class 0.)

Start Method Start Method (Simple & Rapid Treatment)(Simple & Rapid Treatment)

Developed in California in early 1980s .Developed in California in early 1980s . The triage personnel is minimal training.The triage personnel is minimal training. The assessment is done very rapidly The assessment is done very rapidly

< 60 s the following areas:< 60 s the following areas:

1.1. VentilationVentilation

2.2. Perfusion & pulses Perfusion & pulses

3.3. Neurological.Neurological.

The patients were classified as The patients were classified as follows:follows:

a.a. The Walking WoundedThe Walking Wounded

b. b. Critical/ImmediateCritical/Immediate Respiration > 30/minRespiration > 30/min No radial pulseNo radial pulse Unconscious or having altered level of Unconscious or having altered level of

consciousness or altered mental stateconsciousness or altered mental state

c. Delayed

Respiration < 30/min

Pulse present

Normal mental responses

d. Dead/Non-salvageable

Problem

Since the triaging is done by non-medical staff & only based on ventilation, perfusion & neurological assessments, certain early critical situations may be missed eg. Early shock, spinal shock etc.

General Classification of General Classification of Triage at Hospital SettingTriage at Hospital Setting

The triage nurse is often given the The triage nurse is often given the responsibility in deciding on the responsibility in deciding on the priority priority

Most hospitals in Singapore adopt Most hospitals in Singapore adopt the 3 Categories Triage System the 3 Categories Triage System

Priority 1 or Emergent or Critical Definition

Patients with life threatening injuries or illness which require immediate

Area of Care :

Resuscitation Room or

Trolley/Stretcher

Waiting TimeWaiting Time

a. Cardio-vascular collapse or in danger a. Cardio-vascular collapse or in danger of of

imminent collapse : zero waiting imminent collapse : zero waiting time. time.

b. For others who do not require b. For others who do not require

resuscitation : not exceed 5 minutes.resuscitation : not exceed 5 minutes.

Priority 2 or UrgentPriority 2 or Urgent

DefinitionDefinitionUrgent patients with major illness or Urgent patients with major illness or

injuries but who are not in imminent injuries but who are not in imminent danger of collapse. danger of collapse.

Patients should be on a trolley, or Patients should be on a trolley, or

a wheelchair.a wheelchair.

Area of CareArea of CareWheelchairs & ambulatory setting.Wheelchairs & ambulatory setting.

Waiting TimeWaiting TimeWithin 30 minutes of arrival at A&E.Within 30 minutes of arrival at A&E.

Priority 3 or Non-Urgent

Definition

Patients who are usually ambulatory with minor problems, old injury or a condition that has been present for a long time.

Patient does not require immediate threat to patients life or limb.

They may be treated just as well in a private clinic or a polyclinic.

Area of treatmentArea of treatment Managed in an ambulatory setting in Managed in an ambulatory setting in

an area distinct from the P1 & P2 an area distinct from the P1 & P2 Areas. Areas.

This is so that they do not interfere This is so that they do not interfere with the care given to the other two with the care given to the other two groups of patientsgroups of patients

Example PRIORITY 1

Trauma1. Multiple Severe Injuries2. Burns more than 15% 3. Fractures of lower limbs4. Attempted suicides5. Drug overdosages6. Acute head injuries with loss of

consciousness

Non-Trauma1. Airway obstruction2. Cardio-pulmonary arrest3. Shock states4. Acute severe chest pain

5. Acute breathlessness:asthma6. Acute myocardial infarction7. Renal colic8. Severe gastroenteritis9. Bleeding GIT10. Acute low backache11. Terminally ill patient12. Acute abdomen, acute

retention of urine13. Severe Dizziness/Syncope/Fits14. CVA15. All patients drowsy or comatose16. Patients unable to walk

PRIORITY 2

Trauma1. Upper limb fract /disloc 2. Multiple superficial

wounds3. Burns < 15%4. Joint sprains & musc

strains5. Multiple bee & insect

stings & animal bites6. Simple lacerations7. Foreign bodies of ear,

nose, throat & soft tissues

Non-Trauma1. Febrile not requiring

critical care attention2. Mild abdominal pain3. Acute large skin

infectious & emergencies, eg. Cellulitis, urticaria, etc

4. Abscesses5. Acut infect of eye &

ears6. Severe headache or

pains of other regions not requiring-critical care

PRIORITY 3

Trauma1. Old scars2. Deform of bones,

limbs /spine3. Joint contractures4. Old malunited fractures5. Request for removal of

metal plates, screws6. Old unreduced

dislocations7. Old un-united fractures8. Chronic discharging

wounds9. Chronic sprains

Non-Trauma1. Cold lumps & bumps in

the body2. Varicose veins3. Cysts4. Requests for

circumcision5. Patching of earlobe6. Removal of tattoo7. Removal of corns, warts8. Removal of keloids9. Chronic rhinitis10. Defective hearing

11.Nasal polyp12.Wax in ears13.Cataracts14.Upper resp infec

without fever15.Chronic cough16.Social problem –

requests admission

17.Psychosomatic problems

18.Chronic headaches on & off

19.Insomnia

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ASSESSMENT ASSESSMENT & PRIORITY SETTING& PRIORITY SETTING

ASSESSMENT GUIDEASSESSMENT GUIDE

a. Historya. History Taking history from patient & important as Taking history from patient & important as

valuable inform valuable inform

b. Sightb. Sight Patient’s general appearance eg level of Patient’s general appearance eg level of

consciousness, respiratory problem, consciousness, respiratory problem, appears to be breathless, any obvious signs appears to be breathless, any obvious signs of injury such as laceration swelling, of injury such as laceration swelling, bleeding. Body language.bleeding. Body language.

