Transcript Triage - Key Medical Resources Inc.

TRIAGE
Mary Corcoran RN, BSN, MICN
EMTALA: Emergency Medical Treatment
and Labor Act

Requires a hospital to provide an appropriate
medical screening exam to any person who
comes to the emergency department and
requests treatment or an examination for a
medical condition. If the examination reveals an
emergency medical condition, the hospital must
also provide either necessary stabilizing
treatment or appropriate transfer to another
medical facility
EMTALA
•
EMTALA regulations apply to anyone coming to
a hospital seeking emergency medical services
•
EMTALA imposes financial penalties on
physicians and hospitals
•
Additionally, the hospital, if found guilty of
violating EMTALA regulations, can be excluded
from participating in the Medicare program
EMTALA

MEDICAL SCREENING EXAM
Most hospital policies state that only an
Emergency Department MD or PA exam
constitutes a Medical Screening Exam. Check
with your supervisor
•
•
The triage process DOES NOT constitute a
Medical Screening Exam.
EMTALA
•
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A person who presents anywhere on the hospital
campus and requests emergency services, or who
would appear to a reasonably prudent person to be in
need of medical attention, must be handled under
EMTALA
250-yard rule: “Campus means the physical area
immediately adjacent to the provider’s main buildings,
other areas and structures that are not strictly
contiguous to the main buildings but are located within
250 yards of the main buildings, and any other areas
determined on an individual case basis, by the HCFA
regional office, to be part of the provider’s campus”.
EMTALA

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Questions for discussion
Does the triage nurse’s assessment constitute a
Medical Screening Exam?
If a patient is lying on the sidewalk outside of the
parking garage, is the emergency department
required to evaluate and treat the person?
If a homeless person comes to triage complaining
of chronic back pain, is the emergency
department required to evaluate and treat the
person?
What is Triage?
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From the French verb “Trier” which means to “sort” or
to “choose”
Began in the battlefield when they would prioritize
wounded soldiers
1950’s and 60’s Medical staff with military
background began to educate civilian staff on the
concept of “triage”
As physician practice changed to an “office” based
specialty system, and ER’s volume bean to increase
3 Common Triage Systems
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Traffic Director- simplest, non clinical employee
greets patient and directs them to treatment area
or wtg room based on initial impression- by 2002
obsolete
Spot-check triage- appropriate for low volume,
ED. Registration greets patient and pages triage
nurse. The RN performs basic assessment
Comprehensive triage- supported by ENA. Triage
done by competent RN. The RN determines
priority of care based on physical, developmental
and psychosocial needs
Triage Acuity
In 2003, 2 hospitals had EMT’s and RN’s
complete triage’s on 5 scripted patients and
then were asked same scenarios 6 weeks later
and only 24% of participants assigned the
same ratings both times
 The goal is to develop a standardized acuity
system in order for everyone to have the same
understanding of each level assigned

Trends Affecting ED Wait Times


The American Hospital Association (2002)
revealed 90% of ED’s perceive they are
operating over capacity.
The avg time to see ED physician in 2001
(49 min) which was an 11% increase over
1997
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And increased to 56min in 2006
Factors contributing to increased ED
volumes:* decrease in ED’s, aging population,
longer ED stays, inability to move
admissions, increase in the uninsured, po0r
access to primary care, nursing shortage
The Interview
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Introduce Yourself
Confirm the Patients Identity (IMPORTANT)
Obtain a Chief Complaint/Reason for visit
Gather Subjective & Objective Data
 Including

LMP, VS, Weight, History, Mechanism etc
Perform a rapid, concise, focused assessment, with
quick primary and secondary survey
Pediatric Patients
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Use the CIAMPEDS format to triage pediatric patients
C- Chief complaint- primary problem
I- Immunizations- UTD, NUTD
A- Allergies
M- Medications – Name, last dose, how much?
P- PMH
Parents impression of child’s condition
E- Events surrounding illness/injury
D- Diet- bottles, ounces
D- diapers
S- Symptoms associated with illness, injury
Pediatric Patient
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Use Similar A-I Assessment criteria as adults

