Nursing Triage: How to Ensure
Appropriate Care Delivery With
limited Resources
Mark Ellsworth, RN,
BSN, CCHP
Dr. Todd Wilcox, MD,
MBA, CCHP-A
“Learning Experiences”
Prisoner submits a Sick call request for low back
pain. Seen by provider, diagnosed with chronic low
back pain, given Tylenol. 2 weeks later, Patient
complains of increased back pain, submits new kite
every day for a week. Never seen in person, the
paper triage disposition is “you have already been
seen for this” Patient becomes a man-down, sent
to ER where he is diagnosed with an acute
abdominal aneurysm and died.
The Problem
Clinical
mistakes being made under old
system
Scheduling issues
Doctors frustrated
Nurses frustrated
Officers frustrated
Patients frustrated
Litigation exposure
The Solution
Redesign triage
Train up nurses to
standardize skill set and
knowledge base
Create an on-site nursing program
Physicians teach the curriculum
Skills pass off
CQI to revise curriculum and address
problems
Definition of Triage
“To
sort”
“Sorting of patients and setting
priorities for their treatment in
urgent care settings, emergency
rooms, clinics, hospitals, and health
maintenance organizations.”
Tabors
Cyclopedic Medical Dictionary, 2001
Purpose of Triage
Determines
severity of prisoner’s
current chief complaint
Helps allocate limited resources in
most effective manner
Assists in preventing the system
from becoming overwhelmed
Spot Checking-Mass Casualty
Model
Gravely
injured
Moderately injured
Minor Injury
Traffic Director- Physician
Office Model
A
non clinical employee schedules the
patient, can be moved up in priority
based on “impressions”
Comprehensive Triage-Emergency
Severity Index Model
Based
on 5 levels of Acuity
An experienced nurse completes a
comprehensive assessment
Adopted by most hospital ER’s
Clinical Case
Prisoner submits sick call request for leg and back pain.
Paper triage done, patient never evaluated, triage given a
“routine” appointment which meant 3 week wait. Prisoner
begged housing nurse and officers to have him seen, they
responded with “submit a sick call”. Prisoner collapsed 2 days
later, found to have totally necrotic leg from necrotizing
fasciitis. Sent to ER, prisoner underwent a hemipelvectomy,
ended up in hospital for a long time, huge bills, ultimately
died, family sued for deliberate indifference , won several
million dollars.
Keys to Performing Triage
Experienced Nurses
Encourage intuitive skills
Empower Nurses to use the
skills they
have been taught
Support Nursing with appropriate ancillary
staff, you will loose the efficiencies of
your nurses if you turn them into HUC’s
Triage Algorithm
Requires immediate life-saving
int ervention
or
high risk sit uations
Yes
1
No
T he patient is stable but could det eriorate if
t reatment is delayed
Yes
No
2
evaluat e need for differential t est ing
none
one
4
3
many
danger zone
vit als?
HR >100
RR >20
SaO2<92%
No
3
Consider
Building a 5 Tier System


Level 1=Resucitation or life or limb
conditions, that demand care
immediately.
Examples: Apnea or severe
respiratory distress. Pale,
diaphoretic and lightheaded or
weak, hypotension.
Building a 5 Tier System
Level
2=High risk situations that will
deteriorate if left untreated.
Examples: At risk vital signs, severe
pain, lacerations, recent injury and
pain increases with movement
Building a 5 Tier System
Level
3= Stable patient, chief
complaint does not fall into nursing’s
ability to care for with a nursing
intervention, and is not in queue for a
clinician follow up.
Building a 5 Tier System
Level
4= Stable patient who will need
multiple resources prior to
appointment. These can be
administrative or diagnostic in nature.
Building a 5 Tier System
Level
5= Nursing interventions. Chief
complaint can be treated by
implementing a nursing care plan or a
verbal order by a clinician.
Content of a good assessment
 Talk
with each and every inmate who has a
completed sick call request (kites).
Face-to-face contact--Illogical and improper
to base your healthcare delivery system on the
written skills of a 4th grader (AT BEST)
describing their problem
 Obtain complete vital signs--all 5!!!
 Focus assessment on chief complaint
 Assign a priority for provider scheduling
 Triage cannot be re-prioritized unless prisoner is
seen face-to-face
“Protocols”
Nurses
can implement nursing
interventions
Cannot Diagnose or implement
medication without order of clinician
Contact clinician for questions or
orders
The Keys to Performance
Front
load completion of resources.
Resources=labs, x-rays, ECG, serial
vital signs, signed consents for
medical records
Clinicians
and nurses don’t always
agree on the triage priority.
Evolving process
Dynamic
Continual refinement,
quality feedback
and education is essential for ALL
professionals involved
Dental Triage
Level
1
Some abscesses can fall into this
category so it is advisable to call
Dental Triage
Level
2
Trauma with symptoms
Tooth decay with severe symptoms
Wisdom teeth with severe pain and
swelling
Visible facial swelling
Dental Triage
Level 3
Trauma without symptoms
Bleeding gingiva with pus or necrosis
Tooth decay with symptoms
Loose tooth with pus or gingival swelling
Wisdom teeth
Ulcerative lesion
Sessile lesions
Dental Triage
Level
4
Bleeding gingiva
Tooth decay without symptoms
Loose tooth without symptoms
Mental Health
Level
1
Suicidal ideation
Threat of harm to others damage to
facility
Mental Health
Level
2
Psychosis unable to perform ADL’s
Mental Health
Level
3
New mental health chief complaint
Patients in treatment with changes in
symptoms
Mental Health
Level
4
Administrative issues
Medication management
Avoiding Pitfalls
Must see the patient in person
Read the sick call request
Verify the history
Obtain complete set of vital signs,
assessment
Assign triage grade
Research the chart for additional
information
Document your care
focused
Avoiding Pitfalls
It
is imperative that you see & talk with
the inmate
It is imperative that a complete set of
vital signs be documented
There is no right or wrong answer
Prioritize scheduling to the best of your
ability
Practice brings confidence, confidence
brings refined skills
Slides available at
www.wellcon.net
Resources
Emergency
severity
index;www.ahrq.gov/research
Emergency Nursing 5-Tier Triage
Protocols, J.K.Biggs, V.G.A. Grossman