1. Triage in Emergency DepartmentBY
Mohammad abuadas, RN, MSc
Triage
Waiting room
Team leader

2. OBJECTIVES At the end of this lecture the students will be able to:
1- State the definition of word “triage”.
2- Identify the triage categories.
2- Review triage levels.
3- Understand (across the room assessment).
4- Identify the characteristics of triage nurse.
5- Describe the roles of triage nurse.
6- Understand the importance of re triage.

3. First Unit Assess & Secure the Scene
Establish Areas as Outlined in the Schematic
Communicate & Direct Incoming Units
Requests Additional Resources
Notify Hospitals
Establish Triage Unit Coordinator
Relate to your students what the radio transmission of the first arriving unit might be in your jurisdiction.
“Paramedic 203 to dispatch. We have a collision involving two buses. We are requesting three Medical Strike Teams with Rescue. Have the first team begin Triage and the second team establish the Treatment Area at the 7-Eleven parking lot. The third team should stage in the Kindercare Lot.” “Advise EMRC of the incident and that we could be transporting approximately 60 patients. Ask them to begin a call-down. We will contact them for hospital status.”

4. Definition of triage
Triage is the term derived from the French verb trier meaning to sort or to choose
It’s the process by which patients classified according to the type and urgency of their conditions to get the Right patient to the
Right place at the
Right time with the
Right care provider

5. Triage categories
Non disaster: To provide the best care for each individual patient.
Multi casualty/disaster: To provide the most effective care for the greatest number of patients.

6. Non disaster or E.D triage
The primary objectives of an ED triage are to (ENA,1992, P. 1):
Identify patients requiring immediate care.
Determine the appropriate area for treatment
Facilitate patient flow through the ED and avoid unnecessary congestion.

7. 4. Provide continued assessment and reassessment of arriving and waiting patients. 5. Provide information and referrals to patients and families. 6. Allay patient and family anxiety and enhance public relations.

8. Disaster
Definition: an incident, either natural or human-made, that produces patients in numbers needing services beyond immediately available resources. May involve a large no. of patients or a small no. of patients if their needs place significant demands on resources.
The key to successful disaster management is to provide care to those who are in greatest need first and just as importantly, not provide care to to those who have little or no chance of survival. Correct triage is essential to accomplish this goal

9. Disaster The triage team Triage of Victims
- first victims to arrive are frequently not
the most seriously injured.
Critical patients
Fatally Injured Patients
Non critical patients
Contaminated patients

10. Types of E.D. triage system
Type 1: Traffic Director (Non Nurse).
Type 2: Spot Check
Type 3: Comprehensive
Two-tiered systems: initial screening by RN who greets each patients on arrival, perform a primary survey and determine whether the patient is able to wait for further assessment by a second triage nurse.
Divide tasks among staff members, internal triage and external triage

11. Triage levels 1- Resuscitation 2- Emergent 3- urgent 4- less urgent
5- Non urgent
The Canadian E.D. Triage and Acuity Scale

12. Recommended reassessment
Overview of three category triage acuity systems
category
acuity
Recommended reassessment
Examples
Class 1
Emergent
Immediately life or limb threatening
continuous
Cardiopulmonary arrest, severe respiratory distress, major burns, major trauma, massive uncontrolled bleeding
Coma, status epil..
Class 2
Urgent
Requires prompt care, but will not cause loss of life or limb if left untreated for several hours.
Every 30 minutes
Abdominal pain, non cardiac cp, multiple fractures, lacerations, renal calculi,
Class 3
Non urgent
And treatment but time is not a critical factor
Every 1-2 hrs
Rash, chronic headache, sprains, cold symptoms

13. TRIAGE LEVELS 1- Resuscitation -- threat to life
Time to nurse assessment IMMEDIATE Time to physician assessment IMMEDIATE
Cardiac and respiratory arrest
Major trauma
Active seizure
Shock
Status Asthmatics

14. Triage levels 2- Emergent Potential threat to life, limb or function
Nurse Immediate , Physician <15 minutes
Decreased level of consciousness
Severe respiratory distress
Chest pain with cardiac suspicion
Over dose (conscious)
Severe abdominal pain
G.I. Bleed with abnormal vital signs
Chemical exposure to eye

15. Triage levels 3- Urgent Condition with significant distress
Time Nurse < 20 min, physician < 30 min
Head injury without decrease of LOC but with vomiting
Mild to moderate respiratory distress
G.I. Bleed not actively bleed
Acute psychosis

16. Triage levels 4- Less urgent
Conditions with mild to moderate discomfort
Time for Nurse assessment <1h
Time for physician assessment < 1h
Head injury, alert, no vomiting
Chest pain, no distress, no cardiac susp.
Depression with no suicidal attempt

17. Triage levels 5- Non urgent Conditions can be delayed, no distress
Time for nurse and Physician assessment more than 2h
Minor trauma
Sore throat with temp. < 39

18. Reassessment in triage
Level 1 =Continuous
Level 2 = every 15 min
Level 3 = every 60 min
Level 4 = every 60 to 90 min
Level 5 = every 2 hours

