1. Mary Corcoran RN, BSN, MICN
TRIAGE
Mary Corcoran RN, BSN, MICN

2. EMTALA: Emergency Medical Treatment and Labor Act
Requires a hospital to provide an appropriate medical screening exam to any person who comes to the emergency department and requests treatment or an examination for a medical condition. If the examination reveals an emergency medical condition, the hospital must also provide either necessary stabilizing treatment or appropriate transfer to another medical facility

3. EMTALA
EMTALA regulations apply to anyone coming to a hospital seeking emergency medical services
EMTALA imposes financial penalties on physicians and hospitals
Additionally, the hospital, if found guilty of violating EMTALA regulations, can be excluded from participating in the Medicare program

4. EMTALA MEDICAL SCREENING EXAM
Most hospital policies state that only an Emergency Department MD or PA exam constitutes a Medical Screening Exam. Check with your supervisor
The triage process DOES NOT constitute a Medical Screening Exam.

5. EMTALA
A person who presents anywhere on the hospital campus and requests emergency services, or who would appear to a reasonably prudent person to be in need of medical attention, must be handled under EMTALA
250-yard rule: “Campus means the physical area immediately adjacent to the provider’s main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the HCFA regional office, to be part of the provider’s campus”.

6. Questions for discussion
EMTALA
Questions for discussion
Does the triage nurse’s assessment constitute a Medical Screening Exam?
If a patient is lying on the sidewalk outside of the parking garage, is the emergency department required to evaluate and treat the person?
If a homeless person comes to triage complaining of chronic back pain, is the emergency department required to evaluate and treat the person?

7. What is Triage?
From the French verb “Trier” which means to “sort” or to “choose”
Began in the battlefield when they would prioritize wounded soldiers
1950’s and 60’s Medical staff with military background began to educate civilian staff on the concept of “triage”
As physician practice changed to an “office” based specialty system, and ER’s volume bean to increase

8. 3 Common Triage Systems
Traffic Director- simplest, non clinical employee greets patient and directs them to treatment area or wtg room based on initial impression- by obsolete
Spot-check triage- appropriate for low volume, ED. Registration greets patient and pages triage nurse. The RN performs basic assessment
Comprehensive triage- supported by ENA. Triage done by competent RN. The RN determines priority of care based on physical, developmental and psychosocial needs
Comprehensive triage should take 2-5 minutes. Unfortunately pediatric and elderly patients take longer. Incomprehensive triage nurse takes VS, complete history and department specific screening questions, and then correctly triage them based on established acuity. This system bc it is time consuming is beginning to evolve into a 2 step triage. Intial nurse greets patient and if patient is stable they see second nurse for completion of triage.

9. Triage Acuity
In 2003, 2 hospitals had EMT’s and RN’s complete triage’s on 5 scripted patients and then were asked same scenarios 6 weeks later and only 24% of participants assigned the same ratings both times
The goal is to develop a standardized acuity system in order for everyone to have the same understanding of each level assigned

10. Trends Affecting ED Wait Times
The American Hospital Association (2002) revealed 90% of ED’s perceive they are operating over capacity.
The avg time to see ED physician in (49 min) which was an 11% increase over 1997
And increased to 56min in 2006
Factors contributing to increased ED volumes:-
* decrease in ED’s, aging population, longer ED stays, inability to move admissions, increase in the uninsured, po0r access to primary care, nursing shortage

11. The Interview Introduce Yourself
Confirm the Patients Identity (IMPORTANT)
Obtain a Chief Complaint/Reason for visit
Gather Subjective & Objective Data
Including LMP, VS, Weight, History, Mechanism etc
Perform a rapid, concise, focused assessment, with quick primary and secondary survey

13. Pediatric Patients
Use the CIAMPEDS format to triage pediatric patients
C- Chief complaint- primary problem
I- Immunizations- UTD, NUTD
A- Allergies
M- Medications – Name, last dose, how much?
P- PMH
Parents impression of child’s condition
E- Events surrounding illness/injury
D- Diet- bottles, ounces
D- diapers
S- Symptoms associated with illness, injury

14. Pediatric Patient Use Similar A-I Assessment criteria as adults
A- Airway; patency, positioning, audible sounds
B-Breathing; inc or dec WOB. AMU, nasal flaring
C-Circulation; color of skin, cap refill
D- Disability; activity level, response to environment
E-Exposure; identify underlying injuries
F- Fahrenheit
G- Get VS, including weight in kg
H- Head to Toe Assessment; quick related to cc
I- inspect the back and isolate; observe for hidden injuries, communicable illness
Be cognizant of legal issues related to abuse/neglect and the difference between adults and children

