Transcript No Slide Title

Triage
Hospitalist Night Float Curriculum
Lucile Packard Children’s Hospital, Stanford
Written by Becky Blankenburg, MD, MPH
and Erin Augustine, MD
Objectives
1. To refine your own system for triaging
pages and phone calls at night.
2. To identify ways of proactively improving
your triage abilities.
3. To elucidate key details when receiving
medical information over the phone.
Case 1
You are the intern on-call and simultaneously receive the
following 5 pages. How do you prioritize them?
What do you do?
1. “Josh has bad abdominal pain.”
2. “Sophia’s mom just arrived from work and would like
to hear how she is doing.”
3. “Dr. Smith (Zach’s private physician) just called and is
upset that you didn’t start him on Ceftriaxone. He
would like a call back immediately.”
4. “Molly [12 with pre-B cell ALL just admitted with
fever and neutropenia] has a blood pressure that’s
70/30.”
5. “Alex is breathing harder. Would like to start
Albuterol.”
Triage
Definition:
• “A process for sorting injured [or sick] people
into groups based on their need for or likely
benefit from immediate medical treatment.
Triage is used in hospital emergency rooms,
on battlefields and disaster sites, [and at
night] when limited medical resources must
be allocated.”
- American Heritage Dictionary
Triage
• Derived from the French word trier,
meaning “to sort”
• First used by the chief surgeon of
Napoleon’s army (Dominique-Jean
Larrey) in the early 19th century
• First published report of civilian ED
triage in 1966
General Principles to Improve
Ability to Triage on the Wards
• What do you do?
• How can you help others improve their
ability to triage?
General Principles to Improve
Ability to Triage on the Wards
• Get good sign-out
• Check on sicker patients at beginning of shift
• Anticipate how patients will get sicker and
what you will do in response
• Know your resources ahead of time
(physicians in-hospital (and outside), nurses,
respiratory therapists, etc)
• Look/ask for trends
– Trends in vitals, trends in pain, etc
General Principles to Improve
Ability to Triage on the Wards cont
• Communicate delays/concerns to your
attending
– Some delays can lead to poor patient
outcomes (and your attendings can be
helpful mobilizing resources, if they know)
• Communicate delays to families and nurses
(when possible)
– Most people are remarkably understanding
if they just have appropriate expectations
Case 2
You are the senior on-call and take the following phone
advice call from a patient’s parent. What do you do?
• “Eva has been vomiting.”
Phone Triage – Calls from Parents
Goals:
• Answer simple medical questions.
• Advise disposition for a patient (e.g., if
needs to be seen immediately or can
wait to be seen).
• May not be necessary to diagnose.
Phone Triage – Calls from Parents:
Patient’s Medical History
Helpful medical information to know and
document:
• Call Back Number
• Name of Parent
• History of Present Illness
• Past Medical History (also review on-line, if
available)
• Medications
• Allergies to Medications
Phone Triage – Calls from Parents:
Physical Exams Over the Phone
• Mental Status
• Vitals
– Temperature, pulse, respiratory rate
• Respiratory
– Respiratory rate, retractions
• Abdomen
• GU
• Skin
– Rashes
Phone Triage – Calls from Parents:
Management Options
1. Where to Triage
a.
b.
c.
d.
e.
911
ED immediately
Urgent Care
PCP next day/in a few days
Call family same day/next day to follow-up
2. Prescriptions
a. Can call in simple prescriptions
3. Review routine return precautions
a. Signs/symptoms for the parents to be aware of
and return to medical attention if present
4. Document your call (in Cerner at LPCH)
Phone Triage – Outside Providers:
Communicate Patient Information
•
•
•
•
•
•
Name, Age, Weight
Current Medical Condition
Pertinent Past Medical History and Medications
Allergies
Vital Signs (Including BP & O2 Sat)
Pertinent Physical Exam Findings
 Mental Status
 Airway Status
 Perfusion Assessment
• Interventions Performed & Response to Therapy
• Condition Updates
• Send Copies of Notes, Labs, Imaging Studies
Phone Triage – Outside Providers:
Communicate Recommendations
• Providing Advice Is Recommended
• Evaluation
 Labs
 Imaging
• Management
 Airway Management
 Oxygen
 Intubation
 IV Placement
 Medication Administration
• Transportation
Transport Considerations
• Local Resources
 Staff Availability & Training
 Equipment
 Medications
• Distance of Transport
• Transport Availability
• Road Conditions & Weather
Transportation Options
•
•
•
•
•
Basic Life Support (BLS)
Advanced Life Support (ALS)
Critical Care
Neonatal
Air
 Helicopter
 Fixed-Wing Airplane
Basic Life Support Transport
• Team
 EMT-Basic
• Capabilities




Administer Oxygen
Administer IV Fluids
Immobilize
Administer Limited Selection of Medications
 Albuterol, EpiPen, Oral Glucose
• Recommended if
 Stable Patient
 Immediate Transport Necessary (“Load & Go”)
Advanced Life Support Transport
• Team
 EMT-Paramedic
• Capabilities
 Intubate
 Obtain IV Access
 Administer Oral & IV Medications
• Recommended if
 Life-Threatening Condition
 Altered Consciousness
 Respiratory Distress
Critical Care Transport
• Team
 EMT or Special Care Transport Paramedic
 Critical Care Transport Nurse(s)
 +/- Respiratory Therapist
 +/- Physician
• Capabilities
 Cardiac Monitoring
 Vasoactive Medication Administration
 Ventilatory Support
Air Transport
• Recommended if
 Long Distances
 Poor Road Conditions or Weather
 Patient Requires Immediate Intervention
 Intracranial Hemorrhage
Air Transport Special Considerations
• Unable to “pull over” to work on patient
• Noise prohibits auscultation
• Pneumothorax
 Low pressure at high altitude may lead to
pneumothorax expansion.
 Helicopter transport is acceptable because
it flies at sea level.
 Fixed-wing airplane transport is only
acceptable if the cabin is pressurized to sea
level.
 Best to avoid high altitude for 6 weeks after
pneumothorax resolution.
Take Home Points
1. Take proactive steps to aid you in triaging
pages and phone calls at night.
2. Focus on key details when receiving
medical information from a lay person via
phone.
3. It is best for your patient’s outcome to help
advise his/her work-up and treatment as
soon as the outside provider calls you.
References
• Schmitt BD, Thompson DA. Triage Documentation: Setting a Best
Practice. http://www.answerstat.com/articles/5/42.html, 2005.
• Thompson T, Stanford K, Dick R, Graham J. Triage Assessment in
Pediatric Emergency Departments: A National Survey. Ped Em Care,
26(8):544-548, 2010.
• American College of Surgeons Committee on Trauma, American
College of Emergency Physicians, National Association of EMS
Physicians, Pediatric Equipment Guidelines Committee-Emergency
Medical Services for Children (EMSC) Partnership for Children
Stakeholder Group and American Academy of Pediatrics. Policy
Statement – Equipment for Ambulances. Pediatrics. 2009. 124:e166-71.
• Orr RA, Felmet KA, Han Y, McCloskey KA, Dragotta MA, Bills DM,
Kuch BA, Watson RS. Pediatric specialized transport teams are
associated with improved outcomes. Pediatrics. 2009. 124:40-8.
• Sirbaugh PE, Leswing V. Prehospital Pediatrics. UpToDate. 2011.
• Baumann MH. Pneumothorax and Air Travel: Lessions Learned From
a Bag of Chips. Chest. 2009. 136:655-6.