triage

Triage

Paleerat Jariyakanjana, MDEmergency Physician

Faculty of MedicineNaresuan University

30 Nov 2012

originated in WW I by French doctors treating the battlefield wounded at the aid stations behind the front

3 categories Those who are likely to live, regardless of what care

they receive Those who are likely to die, regardless of what care

they receive Those for whom immediate care might make a

positive difference in outcome

simplest term: the sorting or prioritizing of items

Concepts 1) Utility

2) Relevance

3) Validity

1º operational objectives: time to see physician

Assigning Triage"usual presentation"

not totally dictated by the presenting complaint

vital signs, PEFR, O2 saturation, pain scales

Goals of Triage

A. To rapidly identify patients with urgent, life threatening conditions. 

B. To determine the most appropriate treatment area for patients presenting to the ED. 

C. To decrease congestion in emergency treatment areas. 

D. To provide ongoing assessment of patients. E. To provide information to patients and

families regarding services expected care and waiting times. 

F. To contribute information that helps to define departmental acuity. 

Role of Triage PersonnelThe triage nurse should have rapid

access or be in view of the registration and waiting areas at all times.

Role of Triage Personnel1. Greets client and family in a warm empathetic

manner.2. Performs brief visual assessments.3. Documents the assessment.4. Triages clients into priority groups using

appropriate guidelines.5. Transports client to treatment area when

necessary.6. Gives report to the treatment nurse or

emergency physician, documents who report was given to and returns to the triage area.

7. Keeps patients/families aware of delays.8. Reassesses waiting clients as necessary.9. Instructs clients to notify triage nurse of any

change in condition.

Role of Triage PersonnelAccurate: based on

Practical knowledge gained through experience and training.

Correct identification of signs or symptoms. Use of guidelines and triage protocols.

recorded on all patients, during all shifts

General Triage Guidelinesdynamic process

A patient’s condition may improve OR deteriorate during the wait for entry to the treatment area.

Triage Process: Primary survey vs Primary Nursing Assessment

The need to meet time objectives for triage assignment within 10 minutes of arrival means that the triage assessment may be limited to 2 minutes unless there are other operational policies like bringing on more triage personnel. 

The triage assessment

1. Chief complaint2. Subjective3. Objective4. Additional Information:

Allergies Medications

ReassessmentObjectives for time to Nursing

reassessment is related to triage levelexceeded the time objective: up

triaged

Documentation Standards1. Date and time of triage assessment.2. Nurse’s name.3. Chief complaint or presenting concerns.4. Limited subjective history: onset of

injury/symptoms5. Objective observation.6. Triage Level7. Location in the department.8. Report to treatment nurse.9. Allergies10.Medications11.Diagnostic, first aid measures, therapeutic

interventions.12.Reassessment(s).

TRIAGE & ACUITY SCALE CATEGORY DEFINITIONS

Level I ResuscitationConditions that are threats to life or

limb (or imminent risk of deterioration) requiring immediate aggressive interventions.

Level II EmergentConditions that are a potential threat

to life limb or function, requiring rapid medical intervention or delegated acts.

Level II Emergent

Level III UrgentConditions that could potentially

progress to a serious problem requiring emergency intervention.

Level IV Less Urgent (Semi urgent)

Conditions that related to patient age, distress, or potential for deterioration or complications would benefit from intervention or reassurance within 1-2 hours.

Level V Non UrgentConditions that may be acute but non-

urgent as well as conditions which may be part of a chronic problem with or without evidence of deterioration.

ANY QUESTIONS?