15. OB Patients
Most OB patients can be transferred to L&D via wheelchair, Usually patients 20 weeks gestation and greater are evaluated in L&D or by OB physician.
EMERGENT OB-A patient with a “presenting part” must be delivered in ED. Prepare for delivery if patient is multigravida, completely dilated, had SROM, or c/o rectal pressure
Urgent OB- Patients in active labor- ( contractions 2 minutes apart lasting sec, presence of “bloody show”, ROM
Non-urgent OB- Patients not in active labor- per hospital policy
Legal Considerations-Important to know who can transport patients to L& D

16. Geriatric Population
Important points to remember when triaging geriatric patients:
Altered pain perception common
Delayed presentation common
Upper abdominal pain, an ill appearance, abnormal VS= RED FLAG
Consider etiology of falls
Consider elder abuse
Older patients are uniquely prone to delirium

17. Psychiatric Patients
All patients exhibiting aggressive and/or agitated behavior are considered violent unless proven otherwise
Never turn your back on these patients
When speaking to psychiatric patient be simple, direct, clear and concise
Do not overlook physical injuries or illnesses in psychiatric patients

18. What do you think? 40 y/o old female c/o epigastric pain, vomiting
50 y/o male with a ripping sensation in his chest?
23 y/o with RLQ pain and fever?
19 y/o post partum, hypotensive & fever?
2 y/o, vaccines NUTD, drooling & fever?
4 week old male, vomiting after every meal?
80 y/o with abdominal pain, vomiting bilious?
4 m old diff breathing, congestion- winter months?

19. ESI 5 level Triage System
Recommended by the ENA (Emergency Nurses Association) and ACEP (American College of Emergency Physicians)

20. Introduction Level 1- Resuscitation 0 minutes
Level 2- Emergency min
Level 3- Urgent minutes
Level 4- Semi urgent minutes
Level 5- Non-urgent minutes

21. Requires Life Saving Intervention? Yes No
Level 1
Requires Life Saving Intervention?
Yes No
High Risk Situation Or
Confused/Lethargic/ Disoriented
Severe pain/Distress
Yes
Level 2
How Many Resources are Needed?
None One Many
yes
Level 3
Dangerous Vital Signs?
Level 5
Level 4 No

22. Emergency Severity Index (ESI)
Acuity assessment
Airway, breathing, circulation
Potential for life, organ or limb threat
How soon the patient needs to be seen
Expected resource assessment
Number of resources, as estimated by the triage nurse, that a patient is expected to consume in order for a disposition decision to be reached

23. ESI Five explicitly defined categories
Mutually exclusive
Allows for rapid sorting
Differs from a complete assessment
Gather sufficient information to assign an ESI level
Quick sorting

24. ESI
Requirements to maintain the validity and reliability of the instrument
Experienced emergency department nurse at triage
Education of each RN prior to implementation

25. 1 2 5 4 3 Patient dying? yes no Can not wait? yes noB
yes no
How many resources?
none one many C 2
Vital signs D 5 4
consider no 3

26. Yes
Is this patient dying? A 1 No

27. Decision Point A Is This patient Dying?
Does this patient require immediate life-saving intervention?
Airway
Obstructed or partially obstructed
Unable to protect their own airway
Breathing
Apneic
Intubated pre-hospital
Severe respiratory distress
SpO2 less than 90%

28. Decision Point A
Does this patient require immediate life-saving intervention?
Circulation
Pulseless, or concerned about rate, rhythm or quality?
Drugs
Hemodynamic interventions
Immediate IV medications to correct hemodynamic instability

29. Decision Point A
Does this patient have an acute mental status change that requires immediate life-saving intervention?
Examples:
Hypoglycemia needs glucose
Heroin overdose needs Narcan
Subarachnoid bleed needs airway protection

30. What are life Saving Interventions?
Resuscitation
Hemodynamics
Airway and Breathing
Intubation
-Surgical airway
-CPAP, BiPAP
-Bag valve mask ventilation
Defibrillation
External Pacing
Chest needle decompression
Significant IV fluid resuscitation
Blood administration
IV medications
vasopressors
Control of major bleeding

31. What are NOT life saving interventions?
Diagnostic Tests
Medications
ECG
Laboratory studies
Oxygen
Monitor
IV access
ASA
Nitroglycerine
Pain medications
Antibiotics
Heparin

32. No
Yes
Can not wait? B No 2

33. Confused/lethargic/disoriented?
High risk situation? or
Confused/lethargic/disoriented?
Severe pain/distress? B
Yes 2 No

