Download - Triage Level 5
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TRIAGE AT
ST JOSEPHHEALTHCARE
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Provides efficient care utilizing triagemodules.
Provides training and understanding of
concepts of triage
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Developed by Eula Brown RN for Emergency Departmentuse.
Collaborators:Brenda Harris, Education Technology specialist
Patty Sturt RN, Clinical Educator
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picture
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Objectives
At the end of this program the end user will
be able to verbalize skills related to:
Understanding the basic concept of triageDefine 5 levels of triage acuity
Understand components of ED triage process
for all types of patients
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Objectives contd
Define components of triage 1.visual assessment
2.subjective assessment
3.Objective assessment 4.Define resources needed
5.Making the triage decision
Be aware of and incorporate situations regarding legal,abuse, documentation, customer service, hazardousmaterials, and cultural issues into the triage module.
To utilize patient scenerios with clinical end users for abetter understanding of triage
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MODULES PRESENTED
Module 1: Introduction
Module 2: Components of triage
Quick assessment
Subjective data
Objective data
Resources and special situations
Triage decisionModule 3: Examples of each level
Module 4: Triage Pearls
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Triage: French word meaning
to sort.
Developed and used originally by military
during World War I as a model for classifying
patients according to priority of care needed.
Used extensively during WWII
Emergency Departments nation-wide have
adopted and utilize some form of triage system
to use in classifying patients based on careneeded.
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The most common system is the
three level system.
Classification is defined as:
Emergent
Urgent or
Non-urgent.
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Throughout the later part of the 20th
century, this system has been shown to belacking in accuracy and not adequate for
the volume and needs of 21st century
EDs.
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Canada, Australia, and UK have each
developed different 5 level triage systems.
We in the US have been presented with
an Emergency Severity Index 5 level
triage system that has been shown to be
very effective in recognizing different
classifications of patients and identifyingresources needed to provide the most
efficient patient care.
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Two of the most significant factors differentiating theUS system from the others are:
The 5 level classification used by Canada and Australia aredefined by what are safe wait times for different levels
US ESI system recognizes and incorporates needed resourcesfor patient care into the classification system. The US systemdoes not consider safe wait times in determining a level ofclassification
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THE 5 levels are definedas follows:
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Critical: (1)
Conditions that require
immediate and aggressive
intervention
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Emergent: (2)
Conditions that represent
potential loss of life of limb if
interventions not done
promptly.
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Urgent: (3)
Interventions needed in the
emergency department fortimely return to health. HR and
RR within normal limits. Needs
two or more potential resources.
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Non-urgent: (4)
Conditions that will benefit
from being seen in the ED,
but may wait to be seen. One
resource needed.
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Minor: (5)
Conditions that may be seen
in clinic setting and/or have
no expectation of
deterioration. One to zero
resources needed.
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COMPONENTS OF THE
TRIAGE PROCESS:
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1. QUICK ASSESSMENT
2. SUBJECTIVE DATA
3. OBJECTIVE DATA4. RESOURCES
5. TRIAGE DECISION
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Quick assessment: This beginswhen the patient approaches triage.
Across the room assessment is based on
ABCD parameters of airway, breathing,
circulation, mental status/disability,This includes: distress noted, tachypnea,
bradypnea, wheezing, accessory muscles,
nasal flaring, altered skin color, stridor,pt unconscious, psychosis/hallucinations,
inability to recognize familiar people
uncontrolled bleeding
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** If, at anytime during the quick across
the room assessment, the patient
demonstrates a combination of the abovesymptoms that indicates an emergent or
critical situation , they are taken
immediately to an ED room andinterventions are started.
The triage acuity is critical or emergent.
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Subjective data: Triage
history
Chief complaint: this is what the patient
says is wrong (preferably in their own
words)
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Further subjective data:
Medical history: * AMPLE
*AMPLE =
A = al lergies, age of patientM= medications, dose, frequency, last dose
P= past medications, surgical, pregnancy or prenatalhistory
L= Most recent meal, tetanus, LMP, ETOH or drugingestion
E=Events sur rounding present i l lness or injur y,associated symptoms
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Subjective data contd:
pain
Level of pain using appropriate scale
Duration
Severity
Quality
Radiation
Location
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Objective data:
Focus assessment based on patients chief
complaint and initial presentation.
