TRIAGE FOR PCT’S

By
Pat Williams, RN, BSN, CEN
Clinical Educator
City Hospital, Inc.
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 Objectives
– Define the concepts and principles of triage
– List responsibilities of PCT at triage
– Explain ethical and legal issues at triage
– Summarize the learnings
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 TRIAGE-French for “tier” or “sort out”
 WWI-sorting of patients to determine
treatment priority on battlefields
 Military intent was to provide care to the
least injured first to go back to battle, then
the others were taken care of, the dying
were left to die
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 Definition:
– A system of sorting patients based on the
severity of their illness or injury
– Each category is predetermined criteria
• life-threatening chief complaints
• risk for short or long term complications
• availability of treatment area and providers
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 3 reasons for triage in the ED
– Increased number of cases to be treated
– Many patients seeking care in the ED for non-
urgent conditions
– Efficient use of resources and space
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 Primary Objectives
– Promptly identify patients requiring immediate,
definitive care
– Determine the appropriate area for treatment
– Facilitate pt. flow through the ED and avoid
unnecessary congestion
– Provide information and referrals to patients
and families
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 Primary Objectives-cont.
– Allay patient and family anxiety and enhance
favorable public perceptions of and experiences
with emergency services.
– Constant evolution in the type and quality of triage
systems
– Triage is a necessity in the ED setting
– Major component of the EMS & an expected
standard of emergency nursing practice.
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 ED Triage Systems
– Places the RN in the lobby or easily accessible
area to entering or waiting patients
– Proven to increase patient satisfaction
– Screen people for simple information and/or
directions
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 Triage goals and functions depends on:
– Number of patients per day
– Type and availability of health-care providers
– Availability of specialty treatment area
– Environmental, legal, and administrative
constraints
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 Policies and Procedures
– specific to the department
– specific to the employee and the expectations
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 Comprehensive Triage System
– Most advanced triage system
– Assessment and prioritization are performed by
competent RN’s with proven competency
– Use categories to rate patient’s acuity level
– Protocols are initiated of specific diagnostic
tests, initiation of other treatments, and re-
evaluation of the patients.
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 TEAMWORK
– Triage nurse can not control the number of
people walking through the door
– Staff is resistant to working triage area,
especially when extremely busy
– Expectation of the PCT beginning interventions
when the patients are taken to the treatment
area is UNREALISTIC
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 Teamwork, cont. \
– The PCT must return to the triage area as soon as
possible, especially during peak and busy hours,
as well as when high risk patients/family
members are in the lobby
– Communication is the KEY when taking a pt. to
the room and informing the primary nurse (nurse
assigned to that room) of the patients arrival
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 Triage Staffing
• ED volume
• Time of day
• Seasonal fluctuations
• Patient acuity
• Range of triage functions
• Staff ability
• Rotation of staff every 4,6, or 8 hours.
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 Triage is an invaluable, cost-effective asset
to any ED. Competent staffing who is
assigned to triage could decrease the
liability and hospital risks, i.e.:
– Making the right choices, assessments,
decisions, and treatments
– Customer satisfaction
– Decrease patient suffering, etc.
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 Decision-making
– Done via the interview process and amount of
information collected
– Emergent: most life-threatening
– Urgent: needs immediate assessment, but not
life-threatening, etc.
– Non-urgent-no fear of loss of life or limb nor
any other complications
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 Triage Staff
– Can “set the tone” for the ED staff, patients,
and families as well
– Remember to “SMILE”
– Introduce yourself
– Explain what you are doing
– Validate findings
– Explain prioritization’s
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 Triage Staff, cont.
– Explain wait times
– Explain rechecking them
– Direct to next process
– Direct to return to triage if condition changes
– Offer comfort measures, i.e. wheelchair,
stretcher, blanket, ice bag, splint, sling, etc.
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 Triage Staff, cont.
– Remember to convey that calm, caring
approach during the process to allay the patient
and family anxiety and lead to a more
comprehensive and successful visit for the
patient and family.
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 FACTORS FOR QUALITY CARE
• Right person
• Right place
• Right time
• Right reasons

– Triage nurse: Expected to perform prompt

evaluation of all patients entering the ED within
2-5 minutes of their arrival
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 Troubleshooting
– Confidentiality
• Number system for those who wish to not have
their name called
• Monitor voice and actions
• Pull curtain
• Remember to use barriers as needed
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 Communication
• Triage Nurse
• Charge Nurse
• Registration
• Patient Care Tech.’s
• EMS
• Fast-Track Staff
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 Decisions
– The TRIAGE NURSE makes the decision who
goes to which room first
– The time of patient arrival is not the purpose of
triage
• acuity
• symptoms
• VS stability
• Pain Scale >7
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 Other Problems
– Lack of decision making skills
– Not taking triage position seriously
– No advances triage orders, remind RN to write
and/or initiate the orders
– Not taking patient complaints seriously
– List some problems experience, solutions?
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 Support
– New triage staff need support and reminders
– Need support in decision making skills, not
criticisms
– Need feedback and encouragement
– Need patience to improve their efficiency
– Identify ways to improve the system
– Offer solutions to prevent something from occurring
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 Does a nurse to stay in triage at all times?
– Yes, a must during peak times and high census
times
– Discuss legal and ethical reasons for not having
a nurse at triage at all times
– 7a.m. to 3a.m. RN to be a Triage, foresee, 24-
hour RN coverage
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 Does the person who performs triage have to
be a nurse?
– Yes, it is the policy
– Non-nursing personnel do not have the authority
to make advanced protocol and triage decisions

