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EDITORIAL
Emergency Triage
Emergency Triage is a unique practice that deals with unstable, undiagnosed patients usually presenting unexpectedly.
Decisions made by triage nurses are vital in determining the
course of emergency care.1 The triage nurse must be able
to apply principles and concepts to differing situations.2
Recognition of physiological abnormalities, and instigation
of appropriate treatment, are well within the triage nurses
scope of practice. Triage nurses independently make decisions regarding which physiological assessments to perform,
the frequency at which these physiological assessments
should be monitored while the patient is in the waiting room,
which other health care professionals need to be involved in
a patients care, and the urgency with which they should be
involved.1
Triage in Australasian emergency departments must be
performed by appropriately educationally prepared and
experienced registered nurses, who should be the rst point
of contact for the patient, on a 24 hour basis.36 Triage can
be divided into primary triage decisions and secondary triage
decisions. Primary triage decisions involve the allocation of
a triage acuity, while secondary triage decisions refers to
the initiation of nursing interventions aimed at promoting
comfort or expediting care.7,8 Secondary triage decisions
emphasise the ongoing assessment and care of patients in
the waiting room, by the triage nurse9 or other clinicians at
the direction of the triage nurse.
The essential criteria for an effective triage nurse is
emergency nursing experience and skill in rapid assessment
and correct determination of patient urgency.10 The triage
nurses ability to identify, interpret and act on the presenting patients physiological abnormalities are fundamental in
reducing morbidity and mortality through the prevention
of adverse events.1 Major risk factors for adverse events
are the presence of physiological abnormalities and the
failure to recognise and appropriately treat same.1 This relationship between physiological abnormalities and adverse
events highlights the importance of assessment skills for
triage nurses.1
The primary goal of an effective Emergency Department Triage System is the rapid identication of patients
with life-threatening conditions.10 Emergency department
1574-6267/$ see front matter 2007 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia Ltd.
doi:10.1016/S1574-6267(07)00054-7
44
essential. Many triage nurses (42%) felt they had been
inadequately prepared for triage, while 14% still felt inadequately prepared despite having participated in educational
programs.22
No relationship has been found between personal characteristics of registered nurses and their ability to triage.
This lack of a relationship between personal characteristics
of registered nurses and their ability to triage suggests that
there may be intrapersonal characteristics at play, particularly regarding decision-making strategies utilised,23 a factor
which should be responsive to a standardised educational
standard.
A National Minimal Standard for Triage Education was
achieved through work funded by the Commonwealth
Department of Health and Ageing (DoHA) which published
the Triage Education Resource Book (TERB)32 in 2002 to
ensure just such a nationally consistent approach to triage
education.12 Individual emergency departments and health
services have, of necessity, developed local triage education programs based on the principles of the ATS11,33,34 and
the TERB,32 as there exists no nationally accredited triage
education program.13 A major revision of the TERB32 has
been now been completed, and the resulting Emergency
Triage Education Kit35 is now in nal stages of publication.
The Board of Directors of the College of Emergency
Nursing Australasia Ltd. endorsed CENAs Triage Nurse Position Statement6 in March 2007. You will nd this position
statement in this issue of AENJ (page 93), which is also
available on the CENA website at www.cena.org.au. Mention is made within this position statement of the Emergency
Triage Education Kit35 which will be ofcially launched at
the International Conference for Emergency Nurses in Melbourne during October 2007.
These two documents will dene the standard of preparation for, and practice of, the dynamic role of the Triage
Nurse, and will help clinicians, educators, and managers full their obligation to meet the essential requirements of this
vital role.
References
1. Considine J, Potter R, Jenkins J. Can written nursing practice
standards improve documentation of initial assessment of ED
patients? Aust Emerg Nurs J 2006;9(1):118.
2. CENA. Standards for the emergency nursing specialist. 1st ed.
Sydney: College of Emergency Nursing Australasia Ltd.; 2003.
3. Triage Review Team. Triage education package. 1st ed. Gosford: Central Coast Area Health Service; 2001.
4. AAEN. Position statement: Triage nurse. Melbourne: Australian
Association of Emergency Nurses Inc.; 2001.
5. NSW Health. Policy Directive Triage of patients in NSW Emergency Departments. Sydney: NSW Health Department; 2006.
6. College of Emergency Nursing Australasia Ltd. Position Statement Triage Nurse. Aust Emerg Nurs J 2007;10(2):934.
7. Gerdtz M, Bucknall T. Why we do the things we do: applying
clinical decision making frameworks to practice. Accid Emerg
Nurs 1999;7(1):507.
8. Gerdtz M, Bucknall T. Australian triage nurses decision-making
and scope of practice. Aust J Adv Nurs 2000;18(1):2433.
