Triage in Emergency Department

Triage Waiting room Team leader

Definition of Triage
Triage is the term derived from the French verb trier meaning to sort or to choose Its 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: 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 human-made, that produces patients in numbers needing services beyond immediately available resources. The key to successful disaster management is to provide care to those who are in greatest need first. 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

TRIAGE LEVELS
Level 1 - Immediately Life-threatening or Resuscitation: Conditions requiring immediate assessment. Includes: Airway or severe respiratory compromise Cardiac arrest. Severe shock. Symptomatic cervical spine injury. Multisystem trauma. Altered level of consciousness (GCS < 10)..

Triage levels
Triage Level 2Imminently Life-threatening or Emergent: Conditions requiring assessment within 10 to 15 minutes

Include: Head injuries. Severe trauma / Asthma / Allergy Any pain greater than 7 on a scale of 10 GI bleed with unstable vital signs. Abdominal pain in patients older than age 50. Any neonate age 7 days or younger

Triage levels
Triage Level 3Potentially Life-threatening/Time Critical or Urgent Conditions requiring assessment within 30 minutes

Include:
Alert head injury with vomiting. Mild to moderate asthma / trauma GI bleed with stable vital signs. Mild to moderate respiratory distress

Acute psychosis

Triage levels
Triage Level 4Potentially Lifeserious/Situational Urgency or Semi-urgent Conditions requiring assessment within 1 hr.

Include: Head injury without vomiting. Minor trauma / allergy Vomiting and diarrhea in patient older than age 2 without evidence of dehydration. Earache. Chronic back pain

Triage levels
Triage Level 5Less/Non-urgent Conditions requiring assessment within 2 hours Include: Minor trauma, not acute. Sore throat. Chronic abdominal pain.

Color Coding
Red tags - (immediate) are used to label those who cannot survive without immediate treatment but who have a chance of survival.
Yellow tags - (observation) for those who require observation (and possible later retriage). Their condition is stable for the moment and, they are not in immediate danger of death.

 Green tags - (wait) are reserved for the "walking wounded" who will need medical care at some point. White tags - (dismiss) are given to those with minor injuries for whom a doctor's care is not required. Black tags - (expectant) are used for the deceased and for those whose injuries are so extensive that they will not be able to survive given the care that is available.

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)

Air way
Breathing

Circulation

Across the room 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 doesnt 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 apnea periods, retractions, use accessory muscles, nasal flaring, grunting, or audible wheezes

Across the room assessment

Circulation Altered skin signs, pale, mottling, flushing Uncontrolled 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

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