Focus assessment should be completedtaking into consideration the
illness/injuries the patient presents with.
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Think/consider: What is the worst
possible thing that could be wrong with
this patient?Vital Signs are included in a focus
assessment.
O2 sat is included in the objectiveassessment as needed
Objective Data contd
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Carefully consider all assessment data todetermine if the patient has a critical oremergent situation.
pallor
Indications of blood loss
degree of distress
Vital signsO2 sat
Objective data contd
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Objective data contd
The very young patients or very old have
unique considerations or physiological
changes that may place them at a higheracuity level.
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RESOURCES: Resources the triage nurse
believes the patient may need based on thetriage assessment
ED team (nurses, techs) patients requiring one or more initialnurses or technicians to stabilize, protect, prevent other harm, andeffectively care for patient
SITUATIONS REQUIRING EXTRA PERSONNEL: EXAMPLEAlzheimers patient requiring constant care.
Ancillary Resources:
LAB
X-RAY
CASE MANAGER
CT SCAN OR ULTRASOUND
RESPIRATORY THERAPY
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Resources the triage nurse believes the
patient may need based on the triage
assessment
Medical management: does the patient
need MD or can patient be seen by PAonly. Is the patient to be seen by private
MD.
EMTALA issues
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Resources contd
Crisis situations requiring additional
staff or chaplaincy services.
Legal issues (Management oradministrative resources)
Patients that require additional
placement or assistance with meetingdischarge home needs.
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Situations that require additional
Resources
Simple procedures (simple wound, IV
care, dressing)
Complex procedures (moderate sedation,complicated burn care, gastric lavage)
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Evaluating Resource needs and
examples:
Legal issues:
Illness/injury (chief complaint) that leads the
triage nurse to suspect abusive situation:
Example Abuse situations : patient states
was assaulted by boyfriend earlier today.
This would then involve police, abuse form,
and possible community resources.
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Examples legal issues:
Example: patient with right-sided Paralysis
presents from nursing home with multiple
bruising and skin tears to left side of body:
This would involve abuse form, notificationof house administrator
MVC/Trauma patients: police involvement,
community resource involvement, coroners
case, legal evidence collection.
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Special issues that may impact
triage assessment:
Trauma:
What happened?
When?Mechanism of injury: i.e. Four wheeler
accident, MVC (simple fender bender),
MVC rollover, MVC t-bone. Penetrating
trauma vs. blunt trauma
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Special issues contd
COBRA: EMTALA:
No patients can be questioned regarding
insurance/payment of emergencydepartment services without medical
screening first. (Medical screening: any
and all tests, examinations done by qualifiedpractioners to determine an emergent
condition)
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Patients should not be transferred from
another hospital without confirmation
that the accepting facility has the
capacity and resources to care for the
patient. The patient must have an
accepting physician
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Special issues contd
Cultural issues:
Language barriers: need for translator services
Customs of different religions or ethnic groups:coining for fever patients, IV/blood products
restrictions
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Crisis situations:
Patients with new onset mental illness
Patients presenting with intent to harmthemselves or others
Patients in medical distress with families
needing interventions to help copy
Patients presenting with disability thatimpairs communication and/or affects timely
treatment
Example: Aphasia
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HazMat/Environmental situations:
Specif ic agent if known?: chemical,
radiation, biological
Example: Hydrof luoric acid
When did the exposure occur?
What type of exposure:
Inhalationlungs
Dermal - burn to face, eyes, etc.
Resources must anticipate including decon!
Evaluating resource
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Evaluating resource
needs contd
Procedures:
Simple: Saline lock, simple wound, simple
laceration
Complex: procedural sedation, extensive
burn, gastric lavage
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Quickly analyze subjective,
objective data, and resources
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Triage decision:.
IS..
Based on above components
and utilizes the experienced
nurses decision making skills
T i b f i
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Triage can be confusing...
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The next slides are definitions
and pt examples of each level
or category:
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CRITICAL PATIENTS:
Level One - red
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ABCDs:
compromised in one or more areas.
CRITICAL: (1) - brought back to room
immediately with aggressive ED Team
interventions star ted.
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Cardiac arrest
Respiratory arrest
Does not respond to painful stimuli(*AVPU)
the level one patient has a new onset of
decreased AVPU
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EMERGENT PATIENTS:
Level Two - orange
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ABCDs:
Patients with potential compromise to life
or limb and/or chief complaint of
emergent nature
EMERGENT brought back to room
immediately with interventions started.
