Prof.Dr:Zeinab Ali Hessiun
Assist.Prof.Dr:Baghdad Hess
PREPARED BY:hager hussein
Hanan abdelwadoued
Objectives
At the end of this lecture each participant should be able to:
 Define triage and triage systems.
 Determine goals of triage.
 Explain triage team and their role.
OUTLINES:
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Introduction.
Definition.
Levels.
Rapid triage assessment.
Requirement for triage system.
Special circumstances in triage.
Team members of triage.
Characteristics of triage team.
Principles of triage process.
Factors affecting decision making during triage.
Triage category guidelines.
Nursing role during triage process.
Ethical consideration.
Triage systems.
Introduction
Triage includes the identification of an appropriate hospital
destination and method of transport and is based on the patient's
age and medical problem or type of trauma, an objective measure
.of the acuity of the condition, and the distance from an ED
Defination
It is the sorting of victims by giving them grade to prioritize them
for treatment and transportation in order to maximize the number
of survivors in major incidents and war victims.
Goals
1. Rapidly identify patients with urgent life -threatening
conditions.
2. Assess/determine severity and acuity of the presenting
problem.
3. Direct patients to appropriate treatment areas.
4. Re-evaluate patients awaiting treatment.
Levels of triage
1-Resuscitative.
2-Emergent.
3-Urgent.
4-Less urgent.
5-Non-urgent.
Level I: Resuscitative
Conditions that are threats to life or limb (or imminent risk of
deterioration) requiring aggressive interventions.
-Time to MD: Immediate
-Time to Nurse: Immediate
Continuous reassessment .
Examples/Usual presentation
-arrest
-Seizures
-Overdose
-Severe burns
- pneumothorax
-Altered mental status
Level II Emergent
Conditions that are a potential threat of life, requiring rapid
medical intervention or delegated acts.
Time to Nurse: immediat -Time to MD: 15 minute
Reassessment time: 15 minutes.
Examples/usual presentation
-Chest Pain
-Chemical Exposure
-Acute MI
-Severe Asthma
-Acute Psychotic Episode with Agitation
Level III Urgent emergency intervention. May be associated
with significant discomfort or affecting ability to function at work
or activities of daily living. Time to MD: <30 minutes.
-Time to Nurse: 30 minutes
Reassessment time: 30 minutes
Examples/Usual presentations
-Renal colic
- GI bleed with normal
-Shunt dysfunction
-Vital signs outside normal range
-Behavior change
Less urgent
Conditions that related to patient age, distress, or potential for
deterioration or complication
Time to MD < 60 minutes
Time to Nurse < 60 minutes
Reassessment time: 60 minutes
Examples/Usual presentation
Abdominal pain.
Head injury .
UTI sign and symptoms.
Simple laceration requiring sutures.
earache.
Level 5: Non Urgent
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.
Time to MD: 120 minutes
Time to Nurse: 120 minutes
assessment time: 120 minutes.
Examples/ Usual presentation
-Single episode of vomiting.
-Strains.
-Sprains.
- Sore throat.
Chronic problems with no change.
RAPID TRIAGE ASSESSMENT
A rapid triage assessment begins with an across the room survey
(ABCD)
 Airway: Patent or impaired e.g., stridor, hoarseness,
(drooling, facial, or) oropharyngeal edema
Breathing: Unlabored or labored
e.g., (accessory muscle use), retractions, nasal flaring
Circulation: Skin color, e.g., pallor, cyanosis and moisture e.g., dry,
moist, diaphoretic; pulse rate e.g., fast or slow and rhythm e.g.,
regular or irregular; obvious bleeding
Requirements for a triage system
A. There should be shortage of resources in comparison to the
need.
B. There should be a system set by health authority to be used
in such circumstance.
C. Trained personnel to practice the triage to ensure the
justice and prevent personal preference.
Triage team
 An emergency physician, an ED nurse, and medical records or
admitting clerks should receive every patient.
 The physician performing hospital triage should be
acknowledged as being in command of triage area should be
clearly identified by a specially colored vest or other garment;
and must understand all triage options.
 One member of triage team (admitting or medical records
clerk) should be assigned the job of recording the victim's
name on the disaster tag along with triaged destination within
the hospital.