c. Smellc. Smell Odour of alcohol, Ketories bodies or malaena stool Odour of alcohol, Ketories bodies or malaena stool

smell.smell.

d. Touchd. Touch Skin: fever, cold & clammy, sweatySkin: fever, cold & clammy, sweaty Palpate – take pulse ratePalpate – take pulse rate Touch for tenderness & swellingTouch for tenderness & swelling

e. Common Sensee. Common Sense Use common sense to decide what you want to ask Use common sense to decide what you want to ask

for relevant key pointsfor relevant key points

The SOAP process

S :Subjective

O :Objective

A :Assess

P :Plan

S – SubjectiveS – Subjective

Collect subjective dataCollect subjective data Initially use open ended questions eg Initially use open ended questions eg

“Why did you want to see a doctor?” “Why did you want to see a doctor?” Past History – eg. Hypertension, Past History – eg. Hypertension,

DM?DM?

NoteNote : : Trauma Cases : Mechanism of injury Trauma Cases : Mechanism of injury

O – ObjectiveO – Objective

Collect objective dataCollect objective data GeneralGeneral Method of arrival to A&EMethod of arrival to A&E Level of consciousness GCS (Trauma Level of consciousness GCS (Trauma

Case)Case) P/ general appearance using your P/ general appearance using your

sensessenses Vital signs (T,P,RR,BP)Vital signs (T,P,RR,BP)

A – Assess

Assess & evaluate patient from

the S & O data collection.

decide

action plan.

P – Plan

1. Establish your priority

2. Carry out further test: ECG Blood glucose mon Urine labstix Urine for inspection First aid manag

Immobilize fracture Put on cervical collar First aid dressing X – ray

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Role of Field Triage TeamRole of Field Triage Team

The first team to arrive will take charge of The first team to arrive will take charge of triage triage

Not to be stretcher bearers. Not to be stretcher bearers. Explain role of stretcher bearers to them Explain role of stretcher bearers to them

when assigned.when assigned.Show the locations of P1, P2, P3Show the locations of P1, P2, P3

Ensure that all P1 & P2 casualties Ensure that all P1 & P2 casualties are transported via stretchers.are transported via stretchers.

Deploy to assist in other areas when Deploy to assist in other areas when no more patients require triage.no more patients require triage.

Ensure that not more than 2 P1 Ensure that not more than 2 P1 casualties are evacuated in the same casualties are evacuated in the same ambulance. ambulance.

Load & go philosophy of field care.Load & go philosophy of field care.

Triage TeamTriage Team

Each team consist of 1 doctor & 1 nurseEach team consist of 1 doctor & 1 nurse The number depent of availability, The number depent of availability,

requirement dan spacerequirement dan space During disaster, fungtion is mainly to During disaster, fungtion is mainly to

alocate priority of treatmentalocate priority of treatment The equitment : The equitment :

1.1. Triage tag , StretchersTriage tag , Stretchers

2.2. 1 box of dressing & OFT/NFT1 box of dressing & OFT/NFT

MettagMettag

• Priority 0 = blackPriority 0 = black• Priority 1 = redPriority 1 = red• Priority 2 = yellowPriority 2 = yellow• Priority 3 = green Priority 3 = green

Triage Proses Triage Proses 1.1. Mobility ?Mobility ?

If victim can walk and has injury : P If victim can walk and has injury : P 33

2. Cek ABC 2. Cek ABC

Airway by chin lift / jaw thrustAirway by chin lift / jaw thrust

B +

Cek RR

P 1

Circulation ?

Delay > 2 dtkNormal < 2 dtk P2

P 0

B -

< 10 x> 30 x

10 - 30 x

ProblemsProblems

1.1. LanguageLanguage

2.2. No Visible PatientNo Visible Patient

3.3. TermsTerms

4.4. EEvaluationvaluation

Responsbilities It is to assess, sort out all calls & give first

aid advice. How does one do assessment over the

phone ? This can only be done subjectively.

Subjective

What is the main complaint ? What is the duration ? Are there any associated symptom eg. fever,

sweating ? What is the patient’s past medical history? It is good practice to write down the information

on a piece of paper placed in front of you. Another way of avoiding misunderst&ing is to

repeat what the caller has just said eg. Am I correct, your child has fever for five days ?

Objective

There are 4 categories where these calls are sorted into:Decide if p/ needs to call for an ambulance ie dial 995.Decide if p/ needs to be seen in an A&E Dept.Decide if p/ can be seen by general practitioner or a doctor in a polyclinic.Decide if first aid advice is all that is required.

General General Conduct over the Conduct over the phone:phone:

1.1. Always identify yourselfAlways identify yourself

2.2. Be calm & sound confidentBe calm & sound confident

3.3. Speak clearlySpeak clearly

4.4. Substitute medical terms or explain Substitute medical terms or explain them if usedthem if used

5.5. Be patient with the callerBe patient with the caller

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Thank ........Thank ........