TRIAGE IN RURAL HOSPITALS

Anne Hawkins Clinical Nurse Consultant for Emergency Services Greater Murray Area Health Service RN, RMN, A&E Cert(NSW College Nursing) BA APP SC (Nursing) USYD TNCC & ENPC Instructor

Triage and more importantly the National Triage Scale has for a long time been a concern to the nurses working in rural hospitals that do not have medical officers on site. These concerns have been raised, for at least two years, at the NSW Rural Clinical Nurse Consultants (for Emergency Services) meetings, and at the NSW Rural Critical Care Committee meetings. This is a discussion paper on the new ideas being suggested for triage in the rural hospitals that do not have 24 hour medical cover and also the way this process came about.

It is essential to understand the definition of NSW Rural Emergency Department and clarify the type of emergency department that the National Triage Scale (NTS) was designed specifically for.

The definition of a NSW Rural Emergency Department is: An Emergency Department with no on-site medical staff.

These departments do however offer emergency services to the community they serve.

The National Triage Scale (NTS) was developed in 1993 by the Australasian College for Emergency Medicine (ACEM) for use as a benchmark in hospitals that have emergency departments staffed by emergency specialists, registrars and 24 hour emergency services

Thus the National Triage Scale was not written for smaller hospitals, but by default this scale has become the benchmark for all triage and is the basis for all triage education including hospitals without on-site medical staff cover.

On Friday 25th February, 2000 NSW Health held a workshop to raise and discuss the issues relating to triage in rural facilities without on site medical staff. The Convenor of the meeting was Dr Steevie Chan, Clinical Services Planning Unit, and the Facilitator was Ms Ruth Cotton, Mandala Consulting.

Discussion papers on "Triage the Rural Perspective" were presented by Dr Phil Hungerford, (Rural Critical Care Committee), Dr Stephen Doherty (Tamworth Emergency Department) and Anne Hawkins (Rural Clinical Nurse Consultant for Emergency Services).

The National Triage Scale development and future plans was presented by Dr Sue Ieraci (ACEM).

Some of the problems encountered when adopting the NTS to a rural emergency department are listed below.

W h y the Nat ional Triage Scale does not w o r k in the Rural setting?

• There are no Medical Officers on-site

• Medical benchmarks are therefore not met (especially in

categories 1 & 2)

• There is no recognition of Registered Nurse (RN) intervention and therefore

• No performance benchmarks for RN's

• There is no legal frame work for nurses when the NTS is breached

• No legal category for "Nurse Intervention Only category"

• There is no other option for the patient when the Local Medical Officer is fully booked at the surgery than to attend the Emergency Department of their local hospitals

T h e solut ion as we see it

The Rural solution was not to change the National Triage Scale, we propose to keep the one to five category but change the terminology and time frames that more accurately reflected current rural emergency department practice while keeping the same profile for ease of application and education

We believe the Rural Triage Scale © reflects current practices within Rural hospitals and if formalised and approved can be a useful Rural benchmarking tool for both medical and nursing practices.

One issues that needed immediate attention was time to be seen by medical officer. As there are no medical officers on- site, patient care is frequently initiated by nursing staff before a medical officer arrives.

The NTS specifically refers to the time seen by a medical officer. The Rural Triage Scale © refers to Time to Medical Officer Intervention. Time to intervention encompasses phone consultation and phone orders where appropriate (not all cases require MO to attend the patient in person when the care and outcome of a phone consultation can achieve the same end result ie at 0300hr). This change in wording recognises that the patient is receiving medical care in an appropriate time frame despite the patient not being physically seen.

Recognition of Nurse intervention was also a priority in the Rural Scale, as this reflects current practice and allows for accountability and measurable benchmarks. The Rural Triage Scale © refers to Time to Nurse Intervention.

Nursing interventions for emergency presentations have been addressed and teaching programs are provided by the First Line Emergency Care (FLEC) courses in all rural area health services. This is the educational framework that supports the rural nurses' role in the emergency department without on-site medical cover.

"Nurse Intervention Only Category" was a most important inclusion in the scale as it also reflects current practice.

