Triage-in-Emergency-Department.pptx

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1. Triage in emergency department Lye Meng Hon

2. Introduction Definition French noun derived from the verb trier , which means to sift or sort. the methods used to assess patients’ severity of injury or illness within a short time after their arrival, assign priorities, and transfer each patient to the appropriate place for treatment.

3. Problems Faced in ED The volume of admissions to a given emergency department cannot be predicted with any great accuracy. Only a certain proportion of the patients have life endangering or medically urgent conditions . Patients with life-threatening injuries or illnesses need to be reliably identified within minutes of arrival. Patient overcrowding. The demand for medical treatment significantly outstrip available resources .

4. Aim To ensure that the patient receives the level and quality of care appropriate to clinical need (clinical justice). Reduce unnecessary delay of treatment. Departmental resources are most usefully applied (efficiency).

5. Triage in Emergency Department ED triage systems Designed to identify the most urgent (or potentially most serious) cases. To ensure that they receive priority treatment, followed by the less urgent cases. First-come, first-served basis Triage officers routinely assess all patients who present for treatment to sort and prioritize them.

6. Types of Triage in ED 3-level triage system: Level 1 = emergent Level 2 = urgent Level 3 = non-urgent → Lack of specificity and prone to subjectivity 5-level triage systems Eg : Australian Triage Scale (ATS), Manchester Triage Scale (MTS), Canadian Triage Acuity Scale (CTAS), Emergency Severity Index (ESI)

7. Art of Triage Complex and dynamic process Obtaining adequate and relevant information in a short amount of time Decisions are made in a time-sensitive environment with limited manpower and information. Decision made based on pre-existing guidelines and patient’s condition.

8. Roles of Triage Officer Allocate triage category bases on patient assessment Initiate appropriate nursing interventions First aid Initiation of organizational guidelines, eg : x-ray, analgesia. Liaise with members of the public and other healthcare professionals. Escort patient and pass over relevant information Provide patient and public education where necessary documentation

9. Process of Triage Main complaint and brief history Vital signs Physical findings seen, heard, felt or smelt Setting the priority status of the patient Decision of preliminary diagnostic testing should be done Decision whether treatment should be started at triage

10. SOAP System Larry-Weed SOAP system S (Subjective) – main complaint and brief history O (Objective) – physical finding and vital signs A (Assessment) – setting of the priority status based on subjective and objective finding P (Plan) – preliminary diagnostic and treatment

11. Malaysian Triage Category MTC is designed for use in hospital emergency services throughout Malaysia. A scale for rating clinical urgency. Directly relates triage category with a range of outcome measures (inpatient length of stay, ICU admission, mortality rate) and resource consumption (staff time, cost). Provides an opportunity for analysis of a number of performance parameters in the Emergency Department.

12. MTC

13. Critical (RED)

14. Critical (RED) Patients with life threatening injuries or illness which require immediate attention. Assessment and treatment simultaneously within 5 minutes. Subcategories: R1 (immediate life-threatening) R2 (life-threatening)

15. Clinical Descriptions Code arrest (cardiac/ respiratory) or impending arrest Hypoventilation: RR< 10/min Shock state SBP < 80 (adult)or severely shocked child/infant Airway compromise or immediate risk to airway Severe respiratory distress. Tachypnoea and/or dyspnoea with SpO2 <95% Seizuring patient (ongoing/prolonged) and post- ictal states with neurological deficits Coma/ unconscious or responds to pain only (GCS<9/15) Alleged poisoning or drug overdose with impairment of conscious level and need urgent intervention Head injury with GCS 13/15 and below Exsanguinating limb injuries (massive blood loss) Severe crush injuries to limbs Other immediate life threatening conditions Severe or moderate asthma/ COAD Polytrauma / major trauma Burns to more than 25% BSA regardless of depth and/ or more than 20% 2nd degree burns Alleged near-drowning Gun-shot/ stab wounds to head, neck, trunk or abdomen or trajectory undetermined Arrhythmia with tachycardia/ bradycardia and unstable. Hypertensive emergencies: SBP> 220 or DBP >120 with systemic symptoms Chest pain – visceral, non-traumatic associated with parasympathetic and sympathetic symptoms Acute MI/ unstable angina diagnosed by referral Acute abdomen, hemodynamically unstable Hyperglycemia or hypoglycemia with altered conscious level or neurological/ systemic deficit Baby< 3 months with fever > 38°C Other life threatening conditions Obstetric emergency ( Hamodynamically unstable)

