TAUFIQ ABDULLAH

Triage Role

• To determine severity of illness

or injury for each patient who
enters the Emergency
Department (ED).
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
 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.
Category of triage
 In hospital triage

 Multi casualty disaster triage

Types of triage methods
 Three level

 Four level

 Five level
5 Level Triage
 Level 1 Resuscitative
 Level 2 Emergent
 Level 3 Urgent
 Level 4 Less urgent
 Level 5 Non-urgent
Reassessment in triage
 Level 1 =Continuous
 Level 2 = every 15 min
 Level 3 = every 60 min
 Level 4 = every 60 to 90 min
 Level 5 = every 2 hours
Basic triage components
 Across the room assessment

 Triage history

 Physical assessment

 Triage decision
Nursing process in triage
 Assessment time

 Vital signs

 Pain scale

 Nursing diagnosis
Interview methods
 Open ended
 Close ended
 Communication style
 Use of five sense
 attitude
How do I triage?
 Across the room
 General appearance
 Abcd
 Subjective and objective (AMPLE)
 Focused assessment
 Pains scale (Pqrst)
Triage decision
 Step1- visual
 Step 2- chief complaints
 Step3- focused assessment
 Step 4- pose hypothesis
 Step 5- determine acuity
 Step 6- reassess the acuity
Remember That:

Effective triage gets the patient

 To the right place.
 At the right time.
 With the right care provider.
 KEY POINT
 Triage is a dynamic process.

 Reassessment & Reassessment .

 A patient’s condition may improve or

deteriorate during the wait for treatment.
Key concept
 Discontinue assessment and transport
the patient immediately to the treatment
area if immediate care is needed. Do not
delay treatment to finish the assessment
Key Concept
 Never assume the accident caused the
presenting condition. The presenting
condition may have caused the
accident.