 If identification of the patient is not available ethnicity, gender
and approximate age should be noted on the tag this
information is entered into department log and is also placed
in a triage logbook
 Security personal,medical center official person's involvement
is equally important to successfully triage all the patient.
Characteristics of team triage
 Extensive knowledge to emergency medical treatment.
 Adequate training and competent skills, language,
terminology.
 Ability to use critical thinker process.
 Good decision maker.
 The physician performing hospital triage should be
acknowledged as being in command of triage area should be
clearly identified by a specially colored vest or other garment;
and must understand all triage options.
Principal of triage
 Urgency refers to the need for time-critical intervention it is
synonyms with severity.
 Triage assessment is not necessarily intended to make
diagnosis.
 Patient triaged to lower acuity categories may be safe to wait
longer for assessment and treatment but may still require
hospital admissions.
 A method used to categorized patient for priorities of
treatment.
 Assessment of patient injury severity is based on:
1. Abnormal philological signs
2. obvious anatomic injury (including mechanism of injury)
3. Concurrent disease factors that might effect the patient
prognosis
Factor affecting decision making during triage
4. 1.nurse factors
experience
expertise
5. Patient factor
Physiological
Ability to communicate
6. Contextual factor
Busyness of ED
Recent errors in the ED
7. Lack of decision feedback
8. Overcrowding
9. Space constraints
10.
Nursing and physician shortage
11.
Patient volume in the ED
12.
Decrease reimbursement
Increase non urgent.
Triage category guidlines
Red
1-Fist priority.
2-most urgent.
Life threatening shock or hypoxia is present or imminent, but the
patient can likely be stabilized and ,if given immediate car ,will
probably survive.
Yellow
1-second priority.
2-urgent.
The injuries have systemic implications or effects ,but patients are
not yet in life threatening shock or hypoxia although systemic
decline may ensue, given appropriate care ,can likely withstand a
45_60 min wait without immediate risk.
Green
1-Third priority.
2-Not urgent.
Injuries are localized without immediate systemic implications
with a minimum of care these patients generally are unlikely to
deteriorate for several hours if at all Black Dead.
Triage nurse duties and responsibilities include
1. Assess patients when they are admitted to the emergency
room through a physical examination and interview.
2. Reassess patients periodically as they are waiting for
attention.
3. Use a specific set of guidelines when performing patient
assessments to determine how severe their condition is and
how urgent their needs are, exactly what type of attention
they need, which medical professionals are needed for
consultations and which place in the queue for admission
they should occupy.
4. Provide immediate care if the patient's condition is severe,
while they wait for the medical team. Generally, the triage
nurse doesn't provide patient care.
5. Manage patients who are waiting and update doctors about
patient statuses.
Arrange and organize patient care with other departments
or facilities and the transport that they require to get there,
Telephone triage nurses:- also called "telehealth nurses" or
"TTNs," have slightly different roles that involve.
6.
Ethical consideration
1. Respect for Autonomy:
Persons have the right to make choice regarding their
own health care for patient autonomy.
2. Respect for dignity :Good communication, listening as well as talking and is
usually necessary for giving patients information about
the proposed intervention and for fin.
3. No maleficence:The principle of no maleficence can be described as “do
no harm”. the hippocratic oath mentions this obligation
as “i will use treatment to help the sick according to my
ability and judgment, but i will never use it to injure or
wrong them.
4.
Beneficence:
Health care providers in the ed have an ethical obligation
attempt to provide benefits to the patients by taking
their complaints seriously and by managing
problems according to prevailing standards of care.
their
Summary:
Triage is key step in managing major incidents properly. It has no
rigid rules, and the triage officer must look for different aspects of
resources and patients situation to make the best triage decision
making leading to most benefits for all.
Refrances
- Idoguchi K, Mizobata Y, et al. (2006) .
Usefulness of Our Proposed Format of "
Triage Tag" . Journal of Japanese
Association for Acute Medicine. 17 (5)
-Nocera A (Winter 2000). .11 doi:10.3893/jjaam.17.183 .91–183
"Australian
-disaster triage: a colour maze in the
Tower of Babel" (PDF). Australian Journal
of Emergency Management. 69 (8): 35
-doi:10.1046/j.1440 .40
x . PMID 10472919.1622.1999.01643
Archived from the original (PDF) on 2011
034 .