– THE RN IS ULTIMATELY RESPONSIBLE FOR

ALL TRIAGE DECISIONS.
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 Functions of PCT at Triage
– Vital signs on patients
– Assist patients to and from registration, to the
assigned room, x-ray, or other treatment area
– Assist with re-assessing patients in the lobby
– Patient advocate to the family/visitors
– What others functions can be done at Triage?
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 What should we do about patients who
leave the waiting room after triage but
without being seen?
– Monitoring the number of walk-outs
– Discuss what happens with chart and
information
– Discuss the importance of re-assessing patients
in the waiting room
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 KEEPING EVERYONE INFORMED
– Communication is the KEY
– Informing patients of delay is of the utmost
importance
– Can’t predict length of stay or how long it will
take
– Offer comfort measures
– Discuss other reasons for information:
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 FACTORS THAT COMPRISE QUALITY
CARE AT TRIAGE
• Know what works
• Doing what works
• Do what works well
• Know what is right
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 Legal Considerations
– An emergency evaluation must be performed
on any individual with an emergency medical
condition or a woman in active labor
– If the individual’s condition is unstable, then an
attempt to stabilize the individual must be done
– Level of transportation to treatment area/s must
be appropriate
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 Highlights
– A sign is posted in the Lobby area that indicates
that the hospital participates in Medicare and
specifies the rights of the people to examination
and treatment. Must be in the common language
of the population
– Medical screening examination or treatments
cannot be delayed to inquire about the patient’s
method of payment
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 JCAHO Standards
– Domestic abuse victims are identified by criteria
developed by the hospital
– Each patient needs to be reassessed at intervals
designated by the institution
– Each patient’s physical, psychological, and social
status is assessed
– Need for discharge planning assessment is
determined
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 JCAHO
– Staff members integrate the information from
various assessments of the patient to identify
and assign priorities to his/her care needs
– A Registered Nurse assesses the patient’s need
for nursing care in all settings where nursing
care is provided
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 Transfers
– The hospital provides referral, transfer, or
discharge of the patient to another level of care,
health professional, or setting based on the
patient’s needs and the hospital’s capacity to
provide care
– The patient must consent or provide a written
request to be transferred to another facility in the
event the patient is stable for transfer
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 Special Considerations
– Violence in the Emergency Department
• Disruptive Clients
• Disruptive Family members/visitors
• Potential of Psychiatric patients to become agitated
and violent
• Beware of the emotionally distraught clients or family
members especially when advised to loss of a loved
one
• Any other situations?
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 Communicable Diseases
– Chickenpox or Shingles
– Remove from waiting area to an isolated area,
such as a room, out of the way place in the
hallway, etc.
– Identify some other communicable diseases?
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 Immuno-suppressed Patients
– Chemo-therapy patients, AIDS, transplant
patients, high dose of steroids
– Mask them and remove to an area away from
the public and other flu’s, colds, viruses, etc.
– Reverse type isolation treatment for these
patients
HYGIENE
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 Poor Hygiene
– If medically stable, send to shower and give
trousers and gown
– Place in an area to provide privacy and to keep
the odor contained
– Beware there may be other injuries, illnesses, or
other medical concerns with these patients
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 Pediatric Patients
– Remember safety issues with these little ones
– Remember the parent may be suffering more
than the child
– Beware of the child’s activity and bed heights,
side rails, playing in the trash cans, etc.
– List other concerns with pediatric patients?
Triage from Vehicle
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 Triage from a Motor Vehicle
– Use the buddy system
– Use C-spine precautions if indicated
– Use good body mechanics
– List other ideas for getting a patient out of the
vehicles?
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 Hazardous Waste
– Remember to use safety precautions
– Beware of the fact that bio-hazards or
contamination to materials is a major concern
– Look for MSDS sheets or call the 1-800
number for copies of the MSDS sheets, etc.
– Discuss other concerns:
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 Psychiatric Patients
– Beware of their behavior
– Speak softly and slowly in short sentences or
phrases
– Never turn your back to them
– Stay near an exit when interacting with a
psychiatric patient
– Other Pearls from experiences?
Obstetric Patients
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 Obstetric Patients
– Place in wheelchair to go to L&D
– If presenting part is visible or lots of rectal
pressure keep patient in ED for quick evaluation
to determine if eminent delivery is about to occur
– Never send a patient to L&D alone, an employee
must accompanying a woman in labor to the unit
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 Case Studies (identify what vitals to do and
treatments =/comfort measures to be done)
– 46yo male presents with syncope and sweating
– 32yo female present with abdominal pain and
diarrhea
– 14yo male c/o wheezing and short of breath
– 8yo female injured right wrist skating
– 6mo. Old male with crying and fever
QUESTIONS