Download TBA – Triage Before Action - Australian Veterinary Association

TBA – Triage Before Action
Eliska Jerabek Dip VN (E&CC)
Newcastle Animal Emergency Centre Pty Ltd.
4 Lang Road, Broadmeadow, 2292.
What is triage?
Triage; meaning ‘To Sort’, is a process that we use to prioritise our patients based on the
severity of their condition. In the veterinary industry we can use triage in a variety of
situations.
Triage types seen in the veterinary industry.
Disaster Triage – This is where you have multiple patients due to a disaster. Unfortunately,
in Australia we have bush fires, floods, and hurricanes. We can all be affected by these
disasters and may be faced with multiple patients at the one time that need to be triaged as
quickly as possible. When you have large amount of patients you need to assess them so
that you know where to assign your available resources to. You may have 2 vets to 50
patients.
Telephone Triage -This is usually the first contact with the client. You need to assess the
patient without seeing the animal. This is done by some careful questioning. If the owner is
concerned enough to call, then it is usually needs to be seen by the veterinarian. Does this
patient need to come in right now or can it wait a few hours?
Waiting room Triage- This is where your patients are presented to the clinic and you need to
make a quick assessment of the patient to prioritise its care. Does it need to be seen now or
can it wait?
Hospital Triage – This is usually when you have multiple patients in your care and minimal
amount of time/resources. You need to work out what your priorities are within the hospital.
Patient Triage – this is when a patient is presented with multiply trauma or problems and you
need to assess what is the priority for this patient. This is usually done by your veterinarian.
Performing telephone triage.
Telephone triage is usually the first contact with our clients; they can often be distressed
because their pet is sick or injured. This can sometimes make it difficult to get the
information that is required for you to make an accurate assessment.
Usually the caller will tell you that there dog/cat is sick or injured, and it can be quite obvious
“my dog has been hit by a car he is not getting up, or it may be as vague as “I think that my
dog is sick”.
Some questions that can help you make an assessment of the patient over the phone are:•
•
•
•
What species/breed – Some breeds are prone to certain problems example – large
breed dogs are more likely to have a GDV. This can also give you an idea of the
weight of the patient (small/medium/large).
Age of the pet – The younger and the older patients are more susceptible to disease
and problems.
Gender of the pet. Is it desexed?
Describe the problem. (Why have you called us today/tonight?) For this you need to
ask the appropriate questions to assess the following:
- Level of Consciousness - Is the patient conscious? Seizuring? Unsettled?
Alert?
- Is the patient breathing? Or having any trouble breathing?
- Is the patient bleeding / broken bones?
Remember - Our clients are not trained and may not give you a accurate assessment of the
pet so it is best to advise the client to seek veterinary attention especially if there is any sign
of breathing difficulties, altered level of consciousness, or trauma.
It is also an idea to find out the owner’s location to the clinic, if it sounds like first aid is
required then you should advise the owner on how to perform it, also advise them about their
own safety, even their own dog will bite them if it is in pain. Clear directions to the clinic can
help them find the clinic. The advice that you give the owner over the phone could mean life
or death of the animal.
The information gathered from the phone call can help you in preparation for the arrival of
the patient just knowing the breed of the patient can give you an idea of size of IV catheter to
get out, what size oxygen mask to have prepared, what size endotracheal tube you need. If
it is a large dog that can’t walk then you can prepare a trolley or stretcher for quick
transportation to the treatment area.
Performing waiting room triageOnce presented to the clinic you need to make a quick assessment of the patient and
determine the urgency/priority of the patient and then place them into a triage category.
There are a few different ways of categorising triage, they all do the same thing. The traffic
light colours are easy to remember as they are clear and easy to use.
RED – Priority 1 – May Survive if life saving measures are applied. Initiate treatment
immediately. Example- cardiac or respiratory arrest, respiratory distress, active seizures,
heat stroke, GDV (bloat), allergic reactions, poisoning, excessive bleeding, snake bite, open
fractures.
YELLOW – Priority 2 – Likely to survive if care is given within hours. Treatment to be
commenced as soon as possible, keep a close eye on these patients as they can deteriorate
over time. Example - diarrhoea, birthing difficulties, actively vomiting, closed fractures
GREEN – Priority 3 – Will survive regardless of treatment. Example – skin conditions,
lameness, abscess, sore eyes/ears, and chronic problems.
BLACK – Dead on arrival
These categories let our staff know who needs immediate attention.
How do we categorise our patients?
When a patient arrives at the clinic, it requires immediate assessment. To do this we need to
keep calm, look and listen to our patient.
Primary Assessment is based on ABCD.
A- Airway
B- Breathing
C- Circulation
D- Demeanour
This is a quick assessment that should be less than a minute. This determines the urgency
of the patient and gives you an idea of what category you are placing your patient in.
