Consept of Triage

Oleh : Rudi Hamarno

Definition
Triage is a process that sort of patient as base of life threating . History : Napoleon Bonaparte (War I)

PRINCIPLES OF TRIAGE
1. 2. 3. 4. 5. 6. Triage should be immediate & timely Asses should be adequate & accurate Decisions are made based on assess . Provide interv accord to acuity condition Patient satisfaction is achieved Complete of documention

TRIAGE CLASSIFICATION
3 Categories Original form of triage:
1. 2. 3.

Highest priority Second priority Lowest priority

This very general suffered from lack of specificity & too much subjectivity

4 Category Triage
1. Highest priority (immediate, Class 1, severe & emergent.) 2. High priority (secondary, Class 2, moderate & urgent.) 3. Low priority (delayed, Class 3, mild & non urgent.) 4. Deceased (probable death & Class 4/Class 0.)

Start Method (Simple & Rapid Treatment)

Developed in California in early 1980s . The triage personnel is minimal training. The assessment is done very rapidly
< 60 s the following areas: 1. Ventilation 2. Perfusion & pulses 3. Neurological.

The patients were classified as follows:

a.

The Walking Wounded

b. Critical/Immediate

Respiration > 30/min No radial pulse Unconscious or having altered level of consciousness or altered mental state

c. Delayed Respiration < 30/min Pulse present Normal mental responses

d. Dead/Non-salvageable

Problem
Since the triaging is done by non-medical staff & only based on ventilation, perfusion & neurological assessments, certain early critical situations may be missed eg. Early shock, spinal shock etc.

General Classification of Triage at Hospital Setting

The triage nurse is often given the responsibility in deciding on the priority Most hospitals in Singapore adopt the 3 Categories Triage System

Priority 1 or Emergent or Critical

Definition Patients with life threatening injuries or illness which require immediate
Area of Care : Resuscitation Room or Trolley/Stretcher

Waiting Time a. Cardio-vascular collapse or in danger of imminent collapse : zero waiting time. b. For others who do not require resuscitation : not exceed 5 minutes.

Priority 2 or Urgent
Definition Urgent patients with major illness or injuries but who are not in imminent danger of collapse. Patients should be on a trolley, or a wheelchair.

Area of Care Wheelchairs & ambulatory setting.

Waiting Time Within 30 minutes of arrival at A&E.

Priority 3 or Non-Urgent
Definition Patients who are usually ambulatory with minor problems, old injury or a condition that has been present for a long time. Patient does not require immediate threat to patients life or limb. They may be treated just as well in a private clinic or a polyclinic.

Area of treatment Managed in an ambulatory setting in an area distinct from the P1 & P2 Areas. This is so that they do not interfere with the care given to the other two groups of patients

Example PRIORITY 1
Trauma 1. Multiple Severe Injuries 2. Burns more than 15% 3. Fractures of lower limbs 4. Attempted suicides 5. Drug overdosages 6. Acute head injuries with loss of consciousness Acute breathlessness:asthma Acute myocardial infarction Renal colic Severe gastroenteritis Bleeding GIT Acute low backache Terminally ill patient Acute abdomen, acute retention of urine Severe Dizziness/Syncope/Fits CVA All patients drowsy or comatose Patients unable to walk

5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

Non-Trauma 1. Airway obstruction 2. Cardio-pulmonary arrest 3. Shock states 4. Acute severe chest pain

Trauma 1. Upper limb fract /disloc 2. Multiple superficial wounds 3. Burns < 15% 4. Joint sprains & musc strains 5. Multiple bee & insect stings & animal bites 6. Simple lacerations 7. Foreign bodies of ear, nose, throat & soft tissues

Non-Trauma 1. Febrile not requiring critical care attention 2. Mild abdominal pain 3. Acute large skin infectious & emergencies, eg. Cellulitis, urticaria, etc 4. Abscesses 5. Acut infect of eye & ears 6. Severe headache or pains of other regions not requiring-critical care

