Triage

1. TRIAGE Mary Corcoran RN, BSN, MICN

2. EMTALA: Emergency Medical Treatment and Labor ActRequires 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

3. EMTALAEMTALA regulations apply to anyone coming to a hospital seeking emergency medical services

4. EMTALA imposes financial penalties on physicians and hospitals

5. Additionally, the hospital, if found guilty of violating EMTALA regulations, can be excluded from participating in the Medicare programEMTALAMEDICAL SCREENING EXAMMost hospital policies state that only an Emergency Department MD or PA exam constitutes a Medical Screening Exam. Check with your supervisor

6. The triage process DOES NOT constitute a Medical Screening Exam.EMTALAA 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

7. 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”.EMTALAQuestions for discussionDoes the triage nurse’s assessment constitute a Medical Screening Exam?

8. If a patient is lying on the sidewalk outside of the parking garage, is the emergency department required to evaluate and treat the person?

9. 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?From the French verb “Trier” which means to “sort” or to “choose”Began in the battlefield when they would prioritize wounded soldiers1950’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

10. 3 Common Triage Systems Traffic Director- simplest, non clinical employee greets patient and directs them to treatment area or wtg room based on initial impression- by 2002 obsoleteSpot-check triage- appropriate for low volume, ED. Registration greets patient and pages triage nurse. The RN performs basic assessmentComprehensive triage- supported by ENA. Triage done by competent RN. The RN determines priority of care based on physical, developmental and psychosocial needs

11. 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 timesThe goal is to develop a standardized acuity system in order for everyone to have the same understanding of each level assigned

12. Trends Affecting ED Wait TimesThe 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 1997And increased to 56min in 2006Factors 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

13. The InterviewIntroduce YourselfConfirm the Patients Identity (IMPORTANT)Obtain a Chief Complaint/Reason for visitGather Subjective & Objective DataIncluding LMP, VS, Weight, History, Mechanism etcPerform a rapid, concise, focused assessment, with quick primary and secondary survey

15. Pediatric PatientsUse the CIAMPEDS format to triage pediatric patientsC- Chief complaint- primary problemI- Immunizations- UTD, NUTDA- AllergiesM- Medications – Name, last dose, how much?P- PMH Parents impression of child’s conditionE- Events surrounding illness/injuryD- Diet- bottles, ouncesD- diapersS- Symptoms associated with illness, injury

16. Pediatric PatientUse Similar A-I Assessment criteria as adultsA- Airway; patency, positioning, audible soundsB-Breathing; inc or dec WOB. AMU, nasal flaringC-Circulation; color of skin, cap refillD- Disability; activity level, response to environmentE-Exposure; identify underlying injuriesF- FahrenheitG- Get VS, including weight in kgH- Head to Toe Assessment; quick related to ccI- inspect the back and isolate; observe for hidden injuries, communicable illnessBe cognizant of legal issues related to abuse/neglect and the difference between adults and children

17. OB PatientsMost 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 pressureUrgent OB- Patients in active labor- ( contractions 2 minutes apart lasting 60-90 sec, presence of “bloody show”, ROMNon-urgent OB- Patients not in active labor- per hospital policyLegal Considerations-Important to know who can transport patients to L& D

18. Geriatric PopulationImportant points to remember when triaging geriatric patients:Altered pain perception commonDelayed presentation commonUpper abdominal pain, an ill appearance, abnormal VS= RED FLAGConsider etiology of fallsConsider elder abuseOlder patients are uniquely prone to delirium

19. Psychiatric PatientsAll patients exhibiting aggressive and/or agitated behavior are considered violent unless proven otherwiseNever turn your back on these patientsWhen speaking to psychiatric patient be simple, direct, clear and conciseDo not overlook physical injuries or illnesses in psychiatric patients

20. What do you think?40 y/o old female c/o epigastric pain, vomiting50 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?

21. Recommended by the ENA (Emergency Nurses Association) and ACEP (American College of Emergency Physicians)ESI 5 level Triage System

22. IntroductionLevel 1- Resuscitation 0 minutesLevel 2- Emergency 10 minLevel 3- Urgent 30 minutesLevel 4- Semi urgent 60 minutesLevel 5- Non-urgent 120 minutes

23. Level1Requires Life Saving Intervention?YesNoHigh Risk SituationOrConfused/Lethargic/ DisorientedOr Severe pain/DistressLevel2YesHow Many Resources are Needed?None One ManyyesLevel 3Dangerous Vital Signs?Level4Level 5No

24. Emergency Severity Index (ESI) Acuity assessment

25. Airway, breathing, circulation

26. Potential for life, organ or limb threat

27. How soon the patient needs to be seen

28. Expected resource assessment

29. Number of resources, as estimated by the triage nurse, that a patient is expected to consume in order for a disposition decision to be reachedESIFive explicitly defined categories

30. Mutually exclusive

31. Allows for rapid sorting

32. Differs from a complete assessment

33. Gather sufficient information to assign an ESI level

34. Quick sortingESIRequirements to maintain the validity and reliability of the instrument

35. Experienced emergency department nurse at triage

36. Education of each RN prior to implementation Patient dying? 1Ayesno Can not wait?Byesno How many resources? none one manyC 2Vital signsD 5 4considerno 3

37. YesIs this patient dying? A1No

38. Decision Point AIs This patient Dying? Does this patient require immediate life-saving intervention?Airway

39. Obstructed or partially obstructed

40. Unable to protect their own airway

41. Breathing

42. Apneic

43. Intubated pre-hospital

44. Severe respiratory distress

45. SpO2 less than 90%Decision Point ADoes this patient require immediate life-saving intervention?Circulation

46. Pulseless, or concerned about rate, rhythm or quality?

47. Drugs

48. Hemodynamic interventions

49. Immediate IV medications to correct hemodynamic instabilityDecision Point ADoes this patient have an acute mental status change that requires immediate life-saving intervention?