34. Decision point B Can this Person Safely Wait to be Seen?
Determination is made on a brief interview, gross observations, “sixth sense”
Does not require a full set of vital signs
Unsafe for the patient to wait
Suggestive of a condition that could easily deteriorate
Symptoms of a condition where treatment is time sensitive
Potential major life or organ threat

35. Examples of “high risk” patients
Episode of chest pain, denies other symptoms, known cardiac history
Rule out PE
Newborn with a fever
Rule out ectopic pregnancy
Neutropenia with a fever
Suicidal/homicidal
New Onset Confusion in elderly
Adolescent found confused and disoriented
Patients in SEVERE pain
Sexual Assault Patient

36. Decision point B is this person in severe pain or distress?
Is this patient currently in pain?
Pain intensity rating
Chief complaint
PMH, medications
VS, physical assessment findings
Assign ESI level 2 if and only if
Self-reported 7/10 or greater
AND
RN cannot intervene and they require immediate intervention
Do you want to give your last bed to this patient?

37. Examples of Level 2 Severe pain
Kidney stone
Burn victim
Oncology patients
Possible dislocated shoulder
? Compartment syndrome

38. Decision Point C Determined by the experienced ED RN at triage
How Many Resources will this patient require?
Determined by the experienced ED RN at triage
Based on the standard of care
Independent of type of hospital, location, physician on duty, acuity of the department

39. 4 3 How many different resources are needed? None One 2 or more C 5
Vital signs 3

40. Mean Resources Used Per Triage Category
Mean # of resources used
ESI Triage Level

41. Resources Not Resources
Resources: Count number of different types of resources, not individual tests or x-rays (ex: CBC, electrolytes, and coags equal one resource; CBC plus chest x-ray equal two resources.
Resources
Not Resources
Labs (blood, urine)
ECG
X-ray, CT, MRI, ultrasound, angiography
History & Physical (including pelvic)
Point-of-care testing
IV fluids (hydration)
Saline or heplock
IV, IM or nebulized medications
PO medications
Tetanus immunization
Prescription refills
Specialty consultation
Phone call to PCP
Simple procedure = 1(lac repair, foley)
Complex procedure = 2 (conscious sedation)
Simple wound care (dressing, recheck)
Crutches, splints, slings

42. ESI Level 5 No resources Examples:
Healthy 10 year old with “poison ivy”
Healthy 52 year old who ran out of his blood pressure medicine yesterday
22 year old, involved in a car accident 2 days ago, wants to be checked. Nothing hurts.
46 year old with a cold

43. ESI Level 4 Stable, can safely wait hours to be seen
Care by mid-level providers in fast track or express care setting
Requires a physical exam and one resource

44. ESI Level 4 Examples: Healthy 19 year old with sore throat and fever.
Healthy 29 year old with a UTI, denies vaginal discharge.
Healthy 43 year old with stubbed toe who states “I think I broke it!”.
Healthy 12 year old with a minor thumb laceration

45. ESI Level 3 30-40 % of patients in the ED Require in-depth evaluation
Long length of stay
Before assigning a patient to ESI Level 3 the nurse must consider the patients vital signs

46. ESI Level 3,4, and 5 examples ESI Level 3 -Fractured ankle
-Abdominal pain
-Most migraines
ESI Level 4
-Sprained ankle, toe
-Abscess
ESI Level 5
-Toothache

47. Decision point D What are the patients vital signs?
Consider the vital signs
Are they outside the acceptable parameters for age?
If unacceptable consider up-triage to ESI Level 2

48. Danger zone vitals? HR RR SaO2 <3 m >180 >50 <92%
3m-3y > > <92%
3-8y > > <92%
>8y > > <92%
Level 3

49. Pediatric Fever Criteria
1 to 28 days of age: assign at least ESI 2 if temp >38.0C (100.4F)
1 to 3 months of age: consider assigning ESI 2 if temp >38.0c (100.4F)
3 months to 3 years of age: consider assigning ESI 3 if: temp >36.0C (102.2F), or incomplete immunizations, or no obvious source of fever

50. Lets Practice

51. Pediatric Sprained Ankle
An eight year old is brought to triage because of an injured right ankle. The child tripped over a ball while playing soccer. The ankle hurts with ambulation and you notice edema over the medial aspect of the ankle. His mother tells you the child is healthy, takes no medications and has no allergies. VS WNL.
Does this meet Level 1 or Level 2? How many resources will this take? Some facilities use the Ottowa ankle rules which determines whether or not the patient needs an xray. Almost always an xray. Crutch walking does not count as a resource. Most “ankles” are a 4 or 5. Tib/Fib fractures would be a level 3.

