TRIAGE
Goals of Triage
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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
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Streamlines patient flow.
Reduces risk of further
injury/deterioration.
Improves communication and public
relations.
Enhances teamwork.
Identifies resource requirements.
Establishes national benchmarks.
Triage Acuity Determinants
Chief complaint.
 Brief triage history.
Injury or illness(signs & symptoms).
 General appearance.
 Vital signs.
 Brief physical appraisal at triage.
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Triage Role
• To determine severity of illness
or injury for each patient who
enters the Emergency
Department (ED).
Triage
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Patients should have a triage assessment
within 10 minutes of arrival in the ED.
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Accurate triage is the key to the efficient
operation of an emergency department.
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Effective triage is based on the knowledge,
skills and attitudes of the triage staff.
Triage Process
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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.
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5 Level Triage
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Level
Level
Level
Level
Level
1
2
3
4
5
Resuscitative
Emergent
Urgent
Less urgent
Non-urgent
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Triage is a dynamic process.
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Reassessment & Reassessment .
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A patient’s condition may improve or
deteriorate during the wait for
treatment.
Level I: Resuscitative
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Conditions that are threats to LIFE or LIMB
(or imminent risk of deterioration)
requiring aggressive interventions.
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Time to MD: Immediate
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Time to Nurse: Immediate
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Continuous reassessment
Level I
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Usual presentations
Code / arrest.
 Major trauma.
Severe burns--airway compromise .
 Shock states.
 Severe respiratory distress.
Near death asthma (Status asthmatics).
Tension pneumothorax.
 Altered mental state.
 Seizure (Status epileptics).
 Traumatic shock.
 Overdose.
 AAA.
 AMI with complications.
 Congestive heart failure with low BP.
 Major head injury-unconscious.
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Level II Emergent
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Conditions that are a potential threat of life,
limb or function, requiring rapid medical
intervention or delegated acts.
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Time to MD: 15 minutes.
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Time to Nurse: immediate.
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Reassessment time: 15 minutes.
Level II Emergent
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Usual presentation
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Chest Pain Query MI
Trauma
Chemical Exposure
Stroke
Altered Consciousness
Acute MI
Severe Asthma-stridor
Acute Psychotic Episode with Agitation
Severe Pain 8 -10
Reassessment 15 mins
Level III Urgent
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Conditions that could potentially progress to a
serious problem requiring emergency intervention.
May be associated with significant discomfort or
affecting ability to function at work or activities of
daily living.
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Time to MD: <30 minutes.
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Time to Nurse: 30 minutes.
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Reassessment time: 30 minutes
Level III Urgent
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Usual presentations:
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Renal colic, billary colic
GI bleed with normal VS
Previous seizure—alert
Dehydration.
Shunt dysfunction.
Vital signs outside normal range.
Pain scale 4 -7 \10
Moderate risk of harm to self or others.
Inconsolable infant , infant not feeding.
Behavior change.
Reassessment 30 minutes
Level IV: Less Urgent
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Conditions that related to patient age, distress,
or potential for deterioration or complications
would benefit from intervention or reassurance
within (1 –2 hours)
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Time to MD < 60 minutes (1 hr)
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Time to Nurse < 60 minutes (1 hr)
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Reassessment time: 60 minutes (1 hr)
Level IV: Less Urgent
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Usual presentation:
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Head injury—alert.
Earache.
Abdominal pain.
UTI sign and symptoms.
Simple laceration requiring sutures.
VS normal
Reassessment 1 hour
Level 5: Non Urgent
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Conditions that may be acute but non-urgent as well
as conditions which may be part of a chronic problem
with or without evidence of deterioration.
The investigation or interventions could be delayed or
even referred to other area of the hospital or health
care system.
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Time to MD: 120 minutes.
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Time to Nurse: 120 minutes.
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Reassessment time: 120 minutes
Level 5: Non Urgent
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Usual presentation:
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Strains.
Sprains.
Single episode of vomiting.
Sore throat.
Script refills.
Chronic problems with no change.
Investigation or intervention for these illnesses or
injuries could be delayed or even deferred.
Reassessment 2 hours \120 minutes
Pediatric Triage PCTAS
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There are three things that must be
assessed and documented on all
pediatric patients:
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Respiratory rate.
Heart rate.
Capillary refill.
Pediatric CTAS
Poster Pocket Card
Pediatric Vital Signs
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Must include:
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Heart rate.
Blood pressure.
Respiratory rate.
O2 saturation.
Temperature.
Capillary refill.
Accurate weight!
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Vitals Are Your Safety Net.
Less Urgent and Non Urgent patients
have NORMAL vital signs.
Abnormal vital signs are at least an
URGENT.
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Triage is a dynamic process
A patients condition may improve or
deteriorate during the waiting for
treatment
Reassessment, Reassessment,
Reassessment
Triage Practical
Injury Prevention
Injury prevention practical
General Approach to
POISONED Patient
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ABCs…IV, O2, monitor
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History
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Decontaminate if organophosphates prior touching by health
care professionals
Lily kit for cyanide poisoning.
Obtain all prescription and bottles in the household (call
pharmacy).
Pill count.
PM Hx.
Search clothes for clues, medication alerts, pills etc.
Contact family members.
Track marks, consider body packing or stuffing.
Vital signs, Rhythm strip.
General approach to poisoned pt.
What are the essential features of a
30-second toxicological exam?
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Vital signs- HR, RR, BP.
 Temperature- rectal
(resp rate can affect oral temperature).
 Skin- color, temperature, and sweating.
 Odors- provide clues
(their absence means nothing)
 Bowel sounds and bladder function.
 Mental status.
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General approach to poisoned pt
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Tests
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GI Decontamination
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Activated Charcoal
Antidotes
Practical