1. Deputy chairman ED KSMC
TRIAGE
Waseem A Abu-Jamea
MD ,SBEM, AbEM
Program Director KSMC
Deputy chairman ED KSMC

2. Sixty eight years old women, confused, unkempt brought in by paramedics since one today, physically looks tired, and her vital signs as follow:
Her heart rate is 130 BPM (regular),
Her blood pressure is 140/85
Her respiratory rate 23/min
Her GCS 13/15
Dry tongue.
She has HTN as past medical history, but medication not taken far often.
BSL revealed HIGH

3. What is triage? Triage from the French verb ‘trier’ means to sort.
Effective triage gets the right patient to the right place at the right time for the right reason with the right care provider” (Zimmermann, PG & Herr, RD , 2006).
The French verb “ trier” means to sort.
Triage assessment - objective and subjective data collection and analysis followed by triage allocation or decision.

4. What is triage?
Triage is a brief clinical assessment that determines the time and sequence in which patients should be seen in the ED.
Derlet, J. (2003) Triage. Source -

5. Triage Process Is a process with four basic components:
Across The Room Assessment ( ATRA)
Triage History
Triage Physical Assessment
Triage Decision
The process should take 3-5 minutes for most patients.
(ENA, 2001)
Is a process with four basic components:
Across The Room Assessment,
Triage History,
Triage Physical Assessment
Triage Decision.
The process should take 3-5 minutes for most patients.
Each component is addressed separately; in reality, the triage nurse may need to simultaneously perform different components for multiple patients. (ENA, 2001)

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

7. Advantages of Five Category Triage
More objective perspective.
Prioritize patients based on acuity
Improved quality care outcomes
Safer with under and over triage and less likely to over or under triage
Travers, D.A. (2002). Five level Triage System More Effective Than Three Level in Tertiary Emergency Department. Journal of Emergency Nursing, 28:5,

8. GOALS OF TRIAGE Improve patient flow. Expedite Emergency Care.
Rapidly identify patients with urgent, life threatening conditions.
Determine the most appropriate treatment area for patients presenting to the ED.
(ENA,2001)

9. GOALS OF TRIAGE Decrease congestion in emergency treatment areas.
Provide ongoing assessment of patients.
Provide information to patients and families regarding services, expected care and waiting times.
Contribute information that help to define departmental acuity.
(ENA,2001)

10. Canadian Triage and Acuity Scale CTAS 5Level Triage
Level 1 - Resuscitative
Level 2 - Emergent
Level 3 - Urgent
Level 4 - Less urgent
Level 5 - Non-urgent
(CJEM March. 2008)

11. (CJEM March. 2008)

12. Level I Level II Level III Level IV Level V
Resuscitation
Level II
Emergency
Level III
Urgency
Level IV
Less Urgency
Level V
Non Urgency

13. Assignment of Triage Level1
Presenting Complaint 2
Vital Signs 3
Pain Severity 4
Mechanism of Injury

14. Level I: Resuscitative
Conditions that are threats to life or limb (or imminent risk of deterioration) requiring aggressive interventions.
Time to MD: Immediate
Time to Nurse: Immediate
Example: Unconscious patient
(CTAS Implementation Guidelines, CJEM Oct. 1999)

15. Level II: Emergent
Conditions that are a potential threat of life, limb or function, requiring rapid medical intervention or delegated acts.
Time to MD: 15 minutes
Time to Nurse: immediate
Example: Altered LOC(GCS < 13/15)
(CTAS Implementation Guidelines, CJEM Oct. 1999)

16. Level III: Urgent
Conditions that could potentially progress to a serious problem requiring emergency intervention. May be associated with significant discomfort or affecting ability to function at work or activities of daily living.
Time to MD: <30 minutes
Time to Nurse: 30 minutes
Example: Known asthmatic with SOB or worsening of symptoms.
(CTAS Implementation Guidelines, CJEM Oct. 1999)

