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Triage in Emergency Department
TriageWaiting
room
Team leader
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Definition of Triage
Triage is the term derived from the Frenchverb trier meaning to sort or to choose
Its the process by which patients classifiedaccording 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
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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.
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Non disaster or E.D triage
The primary objectives of an ED triage are to
(ENA,1992, P. 1):
1. Identify patients requiring immediate care.
2. Determine the appropriate area for
treatment
3. Facilitate patient flow through the ED and
avoid unnecessary congestion.
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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.
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Disaster
Definition: an incident, either natural or human-made, that produces patients in numbers needingservices beyond immediately available resources.
May involve a large no. of patients or a small no.of patients if their needs place significant demandson resources.
The key to successful disaster management is to
provide care to those who are in greatest need firstand just as importantly, not provide care to tothose who have little or no chance of survival.Correct triage is essential to accomplish this goal
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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 whogreets each patients on arrival, perform a primarysurvey and determine whether the patient is able to
wait for further assessment by a second triagenurse.
Divide tasks among staff members, internal triageand external triage
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Overview of three category triage acuity systems
category acuity Recommended
reassessment
Examples
Class 1 EmergentImmediately life or limb
threatening
continuous Cardiopulmonary
arrest, severe
respiratory distress,
major burns, major
trauma, massiveuncontrolled bleeding
Coma, status epil..
Class 2 UrgentRequires prompt care, but
will not cause loss of life orlimb if left untreated for
several hours.
Every 30
minutes
Abdominal pain, non
cardiac cp, multiple
fractures, lacerations,
renal calculi,
Class 3 Non urgentAnd treatment but time is
not a critical factor
Every 1-2
hrs
Rash, chronic headache,
sprains, cold symptoms
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TRIAGE LEVELS
1- Resuscitation -- threat to lifeTime to nurse assessment IMMEDIATE
Time to physician assessment IMMEDIATE
Cardiac and respiratory arrest Major trauma
Active seizure
Shock
Status Asthmatics
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Triage levels2- Emergent
Potential threat to life,limb or function
Nurse Immediate , Physician
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Triage levels
3- UrgentCondition with significant distress
Time Nurse < 20 min, physician < 30 min
Head injury without decrease of LOC butwith vomiting
Mild to moderate respiratory distress
G.I. Bleed not actively bleed
Acute psychosis
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Triage levels
4- Less urgentConditions with mild to moderate discomfort
Time for Nurse assessment
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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
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Basic component of triage
An across-the room assessment
The triage history
The triage physical assessment The triage decision
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An across the room assessment
To identify obvious life threat conditions
General appearance
Air way
Breathing
Circulation
Disability
(neurogenic)
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Across the door assessment
The triage nurse must scan the area wherepatients enter the emergency door, even while
interviewing other patient.
The triage antenna should be seeking clues toproblems in all people who enter the triage area
If any patient doesnt look right kindly but
quickly interrupt any current interaction and goinvestigate.
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Across the room assessment
Air way
Abnormal airway sounds, stridor, wheezing grunting
Unusual posture e.g.. Sniffing position, inability tospeak, drooling or inability to handle secretion
Breathing
Altered skin signs, cyanosis, dusky skin, tachypnic
bradypnea, or apnea periods, retractions, use
accessory muscles, nasal flaring, grunting, or
audible wheezes
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Across the room assessment Circulation
Altered skin signs, pale, mottling, flushingUn controlled bleeding
Disability (neuro.)
LOCInteraction with environment
Inability to recognize family members
Unusual irritabilityResponse to pain or stimuli
Flaccid or hyper active muscle tone
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Characteristics of triage nurse
Extensive knowledge to emergency medicaltreatment
Adequate training and competent
skills,language, terminology Ability to use the critical thinker process
Good decision maker
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Role of triage nurse
Greet patients and identify your self.
Maintain privacy and confidentiality
Visualize all incoming patients even whileinterviewing others.
Maintain good communication between triage andtreatment area
maintain excellent communication with waitingarea.
Use all resources to maintain high standard of care.
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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.
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Importance of re triage
Reassess the patient within 1-2hours ofinitial triage and continue to re assess on a
regular basis, patients who may have
presented without cardinal signs of severeillness may develop them during long waits.
Patients who appear intoxicated actually
may have life threatening problems such asDKA, and should not be permitted to keep it
off in the waiting room.
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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
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