Transcript st. joseph healthcare triage

TRIAGE AT
ST JOSEPH
HEALTHCARE
Provides efficient care utilizing triage
modules.
Provides training and understanding of
concepts of triage
Developed by Eula Brown RN for Emergency Department
use.
Collaborators:
Brenda Harris, Education Technology specialist
Patty Sturt RN, Clinical Educator
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Objectives
At the end of this program the end user will
be able to verbalize skills related to:
Understanding the basic concept of triage
Define 5 levels of triage acuity
Understand components of ED triage process
for all types of patients
Objectives cont’d
Define components of triage
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1.visual assessment
2.subjective assessment
3.Objective assessment
4.Define resources needed
5.Making the triage decision
Be aware of and incorporate situations regarding legal,
abuse, documentation, customer service, hazardous
materials, and cultural issues into the triage module.
To utilize patient scenerios with clinical end users for a
better understanding of triage
MODULES PRESENTED
Module 1: Introduction
Module 2: Components of triage
Quick assessment
Subjective data
Objective data
Resources and special situations
Triage decision
Module 3: Examples of each level
Module 4: Triage Pearls
Triage: French word meaning
“to sort”.
Developed and used originally by military
during World War I as a model for classifying
patients according to priority of care needed.
Used extensively during WWII
Emergency Departments nation-wide have
adopted and utilize some form of triage system
to use in classifying patients based on care
needed.
The most common system is the
three level system.
Classification is defined as:
Emergent
Urgent or
Non-urgent.
Throughout the later part of the 20th
century, this system has been shown to be
lacking in accuracy and not adequate for
the volume and needs of 21st century
ED’s.
Canada, Australia, and UK have each
developed different 5 level triage systems.
We in the US have been presented with
an Emergency Severity Index 5 level
triage system that has been shown to be
very effective in recognizing different
classifications of patients and identifying
resources needed to provide the most
efficient patient care.
Two of the most significant factors differentiating the
US system from the others are:
The 5 level classification used by Canada and Australia are
defined by what are “safe wait times for different levels”
US ESI system recognizes and incorporates needed resources
for patient care into the classification system. The US system
does not consider safe wait times in determining a level of
classification
THE 5 levels are defined
as follows:
Critical: (1)
Conditions that require
immediate and aggressive
intervention
Emergent: (2)
Conditions that represent
potential loss of life of limb if
interventions not done
promptly.
Urgent: (3)
Interventions needed in the
emergency department for
timely return to health. HR and
RR within normal limits. Needs
two or more potential resources.
Non-urgent: (4)
Conditions that will benefit
from being seen in the ED,
but may wait to be seen. One
resource needed.
Minor: (5)
Conditions that may be seen
in clinic setting and/or have
no expectation of
deterioration. One to zero
resources needed.
COMPONENTS OF THE
TRIAGE PROCESS:
1. QUICK ASSESSMENT
2. SUBJECTIVE DATA
3. OBJECTIVE DATA
4. RESOURCES
5. TRIAGE DECISION
Quick assessment: This begins
when the patient approaches triage.
“Across the room” assessment is based on
ABCD parameters of airway, breathing,
circulation, mental status/”disability”,
This includes: distress noted, tachypnea,
bradypnea, wheezing, accessory muscles,
nasal flaring, altered skin color, stridor, pt
unconscious, psychosis/hallucinations,
inability to recognize familiar people
uncontrolled bleeding
** If, at anytime during the quick “across
the room” assessment, the patient
demonstrates a combination of the above
symptoms that indicates an emergent or
critical situation , they are taken
immediately to an ED room and
interventions are started.
The triage acuity is critical or emergent.
Subjective data: Triage
history
Chief complaint: this is what the patient
says is wrong (preferably in their own
words)
Further subjective data:
Medical history: *AMPLE
*AMPLE =
A = allergies, age of patient
M= medications, dose, frequency, last dose
P= past medications, surgical, pregnancy or prenatal
history
L= Most recent meal, tetanus, LMP, ETOH or drug
ingestion
E=Events surrounding present illness or injury,
associated symptoms
Subjective data cont’d:
pain
Level of pain using appropriate scale
Duration
Severity
Quality
Radiation
Location
Objective data:
Focus assessment based on patients chief
complaint and initial presentation.
Focus assessment should be completed
taking into consideration the
illness/injuries the patient presents with.