17. Level IV: Less Urgent
Conditions that related to patient age, distress, or potential for deterioration or complications would benefit from intervention or reassurance within 1 –2 hours)
Time to MD < 60 minutes (1 hr)
Time to Nurse < 60 minutes (1 hr)
Example: Foreign body in the foot appears well
(CTAS Implementation Guidelines, CJEM Oct. 1999)

18. Level 5: Non Urgent
Conditions that may be acute but non-urgent as well as conditions which may be part of a chronic problem with or without evidence of deterioration. The investigation or interventions for some of these illnesses or injuries could be delayed or even referred to other area of the hospital or health care system.
Time to MD: 120 minutes
Time to Nurse: 120 minutes
Example: Flu symptoms
(CTAS Implementation Guidelines, CJEM Oct. 1999)

19. First Order Modifiers
Defined as modifiers that are broadly applicable to a wide number of different complaints.
These include:
Vital sign modifiers (e.g., respiratory distress, hemodynamic stability, Level of consciousness and fever),
Pain severity (e.g., Central vs. Peripheral)
MOI ( e.g. High Risk, Low Risk)
(CJEM March. 2008)

20. Second Order Modifiers
are specific to a limited number of complaints.
Example?
Like low blood sugar level.
(CJEM March. 2008)

21. Pitfalls of ED triage Failure to recognize a patient with sever pain
Failure to recognize or acknowledge high-risk chief complaint
Failure to take adequate vital sign
Failure to adequately document the triage
Failure to retriage initially assigned to the waiting room
failure to apply the appropriate acuity scale

22. Emergency Care Center – Triage Area Patient’s Flow
Patient arrived to TRIAGE RECEPTION
(Walking, Wheelchair or Stretcher)
Initial Assessment of triage components within
3 minutes - Triage Reception
All stretcher patients will be attended & categorized immediately by triage nurse in front desk
& to be send to appropriate treatment areas directly.
National Guard
Eligible
CTAS First Order Modifiers
(V/S, Pain Severity
& Mechanism of Injury)
Normal NO
YES
Abnormal
Triage Level I OR
Triage Level II
(Life, Limb or
Sight Threatening)
Eligible & Non
eligible Patients)
Triage
Level V
Triage
Level IV
Triage
Level
III
Triage
Assessment
Room
(Triage
Physician
Decision)
Triage
Assessment
Room
(Triage
Physician
Decision)
Triage
Reception
(Triage
Nurse
Decision)
Triage
Assessment
Room
(Triage
Physician
Decision)
Appropriate
Treatment
Area
(Directly
trough Triage
Nurse Decision)
Immediately to
Resuscitative
Area
ID Band
issued
and affixed
CC / PC
AC / PC /
UCC
UCC
AC/ PC
Notify
Registration
and Affixed
Armband
Definitive
Management
in Treatment Area
Definitive
Management
in Treatment Area
Triage Away / PHU
Discharge
Admission
Prepared By: CRN – Saleem Diknash (2009)

23. Triage Challenges Regarding Documentation

24. Essential Components of Triage Documentation
Time seen by the triage nurse
Chief complaint
Allergies
Current medications
Vital signs
Subjective and objective assessment
Patient acuity rating
Diagnostic tests and triage actions
Disposition – not always detection by triage – Float Nurse
Reassessment (If waiting)

25. Triage Nursing Assessment Form

26. Electronic Triage Documentation

28. TRIAGE NURSE CHARACTERISTICS IN ED
Be able to work in stressful situations.
Possess leadership characteristics.
Thinks critically when asking questions and making decisions.
Professionalism and punctuality.
Flexible and Effective communicator.
Expert clinical emergency nurse.
Can participate in organizational enhancement efforts.
Enough clinical experiences in triage area.
Master the learning outcomes of the triage program.
To deliver a coast effective care.
Well versed in triage guidelines (KAMC - R, 2006)

29. Questions

30. Thank You