TRIAGE

Mary Corcoran RN, BSN, MICN

EMTALA: Emergency Medical Treatment and Labor Act Requires a hospital to provide an appropriate

medical screening exam to any person who comes to the emergency department and requests treatment or an examination for a medical condition. If the examination reveals an emergency medical condition, the hospital must also provide either necessary stabilizing treatment or appropriate transfer to another medical facility

EMTALA

• EMTALA regulations apply to anyone coming to a hospital seeking emergency medical services

• EMTALA imposes financial penalties on physicians and hospitals

• Additionally, the hospital, if found guilty of violating EMTALA regulations, can be excluded from participating in the Medicare program

EMTALA

MEDICAL SCREENING EXAM

• Most hospital policies state that only an Emergency Department MD or PA exam

constitutes a Medical Screening Exam. Check with your supervisor

• The triage process DOES NOT constitute a Medical Screening Exam.

EMTALA

• A person who presents anywhere on the hospital campus and requests emergency services, or who would appear to a reasonably prudent person to be in need of medical attention, must be handled under EMTALA

• 250-yard rule: “Campus means the physical area immediately adjacent to the provider’s main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the HCFA regional office, to be part of the provider’s campus”.

EMTALA

Questions for discussion

• Does the triage nurse’s assessment constitute a Medical Screening Exam?

• If a patient is lying on the sidewalk outside of the parking garage, is the emergency department

required to evaluate and treat the person?

• If a homeless person comes to triage complaining of chronic back pain, is the emergency department

required to evaluate and treat the person?

What is Triage?

From the French verb “Trier” which means to “sort” or to “choose”

Began in the battlefield when they would prioritize wounded soldiers

1950’s and 60’s Medical staff with military background began to educate civilian staff on the concept of “triage”

As physician practice changed to an “office” based specialty system, and ER’s volume bean to increase

3 Common Triage Systems

Traffic Director- simplest, non clinical employee greets patient and directs them to treatment area or wtg room based on initial impression- by 2002 obsolete

Spot-check triage- appropriate for low volume, ED. Registration greets patient and pages triage nurse. The RN performs basic assessment

Comprehensive triage- supported by ENA. Triage done by competent RN. The RN determines priority of care based on physical, developmental and psychosocial needs

Triage Acuity

In 2003, 2 hospitals had EMT’s and RN’s complete triage’s on 5 scripted patients and then were asked same scenarios 6 weeks later and only 24% of participants assigned the same ratings both times

The goal is to develop a standardized acuity system in order for everyone to have the same understanding of each level assigned

Trends Affecting ED Wait Times The American Hospital Association (2002)

revealed 90% of ED’s perceive they are operating over capacity.

The avg time to see ED physician in 2001 (49 min) which was an 11% increase over 1997 And increased to 56min in 2006

Factors contributing to increased ED volumes:-

* decrease in ED’s, aging population, longer ED stays, inability to move admissions, increase in the uninsured, po0r access to primary care, nursing shortage

The Interview

Introduce Yourself Confirm the Patients Identity (IMPORTANT) Obtain a Chief Complaint/Reason for visit Gather Subjective & Objective Data

Including LMP, VS, Weight, History, Mechanism etc

Perform a rapid, concise, focused assessment, with quick primary and secondary survey

Pediatric Patients

Use the CIAMPEDS format to triage pediatric patients

C- Chief complaint- primary problem I- Immunizations- UTD, NUTD A- Allergies M- Medications – Name, last dose, how much? P- PMH Parents impression of child’s condition E- Events surrounding illness/injury D- Diet- bottles, ounces D- diapers S- Symptoms associated with illness, injury

Pediatric Patient

Use Similar A-I Assessment criteria as adults A- Airway; patency, positioning, audible sounds B-Breathing; inc or dec WOB. AMU, nasal flaring C-Circulation; color of skin, cap refill D- Disability; activity level, response to environment E-Exposure; identify underlying injuries F- Fahrenheit G- Get VS, including weight in kg H- Head to Toe Assessment; quick related to cc I- inspect the back and isolate; observe for hidden injuries, communicable illness

Be cognizant of legal issues related to abuse/neglect and the difference between adults and children

OB Patients

Most OB patients can be transferred to L&D via wheelchair, Usually patients 20 weeks gestation and greater are evaluated in L&D or by OB physician.

