triage in emergency department
TRANSCRIPT
Triage in Emergency Department
TriageWaiting room
Team leader
Definition of Triage
• Triage is the term derived from the French verb trier meaning to sort or to choose
It’s the process by which patients classified according to the type and urgency of their conditions to get the Right patient to the
Right place at the Right time with the Right care provider
Triage Categories
• Non disaster: To provide the best care for each individual patient.
• Multi casualty/disaster: To provide the most effective care for the greatest number of patients.
Non disaster or E.D triage
The primary objectives of an ED triage are to (ENA,1992, P. 1):
1. Identify patients requiring immediate care.2. Determine the appropriate area for
treatment3. Facilitate patient flow through the ED and
avoid unnecessary congestion.
4. Provide continued assessment and reassessment of arriving and waiting patients.
5. Provide information and referrals to patients and families.
6. Allay patient and family anxiety and enhance public relations.
Disaster• Definition: an incident, either natural or human-
made, that produces patients in numbers needing services beyond immediately available resources. May involve a large no. of patients or a small no. of patients if their needs place significant demands on resources.
• The key to successful disaster management is to provide care to those who are in greatest need first and just as importantly, not provide care to to those who have little or no chance of survival. Correct triage is essential to accomplish this goal
Disaster
The triage teamTriage of Victims
- first victims to arrive are frequently not the most seriously injured.Critical patientsFatally Injured PatientsNon critical patientsContaminated patients
Types of E.D. triage system• Type 1: Traffic Director (Non Nurse).• Type 2: Spot Check• Type 3: Comprehensive
• Two-tiered systems: initial screening by RN who greets each patients on arrival, perform a primary survey and determine whether the patient is able to wait for further assessment by a second triage nurse.
• Divide tasks among staff members, internal triage and external triage
Triage levels
1- Resuscitation2- Emergent3- urgent4- less urgent5- Non urgentThe Canadian E.D. Triage and Acuity Scale
Overview of three category triage acuity systemscategory acuity Recommended
reassessmentExamples
Class 1 EmergentImmediately life or limb threatening
continuous Cardiopulmonary arrest, severe respiratory distress, major burns, major trauma, massive uncontrolled bleedingComa, status epil..
Class 2 UrgentRequires prompt care, but will not cause loss of life or limb if left untreated for several hours.
Every 30 minutes
Abdominal pain, non cardiac cp, multiple fractures, lacerations, renal calculi,
Class 3 Non urgentAnd treatment but time is not a critical factor
Every 1-2 hrs
Rash, chronic headache, sprains, cold symptoms
TRIAGE LEVELS1- Resuscitation -- threat to life
Time to nurse assessment IMMEDIATE Time to physician assessment IMMEDIATE
• Cardiac and respiratory arrest• Major trauma• Active seizure• Shock• Status Asthmatics
Triage levels2- Emergent Potential threat to life,limb or function Nurse Immediate , Physician <15 minutes• Decreased level of consciousness• Severe respiratory distress• Chest pain with cardiac suspicion• Over dose (conscious)• Severe abdominal pain• G.I. Bleed with abnormal vital signs• Chemical exposure to eye
Triage levels
3- UrgentCondition with significant distressTime Nurse < 20 min, physician < 30 minHead injury without decrease of LOC but
with vomiting• Mild to moderate respiratory distress• G.I. Bleed not actively bleed• Acute psychosis
Triage levels4- Less urgent
Conditions with mild to moderate discomfortTime for Nurse assessment <1h Time for physician assessment < 1hHead injury, alert, no vomitingChest pain, no distress, no cardiac susp.Depression with no suicidal attempt
Triage levels5- Non urgentConditions can be delayed, no distressTime for nurse and Physician assessment
more than 2h• Minor trauma• Sore throat with temp. < 39
Basic component of triage
• An “across-the room” assessment• The triage history• The triage physical assessment• The triage decision
An “ across the room assessment”
To identify obvious life threat conditionsGeneral appearance
Air wayBreathing
Circulation
Disability(neurogenic)
Across the door assessment•The triage nurse must scan the area where patients enter the emergency door, even while interviewing other patient.•The triage antenna should be seeking clues to problems in all people who enter the triage area•If any patient doesn’t look right kindly but quickly interrupt any current interaction and go investigate.
Across the room assessment• Air wayAbnormal airway sounds, strider, wheezing gruntingUnusual posture e.g.. Sniffing position, inability to
speak, drooling or inability to handle secretion• Breathing
Altered skin signs, cyanosis, dusky skin, tachypnicbradypnea, or apnea periods, retractions, use accessory muscles, nasal flaring, grunting, or audible wheezes
Across the room assessment• CirculationAltered skin signs, pale, mottling, flushingUn controlled bleeding• Disability (neuro.)
LOC Interaction with environment Inability to recognize family members Unusual irritability
Response to pain or stimuliFlaccid or hyper active muscle tone
Characteristics of triage nurse• Extensive knowledge to emergency medical
treatment• Adequate training and competent
skills,language, terminology• Ability to use the critical thinker process• Good decision maker
Role of triage nurse
• Greet patients and identify your self.• Maintain privacy and confidentiality• Visualize all incoming patients even while
interviewing others.• Maintain good communication between triage and
treatment area• maintain excellent communication with waiting
area.• Use all resources to maintain high standard of care.
Role of triage nurse
• Teaching ----- use of thermometer, first aid ??? avoid lecturing.
• Crowd control.• Telephone.• Communicate with team leader and seek
feed back on decisions.
Importance of re triage• Reassess the patient within 1-2hours of
initial triage and continue to re assess on a regular basis, patients who may have presented without cardinal signs of severe illness may develop them during long waits.
• Patients who appear intoxicated actually may have life threatening problems such as DKA, and should not be permitted to keep it off in the waiting room.
•The last person in along line at triage may have a serious medical problem that requires immediate attention
•Patient should wait no longer than 5 minutes for triage
If in doubt about a category, choose the higher acuity to avoid under triaging a patient