TRIAGE AT ST JOSEPH HEALTHCARE

Provides efficient care utilizing triage modules. Provides training and understanding of concepts of triage

Developed by Eula Brown RN for Emergency Department use. Collaborators:

Brenda Harris, Education Technology specialist Patty Sturt RN, Clinical Educator

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Objectives
At the end of this program the end user will be able to verbalize skills related to:
Understanding the basic concept of triage Define 5 levels of triage acuity Understand components of ED triage process for all types of patients

Objectives contd
Define components of triage
1.visual assessment 2.subjective assessment 3.Objective assessment 4.Define resources needed 5.Making the triage decision

Be aware of and incorporate situations regarding legal, abuse, documentation, customer service, hazardous materials, and cultural issues into the triage module. To utilize patient scenerios with clinical end users for a better understanding of triage

MODULES PRESENTED
Module 1: Introduction Module 2: Components of triage Quick assessment Subjective data Objective data Resources and special situations Triage decision Module 3: Examples of each level Module 4: Triage Pearls

Triage: French word meaning to sort.

Developed and used originally by military during World War I as a model for classifying patients according to priority of care needed. Used extensively during WWII Emergency Departments nation-wide have adopted and utilize some form of triage system to use in classifying patients based on care needed.

The most common system is the three level system.

Classification is defined as: Emergent Urgent or Non-urgent.

Throughout the later part of the 20th century, this system has been shown to be lacking in accuracy and not adequate for the volume and needs of 21st century EDs.

Canada, Australia, and UK have each developed different 5 level triage systems. We in the US have been presented with an Emergency Severity Index 5 level triage system that has been shown to be very effective in recognizing different classifications of patients and identifying resources needed to provide the most efficient patient care.

Two of the most significant factors differentiating the US system from the others are:
The 5 level classification used by Canada and Australia are defined by what are safe wait times for different levels US ESI system recognizes and incorporates needed resources for patient care into the classification system. The US system does not consider safe wait times in determining a level of classification

THE 5 levels are defined as follows:

Critical: (1)

Conditions that require immediate and aggressive intervention

Emergent: (2)

Conditions that represent potential loss of life of limb if interventions not done promptly.

Urgent: (3)

Interventions needed in the emergency department for timely return to health. HR and RR within normal limits. Needs two or more potential resources.

Non-urgent: (4)

Conditions that will benefit from being seen in the ED, but may wait to be seen. One resource needed.

Minor: (5)

Conditions that may be seen in clinic setting and/or have no expectation of deterioration. One to zero resources needed.

COMPONENTS OF THE TRIAGE PROCESS:

1. QUICK ASSESSMENT 2. SUBJECTIVE DATA 3. OBJECTIVE DATA 4. RESOURCES 5. TRIAGE DECISION

Quick assessment: This begins

when the patient approaches triage.
Across the room assessment is based on ABCD parameters of airway, breathing, circulation, mental status/disability, This includes: distress noted, tachypnea, bradypnea, wheezing, accessory muscles, nasal flaring, altered skin color, stridor, pt unconscious, psychosis/hallucinations, inability to recognize familiar people uncontrolled bleeding

** If, at anytime during the quick across the room assessment, the patient demonstrates a combination of the above symptoms that indicates an emergent or critical situation , they are taken immediately to an ED room and interventions are started. The triage acuity is critical or emergent.

Subjective data: Triage history

Chief complaint: this is what the patient says is wrong (preferably in their own words)

Further subjective data:

Medical history: *AMPLE *AMPLE = A = allergies, age of patient M= medications, dose, frequency, last dose P= past medications, surgical, pregnancy or prenatal history L= Most recent meal, tetanus, LMP, ETOH or drug ingestion E=Events surrounding present illness or injury, associated symptoms

Subjective data contd:

pain
Level of pain using appropriate scale Duration Severity Quality Radiation Location

Objective data:
Focus assessment based on patients chief complaint and initial presentation. Focus assessment should be completed taking into consideration the illness/injuries the patient presents with.