In the Rural setting when the General Practitioner/s are fully booked at their surgery there is no other option for the patient than to attend the Emergency Department of their local hospital. Often the patient has been sent by the Local Doctor to the hospital for continuation of their care. In the "Nurse Intervention Only Category" the nurses TRIAGE, TREAT and REFER.

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Time frames for time to medical intervention and time to nursing intervention were the other consideration looked at as a rural issue and were changed. This was changed to meet the clinical need for patient intervention and appropriateness of care. These times are in the draft proposal and are open for discussion.

Proposed Rural Triage Scale ©

Triage Time to Nurse Time to Medical Code Intervention Intervention

1 0 mins 5 mins

2 5 mins 10 mins

3 15 mins 30 mins

4 30 mins 60 mins

5a 60 mins 4 hours

5b 2 hours

Nurse Intervention Only

The Rural Triage Scale ~ was presented as a discussion document.

There were many interested parties at the forum and not all were in agreement with the changes. Sue Ieraci representing ACEM proposed another scale for the Rural setting

A Needs urgent intervention Start treatment now Call doctor now

B Needs intervention within 1 hour Start treatment ASAP Call Medical Officer (within 2 hours)

C Can see GP at convenient time

D Definitive Nursing Care Only

I personally feel this does not reflect the professional role of both Nursing and Medical officers who work in the Rural setting

Where are we going from here.

A plan of action was proposed and adopted at the Rural Triage workshop on the 25th February. This included a discussion document being prepared by the State Rural Critical Care Committee for distribution by mid May 2000 with a time line for return comments and development of a pilot of the Rural Triage Scale(c) in rural emergency departments in the latter part of the year.

For any inquiries or comments regarding this article, contact Anne Hawkins on 02 6938 6608 or e-mail Anne.Hawkins@swsahs.nsw.gov.au

C R U S H I N J U R Y A N D I T S M A N A G E M E N T

Jeanine Tambimuttu Registered Nurse Emergency Department St Vincent's Hospital

Abstract

The significance of crush injury and its treatment became evident in Australia following the Granville train disaster in 1977. Due to the time it took for victims to be freed from the wreckage, many were subjected to compression of various body parts for extended periods of time.

Medical teams treating these victims became aware that, many encountered complications such as renal failure, cardiac arrhythmias and even cardiac arrest in some cases. This prompted further study into crush injury and its effects on multiple organ systems. This article looks at the pathophysiology of crush injury and its treatment.

Mechanism/Causes

Crush syndrome is a predictable change of pathophysiological changes that occur as a result of sustaining a crush injury. Crush injury is defined as "the result of continuous and prolonged pressure applied to the muscle and soft tissues of compressed, wedged or trapped limbs ''~.

Crush injury is not limited to limbs alone; however, the majority of the time the lower extremities are indeed involved. Any muscle or tissue group in contact with compressive forces for any duration

of time is at risk of sustaining a crush injury and developing crush syndrome.

Crush syndrome is a sequence of events that occur as a result of crush injury. The syndrome begins to develop only once the compressive force is removed and the blood commences flowing through the injured tissues.

Crush injury is characterised by ischaemia and anoxia of the muscle tissue due to the compressive forces. This ischaemia is a contributing factor of third spacing of fluid or leaking of fluid into the interstitial space. This causes increased oedema, raised compartment pressures, and impaired tissue perfusion leading to further ischaemia. 2

This is a potentially life threatening syndrome owing to the severity of the numerous complications associated with it. Compartment syndrome, rhabdomyolysis and renal failure are some of the possible complications.

The literature states that the etiology of crush injury may be a result of traumatic events such as building collapses, motor vehicle accidents, industrial accidents and even in some instances, anti- shock garments. These garments exert compressive forces that could injure the patient if they are over inflated and used for excessive periods of timeY

Hillman & Bishop however, divide the etiology into external forces such as those mentioned above, and also due to a patient's own body weight. If an individual is lying in the same position for any length of time, the muscles they are lying on are at risk of sustaining a crush injury. 5

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