Triage

Nursing Care of Adult III

24 Jan 2018
Zoe Ng
[email protected]

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 Learning Outcomes
At the end of the lecture, students will be able to:
• Identify the main principles of triage
• Recognize the logic & decision-making points in triage process
• Describe the treatment priority & immediate management for common
emergency problems
• Identify key concepts in triage documentation

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 History of Triage
• World War I
• Triage- a French ‘Trier’ words means ‘to sort’
• Classification
Ø Traffic control - simplistic
Ø Spot check - urgent vs emergency
Ø Comprehensive - mostly adopted mechanism
e.g. Number scale
Colour code
• System imposed in USA until 1960
• HK -> till 1990
• HA -> 1997
• Disaster
Ø Do the best for the most with the least by the fewest
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 Definition of Triage
• Acuity sorting -> categorizing
• Establish priorities
• Allocate treatment area and control traffic
• Initiate appropriate nursing interventions
• Improve patient rapport & maintain communication
• Provide education

‘Sickest seen quickest’

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 Purpose of Triage
• To get the right patient
• To the right place
• At the right time
• For the right reason
• It is NOT diagnosing

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 Triage Flow

Patient Triage Nurse Decision making

Categorization
Consultation
1 -5

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 Triage Category in HA
Category Definition

I Suffers from a life-threatening condition(s) caused by a major event

(Critical) Unstable vital signs requiring immediately resuscitation
II Suffers from a potentially life threatening condition(s)
(Emergency) Borderline vital signs but with potential risk of rapid deterioration.
Require emergency treatment & immediate continuous close-monitoring

III Suffer from a major condition(s) with potentially risk of deterioration

(Urgent) Stable vital signs
IV Suffer from acute but stable condition(s)
(Semi-urgent) Afford to wait some time without serious complications
Stable vital signs
V Suffer from minor or stable condition(s)
(non-urgent) Afford to wait without deterioration
Stable vital signs 7
 Performance Pledge in HA
Category Target Actions of staff
response time
I (Critical) Immediate • Direct patient to resuscitation room
(100%) • Attend patient immediately by a team comprising
medical and nursing staff
II (Emergency) <15 min • Direct patient to resuscitation room / treatment
(95%) cubicle
• Offer medical attention and immediate continuous
close monitoring within 15 mins
III (Urgent) <30 min • Direct patient to cubicle
(90%)
IV (Semi-urgent) • Direct patient to cubicle / walk-in clinic

V (Non-urgent) • Direct patient to walk-in clinic

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 Triage process
Primary triage:
–Collect key information (objective & subjective) relating to presenting problem & perform a quick
assessment on airway, breathing, circulation, conscious level & general condition
–Screen for Cat. 1 & 2 cases & initiate immediate resuscitation or interventions in resuscitation room
as appropriate
Secondary triage:
–Gather additional information relating to presenting problem, medical & allergy history
–Determine triage category (for Cat. 3-5 cases) & assign patient to appropriate treatment area
–Provide information on treatment time according to assigned category
Tertiary triage:
–Monitor patient’s condition while waiting for treatment / reassessment
–Re-triage when evidence of deterioration is present

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 General Principles
• Introduce yourself
• Identify the right patient
• Maintain privacy & confidentiality
• Across the room
• Know local guidelines and protocols
• Most important of all - your limitations!
• Universal precautions

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 How to determine?
• Who needs immediate medical attention?
• Who is(are) safe to wait?
• What intervention(s) should be done first?
• What investigation(s) should be done next?

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 Triage Methods
1. Symptom-based assessment
Ø Advantage: more clinically relevant
Ø Disadvantage: require experiences in interpreting the findings
2. System-based assessment
Ø Advantage: Easy to learn & apply
Ø Disadvantage: Less clinically relevant

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 Nursing Process
Assessment & Planning:
Ø Patient arrival & registration (across the room assessment)
Ø Triage nurse perform primary assessment (GABCD) & secondary
assessment (c/o, v/s, focus)

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 Nursing Process
Implementation:
Ø Interventions if needed
Ø ? Level of emergency
à assign treatment area
à categories the patient

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1o Assessment Cat. I, II
GABCD
Abn Resuscitation Room

NAD
2o Assessment Cat. ?
Hx, Vital Signs Interventions

Focus assessment
+ Cat. ?
Extend assessment Interventions

Reassessment
• Borderline parameters Upgrade triage ?
• Change conditions Interventions
• New C/O 15
 Primary Triage
• < 10 sec
• Screen out whom require immediate resuscitation obviously
• Once enters your visual field
• Rapid scanning
• First decision making point

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 Primary Triage
• General appearance
• Ambulatory Vs Non-ambulatory
• Conscious level
• Look ‘toxic’ or ‘ill’?
• Posture, gait, color, smell, interaction with others/environment
• Facial/eye expression
– pain, fear, anger, confusion, anxiety …

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 Primary Triage
Airway Status
• Signs of airway obstruction
– Drooling or unable to handle secretions
– Vocalization
• Special position to maintain breathing
– Tripod or ‘sniffing’ position
• Abnormal airway sounds
– Stridor, wheezing, grunting

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 Primary Triage
• Breathing Status – spontaneous breathing?
YES NO
• Rate, depth, chest wall • BVM
movement, work of breathing
• Resuscitation room
• Nasal flaring
• Grunting
• Prolonged expiration
• Audible wheezes
• Skin signs (cyanosis, dusky skin)

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 Primary Triage
Circulatory Status
• Obvious bleeding
• Skin color
– Pale, cyanotic, dusky, flushed, jaundice …
• Pulse
– Rate, volume, regularity, weak / strong
– No pulse
• CPR
• Resuscitation bay

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 Primary Triage
Disability/ Neurologic Status
• Alert, sleepy, irritable
• Stand/walk unaided
• Decrease response to pain or stimuli
• Flaccid or hyperactive muscle tone
• Does conscious level support the airway?

