TRIAGE BASED EMERGENCY CARE

VASANTHA KALYANI,AIIMS,RISHIKESH

TRIAGE BASED EMERGENCY CARE

Emergency care:1. Emergency services is a crutial component of hospital services. The aspect

of speed, accuracy and sympathy are important in the emergency department

2. Major functions of an emergency department To treat unexpected patients with life threatening and routine conditions To provide service at all 365 days in a year To provide immediate appropriate and life searing case To proved services in efficient and effective manner To be sensitive to emotional needs of the patients and their relations To liaise with costs and police in emergency To be ready for disaster and mass casualty

TRIAGE A triage system is the essential structure by

which all incoming emergency patients are prioritized using a standard rating scale.

Category Treatment accurate

(Max. Waiting time)

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Immediate 10 minutes 30 minutes 60 minutes

120 minutes

TRIAGE SCALE:

Colour coding

Group/treatment accurate

Red tag. Immediate cann’t survive without immediate treatment

Yellow tag. Observation: need hospital care and Do re-triage

Green tag. Wait: need medical care for critical injuries

White tag. Dismiss: only minor injury no need of medical care

Black tag. Expectant: injures not able to survive with the given care

ADVANCED TRIAGE SCALE: COLOUR CODES

Immediate 10 minutes 30 minutes 60 minutes

120 minutes

Airway Obstructed/ partially obstructed

Patent Patent Patent Patent

Breathing Severe respiratory distress/absent respiration hypoventilation

Moderate respiratory distress

Mild mild respiratory distress

No R.S No R.S.

Circulation Severe homodynamic compromises/ absent circulation/ uncontrolled haemorrhage

Moderate hemodynamic compromises

Mild hemodynamic compromises

No H C No H C

Disability GCS ≤9 GCS 9-12 GCS ≥12 Normal Normal

ADULT PHYSIOLOGICAL PREDICTORS FOR TRIAGE

Triage nurse must ensure that patients with

physiological abnormalities are not delayed

by the triage process and are allocated to

provide ongoing assessment and treatment of

their condition.

RECOMMENDED TRIAGE METHOD

The collection of physiological

parameters at triage requires the health

professionals to make the best use of

their senses to detect abnormalities.

Assess the following:

Chief complaint

General appearance

Airway

Breathing

Circulation

Disability

Environment

Limited history

Co-morbidities

PATIENT PRESENT FOR TRIAGE SAFETY HAZARDS ARE CONSIDERED

Quick evaluation to check patient stable .

No

Assign appropriate Triage category In

response to clinicalAssessment data

Differentiate Predictors of poor outcome from Other

date collected During the triage Assessment

4- IDENTIFY PATIENTS 5- ASSIGN APPROPRIATE

Who have evidence of (or)

Case at high risk of

physiologic

instability

Triage category In Assessment data response to clinical

ALLOCATE STAFF PROCEED The patient including

brief handover to allocated staffmembers

Start the care as per the hospital protocalf

MENTAL HEALTH TRIAGE

Treatment code Description Care 1. Immediate Definite danger to

violent life (self or others)

Supervision 1:1 observation

2. Emergency within 10 minutes

Probable risk of danger to self or others

Supervision prompt assessment

3. Urgent within 30 minutes

Possible danger to self or others agitation/confused

Supervision/observation

4. Semi-urgent within tensions

Moderate distresss no immediate risk

Supervision intermittent observation

5. Non- urgent No danger to self or others

General observation

MENTAL HEALTH TRIAGE

PAIN- TRIAGE

Pain – triage scale Very severe – emergency Moderately severe – urgent (30 mts)Moderate – semi urgent (60 mts)Minimal – non- urgent

PAIN- TRIAGE SCALE:

PAEDIATRIC TRIAGE

1. The clinical priorities and principles of urgency for infants children and adolescents are the same as those for adults

2. Determining urgency will require recognition of serious illness, some features of which may be different is infants and children

3. The value of parents and their capacity to identify devations from normal in their child’s level of function should not be underestimated

Decreased feeding Decreased activity

Breathing difficulty Being pale or hot

Dehydration Febrile illness of child under 3 months

Decreased urination

PAEDIATRIC TRIAGE:

assessment immediate Emergency 10 minutes

Urgent 30 minutes

Semi urgent 60 minutes

Non- 120 minutes

Airway Obstructed severe Respiratory Distress

Partially obstructed with moderate R. D

Patent mild R. D

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Circulation Absent circulation significant body cardia HR ≤ 60 in infaet

Circulation present

Circulation present

Circulation present

Circulation present

Disability GCS ≤ 8 GCS 9-12 GCS ≥13 Normal GCS Normal GCS

TRIAGE AND PREGNANT MOTHER

The triage nurse needs to be aware of the normal physiological and anatomical adaptations of pregnancy because these will influence assessment

Triage should consider well being of both the mother and the foetus and potential threat to each other

The pregnant mother may present with any disease

TRIAGE AND PREGNANT MOTHER

Assessmen on volume and colour of per vaginal loss.

Bright red – active bleeding

Brownish red - usually old bleeding

Shoulder tip pain – indication ectopic pregnancy

Abdominal pain - ruptured ectopic pregnancy

TRIAGE NURSES ROLE ON PREGNANT MOTHER PRIOR TO 20 WEEKS

Antepartun haemorrhage

Preeclampsia

Pre-term rupture of membrane

Hypertension mother 140/90 mmHg

20 WEEK ONWORDS

Changes in oxygen saturation

Alteration in blood pressure (either high or low)

Active vaginal bleeding

Absent or diminished foetal movements

URGENT THREAT TO FOETAL WELL BEING

Nurses performing the role of triage must have appropriate

education and supersized practice prior to practice independent

triage

Documentation must be accurate and contemporaneous

Clear and understating duty of case

Importance of re-triaging

Policies and protocols should be readily accessible

Preservation of forensic evidence

MEDICO- LEGAL ISSUES OF TRIAGE PRACTICE NURSES ROLE

Infrastructure requirement

Provision of proper and adequate manpower and training

requirements

Standard protocols

STANDARDIZATION OF EMERGENCY SERVICES IN HOSPITALS:

Mismatch between health care facility capacity and demand

population

Lack of infrastructure due to default or lack of funds or poor

planning

Inadequately equipped health care facilities due to inadequately

skilled manpower

Lack of standard operating procedures regarding handling of

patient

Lack of accountability

ISSUES TO OVERCOME

Total monthly attendance:

Total number of patients

attending emergency

department in a month

Total monthly:

Admissions: total number of

patients admitted through

emergency in a month.

Disease wise classification of

patients as per scope of

services document

Number of patients

referred in from periphery

with details of referring

institute along with reason for

referral.

Number of patients referred

out to other hospital with

details of referring institute

along with reason for referral.

Number of successful CPR out

of total CPR done in a month.

QUALITY INDICATIONS OF EMERGENCY CARE

PATIENTS SAFETY INDICATORS Time to initial assessment

Time to treatment

OUTCOME INDICATORS

Total number of emergency

cases per thousand

population

Total number of trips per ambulance

Total number of trauma

cases treated per 1000

emergency cases

Total number of poisoning cases treated

per 1000 emergency

cases Total number of cardiac cases treated per

1000 emergency

cases

Total number of obstetric cases

treated per 1000

emergency cases

Total number of resuscitation

done per 1000 population

Proportion of patients

attended at night

CONCLUSION1. Receiving of the patient 2. Registration of the patient 3. Identification of the patient4. Initial assessment of patient 5. Reassessment of patient 6. Shifting/transfer of patient within hospital 7. Referral of patients 8. Discharge of the patient9. Patient care protocols

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