9. Considine J, LeVasseur SA, Charles A. Development of physiological discriminators for the Australasian Triage Scale. Accid
Emerg Nurs 2002;10(4):22134.
Editorial
10. Bracken J. Triage. In: Newberry L, editor. Sheehys Emergency
Nursing: Principles and Practice. 5th ed. Mosby: St. Louis;
2003.
11. ACEM. Policy document The Australasian Triage Scale.
2000 [cited 4 March 2004]. Available from: http://www.acem.
org.au/open/documents/triage.html.
12. McCallum Pardey, T.G. The clinical practice of Emergency
Department Triage: Application of the Australasian Triage Scale
- An extended literature review. Part 1. Evolution of the ATS.
Aust Emerg Nurs J 2006; 9(4):15562.
13. Smart D, Cane M, Mulcahy M, Jordan B, Anderson C, Reeve F,
Lyneham J. Emergency Department Triage Education Package
Resource Book. Hobart: Calvary Health Care Tasmania; 2002.
14. McNair, RS. Triage acuity systems: a message from
our president [cited 5 January 2006]. Available from:
http://www.triagerst.com/letter.html.
15. Considine J, Hood K. A study of the effects of the appointment of a Clinical Nurse Educator in one Victorian Emergency
Department. Accid Emerg Nurs 2000;8(2):718.
16. AAEN. Position statement: Educational preparation of triage
nurses. Melbourne: Australian Association of Emergency Nurses
Inc.; 2001.
17. Crellin DJ, Johnston L. Who is responsible for pediatric triage
decisions in Australian emergency departments: a description
of the educational and experiential preparation of general and pediatric emergency nurses. Pediatric Emerg Care
2002;18(5):3828.
18. McNally S. Lets have standards for triage education and practice. Aust Emerg Nurs J 2001;4(2):124.
19. Ritchie JE, Crafter NM, Little AE. Triage research in Australia:
Guiding education. Aust Emerg Nurs J 2002;5(1):3741.
20. Fry M, Burr G. Using the Delphi technique to design
a self-reporting triage survey tool. Accid Emerg Nurs
2001;9(4):23541.
21. Fry M, Burr G. Using a survey tool to explore the processes
underpinning the triage role: a pilot study. Aust Emerg Nurs J
2001;4(1):2731.
22. Fry M, Burr G. Current triage practice and inuences affecting clinical decision-making in emergency departments in NSW,
Australia. Accid Emerg Nurs 2001;9(4):22734.
23. G
oransson KE, Ehrenberg A, Marklund B, Ehnfors M. Emergency
department triage: Is there a link between nurses personal
characteristics and accuracy in triage decisions? Accid Emerg
Nurs 2006;14(2):838.
24. Kelly AM, Richardson D. Training for the role of triage in Australasia. Emerg Med 2001;13(2):2302.
25. Considine J. Consistency of Emergency Department Triage
Project. Melbourne: Department of Human Services & Monash
Institute of Public Health; 2000.
26. Considine J, Ung L, Thomas S. Triage nurses decisions using the
National Triage Scale for Australian emergency departments.
Accid Emerg Nurs 2000;8(4):2019.
27. McNally S. The triage role in emergency nursing: development of an educational programme. Int J Nurs Pract
1996;2(3):1228.
28. Smart D, Pollard C, Walpole B. Mental health triage in emergency medicine. Aust N Z J Psychiatry 1999;33(1):5766.
29. Standen P, Dilley SJ. A review of triage nursing practice
and experience in Victorian public hospitals. Emerg Med
1997;9:3015.
30. Tobin M, Chen L, Scott E. Development and implementation of
mental health triage guidelines for emergency departments.
Sydney: South Eastern Sydney Area Health Service; 1999.
31. Australasian College for Emergency Medicine. Policy document:
National Triage Scale. Emerg Med 1994;6:1456.
32. Gerdtz M. Triage Education Resource Book. Canberra: National
Triage Education Committee, Commonwealth Department of
Health and Ageing (DoHA); 2002.
Emergency Triage
33. ACEM. Guidelines for implementation of the Australasian
Triage Scale in Emergency Departments. 2000 [cited 4
March 2004]. Available from: http://www.acem.org.au/open/
documents/triageguide.html.
34. ACEM. The Australasian Triage Scale. Emergency Medicine (Fremantle, W.A.), 2002;14(3):3356.
35. Gerdtz MF, Considine J, Sands N, Stewart CJ, Crenlin D, Pollock
WE, Tchernomoroff R, Knight K, Charles A and the National Edu-
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cation Framework for Emergency Triage Working Party 2007,
Emergency Triage Education Kit, Department of Health and
Ageing, Canberra.
Interim Editor-in-Chief
Toni G. McCallum Pardey