Objective Data contd

Think/consider: What is the worst possible thing that could be wrong with this patient? Vital Signs are included in a focus assessment. O2 sat is included in the objective assessment as needed

Objective data contd

Carefully consider all assessment data to determine if the patient has a critical or emergent situation.
pallor Indications of blood loss degree of distress Vital signs O2 sat

Objective data contd

The very young patients or very old have unique considerations or physiological changes that may place them at a higher acuity level.

RESOURCES: Resources the triage nurse

believes the patient may need based on the triage assessment
ED team (nurses, techs) patients requiring one or more initial nurses or technicians to stabilize, protect, prevent other harm, and effectively care for patient
SITUATIONS REQUIRING EXTRA PERSONNEL: EXAMPLE Alzheimers patient requiring constant care. Ancillary Resources: LAB X-RAY CASE MANAGER CT SCAN OR ULTRASOUND RESPIRATORY THERAPY

Resources the triage nurse believes the patient may need based on the triage assessment
Medical management: does the patient need MD or can patient be seen by PA only. Is the patient to be seen by private MD.

EMTALA issues

Resources contd
Crisis situations requiring additional staff or chaplaincy services. Legal issues (Management or administrative resources) Patients that require additional placement or assistance with meeting discharge home needs.

Situations that require additional Resources

Simple procedures (simple wound, IV care, dressing) Complex procedures (moderate sedation, complicated burn care, gastric lavage)

Evaluating Resource needs and examples:

Legal issues:
Illness/injury (chief complaint) that leads the triage nurse to suspect abusive situation: Example Abuse situations : patient states was assaulted by boyfriend earlier today. This would then involve police, abuse form, and possible community resources.

Examples legal issues:

Example: patient with right-sided Paralysis presents from nursing home with multiple bruising and skin tears to left side of body: This would involve abuse form, notification of house administrator MVC/Trauma patients: police involvement, community resource involvement, coroners case, legal evidence collection.

Special issues that may impact triage assessment:

Trauma:
What happened? When? Mechanism of injury: i.e. Four wheeler accident, MVC (simple fender bender), MVC rollover, MVC t-bone. Penetrating trauma vs. blunt trauma

Special issues contd

COBRA: EMTALA: No patients can be questioned regarding insurance/payment of emergency department services without medical screening first. (Medical screening: any and all tests, examinations done by qualified practioners to determine an emergent condition)

Patients should not be transferred from another hospital without confirmation that the accepting facility has the capacity and resources to care for the patient. The patient must have an accepting physician

Special issues contd

Cultural issues:
Language barriers: need for translator services Customs of different religions or ethnic groups: coining for fever patients, IV/blood products restrictions

Crisis situations:
Patients with new onset mental illness Patients presenting with intent to harm themselves or others Patients in medical distress with families needing interventions to help copy Patients presenting with disability that impairs communication and/or affects timely treatment Example: Aphasia

HazMat/Environmental situations:
Specific agent if known?: chemical, radiation, biological Example: Hydrofluoric acid When did the exposure occur? What type of exposure:
Inhalation lungs Dermal - burn to face, eyes, etc.

Resources must anticipate including decon!

Evaluating resource needs contd

Procedures:
Simple: Saline lock, simple wound, simple laceration Complex: procedural sedation, extensive burn, gastric lavage

Quickly analyze subjective, objective data, and resources

Triage decision:.

IS.. Based on above components and utilizes the experienced nurses decision making skills

Triage can be confusing...

The next slides are definitions and pt examples of each level or category:

CRITICAL PATIENTS:

Level One - red

ABCDs:
compromised in one or more areas.
CRITICAL: (1) - brought back to room immediately with aggressive ED Team interventions started.

Cardiac arrest Respiratory arrest Does not respond to painful stimuli (*AVPU)
the level one patient has a new onset of decreased AVPU

EMERGENT PATIENTS:

Level Two - orange

ABCDs:
Patients with potential compromise to life or limb and/or chief complaint of emergent nature
EMERGENT brought back to room immediately with interventions started.