If you find any problems in your primary assessment then your patient is usually categorised
as RED. This needs immediate attention.
Your Secondary Assessment can continue
•
•
•
•
•
Heart rate and pulse rate
Respiratory rate
Temperature
SpO2.
History.
Once you have assigned your patient a triage status this is not the end of the process. If the
veterinarian has not been able to assess the patient after 10-15min, then re-triage may be
required. If you receive a new patient then the triage process is reassessed to ensure
patients are seen in the right order.
Know your normals.
Knowing what is normal helps us to assess what is not normal. Your observations are what
you make your conclusion from so if you don’t know what is normal then it is really hard to
make an accurate decision about your patient and therefore can be detrimental to him or
her.
Airway – Is the airway patent? Your patient’s airway can be obstructed by swelling (facial,
tongue, neck, glands), foreign bodies, soft palette. Are there any respiratory sounds that are
associated with inspiration or expiration?
Breathing – Is the patient breathing? Is the rate normal/abnormal. If possible respiration rate
should be assessed before approaching the patient. Is there any respiratory effort present?
Is there any abdominal effort? What is the respiratory pattern like?
Circulation – Assess mucous membrane colour and capillary refill time. Is there any active
bleeding? Is there a femoral pulse present? What is the character of the pulse (This can be
subjective) Does it match the heart rate?
Mucous membrane assessment
Pink – normal
Pale/White – can be indication of blood loss, shock, anaemia.
Grey/Blue – hypoxemia.
Bright Red – vasodilation, sepsis, pyrexia.
Yellow – Liver Disease, severe heamolysis.
Normal CRT – is 1-2 seconds if it is <1 sec you could have hyperdynamic, vosodilation
present. If >2 sec then there is a decrease in peripheral perfusion.
Demeanour – This is an assessment of the patients Level of consciousness and attitude. Is
the patient comatose? Is it actively seizuring? Is the patient dull/depressed? Has it
responded to your stimuli?
Also observe your patients positioning, if it is hunched it may be painful. Vocalising can also
be a sign of pain.
Heart rate and auscultation – Does the heart sound normal? Is there any arrhythmia
present? Is the rate normal? It is an idea to match your heart rate with your patient
behaviour. If you have a dull dog with a heart rate if 160 then it needs to be assessed by the
veterinarian.
Pulse rate should match heart rate.
Temperature – If patient temp is < 37.5⁰C then you may require active heating, if greater
than 39.5⁰C then your patient is hyperthermic. Temp > 40⁰C consider active cooling.
SpO2 – Pulse oximetry is a measure of oxygen that is bound to haemoglobin. A normal
pulse-ox is >98%. Any pulse-ox reading below 95% you should consider giving
supplementary oxygen to. If your patient is hypoxic (grey/blue gums) then don’t stuff around
getting a reading - it NEEDS oxygen.
Client communication
Client communication is really important in the triage process. It is important for you to stay
calm and introduce yourself to the owner. Let them know what you are doing. If the patient is
categorised as RED, advise the owners that you are taking their pet into the treatment area
for the veterinarian to assess straight away and that someone will be back to let them know
what’s going on shortly. The owners can be really distressed and all they see is that you are
taking their pet away from them.
History is also important. For some presentations time is of the essence. There is a window
of opportunity for treatment. With allergic reactions, you may only have a short time for
treating the patient. Toxicities, the longer the patient is exposed to the toxin the more toxin
absorbed. Pain can also take priority. Sometimes the patient presents standing up wagging
its tail yet it has a broken leg - it has to be painful.
Action
Nurses are usually the first staff member to see our clients and their pets. Our veterinarians
can be very busy and we need to help organise their workflow.
Readiness and having a crash area can improve outcome of your critical patients. In this
area you should have an oxygen source, ambu-bag, endotracheal tubes, IV catheters and
lines, and emergency drugs (most veterinary textbooks have a crash cart list in them).
Whether you are working in an emergency clinic or a general practice, it is a good idea that
within your clinic you look at a protocol that works for your team. When you have assessed a
patient as a RED - priority 1, you need to know what is needed and acceptable for you to do
to your patient, whist you are waiting on the veterinarian. Can you start supplemental oxygen
can you start CPR or place a compression bandage while you are waiting on the
veterinarian.
If you are seeing an increasing number of emergencies your clinic may need to consider a
critical form that explains to the client that their pet is really ill, this form gives you
authorisation to start emergency treatment to their pet before veterinary consultation. This
can also be the time that you discuss resuscitation orders with your client.
Triaging your patients can be very scary, as it can be a life or death decision for the patient.
If you work with your veterinarians and gain as much knowledge and experience that you
can to ensure that your patients get the care that they need. It doesn’t have to be scary.