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Examples Level 2
Sudden onset speech deficits or motor
weakness indicative of acute stroke
Active chest pain suspicious for CADImmunocompromised patient with fever
Suicidal patient with a plan
I nfant < 4 mo of age with temp >100.4rectal
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Abdominal pain or back pain with
indicators of hypovolemic shock
Noticeable respiratory distress (i .e.Retractions and O2 Sat
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Patient with auditory hallucinations
Chemical splash to eye
Sudden partial or full loss of vision
I ndicators of neurovascular compromise
in an injured extremity
Acute lethargy/decreased Level of
consciousness:
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Acute sickle cell pain cr isis
I ndicators of ineffective cardiac
outputFebri le seizure
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URGENT PATIENTS:
Level 3 (yellow)
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ABCDS
Compromise may occur, but less likely
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Vital signs
HR and RR are not above normalparameters
O2sat is not less than 92%Blood pressure is not at a dangerouslevel.
Pain scale: Generally
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Will need to be seen after critical and
emergent patients.
Obtain additional subjective, objectivedata as needed to determine if the patient
is urgent.
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Examples Level 3
C/O of flank pain with pain level = or < 8
and history of kidney stones
Cough and fever
Vaginal bleeding with mild-moderate
discomfort and no indicators of
hypovolemiaExtremity injury with indicators of
possible fracture or dislocation
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Cellulitis without indicators of septic
shock or severe sepsis
= or > 65 y.o. with abdominal painVomiting and diarrhea in child with no
indicators or poor perfusion
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Headache with: GCS = 15, no
motor/sensory deficits, no history of
trauma, mild-mod pain
Croup
Abdominal pain with fever with no
indicators peritonitis
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Pediatric pt with fever and no indicators
of meningitis, meningococcemia, sepsis,
febrile seizure, or decreased perfusion.Laceration that definitely requires suture
repair
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Non-urgent: Level 4 (green)
ABCDs : Compromise not likely
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Patients seen after above three
levels.
Stable patients requiring one
resource.
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Examples level 4:
Foreign body sensation in eye with no
history of trauma, no visual changes and
mild pain
Vaginal itching and burning
Extremity injury with no indicators of
fracture or dislocation
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Non-productive cough with no or
minimal pain and no fever
Dysuria with no indicators ofpyelonephritis and no or minimal fever
Minor laceration with no sutures
required (may require steri-strips)
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Back pain with no indicators of
neurological compromise and no
significant mechanism of injury (i.e.
rollover MVC vs. twisted while
bending)
Rash for multiple days with no indicators
of respiratory distress or cellulitis
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Minor: Level 5 (blue)
ABCDs : No compromise
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Progression of i l lness/injury: l ittle to no
change from onset
Vital signs: stablePain scale:
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Resources: no resources needed.
Stable patients: could be seen in clinic or
office setting. Requires no or minimumresources.
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Examples level 5:
Request for prescription refill with no
symptoms or complaints
Superficial abrasionRequest for tetanus shot
Request for allergy shot
Suture removal with well healed woundand no indications of infection
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Triage Pearls
Triage guidelines should never replace goodnursing judgment.
Always validate what you think you heard.
Patients sometimes tell you what they think youwant to hear.
All female patients of childbearing age needLMP documented
New onset confusion: consider sepsis orhypoglycemia
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Patients who are a threat to themselves orothers must be suspect for higher level ofclassification
Many older patients may dismisscomplaints as normal for their age.However symptoms in the elderlypopulation may not always be age related.
Always think of the worst situation andtriage accordingly. It is better to triage upthan under triage.
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Maintain customer service attitude or callfor help as needed
Protect yourselfnever go to the end and
down the hill to retrieve a patient.call forhelp
Always pay attention to parents/caregiverssubjective data.
Females always need gynologicalassessment with GI problem
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Do not ignore the frequent flyers! They too canhave real disease.
Communication is more difficult with the very oldand very young. Therefore you need to take more
time with these patients.Bradycardia is an ominous sign in a child
More resources = may equal higher acuity!
Triage is a challenge to all nurses.but you can
do it!
BEYOND TRIAGE
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BEYOND TRIAGE.