Triage In Emergency Department

1. Triage in Emergency Department
Triage
Waiting
room
Team leader

2. 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

3. 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
patients.

4. Non disaster or E.D triage
The primary objectives of an ED triage are to
(ENA,1992, P. 1):
2.Identify patients requiring immediate care.
3.Determine the appropriate area for
treatment
4.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
•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

7. Disaster
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

8. 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, internal triage
and external triage

9. Triage levels
1- Resuscitation
2- Emergent
3- urgent
4- less urgent
5- Non urgent
The Canadian E.D. Triage and Acuity Scale

10. Overview of three category triage acuity systems
category acuity Recommended
reassessment
Examples
Class 1Emergent
Immediately life or limb
threatening
continuous Cardiopulmonary
arrest, severe
respiratory distress,
major burns, major
trauma, massive
uncontrolled bleeding
Coma, status epil..
Class 2Urgent
Requires prompt care, but
will not cause loss of life or
limb if left untreated for
several hours.
Every 30
minutes
Abdominal pain, non
cardiac cp, multiple
fractures, lacerations,
renal calculi,
Class 3Non urgent
And treatment but time is
not a critical factor
Every 1-2
hrs
Rash, chronic headache,
sprains, cold symptoms

11. 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

12. 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

13. 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

14. 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

15. 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

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

17. An “ across the room assessment”
To identify obvious life threat conditions
General appearance
Air way
Breathing
Circulation
Disability
(neurogenic)

18. 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
investigate.

19. 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

20. 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

21. 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

22. 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.

23. 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.

24. 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.

25. •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