52. Respiratory Distress
Paramedics arrive with a 42 y/o morbidly obese female who called EMS with a CC of SOB. On arrival the paramedics found her sitting upright, working hard at breathing with a respiratory rate of 48 and a room air SPO2 of 84%. They are unable to obtain any further history.
Does this meet Level 1 or 2? She needs life saving treatment immediately, most likely intubation. Her condition needs physician intervention immediately! VS out of normal range (RR>24, O2 sat<90%. LEVEL 1

53. Lump…
“I have a lump on my back” reports a 28 year old healthy male. Upon further questioning he tells you the lump looks like a huge, large pimple. He reports no drainage or fever.
No PMH or meds.
His vital signs are:
BP 118/74, T 98.8, HR 72, RR 16
Obviously not level 1 or 2. How many resources will this take? If the lump is the size of a golf ball, most likely will require I&D (1 resource).

54. Vaginal Bleeding/ Abdominal Pain
23 y/o female presents to triage with a CC of moderate vaginal bleeding and generalized abdominal cramping (5/10) for 2 hours. Her LMP was 8 weeks ago. She is G1P0. Her skin is warm and dry. Her vital signs are: BP 110/80, T 98.6, HR 84, RR 20
Level 1 or 2? Possibly. Need to look at general “look” of patient. Needs a thorough OB assessment…clots, pads/hr, LMP, G/P. Could be spontaneous AB, ectopic pregnancy, or irregular menses. Almost all abd pains will be at least a 3 because of so many resources. Some will be level 2 depending on vital signs.

55. Shoulder
A 45 y/o male is brought to triage by his friend who states the patient injured his left shoulder while playing football. The patient has a gross deformity to his shoulder with neuro deficits to the left arm. He is unable to move his arm, complains of excruciating pain (20/10 when asked), and is diaphoretic.
Level 1 or 2? Moderate distress…is there anything we can do in triage to help this patient? He is probably level 2. Resources? Xray, procedure, and conscious sedation (2 resources)

56. Bite
Mom brings her 4 y/o son to triage with a CC of a red arm. The patient was bitten by the family dog about 3 days ago. The child is cranky. His right arm is reddened, with edema to a large area surrounding the dog bite.
His vital signs are:
T 99.5, HR 120, RR 24
VS=normal. Resources=antibiotics, labs. Level 3. Need to assess for s/s of compartment syndrome (pain, parasthesia, pallor, pulselessness, paralysis, poikilothermia)

57. PNA
A 70 year old male arrives by ambulance from a nursing home. The nursing home reports a non-productive cough since he choked on his lunch today. His baseline mental status is unchanged, although he is normally confused. Skin is warm and moist.
His vital signs are:
BP 135/80, T 100.2, HR 94, RR 20,
SpO2 94% on RA
Pneumonia protocol…high risk? Level 1 if she required intubation-probably not. Level 2-only if her aloc was new onset or abnormal. Or if VS out of normal range. At least 2 resources. Talk about placement of patient and triage level are 2 different things.

58. Laceration
A tearful 5 year old is carried in by her father who reports is daughter was trying to help set the dinner table and broke a glass. You notice a 3 cm laceration on her left hand. The bleeding is controlled. No history, allergies or meds.
Her vital signs are:
BP 98/64, T 97.8, HR 108, RR 24
Level 4. One resource. If this pt was 3 and screaming all about….would probably require conscious sedation and need to be level 3. Wound glue…level 5

59. Hematemesis
EMS arrives with a 49 year old male with a history of cirrhosis and hepatitis C. His wife called 911 when he started vomiting bright red blood. On arrival he is pale, diaphoretic and has a BP of 92/78, HR 130, RR 28.
Probably level 1…needs IVF immediately and possibly blood. If VS were a little better maybe level 2. R/F bleeding varices

60. Wound
19 y/o male states he had an appy last week. Wound is red, opened up, and yellow pus is oozing out. No other medical history. No meds , HR=98
2 resources…level 3. Most post-op patients will be at least a level 3. Check VS…may need to up triage

61. Trauma
Notified by EMS you are receiving an 8 y/o female hit by a bus. Witnesses state she was thrown across the street.
VS= HR=148, RR=36, BP=70/palp, O2 sat=91%.

62. What if they Leave?
LWBS
Pts who are LWBS (Left Without Being Seen), are more common in high volume ER’s
Most patients are frustrated with the long wait times
Discuss the LWBS policy with your specific facilities

63. Triage Nurse Qualifications
Triage Nurses are the Gate Keepers to the ER, if they Over-triage they can use up vital beds in the ER, if they Under-triage they can delay vital care
Triage Nurses must be knowledgeable, experience, temperament, and qualifications necessary to function in a high stress roll
Most facilities require at least 6mo- 1year of ER experience before allowing nurses to triage

64. Questions?