EMERGENT OB-A patient with a “presenting part” must be delivered in ED. Prepare for delivery if patient is multigravida, completely dilated, had SROM, or c/o rectal pressure

Urgent OB- Patients in active labor- ( contractions 2 minutes apart lasting 60-90 sec, presence of “bloody show”, ROM

Non-urgent OB- Patients not in active labor- per hospital policy

Legal Considerations-Important to know who can transport patients to L& D

Geriatric Population

Important points to remember when triaging geriatric patients: Altered pain perception

common Delayed presentation common Upper abdominal pain, an ill

appearance, abnormal VS= RED FLAG

Consider etiology of falls Consider elder abuse Older patients are uniquely

prone to delirium

Psychiatric Patients

All patients exhibiting aggressive and/or agitated behavior are considered violent unless proven otherwise

Never turn your back on these patients When speaking to psychiatric patient

be simple, direct, clear and concise Do not overlook physical injuries or

illnesses in psychiatric patients

What do you think?

40 y/o old female c/o epigastric pain, vomiting 50 y/o male with a ripping sensation in his chest? 23 y/o with RLQ pain and fever? 19 y/o post partum, hypotensive & fever? 2 y/o, vaccines NUTD, drooling & fever? 4 week old male, vomiting after every meal? 80 y/o with abdominal pain, vomiting bilious? 4 m old diff breathing, congestion- winter months?

Recommended by the ENA (Emergency Nurses Association) and ACEP (American College of Emergency Physicians)

ESI 5 level Triage System

Introduction

Level 1- Resuscitation 0 minutes

Level 2- Emergency 10 minLevel 3- Urgent 30 minutes

Level 4- Semi urgent 60 minutes

Level 5- Non-urgent 120 minutes

Requires Life Saving Intervention?

Level1Yes

High Risk SituationOr

Confused/Lethargic/ DisorientedOr

Severe pain/Distress

No

Level2

Yes

How Many Resources are Needed?None One Many

Level 3

Level4

Level 5

Dangerous Vital Signs?

yes

No

Emergency Severity Index (ESI)

• Acuity assessment• Airway, breathing, circulation

• Potential for life, organ or limb threat

• How soon the patient needs to be seen

• Expected resource assessment• Number of resources, as estimated by the

triage nurse, that a patient is expected to consume in order for a disposition decision to be reached

ESI

• Five explicitly defined categories

• Mutually exclusive

• Allows for rapid sorting

• Differs from a complete assessment

• Gather sufficient information to assign an ESI level

• Quick sorting

ESI

• Requirements to maintain the validity and reliability of the instrument

• Experienced emergency department nurse at triage

• Education of each RN prior to implementation

Patient dying?

Can not wait?

How many resources? none one many

no

no

yes 1

5 4 Vital signs no

3

yes

consider

2C

B

A

D

Is this patient dying? A

Yes1

No

Decision Point A

Is This patient Dying?

Does this patient require immediate life-saving intervention?

• Airway

• Obstructed or partially obstructed

• Unable to protect their own airway

• Breathing

• Apneic

• Intubated pre-hospital

• Severe respiratory distress

• SpO2 less than 90%

Decision Point A

Does this patient require immediate life-saving intervention?

• Circulation

• Pulseless, or concerned about rate, rhythm or quality?

• Drugs

• Hemodynamic interventions

• Immediate IV medications to correct hemodynamic instability

Decision Point A

• Does this patient have an acute mental status change that requires immediate life-saving intervention?

• Examples:

• Hypoglycemia needs glucose

• Heroin overdose needs Narcan

• Subarachnoid bleed needs airway protection

What are life Saving Interventions?

