Triage

Definition of Triagea
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

1. Master Program
second Semester
Seminar on triage

2. Definition of Triagea
•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

3. Triage Categories
•Non disaster: To provide the best care for
each individual patient.
•disaster: To provide the most effective
care for the greatest number of patients.

4. Non disaster or E.D triage
1.Identify patients requiring immediate
care.
2.Determine the appropriate area for
treatment
3.Facilitate patient flow through the ED
and avoid unnecessary congestion.

5. 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.

6. Disaster
The triage team
1.Triage of Victims
2.Critical patients
3.Fatally Injured Patients
4.Non critical patients
5.Contaminated patients

7. Types of E.D. triage system
•Type 1: Traffic Director (Non Nurse).
•Type 2: Spot Check
•Type 3: Comprehensive
•Two-tiered systems: intial 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.

8. Triage levels
1- Resuscitation
2- Emergent
3- urgent
4- less urgent
5- Non urgent

9. TRIAGE LEVELS
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

10. 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

11. 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

12. 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

13. 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

14. Basic component of triage
•An “across-the room” assessment
•The triage history
•The triage physical assessment
•The triage decision

15. An “ across the room assessment”
To identify obvious life threat conditions
General appearance
Air way
Breathing
Circulation*mtim m
+aenam,
Disability
(neurogenic)

16. 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

17. Across the room assessment
•Circulation
Altered skin signs, pale, mottling, flushing
Un controlled 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

18. 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

19. Role of triage nurse
•Greet patients and identify your self.
•Maintain privacy and confidentiality
•Visualize all incoming patients even while
interviewing others.
•Maintain good communication between triage and
treatment area
•maintain excellent communication with waiting
area.
•Use all resources to maintain high standard of care.

20. 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.

21. Thank you