Chapter 2: Emergency Triage and Rapid Assessment

What is triage?

Triage is the process of sorting patients as they present to the emergency care setting. Patients are generally sorted into one of three
categories: (1) those requiring immediate care, (2) those requiring some type of urgent care, but who are able to wait a short time (e.g. minutes)
to receive this care, and (3) those requiring some type of standard care, and who are able to wait considerable time (e.g. hours) to receive this
care. Triage involves performing a rapid assessment of a patient; as will be described in some detail in a later section of this chapter, rapid
assessment is a two- to five-minute process undertaken by a nurse to identify a patient's presenting problem, collect the patient's basic history
and ascertain the patient's current physical / psychological condition. Based on this rapid assessment, the nurse is able to make a decision
about the level of acuity assigned to the patient - that is, the type of care they require, and how soon they require it.

Triage systems

All emergency settings use some form of triage system; however, it is important to be aware that there is no single triage system in use in the
UK. Regardless of the specific type of triage system used, though, all triage systems involve assigning a patient a level of acuity. This identifies
how serious the patient's condition is and, subsequently, how urgently the patient requires care. In the UK, a patient's level of acuity may be
identified using a word, a number and / or a colour.

Examples of clinical presentations which may be categorised into each acuity level are provided following:

1. Cardiac and / or respiratory arrest, intubated trauma patient, severe overdose.

2. Ischaemic chest pain, child with fever and lethargy, disruptive psychiatric patient.
3. Moderate abdominal pain, gynaecological disorders, closed-extremity trauma.
4. Simple lacerations, cystitis, typical migraine, sprains and strains.
5. Mild influenza-like symptoms, minor burn, re-checks (e.g. of casts, wounds, etc.).

It is important to note that patients may present to emergency care settings in a variety of different ways, and this will affect how they are
triaged. Approximately 24% of patients arrive in UK A&E Departments by ambulance or helicopter; in these situations, the patient will have
already been triaged, usually (though not always) as a patient requiring immediate care. In most cases, however, patients self-present by
walking themselves into the emergency care setting; in these situations, the nurse will be required to undertake a process of triage.
The triage process

Triage progresses through a series of clearly-defined steps, which focus on the rapid assessment of a patient. Rapid assessment includes
three tasks: (1) the observation of the patient, (2) the collection of a health history, and (3) the physical and / or psychological assessment of
the patient - including a primary survey, and perhaps a secondary survey. The information gathered at each of these steps is used by the nurse
to make a decision about the level of acuity assigned to the patient. This section will consider each of these three rapid assessment tasks in
greater detail.

Rapid assessment - observation: The first step in rapid assessment is the observation of the patient. This is done in the first few seconds in
which you engage with a patient. Observation involves visually examining the patient to gather information about how they appear (physically)
and behave (psychologically). For example, you may observe:

 Any issues which immediately threaten the life or wellbeing of the patient.
 Any obvious physical or psychological problems (e.g. deformity, bleeding, psychosis).
 The client's level of consciousness, and their behaviour or manner.
 The client's rate and depth of breathing, and the ease of air entry.
 The client's current state (e.g. position, stature, colour, tone, mood, distress).
 The client's ability to engage and communicate appropriately with others.
 The level of support the client has, including whether they present with others.
 Other general information about the client (e.g. their weight, hygiene, dress).

Rapid assessment - health history: Collecting a health history involves speaking with a patient and / or their family (as appropriate), to find out
about: (1) their presenting complaint, and (2) their relevant past medical history. During this stage of the rapid assessment, you may collect
information about:

 The client's presenting complaint.

 The history of the client's complaint.
 The client's medical history.
 The client's medications.
 The client's allergies.
 The client's pre-existing treatment plans.
 The client's last consumption.
Most organisations will have a template which nurses working in emergency care settings can use to guide them in collecting a health history
from a patient.

It is important to note that, in emergency care settings, the process of collecting a health history from a patient may be brief; this is particularly
true if a patient requires immediate care. In these situations, a nurse should focus on collecting only the information which is necessary for the
patient's immediate care.

Rapid assessment - primary survey: Once the health history has been completed, the nurse can progress to the primary survey. This involves
physically assessing the patient's life-sustaining body systems to identify issues which may immediately threaten their life or wellbeing. It
involves five stages, which may be remembered using the 'ABCD' mnemonic:

A Airway This step involves assessing the patency of the airway. A patient whose airway is compromised may be dyspnoeic
and unable to vocalise; furthermore, the nurse may be able to visualise secretions, a foreign body or trauma affecting
the airway.
B Breathing This step involves assessing the adequacy of the patient's breathing and gas exchange. Patients who are having
difficulty breathing may be dyspnoeic, have paradoxic or asymmetrical movements of the chest wall, use accessory
muscles, have increased or decreased breath sounds, or be cyanotic, tachycardic and / or hypertensive.
C Circulation This step involves assessing the functioning of the cardiovascular system - specifically, the quality and rate of the
pulse and capillary refill time - and determining whether the patient has adequate blood volume. The nurse may also
assess the patient's skin colour and temperature, particularly centrally versus at the peripheries.
D Disability This step involves briefly assessing the patient's neurological system, including their level of consciousness. Another
simple mnemonic - 'AVPU' - is used to prompt nurses during this step:

A The patient is alert.

