CHAPTER 2 Triage

Nicki Gilboy, RN, MS, CEN, FAEN , Debbie Travers, RN, Phd, CEN, FAEN

MAJOR TOPICS

Triage Overview

Objectives

Nursing Qualifications

Assessment

Acuity Rating Systems

Location of Care Assignment

Treatment and Diagnostic Testing

Decision-making Process

Interfacility Transfers

Additional Triage Responsibilities

Waiting Room Management

Communication Issues

Administrative Responsibilities

Safety

Infection Control

Triage Legalities

Triage Performance Improvement

Triage Data Utilization

Selected Considerations

Populations

Illness/Injury

Triage is an information-collecting and decision-making process. It is performed in order to sort injured and ill patients into categories of acuity and prioritization based on the urgency of their medical or psychological needs. Triage begins when the patient enters the emergency department and is performed either in a specified location or at the patient’s bedside. It is a dynamic process; patients’ priorities may change as their conditions stabilize or deteriorate. Triage assessment and assignment of an acuity rating do not fulfill the legal requirement of the patient’s receiving a medical screening examination (MSE) under the United States Emergency Medical Screening and Active Labor Act (EMTALA [see Chapter 44]).

I. TRIAGE OVERVIEW

A. Objectives

1. Identify patients who need immediate care and treatment

2. Perform a brief assessment on all incoming patients

3. Assign an appropriate acuity level

4. Assign location of care if applicable

B. Nursing Qualifications

1. Emergency Nurses Association (ENA) recommendations

a. Registered nurse with a minimum of 6 months emergency nursing experience

b. Completion of triage education course involving

1) Didactic component

2) Clinical orientation with a preceptor

c. Current certification in Basic Life Support (BLS) and Advanced Life Support (ALS)

d. Successful completion of Trauma Nursing Core Course Provider (TNCC-P)

e. Successful completion of Emergency Nursing Pediatric Course Provider (ENPC-P)

f. Certified Emergency Nurse (CEN) credential (preferred)

2. Additional qualifications

a. Strong interpersonal skills

b. Ability to conduct a brief, focused interview

c. Strong physical assessment skills

d. Ability to make rapid, accurate decisions

e. Ability to work collaboratively with other members of the health care team

f. Ability to adjust to fluctuations in workload

g. Ability to effectively communicate understanding of patient and family expectations

h. Possession of an understanding of cultural and religious concerns that could arise at triage

i. Possession of knowledge of specific institutional policies affecting triage

C. Assessment

1. Purpose

a. Perform rapid assessment in order to

1) Determine urgency of patient’s need for emergency care

2) Gather pertinent assessment data to determine an accurate acuity rating

3) Identify patients with life-threatening and potentially life-threatening conditions to ensure they receive immediate treatment

4) Identify patients without apparent life-threatening conditions

2. “Across-the-room” assessment

a. Triage nurse’s first contact with patient, using sense of sight, hearing, and smell

b. Purpose: identify obvious life-threatening conditions

1) The triage assessment should not be completed in the triage area on patients who are clearly in need of immediate, lifesaving interventions or on those who are at high risk for serious illness

2) Immediately place patient in treatment area once a life-threatening or high-risk condition is identified

c. Brief primary assessment (see Chapters 1 and 31)

1) Airway and cervical spine

2) Breathing

3) Circulation

4) Disability

5) Expose/environmental controls

3. Subjective data collection

a. If English is a second language, use a hospital interpreter or, if necessary, a family member to obtain information

b. Information gathered from appropriate sources

1) Patients: if able to speak for self

2) Family, other historian, such as a guardian, friend, caseworker

3) Emergency medical services (EMS) personnel

c. Chief complaint

1) Determine patient’s primary reason for seeking emergency department care

2) Document chief complaint as accurately as possible in words used by the patient, family member, or other historian

3) Patients with multiple complaints or history/long duration of illness

a) Focus on problem requiring treatment today

d. Brief history of present illness/injury

1) Elicit and document a focused history of present illness/injury

a) Description of symptoms

b) Any precipitating events, illnesses

(1) Possible/actual victim of assault, abuse, or intimate partner violence situations (see Chapter 3)

c) Duration and progression of symptoms

d) Pain assessment (see Chapter 9)

e) Mechanism of injury and related information (see Chapter 30)

f) Efforts to relieve symptoms and response, prior to arrival at emergency department

e. Significant past medical history

1) Current or preexisting diseases/illness

2) Last normal menstrual period: female patients of childbearing age

3) Smoking history

4) Current medications

a) Include prescription, over-the-counter medications, and alternative therapies (e.g., herbals, acupuncture)

5) Allergies

6) Immunization status when indicated

4. Objective data collection (see Chapters 1 and 31)

a. Secondary and focused assessments related to chief complaint

D. Acuity Rating Systems

Combining the information collected from the “across-the-room” assessment and subjective and objective data, a triage acuity rating is assigned to the patient.