A- Airway; patency, positioning, audible sounds

B-Breathing; inc or dec WOB. AMU, nasal flaring

C-Circulation; color of skin, cap refill

D- Disability; activity level, response to environment

E-Exposure; identify underlying injuries

F- Fahrenheit

G- Get VS, including weight in kg

H- Head to Toe Assessment; quick related to cc

I- inspect the back and isolate; observe for hidden injuries, communicable illness
Be cognizant of legal issues related to abuse/neglect
and the difference between adults and children
OB Patients
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Most OB patients can be transferred to L&D via wheelchair,
Usually patients 20 weeks gestation and greater are
evaluated in L&D or by OB physician.
EMERGENT OB-A patient with a “presenting part” must be
delivered in ED. Prepare for delivery if patient is multigravida,
completely dilated, had SROM, or c/o rectal pressure
Urgent OB- Patients in active labor- ( contractions 2 minutes
apart lasting 60-90 sec, presence of “bloody show”, ROM
Non-urgent OB- Patients not in active labor- per hospital
policy
Legal Considerations-Important to know who can transport
patients to L& D
Geriatric Population

Important points to remember when
triaging geriatric patients:
 Altered
pain perception common
 Delayed presentation common
 Upper abdominal pain, an ill
appearance, abnormal VS= RED FLAG
 Consider etiology of falls
 Consider elder abuse
 Older patients are uniquely prone to
delirium
Psychiatric Patients
All patients exhibiting aggressive and/or
agitated behavior are considered violent
unless proven otherwise
 Never turn your back on these patients
 When speaking to psychiatric patient be
simple, direct, clear and concise
 Do not overlook physical injuries or illnesses in
psychiatric patients

What do you think?
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40 y/o old female c/o epigastric pain, vomiting
50 y/o male with a ripping sensation in his chest?
23 y/o with RLQ pain and fever?
19 y/o post partum, hypotensive & fever?
2 y/o, vaccines NUTD, drooling & fever?
4 week old male, vomiting after every meal?
80 y/o with abdominal pain, vomiting bilious?
4 m old diff breathing, congestion- winter months?
ESI 5 level Triage System
Recommended by the ENA (Emergency Nurses
Association) and ACEP (American College of
Emergency Physicians)
Introduction
Level 1- Resuscitation
Level 2- Emergency
Level 3- Urgent
Level 4- Semi urgent
Level 5- Non-urgent
0 minutes
10 min
30 minutes
60 minutes
120 minutes
Level
1
Requires Life Saving Intervention?
Yes
No
High Risk Situation
Or
Confused/Lethargic/ Disoriented
Or
Severe pain/Distress
Yes
How Many Resources are Needed?
None
One
Many
Level
5
Level
4
Level
2
yes
Level
3
Dangerous Vital Signs?
No
Emergency Severity Index (ESI)
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Acuity assessment
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Airway, breathing, circulation
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Potential for life, organ or limb threat
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How soon the patient needs to be seen
Expected resource assessment
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Number of resources, as estimated by the
triage nurse, that a patient is expected to
consume in order for a disposition decision
to be reached
ESI
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Five explicitly defined categories
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Mutually exclusive
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Allows for rapid sorting
Differs from a complete assessment
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Gather sufficient information to assign an ESI
level
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Quick sorting
ESI
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Requirements to maintain the validity
and reliability of the instrument
•
Experienced emergency department nurse
at triage
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Education of each RN prior to
implementation
Patient dying?
A
1
yes
no
Can not wait?
B
yes
no
How many resources?
none
5
one
4
C
2
many
Vital signs
no
3
D
consider
Is this patient dying?
No
A
Yes
1
Decision Point A
Is This patient
Dying?

Does this patient require immediate life-saving
intervention?
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Airway
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Obstructed or partially obstructed
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Unable to protect their own airway
Breathing
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Apneic
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Intubated pre-hospital
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Severe respiratory distress
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SpO2 less than 90%
Decision Point A

