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Triage in Emergency Department


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
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
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.
• 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
 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
• 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 Recommended Examples

Class 1 Emergent continuous Cardiopulmonary

arrest, severe
Immediately life or limb respiratory distress,
threatening major burns, major
trauma, massive
uncontrolled bleeding
Coma, status epil..

Class 2 Urgent Every 30 Abdominal pain, non

cardiac cp, multiple
Requires prompt care, but will
not cause loss of life or limb if minutes
fractures, lacerations, renal
left untreated for several

Class 3 Non urgent Every 1-2 hrs Rash, chronic headache,

sprains, cold symptoms
And treatment but time is not
a critical factor
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
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


Air way Circulation

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
Across the room assessment
• Air way
Abnormal airway sounds, strider, 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
Un controlled bleeding
• Disability (neuro.)
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
• 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
• 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