1. Common types of rating systems

a. Three-level triage rating system

1) Historically, most widely used in the United States

2) Category examples

a) Emergent

b) Urgent

c) Nonurgent

b. Four-level triage rating system

1) Category examples

a) Life-threatening

b) Emergent

c) Urgent

d) Nonurgent

c. Five-level triage rating systems

1) Currently recommended as the standard by the ENA and American College of Emergency Physicians (ACEP)

2) Examples and comparisons (Tables 2-1 and 2-2):

a) Canadian Triage and Acuity Scale (CTAS): utilizes lists of clinical descriptors for each level of acuity

b) Emergency Severity Index (ESI): integrates acuity levels and utilization of resources

c) Australasian Triage Scale (ATS): utilizes lists of clinical descriptors for each level of acuity

d) Manchester: combines subjective and objective data collection based on flowcharts

(a) Triage nurse selects a presentational flowchart (e.g., chest pain)

(b) Flowchart questions are followed until a positive answer is given; corresponding color level is then assigned

Table 2-1 FIVE-LEVEL ACUITY RATING SYSTEMS

Table 2-2 COMPARISONS OF FIVE-LEVEL TRIAGE SYSTEMS

E. Location of Care Assignment

Triage nurses are typically responsible for addressing the initial logistical considerations related to each patient’s emergency department visit. The logistical decision as to where continuing treatment will be provided is distinct from the triage acuity rating decision.

1. Logistical considerations

a. Treatment areas within the emergency department

1) Acute versus less acute, minor care, fast-track area

2) Pediatric versus adult area

3) Surgical versus medical area

4) Specialty area needs, such as

a) Gynecology

b) Ocular, ear, nose, throat area

c) Trauma/medical resuscitation

d) Chest pain area

e) Psychiatric

f) Isolation needs

b. Treatment areas outside the emergency department

1) Using institutional-approved protocols and in compliance with EMTALA, triage nurses may send a patient to areas outside the emergency department but within the hospital

a) Fast-track or urgent care

b) Mental health services

c) Labor and delivery

F. Treatment and Diagnostic Testing

1. Triage treatments

a. Basic first aid

1) Nursing interventions

a) Wound care, bleeding control

b) Application of ice and elevation of injured extremities

c) Providing rest and comfort (e.g., slings, wheelchairs)

b. Written policies for initiating treatment

1) Administering antipyretic medications for fever control

2) Obtaining glucose level by point-of-care testing

3) Administering analgesic medications for mild pain (e.g., acetaminophen, ibuprofen)

4) Instilling topical anesthetic medication for eye injuries

2. Initiating diagnostic tests at triage

a. Institutional-approved protocols must be in place and followed

b. Competency-based education of protocol use is recommended

c. Often utilized when department is overcrowded and wait times are longer

d. Examples

1) Ordering radiographs of injured extremities

2) Obtaining 12- to 15-lead electrocardiograms on patients with the potential for having acute coronary syndromes

3) Obtaining urine and ordering/performing urinalysis on patients with suspected urinary tract infection

4) Obtaining urine and ordering/performing pregnancy tests when appropriate

5) Obtaining blood and ordering specific diagnostic tests

G. Decision-Making Process

1. Scientific evidence is lacking that demonstrates how triage nurses make acuity rating decisions. It is believed to be based on the following:

a. Knowledge of human anatomy, physiology, pathophysiology, pharmacology, and other related disciplines

b. Clinical portraits: through experience, emergency nurses accumulate memories or pictures of what certain conditions look like

c. Rules of thumb, such as all women of childbearing age are pregnant until proven otherwise

d. Gestalt instinct or intuition

e. Knowledge and use of specific hospital triage guidelines

H. Interfacility Transfers

1. Emergency departments receive transfers from health centers, other hospital emergency departments, nursing homes, and other long-term care facilities as a result of

a. Specific transfer agreements between facilities

b. Capabilities of the accepting facility such as a regional referral center

2. Transfer patients should have triage assessment performed on arrival to the emergency department

3. Other considerations of transfer patients

a. Obtain patient information from

1) Transferring facility

2) Transport personnel

3) Patient and/or family

b. Additional information

1) Medications, treatment, course of care at transferring facility

2) Medications, treatment, course or care while en route to receiving facility

II. ADDITIONAL TRIAGE RESPONSIBILITIES

A. Waiting Room Management

1. Triage nurse is clinically and legally responsible for patients in waiting room

a. Must be accessible to patients/others in waiting room

b. Must be able to view the waiting room and periodically perform a minimal “across-the-room assessment” of waiting patients