V The patient responds to voice.
P The patient responds to pain.
U The patient is unresponsive.
During this brief neurological examination, the patient's pupils should also be assessed for their size, shape, equality
and response to light.

It is important to note that there are a variety of reasons why a patient's level of consciousness may be altered -
including use of substances, physical conditions, and / or psychological conditions.
 During this step of the primary survey, other disabilities - for example, obvious physical or psychological problems -
may also be identified. These are explored further in the secondary survey. Some organisations recommend that
nurses complete a brief pain assessment at this stage; however, pain is also assessed comprehensively in the
secondary survey.
Once the primary survey has been completed, and if no issues which may immediately threaten their life or wellbeing have been identified, the
nurse may progress to the secondary survey.

Rapid assessment - secondary survey: Following on from the primary survey, the secondary survey is a more comprehensive assessment of
the functioning of a patient's body systems. It is the first step in identifying exactly what type of care and management a patient may require. It
involves four stages, which may again be remembered using a mnemonic - in this case, 'EFGH':

E Exposure This step is usually only completed for patients with traumatic injury/ies (suspected or actual). It involves
completely removing the patient's clothing, with the aim of identifying subtle issues which were not obvious during
the primary survey.
F Full Vital This step involves taking a complete set of vital signs. Vital sign data provides important objective information
Signs about the patient's current physiological state. In particular, the nurse should measure:

T The patient's body temperature may be affected by certain disease processes, environmental factors,
inflammation, infection and / or injury. Temperature is measured using a thermometer at the oral, axillary,
temporal or tympanic sites or, less commonly, via a rectal or intravascular probe.
HR A patient's heart rate, or pulse, is measured for its rate, its rhythm, and its quality. It is generally
recommended that nurses in emergency settings palpate a patient's pulse, rather than using electronic
monitoring equipment to simply count the rate.
RR A patient's rate of respiration should be measured over one full minute, and the rhythm, depth and work of
their breathing assessed. Signs of airway and breathing issues, as described in the primary survey
section, should be evaluated in greater detail.
O2 sats A patient's oxygen saturation should be measured using a pulse oximeter. This measurement provides
important information on the amount of oxygen present in a person's blood and, therefore, the
effectiveness of the gas exchange process.
BP Ideally, a patient's blood pressure should be measured using a manual sphygmanometer. The blood
pressure reading may provide information about the efficiency of a patient's cardiac function, as well as
their circulating blood volume. Orthostatic blood pressure - that is blood pressure measured in two or three
different positions (e.g. lying, sitting and standing) - may be recommended by some organisations.
Depending on the reason/s for the patient's presentation to the emergency care setting, a variety of other assessments may be
undertaken at this stage. These assessments may include:

 Electrocardiogram (ECG) monitoring.

 Other diagnostic imaging studies (e.g. X-rays, CAT scans, MRI scans, etc.).
 Urinalysis.
 Blood laboratory studies.
 Blood glucose levels.
 Comprehensive neurological evaluation.
 Neurovascular function.
 Height, weight and Body Mass Index (BMI).
 Sensory perception.
 Skin assessment.
 Mental health assessment.
 Pain assessment - this can be completed using the 'OPQRST' mnemonic:

O Onset

P Provocation and palliation

Q Quality
R Region and radiation
S Severity
T Time
G Give Most patients presenting to emergency care settings will experience some degree of pain. Providing comfort
Comfort measures - that is, pain management - early in the patient's care is therefore an important consideration. Comfort
Measures measures may include a combination of:

 Pharmacologic interventions (e.g. non-steroidal anti-inflammatory drugs, intravenous opioids, etc.).

 Non-pharmacologic interventions (e.g. imagery, distraction, repositioning, breathing techniques, heat

packs, etc.).
H Head-to- In this step, a more comprehensive head-to-toe assessment is undertaken. This involves sequentially assessing:
Toe
Assessment  The head, neck and face.
 The chest.
 The abdomen and flanks.
 The pelvis, and the perineal area (if appropriate).
 The extremities.
 The posterior surfaces.

In many A&E Departments in the UK, the triage process is supported by a Clinical Decisions Unit (CDU) or similar service. The purpose of
CDUs is to help improve the efficiency of the triage process. CDUs use specialist teams of medical, nursing and allied health staff to assess,
investigate and diagnose patients - and, subsequently, plan their care. CDUs are particularly useful for supporting the triage of patients with
multiple and / or complex conditions.

Management of a patient post-triage

Once the process of triage, as described throughout this chapter, is complete, a patient will be provided care - specifically, investigations and /
or interventions to manage the clinical complaint for which they presented. Once care has been provided within the emergency care setting and
the patient is stable, or the care options which can be provided in this setting have been exhausted, a patient will be discharged from
emergency care.

Conclusion

This chapter has provided a broad overview of triage in emergency care settings. It has considered the system of triage, including the
strategies used to determine a patient's level of acuity. It has explained in detail how a nurse in the emergency care setting may undertake the
triage of a patient, describing the practical techniques involved in rapid assessment - including observation, the collection of a health history,
and physical assessment using primary and secondary surveys.