Download Triage levels

Triage in Emergency
Department
BY
Mohammad abuadas, RN, MSc
Triage
Team leader
OBJECTIVES
At the end of this lecture the students will be able
to:
 1- State the definition of word “triage”.
 2- Identify the triage categories.
 2- Review triage levels.
 3- Understand (across the room assessment).
 4- Identify the characteristics of triage nurse.
 5- Describe the roles of triage nurse.
 6- Understand the importance of re triage.
First Unit
 Assess
& Secure the Scene
 Establish Areas as Outlined in the
Schematic
 Communicate &
Direct Incoming Units
 Requests Additional
Resources
 Notify Hospitals
 Establish Triage
Unit Coordinator
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
treatment
3. 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 humanmade, 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 team
 Triage of Victims
- first victims to arrive are frequently not
the most seriously injured.
 Critical patients
 Fatally Injured Patients
 Non critical patients
 Contaminated 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- Resuscitation
2- Emergent
3- urgent
4- less urgent
5- Non urgent
The Canadian E.D. Triage and Acuity Scale
Overview of three category triage acuity systems
category
acuity
Class 1 Emergent
Recommended
reassessment
continuous
Cardiopulmonary
arrest, severe
respiratory distress,
major burns, major
trauma, massive
uncontrolled
bleeding
Coma, status epil..
Every 30
minutes
Abdominal pain, non
cardiac cp, multiple
fractures, lacerations,
renal calculi,
Every 1-2
hrs
Rash, chronic
headache, sprains,
cold symptoms
Immediately life or
limb threatening
Class 2 Urgent
Requires prompt care,
but will not cause loss of
life or limb if left untreated
for several hours.
Class 3 Non urgent
And treatment but time is
not a critical factor
Examples
TRIAGE LEVELS
1- 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 levels
2- 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- Urgent
Condition with significant distress
Time Nurse < 20 min, physician < 30 min
Head injury without decrease of LOC but
with vomiting
 Mild to moderate respiratory distress
 G.I. Bleed not actively bleed
 Acute psychosis
Triage levels
4- Less urgent
Conditions with mild to moderate
discomfort
Time for Nurse assessment <1h
Time for physician assessment < 1h
Head injury, alert, no vomiting
Chest pain, no distress, no cardiac susp.
Depression with no suicidal attempt
Triage levels
5- Non urgent
Conditions can be delayed, no distress
Time for nurse and Physician assessment
more than 2h
 Minor trauma
 Sore throat with temp. < 39
Reassessment in triage
 Level
1 =Continuous
 Level 2 = every 15 min
 Level 3 = every 60 min
 Level 4 = every 60 to 90 min
 Level 5 = every 2 hours
ES I
M
E
R
G
E
N
C
Y
EN
VD
EE
RX
I
T
Y
Is patient dying ?
Yes
No
Level I
Level II, III, IV, V
Can patient wait ?
Yes
No
Level III, IV, V
Level II
How many resources ?
TWO
Level III
ONE
Level IV
NON
Level V
What are resources ?
Resources
Not resources

Labs


ECG-X-rays C-T MRI
Point

IV Fluids /hydration

Saline or Hep lock

IV /IM Medication

PO. Medication

Specialty consult


Simple procedure

Complex procedure
HX and physical exam.
of care testing
Simple wound care
(dressing check /recheck)
crutches ,splints,slings.
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 conditions
General appearance
Disability
(neurogenic)
Circulation
Air way
Breathing
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 way
Abnormal airway sounds, stridor, wheezing grunting
Unusual posture e.g.. Sniffing position, inability to
speak, drooling or inability to handle secretion
 Breathing
Altered skin signs, cyanosis, dusky skin,
tachypnic, bradypnea, or apneic periods,
retractions, use accessory muscles, nasal flaring,
grunting,or audible wheezes
Across the room assessment
 Circulation
Altered skin signs, pale, mottling, flushing
Un controlled bleeding
 Disability (neuro.)
LOC
Interaction with environment
Inability to recognize family members
Unusual irritability
Response to pain or stimuli
Flaccid 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
Triage
Tag
 Patient
MIEMSS
A V P U
A V P U
A V P U
Information

Triage Status

Chief Complaint
Tourniquet @ _______
Extremity Splint
HOSP NOTIFIED

Transportation

Peel - off Bar
Codes

Transport Record

Vital Signs

History

Treatment
Gauge
PASG
Inflated at _______________
Gross Decon.
Final Decon.
TRIAGE TAG
Maryland Emergency
Medical Services
Maryland Department
of Transportation
Patient Information Section
 During
MCIs this information is not
always obtainable.
 Information is not a priority, can be added
throughout triage, treatment,
transportation, and hospital reception
phases.
Triage Status Section

Universal color coding system
 Space provided for four individual evaluations




Initial assessment - apply tag for priority assignment
Secondary reassessment (in treatment area)
Blank - can be used in the treatment area or during
transportation
Hospital
Chief Complaint Section
 Major
obvious injuries or illness can be
circled
 Indicate injuries on the human figure
 Additional information is added on the
comments line
Transportation Line
transporting unit notes it’s agency
information, destination facility, and the
time the patient physically arrives at
destination facility
 The
Transportation Record Section
 Detachable
by tear-off ticket and as a
peel-off label
 Used to document patients removed from
the scene to a hospital or other facility
 Transportation record label can be fixed
to the transportation tactical worksheet make certain unit, priority, and destination
is marked and initialed
HOSP
NOTIFIED
Vital Signs Section
In START
Order
R-P-M
Medical History Section
 Information
can be obtained anytime
during the incident
 Information can be obtained from Medic
Alert identification devices
 Relevant medical history & medications
Treatment Record Section
 Documents
treatment sequence and
progress
 Quick
documentation of common
treatments
 Space
provided for additional treatments
and remarks
 Spaces
provided for time treatment
actions are taken and for provider initials
Treatment Record Layout