19. E S I M R G N C Y E V R I T Y N D E X Is patient dying ?
Yes No
Level I
Level II, III, IV, V
Can patient wait ?
Yes No
Level III, IV, V
Level II
How many resources ?
TWO
Level III
ONE
Level IV
NON
Level V

20. What are resources ? Resources Not resources Labs
HX and physical exam.
ECG-X-rays C-T MRI
Point of care testing
IV Fluids /hydration
Saline or Hep lock
IV /IM Medication
PO. Medication
Specialty consult
Simple wound care (dressing check /recheck) crutches ,splints,slings.
Simple procedure
Complex procedure

21. Basic component of triage
An “across-the room” assessment
The triage history
The triage physical assessment
The triage decision

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

23. Across the door assessment
The triage nurse must scan the area where patients enter the emergency door, even while interviewing other patient.
The triage antenna should be seeking clues to problems in all people who enter the triage area
If any patient doesn’t look right kindly but quickly interrupt any current interaction and go investigate.

24. Across the room assessment
Air way
Abnormal airway sounds, stridor, wheezing grunting
Unusual posture e.g.. Sniffing position, inability to speak, drooling or inability to handle secretion
Breathing
Altered skin signs, cyanosis, dusky skin, tachypnic, bradypnea, or apneic periods, retractions, use accessory muscles, nasal flaring, grunting,or audible wheezes

25. Across the room assessment
Circulation
Altered skin signs, pale, mottling, flushing
Un controlled bleeding
Disability (neuro.)
LOC
Interaction with environment
Inability to recognize family members
Unusual irritability
Response to pain or stimuli
Flaccid or hyper active muscle tone

26. Characteristics of triage nurse
Extensive knowledge to emergency medical treatment
Adequate training and competent skills, language, terminology
Ability to use the critical thinker process
Good decision maker

27. Role of triage nurse Greet patients and identify your self.
Maintain privacy and confidentiality
Visualize all incoming patients even while interviewing others.
Maintain good communication between triage and treatment area
maintain excellent communication with waiting area.
Use all resources to maintain high standard of care.

28. Role of triage nurse
Teaching use of thermometer, first aid ??? avoid lecturing.
Crowd control.
Telephone.
Communicate with team leader and seek feed back on decisions.

29. Importance of re triage
Reassess the patient within 1-2hours of initial triage and continue to re assess on a regular basis, patients who may have presented without cardinal signs of severe illness may develop them during long waits.
Patients who appear intoxicated actually may have life threatening problems such as DKA, and should not be permitted to keep it off in the waiting room.

30. The last person in along line at triage may have a serious medical problem that requires immediate attention
Patient should wait no longer than 5 minutes for triage
If in doubt about a category, choose the higher acuity to avoid under triaging a patient

31. Maryland Department of Transportation
MIEMSS
HOSP NOTIFIED
Triage Tag
Maryland Emergency
Medical Services
TRIAGE TAG
A V P U
Inflated at _______________
PASG
Gauge
_______
Extremity Splint
Gross Decon.
Final Decon.
Maryland Department of Transportation
Patient Information
Triage Status
Chief Complaint
Transportation
Peel - off Bar Codes
Transport Record
Vital Signs
History
Treatment

32. Patient Information Section
During MCIs this information is not always obtainable.
Information is not a priority, can be added throughout triage, treatment, transportation, and hospital reception phases.

33. Triage Status Section Universal color coding system
Space provided for four individual evaluations
Initial assessment - apply tag for priority assignment
Secondary reassessment (in treatment area)
Blank - can be used in the treatment area or during transportation
Hospital
Once the tag is applied to the patient. refer to the tag NOT the ribbon to determine priority.

34. Chief Complaint Section
Major obvious injuries or illness can be circled
Indicate injuries on the human figure
Additional information is added on the comments line

35. Transportation Line
The transporting unit notes it’s agency information, destination facility, and the time the patient physically arrives at destination facility

36. Transportation Record Section
Detachable by tear-off ticket and as a peel-off label
Used to document patients removed from the scene to a hospital or other facility
Transportation record label can be fixed to the transportation tactical worksheet - make certain unit, priority, and destination is marked and initialed
Point Out “Initials” Area, Priority, Hospital, & Unit
Note Log-in Sheet is Different from Transportation Tactical Worksheet
Initial notified box after the hospital has been notified of the patient
HOSP NOTIFIED

37. R - P - M Vital Signs Section In START Order R - P - M In START Order
In RPM format described by S.T.A.R.T.
-Respiration
-Pulse
-Mental Status

38. Medical History Section
Information can be obtained anytime during the incident
Information can be obtained from Medic Alert identification devices
Relevant medical history & medications

39. Treatment Record Section
Documents treatment sequence and progress
Quick documentation of common treatments
Space provided for additional treatments and remarks
Spaces provided for time treatment actions are taken and for provider initials
Graphic is on the next slide
Stress importance of documenting time

40. Treatment Record Layout

41. THANK YOU