Does this patient require immediate life-saving
intervention?
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Circulation
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Pulseless, or concerned about rate, rhythm or
quality?
Drugs
•
Hemodynamic interventions
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Immediate IV medications to correct
hemodynamic instability
Decision Point A
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Does this patient have an acute mental status
change that requires immediate life-saving
intervention?
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Examples:
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Hypoglycemia needs glucose
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Heroin overdose needs Narcan
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Subarachnoid bleed needs airway
protection
What are life Saving Interventions?
Resuscitation
Hemodynamics
•Airway
•Significant
and Breathing
•Intubation
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-Surgical airway
-CPAP, BiPAP
-Bag valve mask ventilation
•Defibrillation
•External
•Chest
Pacing
needle decompression
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IV fluid resuscitation
Blood administration
IV medications
•
vasopressors
•Control
of major bleeding
What are NOT life saving
interventions?
Diagnostic Tests
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ECG
Laboratory studies
Oxygen
 Monitor
 IV access
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Medications
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ASA
Nitroglycerine
Pain medications
Antibiotics
Heparin
No
Can not wait? B
Yes
No
2
High risk situation?
B
or
Confused/lethargic/disoriented?
Yes
or
Severe pain/distress?
No
2
Can this Person Safely
Wait to be Seen?
Decision point B
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Determination is made on a brief
interview, gross observations, “sixth
sense”
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Does not require a full set of vital signs
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Unsafe for the patient to wait
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Suggestive of a condition that could easily
deteriorate
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Symptoms of a condition where treatment is
time sensitive
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Potential major life or organ threat
Examples of “high risk” patients
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Episode of chest pain, denies other symptoms, known
cardiac history
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Rule out PE
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Newborn with a fever
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Rule out ectopic pregnancy
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Neutropenia with a fever
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Suicidal/homicidal
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New Onset Confusion in elderly
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Adolescent found confused and disoriented
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Patients in SEVERE pain
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Sexual Assault Patient
Decision point B
is this person in severe pain or distress?
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Is this patient currently in pain?
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Pain intensity rating
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Chief complaint
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PMH, medications
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VS, physical assessment findings
Assign ESI level 2 if and only if
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Self-reported 7/10 or greater
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AND
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RN cannot intervene and they require immediate intervention
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Do you want to give your last bed to this patient?
Examples of Level 2 Severe pain
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Kidney stone
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Burn victim
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Oncology patients
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Possible dislocated
shoulder

? Compartment
syndrome
How Many Resources will
this patient require?
Decision Point C
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Determined by the
experienced ED RN at triage
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Based on the standard of
care
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Independent of type of
hospital, location, physician
on duty, acuity of the
department
How many different resources are needed?
None
5
One
4
2 or more
Vital signs
3
C
Mean # of resources used
Mean Resources Used Per Triage Category
5
4
3
2
1
0
1
2
3
ESI Triage Level
4
5
Resources: Count number of different types of resources, not individual
tests or x-rays (ex: CBC, electrolytes, and coags equal one resource;
CBC plus chest x-ray equal two resources.
Resources
Not Resources
Labs
History
(blood, urine)
ECG
& Physical (including pelvic)
Point-of-care testing
X-ray,
CT, MRI, ultrasound,
angiography
IV
fluids (hydration)
Saline
IV,
IM or nebulized medications
PO
Specialty
Simple
consultation
procedure = 1(lac repair, foley)
Complex procedure = 2 (conscious
sedation)
or heplock
medications
Tetanus immunization
Prescription refills
Phone
Simple
call to PCP
wound care (dressing, recheck)
Crutches, splints, slings
ESI Level 5
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No resources

Examples:
 Healthy
10 year old with “poison ivy”
 Healthy
52 year old who ran out of his blood
pressure medicine yesterday
 22
year old, involved in a car accident 2 days
ago, wants to be checked. Nothing hurts.
 46
year old with a cold
ESI Level 4

Stable, can safely wait hours to
be seen

Care by mid-level providers in
fast track or express care setting

Requires a physical exam and
one resource
ESI Level 4
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Examples:
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Healthy 19 year old with sore throat and
fever.
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Healthy 29 year old with a UTI, denies
vaginal discharge.
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Healthy 43 year old with stubbed toe who
states “I think I broke it!”.
•
Healthy 12 year old with a minor thumb
laceration
ESI Level 3

30-40 % of patients in the ED
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Require in-depth evaluation

Long length of stay

Before assigning a patient to ESI
Level 3 the nurse must consider the
patients vital signs
ESI Level 3,4, and 5 examples
ESI Level 3

-Fractured ankle

-Abdominal pain
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-Most migraines
• ESI Level 4
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-Sprained ankle, toe
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-Abscess
• ESI Level 5
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-Toothache
•
What are the
patients vital signs?
Decision point D
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Consider the vital signs