PRIORITY 3
Trauma 1. Old scars 2. Deform of bones, limbs /spine 3. Joint contractures 4. Old malunited fractures 5. Request for removal of metal plates, screws 6. Old unreduced dislocations 7. Old un-united fractures 8. Chronic discharging wounds 9. Chronic sprains Non-Trauma 1. Cold lumps & bumps in the body 2. Varicose veins 3. Cysts 4. Requests for circumcision 5. Patching of earlobe 6. Removal of tattoo 7. Removal of corns, warts 8. Removal of keloids 9. Chronic rhinitis 10. Defective hearing

11.Nasal polyp 12.Wax in ears 13.Cataracts 14.Upper resp infec without fever 15.Chronic cough 16.Social problem requests admission

17.Psychosomatic problems 18.Chronic headaches on & off 19.Insomnia

??

ASSESSMENT & PRIORITY SETTING

ASSESSMENT GUIDE
a. History Taking history from patient & important as valuable inform b. Sight Patients general appearance eg level of consciousness, respiratory problem, appears to be breathless, any obvious signs of injury such as laceration swelling, bleeding. Body language.

c. Smell Odour of alcohol, Ketories bodies or malaena stool smell. d. Touch Skin: fever, cold & clammy, sweaty Palpate take pulse rate Touch for tenderness & swelling

e. Common Sense Use common sense to decide what you want to ask for relevant key points

The SOAP process

S :Subjective O :Objective

:Assess

:Plan

S Subjective
Collect subjective data Initially use open ended questions eg Why did you want to see a doctor? Past History eg. Hypertension, DM? Note : Trauma Cases : Mechanism of injury

O Objective

Collect objective data General Method of arrival to A&E Level of consciousness GCS (Trauma Case) P/ general appearance using your senses Vital signs (T,P,RR,BP)

A Assess

Assess & evaluate patient from the S & O data collection.

decide action plan.

P Plan
1. Establish

your
Immobilize fracture Put on cervical collar First aid dressing X ray

priority
2. Carry out further test: ECG Blood glucose mon Urine labstix Urine for inspection First aid manag

Role of Field Triage Team

The first team to arrive will take charge of triage Not to be stretcher bearers. Explain role of stretcher bearers to them when assigned. Show the locations of P1, P2, P3

Ensure that all P1 & P2 casualties are transported via stretchers. Deploy to assist in other areas when no more patients require triage. Ensure that not more than 2 P1 casualties are evacuated in the same ambulance. Load & go philosophy of field care.

Triage Team

1.
2.

Each team consist of 1 doctor & 1 nurse The number depent of availability, requirement dan space During disaster, fungtion is mainly to alocate priority of treatment The equitment : Triage tag , Stretchers 1 box of dressing & OFT/NFT

Mettag
Priority 0 = black Priority 1 = red Priority 2 = yellow Priority 3 = green

Triage Proses
1. Mobility ? If victim can walk and has injury : P 3

2. Cek ABC

Airway
B+

by chin lift / jaw thrust

B-

Cek RR P0 10 30 x Circulation ? P1 Delay > 2 dtk Normal < 2 dtk P2

< 10 x > 30 x

Problems
1. 2. 3. 4.

Language No Visible Patient Terms Evaluation

Responsbilities It is to assess, sort out all calls & give first aid advice. How does one do assessment over the phone ? This can only be done subjectively.

Subjective

What is the main complaint ? What is the duration ? Are there any associated symptom eg. fever, sweating ? What is the patients past medical history? It is good practice to write down the information on a piece of paper placed in front of you. Another way of avoiding misunderst&ing is to repeat what the caller has just said eg. Am I correct, your child has fever for five days ?

Objective
There are 4 categories where these calls are sorted into: Decide if p/ needs to call for an ambulance ie dial 995. Decide if p/ needs to be seen in an A&E Dept. Decide if p/ can be seen by general practitioner or a doctor in a polyclinic. Decide if first aid advice is all that is required.

General Conduct over the phone:

1.
2. 3. 4.

5.

Always identify yourself Be calm & sound confident Speak clearly Substitute medical terms or explain them if used Be patient with the caller

Thank ........