50. Examples:

51. Hypoglycemia needs glucose

52. Heroin overdose needs Narcan

53. Subarachnoid bleed needs airway protectionWhat are life Saving Interventions?Airway and Breathing

54. Intubation

55. -Surgical airway

56. -CPAP, BiPAP

57. -Bag valve mask ventilation

58. Defibrillation

59. External Pacing

60. Chest needle decompression

61. Significant IV fluid resuscitation

62. Blood administration

63. IV medications

64. vasopressors

65. Control of major bleedingResuscitation Hemodynamics

66. What are NOT life saving interventions?ECGLaboratory studiesOxygenMonitorIV accessASANitroglycerinePain medicationsAntibioticsHeparinDiagnostic Tests Medications

67. NoYesCan not wait? BNo2

68. High risk situation?orConfused/lethargic/disoriented?orSevere pain/distress?BYes2No

69. Decision point BCan this Person Safely Wait to be Seen?Determination is made on a brief interview, gross observations, “sixth sense”

70. Does not require a full set of vital signs

71. Unsafe for the patient to wait

72. Suggestive of a condition that could easily deteriorate

73. Symptoms of a condition where treatment is time sensitive

74. Potential major life or organ threatExamples of “high risk” patientsEpisode of chest pain, denies other symptoms, known cardiac history

75. Rule out PE

76. Newborn with a fever

77. Rule out ectopic pregnancy

78. Neutropenia with a fever

79. Suicidal/homicidal

80. New Onset Confusion in elderly

81. Adolescent found confused and disoriented

82. Patients in SEVERE pain

83. Sexual Assault PatientDecision point Bis this person in severe pain or distress?Is this patient currently in pain?

84. Pain intensity rating

85. Chief complaint

86. PMH, medications

87. VS, physical assessment findings

88. Assign ESI level 2 if and only if

89. Self-reported 7/10 or greater

90. AND

91. RN cannot intervene and they require immediate intervention

92. Do you want to give your last bed to this patient?Examples of Level 2 Severe painKidney stone

93. Burn victim

94. Oncology patients

95. Possible dislocated shoulder

96. ? Compartment syndromeDecision Point CHow Many Resources will this patient require?Determined by the experienced ED RN at triage

97. Based on the standard of care

98. Independent of type of hospital, location, physician on duty, acuity of the department How many different resources are needed? None One 2 or moreC Vital signs 543

99. Mean Resources Used Per Triage Category Mean # of resources used ESI Triage Level

100. 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.

101. ESI Level 5No resources

102. Examples:

103. Healthy 10 year old with “poison ivy”

104. Healthy 52 year old who ran out of his blood pressure medicine yesterday

105. 22 year old, involved in a car accident 2 days ago, wants to be checked. Nothing hurts.

106. 46 year old with a coldESI Level 4Stable, can safely wait hours to be seen

107. Care by mid-level providers in fast track or express care setting

108. Requires a physical exam and one resourceESI Level 4Examples:

109. Healthy 19 year old with sore throat and fever.

110. Healthy 29 year old with a UTI, denies vaginal discharge.

111. Healthy 43 year old with stubbed toe who states “I think I broke it!”.

112. Healthy 12 year old with a minor thumb lacerationESI Level 330-40 % of patients in the ED

113. Require in-depth evaluation

114. Long length of stay

115. Before assigning a patient to ESI Level 3 the nurse must consider the patients vital signsESI Level 3,4, and 5 examplesESI Level 3 -Fractured ankle -Abdominal pain -Most migrainesESI Level 4 -Sprained ankle, toe -AbscessESI Level 5 -Toothache

116. Decision point DWhat are the patients vital signs?Consider the vital signsAre they outside the acceptable parameters for age?If unacceptable considerup-triage to ESI Level 2

117. Danger zone vitals? HR RR SaO2<3 m >180 >50 <92% 3m-3y >160 >40 <92%3-8y >140 >30 <92%>8y >100 >20 <92%Level 3

118. Pediatric Fever Criteria1 to 28 days of age: assign at least ESI 2 if temp >38.0C (100.4F)

119. 1 to 3 months of age: consider assigning ESI 2 if temp >38.0c (100.4F)

120. 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 feverLets Practice

121. Pediatric Sprained AnkleAn 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 DistressParamedics 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

122. Vaginal Bleeding/ Abdominal Pain23 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

123. ShoulderA 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.BiteMom 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

124. PNAA 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

125. LacerationA 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

126. HematemesisEMS 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.Wound19 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

127. TraumaNotified 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%.

128. What if they Leave?LWBSPts who are LWBS (Left Without Being Seen), are more common in high volume ER’s Most patients are frustrated with the long wait timesDiscuss the LWBS policy with your specific facilities

129. Triage Nurse QualificationsTriage 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 careTriage Nurses must be knowledgeable, experience, temperament, and qualifications necessary to function in a high stress rollMost facilities require at least 6mo- 1year of ER experience before allowing nurses to triage

130. Questions?

Triage

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