16. Semi-Critical (YELLOW)

17. Semi-Critical (YELLOW) Assessment and treatment starts within 30 minutes. Usual presentation: Unable to walk but airway is secure, hemodynamically stable and on trolleys

18. Clinical Descriptions Altered conscious level but not comatose. Head injury = 14/15 or GCS full but pupils unequal Fractures of long bones of lower limbs/ pupils Open fracture of upper limbs Spine injuries (not in shock, no neurological deficit) Eye injury with loss or impaired vison Dislocation of major joints Limb amputation: total or/ near-total ( haemodynamically stale) Burns 15-25% of BSA regardless of depth and/or 10-20% 3 rd degree burns with no compromise to airway and circulation Vascular injuries but hemodynamically stable Patients with acute abdomen but hemodynamically stable Chemical exposure involving eyes Alleged poisoning/ drug overdose – patient conscious and need no intervention Severe pain: Trauma: pain score: 8-10 Non-trauma: pain score 4-7/10 Allergic reaction – moderate Mild to moderate dyspnoea with saturation >95% and/or rate <40/ min Hyperventilation and unable to maintain posture Cheat pain – visceral and not associated with other symptoms Hepertensive urgencies: elevated SBP < 220mmHg or DBP <120mmHg with minimal systemic symptoms but no neurological deficit. Baby > 3 months with fever > 38°C Infant < 1 month regardless of any symptoms Significant per vaginal bleed with hemodynamically stable Other medical urgencies requiring intravenous intervention and intermittent monitoring only: Dehydration, diarrhea with vomiting, pyrexia >40°C, signs of infection, dialysis problem, acute psychotic episodes, chemotherapy or immunocompromised , acute urinary retention.

19. Non-Critical (GREEN)

20. Non-Critical (GREEN) Assessment and treatment starts within 90 minutes Usual presentation: Airway secure, hemodynamically stable patients not in any distress and ambulant Subcatagories : G1 (fast line) G2 (require initial management or first aid before seen by doctor) G3 (patients who can wait) G4 (triage away to primary care or another center) G5 (not seen in ED)

21. Non-Critical (GREEN) G1 (Fast Lane) Children < 2 years old Senior citizen > 65 years old Acute pain (trauma): pain score <4/10 Chest pain – non-visceral, musculoskeletal and not associated with other symptoms but with history of heart disease Abuse/neglect/assault – stable Post seizure – alert on arrival POP complications Elevated blood sugar without any major symptoms Mild asthma Closed fracture of upper limbs or ankle with major angulations Dislocation of small joints Foreign body Hemodynamically stable per vaginal bleed

22. Non-Critical (GREEN) G2 (Require initial management or 1 st aid before seen by doctor) Chest pain – non-visceral, musculoskeletal and not associated with other symptoms and no previous heart disease Minor allergic reaction

23. Non-Critical (GREEN) G3 (patients who can wait) Burn < 15% of BSA regardless of depth and/or <10% 3 rd degree burns Minor trauma Head injury – alert, no vomiting Bumps and bruises Closed fracture of upper limbs Controllable bleeding with closed fracture of upper limbs or ankle without major angulations Nail prick Simple cut

24. Non-Critical (GREEN) G4 (for LOCUM or triage away to OPD or another center) Chronic trauma injuries > 6 months Diarrhea alone (no dehydration) Vomiting alone (normal mental status with no dehydration) Acute pyrexia <38°C for adult < 65 years old or child between 2-12 years old Simple skin diseases – chronic Menses related complaints Chronic psychiatric complaints General medicine conditions or minor illness not requiring monitoring Sore throat – no respiratory symptoms Earache Infective eye conditions

25. Non-Critical (GREEN) G5 (not seen in ED) Missed appointment Medications exhausted Second opinion seeking STO Medical certificate Specialist clinic cases

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