Examples Level 2
Sudden onset speech deficits or motor weakness indicative of acute stroke
Active chest pain suspicious for CAD Immunocompromised patient with fever Suicidal patient with a plan Infant < 4 mo of age with temp >100.4 rectal

Abdominal pain or back pain with indicators of hypovolemic shock Noticeable respiratory distress (i.e. Retractions and O2 Sat <90%) Severe pain with behavioral and physiologic indicators of severe pain Sudden onset of testicular pain

Patient with auditory hallucinations Chemical splash to eye Sudden partial or full loss of vision Indicators of neurovascular compromise in an injured extremity Acute lethargy/decreased Level of consciousness:

Acute sickle cell pain crisis Indicators of ineffective cardiac output Febrile seizure

URGENT PATIENTS:

Level 3 (yellow)

ABCDS

Compromise may occur, but less likely

Vital signs
HR and RR are not above normal parameters O2 sat is not less than 92% Blood pressure is not at a dangerous level. Pain scale: Generally <8 **Vital sign parameters are not an isolated determination.

Will need to be seen after critical and emergent patients. Obtain additional subjective, objective data as needed to determine if the patient is urgent.

Examples Level 3
C/O of flank pain with pain level = or < 8 and history of kidney stones Cough and fever Vaginal bleeding with mild-moderate discomfort and no indicators of hypovolemia Extremity injury with indicators of possible fracture or dislocation

Cellulitis without indicators of septic shock or severe sepsis = or > 65 y.o. with abdominal pain Vomiting and diarrhea in child with no indicators or poor perfusion

Headache with: GCS = 15, no motor/sensory deficits, no history of trauma, mild-mod pain Croup Abdominal pain with fever with no indicators peritonitis

Pediatric pt with fever and no indicators of meningitis, meningococcemia, sepsis, febrile seizure, or decreased perfusion. Laceration that definitely requires suture repair

Non-urgent: Level 4 (green)

ABCDs : Compromise not likely

Patients seen after above three levels. Stable patients requiring one resource.

Examples level 4:
Foreign body sensation in eye with no history of trauma, no visual changes and mild pain Vaginal itching and burning Extremity injury with no indicators of fracture or dislocation

Non-productive cough with no or minimal pain and no fever Dysuria with no indicators of pyelonephritis and no or minimal fever Minor laceration with no sutures required (may require steri-strips)

Back pain with no indicators of neurological compromise and no significant mechanism of injury (i.e. rollover MVC vs. twisted while bending) Rash for multiple days with no indicators of respiratory distress or cellulitis

Minor: Level 5 (blue)

ABCDs : No compromise

Progression of illness/injury: little to no change from onset Vital signs: stable Pain scale: <4/10

Resources: no resources needed. Stable patients: could be seen in clinic or office setting. Requires no or minimum resources.

Examples level 5:
Request for prescription refill with no symptoms or complaints Superficial abrasion Request for tetanus shot Request for allergy shot Suture removal with well healed wound and no indications of infection

Triage Pearls
Triage guidelines should never replace good nursing judgment. Always validate what you think you heard. Patients sometimes tell you what they think you want to hear. All female patients of childbearing age need LMP documented New onset confusion: consider sepsis or hypoglycemia

Patients who are a threat to themselves or others must be suspect for higher level of classification Many older patients may dismiss complaints as normal for their age. However symptoms in the elderly population may not always be age related. Always think of the worst situation and triage accordingly. It is better to triage up than under triage.

Maintain customer service attitude or call for help as needed Protect yourself never go to the end and down the hill to retrieve a patient.call for help Always pay attention to parents/caregivers subjective data. Females always need gynological assessment with GI problem

Do not ignore the frequent flyers! They too can have real disease. Communication is more difficult with the very old and very young. Therefore you need to take more time with these patients. Bradycardia is an ominous sign in a child More resources = may equal higher acuity! Triage is a challenge to all nurses.but you can do it!

BEYOND TRIAGE.