Introduction to

TRIAGE
Kim Fuzzard - Clinical Educator

Key Reference:
Session Outline
Background
Triage role
Australasian Triage Scale
Application of the ATS
Communication at triage
Mental Health triage
Pregnancy and Triage
Medico-legal considerations
Pitfalls & hints
Triage scenarios
Background
Nationally consistent approach to triage

In an ideal world…..
Why triage?

Aim of triage:
To ensure that access to emergency care is based on
objective clinical criteria, therefore optimising safety &
efficiency, with equity of access across the population.
Clinical outcome is optimized, based on assessment of clinical
urgency

Australasian Triage Scale (ATS)

Triage is an essential system where all presenting emergency
patients are prioritised using a standard scale.
Triage Role
Primary roles
Other roles
Establish chief – Expedite care
complaint – Provide a safe
environment
Diagnose clinical – Communicate with
urgency colleagues
– Provide treatment
Assign ATS – Provide information
(allocation to the – Public relations
highest applicable – Data collection
ATS category) – Provide education
– Point of contact
Overview of the ATS

5 Categories SB clinician:
• Cat 1 Immediately Life Threatening Immediate
» Resuscitation

• Cat 2 Emergent <10min

• Cat 3 Urgent <30min

• Cat 4 Semi-urgent <1hr

• Cat 5 Non- Urgent <2hr

Triage assessment- Primary survey
Danger
General appearance, chief
complaint
Airway & Cx spine All triage clinicians must be able
Breathing to perform an accurate, rapid
Circulation and thorough Primary Survey

Disability
Environment

Mental Health
Ophthalmic

Risk Factors
Australasian Triage Scale

A copy of the tables must be easily accessible at every

triage area
Adult ATS Page 1
Adult ATS Page 2
Adult ATS Page 3
Adult ATS Page 4
Paed ATS Page 1
Paed ATS Page 2
Paed ATS Page 3
Paed ATS Page 4
Communication at Triage
Basic human needs
– To be understood
– To feel welcome
– To feel important- self concept
– Need for comfort- psychological & physical
Common signals of unmet needs
Use strategies to unmet fulfil needs
Mental Health Triage Tool
Access the training manual online:

http://www.health.vic.gov.au/emergency/mhtrainingmanual.pdf
ABC’s of mental health assessment
Appearance
– What does the pt look like?
Affect
– What is your observation of
the pts current emotional
state?
Behaviour
– How is the pt behaving?

– How is the pt reacting?

Conversation & Mood
– How is the pt talking?
– Does the conversation make sense?

– How does the pt describe their mood?

– What do you think is the risk of suicide/homicide?

– Every patient must undergo a primary survey

Pregnancy & Triage
Well-being of mother & foetus
Best initial treatment for the foetus is optimal treatment /
resuscitation of the mother

Threats to foetal well being:

• Low SpO2
• Hypertension / hypotension
• PV Bleeding
• Abdominal pain
• Decreased foetal movement

Pregnant women may present with any disease

Medico-legal considerations
Role of the triage nurse Privacy & confidentiality
– Clinical skills &
knowledge
– Accountability
– Standards of care Keep documents out of
– Qualifications public view
– Competency
Use a private triage
assessment area
Consent

Duty of care

For what is the triage nurse legally responsible?

– Accurate diagnosis of urgency (based on available
objective and subjective data)
– The patient must be assessed
– Observation and documentation
– All care while the patient is in the waiting room

Negligence
Documentation
– Date and time of triage assessment
– Name of triage nurse
– Chief complaint/presenting problem/s
– Relevant assessment findings (A,B,C,D, E, risk factors)
– Limited, relevant history
– Initial triage category allocated
– Re-triage category with time and reason
– Any diagnostic, first aid or treatment measures initiated
Beware
‘Flu like symptoms, ?meningococcal disease
Feels really awful, ?AMI
Very worried parent, ?very sick child
Aggression, ?intracerebral bleed
ETOH use, altered conscious state ?intracerebral bleed
‘Naughty’ child, may be hypoxic or cerebrally irritated

Use objective assessment

– Danger, General Appearance, Chief Complaint, ABCDE, risk
factors
References
Curtis & Ramsden (2011) Emergency & Trauma Care for Nurses & Paramedics
Dept of Health & Ageing (2007) Emergency Triage Education Kit
Monash Institute of Health Services Research (2001) Consistency of Triage in Victoria’s Emergency
Departments
BH Patient Flow Project Control Group (2005) Innovative Care
National Institute of Clinical Studies (2006) Vic Emerg Dept Mental Health Triage Project: Training
Manual
College of Emergency Nursing Australasia (2012) Position statement: Triage & the Australasian Triage
Scale
Australasian College for Emergency Medicine (2006) Policy on the Australasian Triage Scale
Richardson, D (2009) ‘Triage’ in Textbook of Adult Emergency Medicine, Cameron et al eds.
Hodge, A et al (2013) ‘A review of the quality assurance processes for the Australasian Triage Scale
(ATS) and implications for future practice’ Australasian Emergency Nursing Journal
Broadbent, M et al (2010) ‘Issues associated with the triage of clients with a mental illness in
Australian emergency departments’ Australasian Emergency Nursing Journal

Consent obtained from all Bendigo Health Emergency Department staff appearing in photographs for use of their
image for publicity purposes.