Are they outside the acceptable
parameters for age?
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If unacceptable consider uptriage to ESI Level 2
Danger zone vitals?
HR
RR
SaO2
>180
>50
<92%
3m-3y >160
>40
<92%
3-8y
>140
>30
<92%
>8y
>100
>20
<92%
<3 m
Level
3
Pediatric Fever Criteria
•
1 to 28 days of age: assign at least ESI 2
if temp >38.0C (100.4F)
•
1 to 3 months of age: consider assigning
ESI 2 if temp >38.0c (100.4F)
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3 months to 3 years of age: consider
assigning ESI 3 if: temp >36.0C (102.2F),
or incomplete immunizations, or no
obvious source of fever
Lets
Practice
Pediatric Sprained Ankle
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An eight year old is brought to triage
because of an injured right ankle. The
child tripped over a ball while playing
soccer. The ankle hurts with ambulation
and you notice edema over the medial
aspect of the ankle. His mother tells you
the child is healthy, takes no medications
and has no allergies. VS WNL.
Respiratory Distress
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Paramedics arrive with a 42 y/o morbidly
obese female who called EMS with a CC
of SOB. On arrival the paramedics found
her sitting upright, working hard at
breathing with a respiratory rate of 48 and
a room air SPO2 of 84%. They are
unable to obtain any further history.
Lump…
“I have a lump on my back” reports a 28
year old healthy male. Upon further
questioning he tells you the lump looks
like a huge, large pimple. He reports no
drainage or fever.
No PMH or meds.
His vital signs are:
BP 118/74, T 98.8, HR 72, RR 16
Vaginal Bleeding/ Abdominal Pain
23 y/o female presents to triage with a CC
of moderate vaginal bleeding and
generalized abdominal cramping (5/10)
for 2 hours. Her LMP was 8 weeks ago.
She is G1P0. Her skin is warm and dry.
Her vital signs are:
BP 110/80, T 98.6, HR 84, RR 20
Shoulder

A 45 y/o male is brought to triage by his
friend who states the patient injured his
left shoulder while playing football. The
patient has a gross deformity to his
shoulder with neuro deficits to the left arm.
He is unable to move his arm, complains
of excruciating pain (20/10 when asked),
and is diaphoretic.
Bite
Mom brings her 4 y/o son to triage with a
CC of a red arm. The patient was bitten
by the family dog about 3 days ago. The
child is cranky. His right arm is reddened,
with edema to a large area surrounding
the dog bite.
His vital signs are:
T 99.5, HR 120, RR 24
PNA
A 70 year old male arrives by ambulance
from a nursing home. The nursing home
reports a non-productive cough since he
choked on his lunch today. His baseline
mental status is unchanged, although he is
normally confused. Skin is warm and moist.
His vital signs are:
BP 135/80, T 100.2, HR 94, RR 20,
SpO2 94% on RA
Laceration
A tearful 5 year old is carried in by her
father who reports is daughter was trying
to help set the dinner table and broke a
glass. You notice a 3 cm laceration on
her left hand. The bleeding is controlled.
No history, allergies or meds.
Her vital signs are:
BP 98/64, T 97.8, HR 108, RR 24
Hematemesis

EMS arrives with a 49 year old male with
a history of cirrhosis and hepatitis C. His
wife called 911 when he started vomiting
bright red blood. On arrival he is pale,
diaphoretic and has a BP of 92/78, HR
130, RR 28.
Wound
19 y/o male states he had an appy last
week. Wound is red, opened up, and
yellow pus is oozing out. No other medical
history. No meds.
101.8, HR=98
Trauma
Notified by EMS you are receiving an 8
y/o female hit by a bus. Witnesses state
she was thrown across the street.
 VS= HR=148, RR=36, BP=70/palp, O2
sat=91%.
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What if they Leave?
L
W
B
S
Pts who are LWBS (Left Without
Being Seen), are more common
in high volume ER’s
 Most patients are frustrated
with the long wait times
 Discuss the LWBS policy with
your specific facilities
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Triage Nurse Qualifications
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Triage Nurses are the Gate Keepers to the ER, if
they Over-triage they can use up vital beds in the
ER, if they Under-triage they can delay vital care
Triage Nurses must be knowledgeable, experience,
temperament, and qualifications necessary to
function in a high stress roll
Most facilities require at least 6mo- 1year of ER
experience before allowing nurses to triage
Questions?