Eemergency Department Triage Policy

OBJECTIVE

1.To classify different illness and injuries.

2.To ensure proper management of the emergency.

3.To prioritize those in need of immediate treatment.

4.To stabilize and provide critical treatment, and prompt transfer to appropriate setting (ICU, OR, General Unit).

1.The triage nurse does a brief evaluation of the patient to determine a level of acuity or priority of care.

2.She acts as a caretaker, sorting patients into categories, ensuring that the more seriously ill are treated first.

3.Routine hospital triage directs all available resources to the patient's who are most critically ill, regardless of potential outcome.

5.The primary focus of a triage is to stabilize life threatening conditions.

6.The triage system consist of 3 levels of activity: 6.1 Emergent I Conditions requiring immediate medical intervention 6.1.1 Airway compromise 6.1.2 Cardiac arrest

Conditions requiring immediate medical intervention 6.1.1 Airway compromise 6.1.2 Cardiac arrest

TRIAGE INDEX NUMBERSNR-ER-004PAGE NUMBER2 OF 3 6.1.3 Severe shock 6.1.4 Cervical spine injury 6.1.5 Multisystem trauma 6.1.6 Altered level of consciousness 6.1.7 Eclampsia

6.2Urgent II- Patients who present a stable but whose condition requires medical interventions within a few hours. There is no immediate threat to life or limbs for these patients.

Management III Patients who presents with chronic or minor injuries. There is no danger to life or limb by having these patients wait to be seen. These patients are in no obvious distress.

6.3.1 Chronic low, back pain 6.3.2 Routine medical refills 6.3.3. Dental problems 6.3.4 Missed menses

7.1 Red- Emergent 7.2 Yellow- Immediate 7.3 Green- Urgent 7.4 Blue Fast- track or psychological support needed.7.5 Black- Either dead or progressing rapidly toward death.

MATERIALS & EQUIPMENT

1.Oxygen , airway 2.Cervical collar 3.ECG machine 4.Urinary catheters 5.Splints for fractures6.Suction machine

Position the patient.

2.2 Administer O2 immediately resuscitation, if necessary Check and monitor vital sings and neurological assessment by using Glasgow coma scale.

2.1To establish patent airway.

2.2To provide adequateVentilation

2.3To determine neurological disability3.Apply cervical collar for patients suspected of spinal cord injury.3. To prevent further trauma4.Initiate fluid replacement:4. To control bleeding, prevent and treat shock, and restore effective circulation. 5.After priorities have been done, do the following:5.1 History and head- to-toe assessment.

5. To assess patient's condition for further evaluation5.2 Diagnostic and laboratory testing5.3 ECG monitoring 5.4 Cleansing and dressing of wounds5.5 Look for suspected fractures.6.Document all procedures in the nurse's notes.

Female Observation Room exclusively for female patients for further evaluation without male attendance inside.

Observation Room for patients for further work up and evaluation.Treatment Room suturing, dressing, injections to be done.Triage where patients are screened for priority of cases.Resuscitation/Trauma Room for serious patients and code blue.Documentation is emphasized properly

4.6.1A & E form is accomplished properly to include telephone number, relative's name and address.4.6.2Vital signs4.6.3Time and date4.6.4Proper entering in the registry book and where to fill the patient's chart5.Charge nurse will be responsible for the overall supervision of the orientation and assign allocation per shift, per week if necessary.6.Technical skill checklist will be the responsibility of the charge nurse to be completed within the first week.

7. At the end of the two-week orientation the charge nurse may discuss with the orientee any problems encountered and may give oral test to ensure that the orientation has been satisfactory.8.At the end of the two-week orientation, the orientee should be a functional member of the staff and if not so, the chief nurse or supervisor should be informed, for information and planned action.