•Airway and Breathing•Intubation• -Surgical airway• -CPAP, BiPAP• -Bag valve mask ventilation

•Defibrillation

•External Pacing

•Chest needle decompression

•Significant IV fluid resuscitation• Blood administration• IV medications

• vasopressors

•Control of major bleeding

Resuscitation Hemodynamics

What are NOT life saving interventions?

ECG Laboratory studies Oxygen Monitor IV access

ASA Nitroglycerine Pain medications Antibiotics Heparin

Diagnostic Tests Medications

Can not wait? B

No

No

Yes

2

High risk situation?

or

Confused/lethargic/disoriented?

or

Severe pain/distress?

B

Yes

2

No

Decision point B

Can this Person Safely Wait to be Seen?

• Determination is made on a brief interview, gross observations, “sixth sense”

• Does not require a full set of vital signs

• Unsafe for the patient to wait• Suggestive of a condition that could easily

deteriorate

• Symptoms of a condition where treatment is time sensitive

• Potential major life or organ threat

Examples of “high risk” patients• Episode of chest pain, denies other symptoms, known

cardiac history

• Rule out PE

• Newborn with a fever

• Rule out ectopic pregnancy

• Neutropenia with a fever

• Suicidal/homicidal

• New Onset Confusion in elderly

• Adolescent found confused and disoriented

• Patients in SEVERE pain

• Sexual Assault Patient

Decision point Bis this person in severe pain or distress?

• Is this patient currently in pain?• Pain intensity rating

• Chief complaint

• PMH, medications

• VS, physical assessment findings

• Assign ESI level 2 if and only if• Self-reported 7/10 or greater

• AND

• RN cannot intervene and they require immediate intervention

• Do you want to give your last bed to this patient?

Examples of Level 2 Severe pain

Kidney stone

Burn victim

Oncology patients

Possible dislocated shoulder

? Compartment syndrome

Decision Point C

How Many Resources will this patient require?

Determined by the experienced ED RN at triage

Based on the standard of care

Independent of type of hospital, location, physician on duty, acuity of the department

How many different resources are needed?

None One 2 or more

C

Vital signs 5 4

3

Mean Resources Used Per Triage Category

0

1

2

3

4

5

1 2 3 4 5

M

ea

n #

of r

eso

urc

es

use

d

ESI Triage Level

Resources: Count number of different types of resources, not individual tests or x-rays (ex: CBC, electrolytes, and coags equal one resource; CBC plus chest x-ray equal two resources.

Resources Not Resources

Labs (blood, urine)ECGX-ray, CT, MRI, ultrasound, angiography

History & Physical (including pelvic)Point-of-care testing

IV fluids (hydration) Saline or heplock

IV, IM or nebulized medications PO medicationsTetanus immunizationPrescription refills

Specialty consultation Phone call to PCP

Simple procedure = 1(lac repair, foley)Complex procedure = 2 (conscious sedation)

Simple wound care (dressing, recheck)Crutches, splints, slings

ESI Level 5

No resources

Examples: Healthy 10 year old with “poison ivy”

Healthy 52 year old who ran out of his blood pressure medicine yesterday

22 year old, involved in a car accident 2 days ago, wants to be checked. Nothing hurts.

46 year old with a cold

ESI Level 4

Stable, can safely wait hours to be seen

Care by mid-level providers in fast track or express care setting

Requires a physical exam and one resource

ESI Level 4

• Examples:

• Healthy 19 year old with sore throat and fever.

• Healthy 29 year old with a UTI, denies vaginal discharge.

• Healthy 43 year old with stubbed toe who states “I think I broke it!”.

• Healthy 12 year old with a minor thumb laceration

ESI Level 3

30-40 % of patients in the ED

Require in-depth evaluation

Long length of stay

Before assigning a patient to ESI Level 3 the nurse must consider the patients vital signs

ESI Level 3,4, and 5 examples

• ESI Level 3 -Fractured ankle -Abdominal pain -Most migraines

• ESI Level 4 -Sprained ankle, toe -Abscess

• ESI Level 5 -Toothache

Decision point D

What are the patients vital signs?

• Consider the vital signs

Are they outside the acceptable parameters for age?

If unacceptable consider up-triage to ESI Level 2

Danger zone vitals?

