TRIAGE

Ns. Ni Made Dewi Wahyunadi, S.Kep.,M.Kep

 Triage:

Essential, effective system to reduce waiting

time, and patient receive the appropriate
treatment (Nuttal; Bailey, Hallam & Hurst as
cited in McNally, 1996).
 HISTORY OF TRIAGE
 Definition : French word “To sort”
 Developed in the battlefields
 Concept used for disasters
 Implemented in EDs from 1950s
 PRINCIPLES OF
TRIAGE
1. Immediate & timely
2. Adequate and accurate
assessment
3. Assessment based decisions
4. Interventions according to acuity
5. Patient satisfaction
6. Complete documentation
PHONE TRIAGE
Telephone triage aids in directing the patient to the right level
of care with the right provider in the right place at the right
time (Blank et al., 2012).
 Telenurses encounter crisis-level calls, such as poison
ingestions, domestic abuse, rape, cardiopulmonary
resuscitation (CPR) coaching, or threatened suicide.
 However, in many communities, nonmedical
personnel with specialized training operate crisis
hotlines such as poison prevention, rape crisis, and
suicide prevention.
 Likewise, 911 medical dispatchers perform high-level
telephone triage and coach callers in first-aid
treatment, CPR, and the Heimlich maneuver until
paramedics arrive.
 Telenurse Functions

 The helping function:

1) attending to (listening) or “presencing” (being present),
2) maximizing patients’ control
3) providing comfort and connection through the voice (rather
than touch).
 The diagnostic function:
Nurses can detect and document significant changes in the
patient’s condition, perform pattern recognition and matching,
anticipate problems, and formulate treatment strategies.
 The crisis-intervention function:
Nowhere else is the instant grasp of rapidly changing situations
more vital than in crisis intervention by phone.
 The monitoring function: monitor simple home treatment
interventions and instruct patients in self-evaluation.
Three best practices to enhance critical
thinking in phone triage:
• adequate time
• open-ended questions
• speaking directly to the patient.
 TRIAGE

Triage is meant to
get the
Right patient to the
Right place at the
Right time with the
Right care provider.
 CATEGORIES OF TRIAGE

• Daily triage
• –To identify the sickest patients: assess and provide treatment to them
first, before providing treatment to others who are less ill.
• –The highest intensity of care is provided to the most seriously ill patients,
even if those patients have a low probability of survival

• Incidental triage
• –ED: a large number of patients but is still able to provide care to all
victims utilizing existing agency resources.
• –Additional resources are used but disaster plans do not have to be
activated.
• –The highest intensity of care is still provided to the most critically ill
patients.
Disaster triage
• –A paradigm shift from “rapid, high tech care to the most
unstable or acutely ill”
• –To “doing the greatest good for the greatest number”
• –To identify injured or ill patients who have a good chance
of survival with immediate care
• that does not require extraordinary resources.
Tactical-military triage
• –Similar to disaster triage, only miliatary mission

Special conditions triage

• –Ex. epidemic: triage to prevent secondary
transmission
 IN HOSPITAL: DAILY TRIAGE

 Three-tier system
 Four-tier system
 Five-tier system :
• The Australasian Triage Scale (ATS )
• Canadian Triage and Acuity Scale (CTAS) - ESI -
Manchester - etc
 JAPAN
THE CATEGORIES OF TRIAGE IN CORRESPONDING COLOR CODES:

1. Category I: Used for viable victims with

potentially life-threatening conditions.
2. Category II: Used for victims with non-
life-threatening injuries, but who
urgently require treatment.
3. Category III: Used for victims with
minor injuries that do not require
ambulance transport.
4. Category 0: Used for victims who are
dead, or whose injuries make survival
unlikely.
THE AUSTRALASIAN TRIAGE SCALE

Australasian Triage Scale

Should be seen by
Level Description
provider within
1 Resuscitation 0 minutes
2 Emergency 10 minutes
3 Urgent 30 minutes
4 Semi-Urgent 60 minutes
5 Nonurgent 120 minutes
 PREHOSPITAL AND DISASTER:
TRIAGE

• Simple Triage and Rapid Treatment (START) system:

for triaging adults
• JumpSTART system: for triage pediatric
• Start/Save: when the triage process must be over an
extended period of time
 TRIAGE TEAM