Objective Data cont’d
Think/consider: What is the worst
possible thing that could be wrong with
this patient?
Vital Signs are included in a focus
assessment.
O2 sat is included in the objective
assessment as needed
Objective data cont’d
Carefully consider all assessment data to
determine if the patient has a critical or
emergent situation.
pallor
Indications of blood loss
degree of distress
Vital signs
O2 sat
Objective data cont’d
The very young patients or very old have
unique considerations or physiological
changes that may place them at a higher
acuity level.
RESOURCES: Resources the triage nurse
believes the patient may need based on the
triage assessment
ED team (nurses, techs) patients requiring one or more initial
nurses or technicians to stabilize, protect, prevent other harm, and
effectively care for patient
SITUATIONS REQUIRING EXTRA PERSONNEL: EXAMPLE –
Alzheimer’s patient requiring constant care.
Ancillary Resources:
LAB
X-RAY
CASE MANAGER
CT SCAN OR ULTRASOUND
RESPIRATORY THERAPY
Resources the triage nurse believes the
patient may need based on the triage
assessment
Medical management: does the patient
need MD or can patient be seen by PA
only. Is the patient to be seen by private
MD.
EMTALA issues
Resources cont’d
Crisis situations requiring additional
staff or chaplaincy services.
Legal issues (Management or
administrative resources)
Patients that require additional
placement or assistance with meeting
discharge home needs.
Situations that require additional
Resources
Simple procedures (simple wound, IV
care, dressing)
Complex procedures (moderate sedation,
complicated burn care, gastric lavage)
Evaluating Resource needs and
examples:
Legal issues:
Illness/injury (chief complaint) that leads the
triage nurse to suspect abusive situation:
Example Abuse situations : patient states
was assaulted by boyfriend earlier today.
This would then involve police, abuse form,
and possible community resources.
Examples legal issues:
Example: patient with right-sided Paralysis
presents from nursing home with multiple
bruising and skin tears to left side of body:
This would involve abuse form, notification
of house administrator
MVC/Trauma patients: police involvement,
community resource involvement, coroner’s
case, legal evidence collection.
Special issues that may impact
triage assessment:
Trauma:
What happened?
When?
Mechanism of injury: i.e. Four wheeler
accident, MVC (simple fender bender),
MVC rollover, MVC t-bone. Penetrating
trauma vs. blunt trauma
Special issues cont’d
COBRA: EMTALA:
No patients can be questioned regarding
insurance/payment of emergency
department services without medical
screening first. (Medical screening: any
and all tests, examinations done by qualified
practioners to determine an emergent
condition)
Patients should not be transferred from
another hospital without confirmation
that the accepting facility has the
capacity and resources to care for the
patient. The patient must have an
accepting physician
Special issues cont’d
Cultural issues:
Language barriers: need for translator services
Customs of different religions or ethnic groups:
coining for fever patients, IV/blood products
restrictions
Crisis situations:
Patients with new onset mental illness
Patients presenting with intent to harm
themselves or others
Patients in medical distress with families
needing interventions to help copy
Patients presenting with disability that
impairs communication and/or affects timely
treatment
Example: Aphasia
HazMat/Environmental situations:
Specific agent if known?: chemical,
radiation, biological
Example: Hydrofluoric acid
When did the exposure occur?
What type of exposure:
• Inhalation – lungs
• Dermal - burn to face, eyes, etc.
Resources must anticipate including decon!
Evaluating resource
needs cont’d
Procedures:
Simple: Saline lock, simple wound, simple
laceration
Complex: procedural sedation, extensive
burn, gastric lavage
Quickly analyze subjective,
objective data, and resources
Triage decision:.
IS…..
Based on above components
and utilizes the experienced
nurse’s decision making skills
Triage can be confusing...
The next slides are definitions
and pt examples of each level
or category:
CRITICAL PATIENTS:
Level One - red
ABCD’s:
compromised in one or more areas.
CRITICAL: (1) - brought back to room
immediately with aggressive ED Team
interventions started.
Cardiac arrest
Respiratory arrest
Does not respond to painful stimuli
(*AVPU)
the level one patient has a new onset of
decreased AVPU
EMERGENT PATIENTS:
Level Two - orange
ABCD’s:
Patients with potential compromise to life
or limb and/or chief complaint of
emergent nature
EMERGENT brought back to room
immediately with interventions started.