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 Immediate Triage Interventions
• A - various maneuvers to open airway
• B - Oxygen, BVM
• C - CPR, pressure dressing to stop bleeding
• Others - wheelchair, stretcher

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 Secondary Triage
• Includes taking history, vital signs and focus assessment
• Approaches:
1. Symptom based i.e. pattern recognition approach e.g. dizziness,
headache, etc.
2. Systematic based i.e focusing approach e.g. CVS, Resp., etc.
• Second decision making point

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 Objective Data Collection
Vital Signs Additional Information
Temp. • Temp. at home
Thermometer vs Thermoscan vs IR • Fever pattern
Gun • Time of anti-pyrexia
Pulse • Difference at peripheral (shock, aneurysm)
Rate & Quality of radial pulse • Apical rate deficit (arrhythmia)

Respiration & SpO2 • Peak flow rate (ventilation capacity)

Rate, depth, effort & symmetry • SpO2 (measurement of oxygenation)

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 Objective Data Collection
Vital Signs Additional Information
Blood Pressure • Present of central / peripheral pulse (rough
Manual vs NIBP BP)
• Compare of both arms (dissecting aneurysm)
SBP x shock • Shock index (SBP / PR < 0.9 = shock)
• MAP (for compare BP) = SBP – (2/3 x pulse
pressure)

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 Objective Data Collection
Pupil size Light response Interpretation
Bilaterally small Reactive/ sluggish Early Central Herniation
(1-3mm)
Midpoint Sluggish/ non-reactive Progress of central herniation
(3-5mm) (midbrain)

Unilaterally dilated Sluggish/ fixed 3rd nerve compression (Uncal

(5-6mm) Herniation)

Bilaterally dilated Sluggish/ fixed Late herniation

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 Subjective Data Collection
Brief History Taking
• C/O -> Open-ended questions
• CLOSED-ENDED QUESTIONS
– Use examples
– Provide general guiding
– Clarify and restate
– Offer reality
– Provide focus
– State observations
– Summarize
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 Questioning Mnemonic
Chief Complaint - OLD CART
O Onset of symptoms
L Location of problem
D Duration of symptoms
C Characteristics of the symptoms described
A Aggravating factors
R Relieving factors
T Treatment administered before arrival

*COLDSPA learned in HA course

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 Questioning Mnemonic
Chest Pain - PQRST
P Provoking factors
Q Quality of pain
R Radiation / Region
S Severity
T Time – onset & duration

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 Questioning Mnemonic
Past Health - SAMPLE
S Symptoms
A Allergy
M Regular Medication / just-take medication
P Past medical history
L Last meal
LMP +/- PMP
E Event happened

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 Interventions
• Resuscitation / Trauma team activation
• Standard protocol (Oxygen-IV-Monitor)
• Stretcher / wheelchair / position…
• Dressing / bandaging / sling / cold pad / splint / neck collar
• Eye irrigation
• Extended roles: ATT / ECG / H’stix / Hb / Urine test / Drug
(standing order)

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 Focus Assessment
Symptoms based approach
• Focus history taking and health assessment
• Current practice - Triage guidelines
• Start on with the patient’s C/O
• To rule out differential diagnosis
• Require high level of knowledge
• Third decision making point

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 Tertiary Triage
Re-assessment / Continuous assessment
• Updated of patient's condition
• Capture the changing condition especially borderline conditions
• Assess time - post treatment, periodic as indicated and before patient
discharge
• Conducted and documented both subjective and objective assessment
• Fourth decision making point

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 Key Points in Documentation
1.Clear and legible writing
2.Only document the significant information
3.Subjective information vs Objective parameter
4.Document time precisely

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 Essential Skills
• Questioning mind
• High index of suspicion
• Understand A & P, disease process
• Interpersonal communication skills
• Public relations skills
• Medico-legal aspects

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 Pitfalls
• Extremes of age
• Immuno-compromised patients
• Women of child-bearing age (abdominal pain)
• Re-attended patients
• Frequent attendants
If they look unwell, they probably
are unwell

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 Summary
• A triage nurse is challenged to obtain concise, useful subjective and objective data in
a small amount of time while maintaining vigilance over patients who are arriving or
waiting
• An effective triage nurse uses a systematic approach to focus assessment on the
specific problem while remaining flexible to accommodate the unexpected
• Reassessment of patient’s condition becomes the responsibility of the triage nurse,
and appropriate interventions should be implemented if any decline in condition is
identified

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 References
• Beebe R., Funk D., & Scadden J. (2010). Fundamentals of Basic Emergency Care. (3rd Ed.). Clifton Park, NY: Delmar/Cengage
Learning.

• Hospital Authority. (2011). Triage Guidelines for Accident & Emergency Departments. Hospital Authority: Hong Kong.

• Howard, P. K. & Steinmann, R. A. (2010). Sheehy’s Emergency Nursing. Principles and Practice. (6thed). St. Louis: Mosby.

• LeMone P., Burke, K. & Bauldoff G. (2011). Medical-Surgical Nursing: Critical Thinking in Patient Care. (5th Ed.). New Jersey:
Pearson Prentice Hall.

• Mackway-Jones, K., Marsden, J. and Windle, J. (eds) (2013) The Triage Method, in Emergency Triage: Manchester Triage Group,
Third Edition, John Wiley & Sons Ltd, Chichester, UK.

• Pines J.M., & Everett W.W. (2013). Evidence-based Emergency Care: Diagnostic Testing and Clinical Decision Rules. (2nd Ed.).
Chichester, UK; Hoboken, NJ: Blackwell /BMJ Books.

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