• Consists of 1 doctor and 1 nurse

• Any number of triage teams can operate at the
Triage Area
• Main function is to allocate priority of care
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EQUIPMENT

• Medical casualty list

• Triage tags
• Pens
• Dressings
• Airways
• Stretchers ± blankets
 PRIORITY 1

1. Perdarahan Major
2. Sesak nafas dan adanya injuri cervical,
maxillary dan wajah
3. Trauma Kepala dengan shock
4. Frakture terbuka dan multiple fraktur
5. Extensive burns > 30% BSA
6. Crush injuries
7. Any type of shock
 PRIORITY 2
• Trauma dada yang tidak menyababkan asphyxia
• Fraktur tertutup pada tulang panjang
• Burns < 30% BSA
• Injuries to soft parts
 PRIORITY 3

• Minor injuries
• All are ambulant
 ASSESSMENT &
PRIORITY SETTING
 ASSESSMENT GUIDE

• History from patient/relative/others

• The 5 senses including Common Sense
 USE THE FIVE
SENSES
SIGHT SMELL
• general appearance • alcohol
(head to toe) • ketone bodies
• obvious signs of injuries • malaena stools
• body language
 USE THE 4 SENSES
HEARING
• listen attentively
• shortness of breath
• ability to talk in complete
sentences

TOUCH
• skin temperature
• palpate for quality of pulse,
tenderness, swelling
 ASSESSMENT & PRIORITY
SETTING
Purpose of Triage
• not to diagnosis
• but to assess and plan intervention

SOAP System
• organized & systematic approach
• formulated by Larry Weed
• problem - orientated medical record
system
 WHAT IS SOAP?
S - Subjective
Mengumpulkan data dari apa yang
disampaikan pasien
O - Objective
What are you actually seeing?
Parameters
A - Assessment
Assess the situation
P - Plan
Establish a plan for the patient
Investigations
Interventions
 TRIAGE PROCESS
S - SUBJECTIVE
Collect subjective data
• Ask open ended questions
• Gather other relevant information
• Obtain brief one-line statements
 QUESTIONS TO ASK

• What is the chief complaint?

• Time of onset, duration, frequency
• Use acronym PAIN for pain assessment (Place,
Aggravating factors, Intensity/Nature/Duration,
Neutralizing/Relieving Factors)
• Effects to other system and activities e.g. unable to
bear weight after twisting ankle
• Effort to treat
• GP/Polyclinic/other emergency departments
• self medicate
• Past travel history, medical history, & drug allergy
 TRAUMA CASES
Mechanism of injury must be noted
1. Ask how the patient was injured
2. Other Questions
When did the accident occur?
How fast was the car travelling?
Where were you sitting?
Were you wearing a seat belt?
Did you hit the dashboard and were you
thrown against another car?
Did you lose consciousness?
 O - OBJECTIVE
Collect objective data :
General
• Mode of arrival to ED
• Level of consciousness; GCS (Trauma Case)
• Patient’s general appearance using your
senses

Vital signs
• temperature,pulse, respiration, BP, SpO 2 & pain
score
 A - ASSESSMENT
Assess and evaluate patient
based on subjective and
objective data findings
 A - ASSESSMENT
• Carry out further tests if required
• ECG
• Peripheral blood glucose
• Urine HCG
• X-ray

• Institute first aid management

• Immobilize fracture
• Put on cervical collar
• First aid dressing
 P - PLAN
• Establish your priority & direct to
appropriate area.
 GOALS OF
DOCUMENTATION

• To support the triage decision

• To communicate essential information to
other caregivers
• To meet medical legal requirements
WHAT MUST BE DOCUMENTED?

1. Time of triage
2. Chief complaint & associated symptoms
3. Past medical history
4. Allergies
5. Vital signs
6. Subjective and objective assessment
7. Acuity category
8. Diagnostic tests ordered
9. Interventions
10. Disposition
11. Re-evaluation and changes in condition
 KEY POINTS

• Describe chief complaint as accurately as

possible
• Document patient’s expectations
• Document obstacles e.g. language barrier
• Document any conflict between subjective
and objective data
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THANK YOU