Examples Level 2
Sudden onset speech deficits or motor
weakness indicative of acute stroke
Active chest pain suspicious for CAD
Immunocompromised patient with fever
Suicidal patient with a plan
Infant < 4 mo of age with temp >100.4
rectal
Abdominal pain or back pain with
indicators of hypovolemic shock
Noticeable respiratory distress (i.e.
Retractions and O2 Sat <90%)
Severe pain with behavioral and
physiologic indicators of severe pain
Sudden onset of testicular pain
Patient with auditory hallucinations
Chemical splash to eye
Sudden partial or full loss of vision
Indicators of neurovascular compromise
in an injured extremity
Acute lethargy/decreased Level of
consciousness:
Acute sickle cell pain crisis
Indicators of ineffective cardiac
output
Febrile seizure
URGENT PATIENTS:
Level 3 (yellow)
ABCD”S
Compromise may occur, but less likely
Vital signs
HR and RR are not above normal
parameters
O2 sat is not less than 92%
Blood pressure is not at a dangerous
level.
Pain scale: Generally <8
**Vital sign parameters are not an
isolated determination.
Will need to be seen after critical and
emergent patients.
Obtain additional subjective, objective
data as needed to determine if the patient
is urgent.
Examples Level 3
C/O of flank pain with pain level = or < 8
and history of kidney stones
Cough and fever
Vaginal bleeding with mild-moderate
discomfort and no indicators of
hypovolemia
Extremity injury with indicators of
possible fracture or dislocation
Cellulitis without indicators of septic
shock or severe sepsis
= or > 65 y.o. with abdominal pain
Vomiting and diarrhea in child with no
indicators or poor perfusion
Headache with: GCS = 15, no
motor/sensory deficits, no history of
trauma, mild-mod pain
Croup
Abdominal pain with fever with no
indicators peritonitis
Pediatric pt with fever and no indicators
of meningitis, meningococcemia, sepsis,
febrile seizure, or decreased perfusion.
Laceration that definitely requires suture
repair
Non-urgent: Level 4 (green)
ABCD’s : Compromise not likely
Patients seen after above three
levels.
Stable patients requiring one
resource.
Examples level 4:
Foreign body sensation in eye with no
history of trauma, no visual changes and
mild pain
Vaginal itching and burning
Extremity injury with no indicators of
fracture or dislocation
Non-productive cough with no or
minimal pain and no fever
Dysuria with no indicators of
pyelonephritis and no or minimal fever
Minor laceration with no sutures
required (may require steri-strips)
Back pain with no indicators of
neurological compromise and no
significant mechanism of injury (i.e.
rollover MVC vs. “twisted while
bending”)
Rash for multiple days with no indicators
of respiratory distress or cellulitis
Minor: Level 5 (blue)
ABCD’s : No compromise
Progression of illness/injury: little to no
change from onset
Vital signs: stable
Pain scale: <4/10
Resources: no resources needed.
Stable patients: could be seen in clinic or
office setting. Requires no or minimum
resources.
Examples level 5:
Request for prescription refill with no
symptoms or complaints
Superficial abrasion
Request for tetanus shot
Request for allergy shot
Suture removal with well healed wound
and no indications of infection
Triage “Pearls”
Triage guidelines should never replace good
nursing judgment.
Always validate what you think you heard.
Patients sometimes tell you what they think you
want to hear.
All female patients of childbearing age need
LMP documented
New onset confusion: consider sepsis or
hypoglycemia
Patients who are a threat to themselves or
others must be suspect for higher level of
classification
Many older patients may dismiss
complaints as normal for their age.
However symptoms in the elderly
population may not always be age related.
Always think of the worst situation and
triage accordingly. It is better to “triage up”
than under triage.
Maintain customer service attitude or call
for help as needed
Protect yourself – never go to the end and
down the hill to retrieve a patient….call for
help
Always pay attention to parents/caregivers
subjective data.
Females always need gynological
assessment with GI problem
Do not ignore the frequent flyers! They too can
have real disease.
Communication is more difficult with the very old
and very young. Therefore you need to take more
time with these patients.
Bradycardia is an ominous sign in a child
More resources = may equal higher acuity!
Triage is a challenge to all nurses…….but you can
do it!
BEYOND TRIAGE….