TRIAGE

Goals of Triage
 Rapidly identify patients with urgent,
life-threatening conditions
 Assess/determine severity and acuity of
the presenting problem
 Direct patients to appropriate treatment
areas
 Re-evaluate patients awaiting treatment
Advantages of Triage
 Streamlines patient flow.
 Reduces risk of further
injury/deterioration.
 Improves communication and public
relations.
 Enhances teamwork.
 Identifies resource requirements.
 Establishes national benchmarks.
Triage Acuity Determinants
 Chief complaint.
 Brief triage history.

Injury or illness(signs & symptoms).

 General appearance.

 Vital signs.

 Brief physical appraisal at triage.

 Triage Role

• To determine severity of illness

or injury for each patient who
enters the Emergency
Department (ED).
Triage
 Patients should have a triage assessment
within 10 minutes of arrival in the ED.
 Accurate triage is the key to the efficient
operation of an emergency department.
 Effective triage is based on the knowledge,
skills and attitudes of the triage staff.
Triage Process
 Assess and determine the severity or
acuity of the presenting problem.
 Process the patient into a triage level.
 Determine and direct the patient to
appropriate treatment areas.
 Effectively and efficiently assign
appropriate human health resources.
Triage Assessment
 Chief complaint.
 Brief triage history

Injury or illness (signs & symptoms)

 General appearance.

 Vital signs.

 Brief physical appraisal at triage.

5 Level Triage
 Level 1 Resuscitative
 Level 2 Emergent
 Level 3 Urgent
 Level 4 Less urgent
 Level 5 Non-urgent
 Triage is a dynamic process.

 Reassessment & Reassessment .

 A patient’s condition may improve or

deteriorate during the wait for
treatment.
Level I: Resuscitative
 Conditions that are threats to LIFE or LIMB
(or imminent risk of deterioration)
requiring aggressive interventions.

 Time to MD: Immediate

 Time to Nurse: Immediate

 Continuous reassessment
 Level I
 Usual presentations
 Code / arrest.
 Major trauma.
Severe burns--airway compromise .
 Shock states.
 Severe respiratory distress.
Near death asthma (Status asthmatics).
Tension pneumothorax.
 Altered mental state.
 Seizure (Status epileptics).
 Traumatic shock.
 Overdose.
 AAA.
 AMI with complications.
 Congestive heart failure with low BP.
 Major head injury-unconscious.
Level II Emergent
 Conditions that are a potential threat of life,
limb or function, requiring rapid medical
intervention or delegated acts.

 Time to MD: 15 minutes.

 Time to Nurse: immediate.

 Reassessment time: 15 minutes.

Level II Emergent
 Usual presentation
 Chest Pain Query MI
 Trauma
 Chemical Exposure
 Stroke
 Altered Consciousness
 Acute MI
 Severe Asthma-stridor
 Acute Psychotic Episode with Agitation
 Severe Pain 8 -10

 Reassessment 15 mins
 Level III Urgent
 Conditions that could potentially progress to a
serious problem requiring emergency intervention.

 May be associated with significant discomfort or

affecting ability to function at work or activities of
daily living.

 Time to MD: <30 minutes.

 Time to Nurse: 30 minutes.

 Reassessment time: 30 minutes

Level III Urgent
 Usual presentations:
 Renal colic, billary colic
 GI bleed with normal VS
 Previous seizure—alert
 Dehydration.
 Shunt dysfunction.
 Vital signs outside normal range.
 Pain scale 4 -7 \10
 Moderate risk of harm to self or others.
 Inconsolable infant , infant not feeding.
 Behavior change.

Reassessment 30 minutes
 Level IV: Less Urgent
 Conditions that related to patient age, distress,
or potential for deterioration or complications
would benefit from intervention or reassurance
within (1 –2 hours)

 Time to MD < 60 minutes (1 hr)

 Time to Nurse < 60 minutes (1 hr)

 Reassessment time: 60 minutes (1 hr)

Level IV: Less Urgent
 Usual presentation:
 Head injury—alert.
 Earache.
 Abdominal pain.
 UTI sign and symptoms.
 Simple laceration requiring sutures.
 VS normal
 Reassessment 1 hour
 Level 5: Non Urgent
 Conditions 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.

 The investigation or interventions could be delayed or

even referred to other area of the hospital or health
care system.

 Time to MD: 120 minutes.

 Time to Nurse: 120 minutes.

 Reassessment time: 120 minutes

Level 5: Non Urgent
 Usual presentation:
 Strains.
 Sprains.
 Single episode of vomiting.
 Sore throat.
 Script refills.
 Chronic problems with no change.
 Investigation or intervention for these illnesses or
injuries could be delayed or even deferred.
 Reassessment 2 hours \120 minutes
Pediatric Triage PCTAS
 There are three things that must be
assessed and documented on all
pediatric patients:
 Respiratory rate.
 Heart rate.
 Capillary refill.
 Pediatric CTAS
Poster Pocket Card
Pediatric Vital Signs
 Must include:
 Heart rate.
 Blood pressure.
 Respiratory rate.
 O2 saturation.
 Temperature.
 Capillary refill.
 Accurate weight!
 Vitals Are Your Safety Net.

 Less Urgent and Non Urgent patients

have NORMAL vital signs.

 Abnormal vital signs are at least an

URGENT.
 Triage is a dynamic process

 A patients condition may improve or

deteriorate during the waiting for
treatment

 Reassessment, Reassessment,
Reassessment
Triage Practical
Injury Prevention
Injury prevention practical
General Approach to
POISONED Patient
 ABCs…IV, O2, monitor
 Decontaminate if organophosphates prior touching by health
care professionals
 Lily kit for cyanide poisoning.

 History
 Obtain all prescription and bottles in the household (call
pharmacy).
 Pill count.
 PM Hx.
 Search clothes for clues, medication alerts, pills etc.
 Contact family members.
 Track marks, consider body packing or stuffing.

 Vital signs, Rhythm strip.

General approach to poisoned pt.
 What are the essential features of a
30-second toxicological exam?
 Vital signs- HR, RR, BP.
 Temperature- rectal

(resp rate can affect oral temperature).

 Skin- color, temperature, and sweating.

 Odors- provide clues

(their absence means nothing)

 Bowel sounds and bladder function.

 Mental status.
General approach to poisoned pt

 Tests
 GI Decontamination
 Activated Charcoal

 Antidotes
Practical