HR RR SaO2

<3 m >180 >50 <92%

3m-3y >160 >40 <92%

3-8y >140 >30 <92%

>8y >100 >20 <92%

Level 3

Pediatric Fever Criteria

• 1 to 28 days of age: assign at least ESI 2 if temp >38.0C (100.4F)

• 1 to 3 months of age: consider assigning ESI 2 if temp >38.0c (100.4F)

• 3 months to 3 years of age: consider assigning ESI 3 if: temp >36.0C (102.2F), or incomplete immunizations, or no obvious source of fever

Lets Practice

Pediatric Sprained Ankle

An eight year old is brought to triage because of an injured right ankle. The child tripped over a ball while playing soccer. The ankle hurts with ambulation and you notice edema over the medial aspect of the ankle. His mother tells you the child is healthy, takes no medications and has no allergies. VS WNL.

Respiratory Distress

Paramedics arrive with a 42 y/o morbidly obese female who called EMS with a CC of SOB. On arrival the paramedics found her sitting upright, working hard at breathing with a respiratory rate of 48 and a room air SPO2 of 84%. They are unable to obtain any further history.

Lump…

“I have a lump on my back” reports a 28 year old healthy male. Upon further

questioning he tells you the lump looks like a huge, large pimple. He reports no

drainage or fever.No PMH or meds.His vital signs are:

BP 118/74, T 98.8, HR 72, RR 16

Vaginal Bleeding/ Abdominal Pain

23 y/o female presents to triage with a CC of moderate vaginal bleeding and

generalized abdominal cramping (5/10) for 2 hours. Her LMP was 8 weeks ago. She is G1P0. Her skin is warm and dry.

Her vital signs are:BP 110/80, T 98.6, HR 84, RR 20

Shoulder

A 45 y/o male is brought to triage by his friend who states the patient injured his left shoulder while playing football. The patient has a gross deformity to his shoulder with neuro deficits to the left arm. He is unable to move his arm, complains of excruciating pain (20/10 when asked), and is diaphoretic.

Bite

Mom brings her 4 y/o son to triage with a CC of a red arm. The patient was bitten by the family dog about 3 days ago. The child is cranky. His right arm is reddened, with edema to a large area surrounding

the dog bite.His vital signs are:

T 99.5, HR 120, RR 24

PNA

A 70 year old male arrives by ambulance from a nursing home. The nursing home reports a non-productive cough since he choked on his lunch today. His baseline

mental status is unchanged, although he is normally confused. Skin is warm and moist.

His vital signs are:BP 135/80, T 100.2, HR 94, RR 20,

SpO2 94% on RA

Laceration

A tearful 5 year old is carried in by her father who reports is daughter was trying to help set the dinner table and broke a glass. You notice a 3 cm laceration on

her left hand. The bleeding is controlled. No history, allergies or meds.

Her vital signs are:BP 98/64, T 97.8, HR 108, RR 24

Hematemesis

EMS arrives with a 49 year old male with a history of cirrhosis and hepatitis C. His wife called 911 when he started vomiting bright red blood. On arrival he is pale, diaphoretic and has a BP of 92/78, HR 130, RR 28.

Wound

19 y/o male states he had an appy last week. Wound is red, opened up, and yellow pus is oozing out.

No other medical history. No meds.

101.8, HR=98

Trauma

Notified by EMS you are receiving an 8 y/o female hit by a bus. Witnesses state she was thrown across the street.

VS= HR=148, RR=36, BP=70/palp, O2 sat=91%.

What if they Leave?

LWBS

Pts who are LWBS (Left Without Being Seen), are more common in high volume ER’s

Most patients are frustrated with the long wait times

Discuss the LWBS policy with your specific facilities

Triage Nurse Qualifications

Triage Nurses are the Gate Keepers to the ER, if they Over-triage they can use up vital beds in the ER, if they Under-triage they can delay vital care

Triage Nurses must be knowledgeable, experience, temperament, and qualifications necessary to function in a high stress roll

Most facilities require at least 6mo- 1year of ER experience before allowing nurses to triage

Questions?