2. Safety

a. Waiting room must remain a safe environment for patients and others

b. Triage personnel must work closely with other hospital personnel to identify unsafe conditions/situations

1) Patients who are potentially dangerous to self or others

a) Notify hospital security/law enforcement personnel to

(1) Stay with patient

(2) Screen/search for weapons or other items (e.g., medications) that the patient may use to harm self or others

b) Relocate persons from waiting room to more secure location as soon as possible

3. Reassessment

a. Consider a triage reassessment policy that may include

1) Reassessment time frames based on patient acuity

a) More frequent assessments for more acute patients

2) Components of patient reassessment

a) Vital signs, pain rating

b) General appearance, mental status

c) Information relevant to chief complaint (e.g., wound status for lacerations, respiratory status for asthma exacerbation)

3) Reassessment documentation

4. Initiation of patient teaching

a. Injury prevention (e.g., helmet, car seat, seat belt use)

b. Providing written patient/family education information (e.g., department operations, triage process)

B. Communication Issues

1. Customer service

a. Patient/family’s first impression of emergency clinical staff is the triage nurse

b. Be courteous, respectful, empathetic, calm, and practice active listening

c. Explain to patient and others expectations regarding wait times

1) Patients frequently not treated on a “first come, first served” basis

2) Wait times vary and are influenced by many factors

a) Patient acuity ratings

b) Location of care (e.g., acute, nonacute areas of emergency department)

c) Specialty area needs

d) Volume and criticality of other patients in the emergency department

e) Staffing for nurses, physicians, and ancillary personnel

3) Attempt to provide accurate estimates of the wait time

a) When in doubt, overestimate wait times

4) If available, patient pagers may be provided if prolonged wait time is expected

2. Visitors

a. Department visitation policy should include

1) Process for identification of visitors

2) Number of visitors in treatment area at a time

3) Minimum age limits (e.g., no children under specified age)

b. Triage nurse may be responsible for communicating and/or enforcing policy

c. Triage nurse may serve as liaison between family in waiting room and primary (bedside) nurse and/or treating provider

d. Ensure patient confidentiality

3. Dealing with upset patients, families, or visitors (service recovery)

a. Determine nature of problem

b. Attempt to address problem

1) Provide information

2) Allow person to vent, but not become hostile or violent

c. Identification of violent/potentially violent patients and or visitors

1) Objective signs: increasing agitation including pacing, clenched fists, yelling, verbal threats, signs of alcohol or drug use

2) Subjective information from the patient, family, police, or others

d. Deescalating actions

1) Verbal escalation

a) Manage with verbal interventions

b) Anxiety: provide support and explanations, answer questions

c) Agitation: be directive and address specific needs, set appropriate limits

2) Verbally threatening

a) Take threat seriously

b) Involve hospital security and/police

3) Physically acting out

a) Initiate immediate security response

b) Take actions to protect others

e. Solicit help if needed

1) Involve patient advocate/relations personnel if available

2) Involve supervising personnel as needed

4. Public and media relations

a. Notify public and media relations of any high-profile patient or unusual incident per institutional policy

b. Transfer all telephone calls and inquiries about the incident or patient(s) per institutional policy

5. Arrival of families of critically ill or deceased patients

a. Anticipate family arrival

b. Escort family to a private waiting area

c. Contact hospital chaplain, social worker, or other support personnel if available

d. Notify treating emergency personnel of family arrival

III. ADMINISTRATIVE RESPONSIBILITES

A. Safety

1. Implementation of safety measures

a. Security and/or police presence

b. Security monitoring with cameras in specific locations

c. Panic buttons

d. Restricted access doors

e. Employee identification badges

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

1. Neurologic Emergencies
2. Wounds and Wound Management
3. Disaster Preparedness and Response
4. Cardiovascular Emergencies

Stay updated, free articles. Join our Telegram channel

Join

Full access? Get Clinical Tree