Emergency
Department
Triage Protocols
Policy
O Each patient presenting to the Emergency
Department, either ambulatory or transferred by
emergency medical personnel, shall be
prioritized and categorized utilizing the 5 Level
Emergency Severity Index (ESI) Instrument.
O Triaging is not equivalent to a medical screening
examination.
O Triaging merely determines the “order” in which
patients will be seen, not the presence or
absence of an emergency medical condition.
Purpose
O The Registered Nurse in the ED may initiate
the following protocols for patients requiring
immediate intervention or to expedite
patient treatment.
O It is understood that protocols initiated by a
Registered Nurse require documentation on
the patient record.
O Implementation of protocols is contingent on
communication between the nurse and
physician!
Special Instructions
O A. All patients presenting to the Emergency
Department requesting services, will be
seen by a Qualified Medical Personnel,
regardless of ability to pay.
O Questions regarding ability to pay or
insurance information are not to be
obtained at triage.
Special Instructions
O B. Ambulatory patients will have a brief
assessment performed by the Triage Nurse
utilizing subjective and objective data.
O Those patients presenting via ambulance
entrance will have an assessment
performed at the bedside by an RN.
Special Instructions
O C. Information to identify the patient and to
initiate the ED record, will be obtained from
family or the patient while the initial
assessment and/or treatment is begun.
Special Instructions
O D. Patients will be categorized using ESI
level 1-5, by evaluating patient acuity and
resources needed.
O Acuity is determined by stability of vital
functions and potential for life, limb, or
organ threat.
O Resources needed are defined as the
number of resources a patient is expected to
consume in order for a disposition decision
to be reached.
ESI Levels
O Level I
O A medical condition manifesting itself by
symptoms of sufficient severity that they
require immediate life-saving interventions.
O These patients are critically ill and require
immediate physician evaluation ad
interventions.
ESI Levels
O Level II
O A medical condition that is a high risk
situation, newly confused, lethargic or
disoriented or in sever pain or distress.
O A high risk patient is one whose condition
could easily deteriorate or a patient who
presents with symptoms suggestive of a
condition requiring time sensitive treatment
ESI Levels
O Level III
O A patient predicted to require two or more
resources
ESI Levels
O Level IV
O A patient predicted to require one resource
ESI Levels
O Level V
O A patient predicted to require no resources
O NOTE: The patient may be re-categorized at
any time as changes in condition
necessitates.
Designated Room Usage
O All rooms have O2 and Cardiac Monitors and therefore
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can be versatile at any time patient treatment warrants
Isolation rooms will be used for infectious disease
requiring negative pressure
Exam 20 and 40 will be utilized for patients who are
suicidal or a safety risk
Forensic Room for sexual assault victims or child
molestation
Trauma 1, 2,3, and Pediatric Trauma for unstable chest
pain or obvious distress, anaphylactic reactions,
moderate trauma, GI bleed that is unstable, Overdoses,
Major Trauma or CPR or an Imminent Delivery
Procedures
O In order to facilitate patient flow in the
department, the triage orders outlined below
can be initiated immediately after the patient
has been assessed during triage.
O If, however, the current workload at triage
prohibits them being initiated by the triage
nurse, they can be started as soon as the
patient gets placed in a room.
O Implementation of these orders is contingent on
communication between the nurse and
physician.
Notify MD ASAP
O Critically ill patients
O Unconscious patients
O Patients with unstable vital signs
IV Access
O Patients with a Triage ESI level of 1, 2 or 3
may have intravenous access inserted.
O Blood samples should be obtained a part of
the access procedure to avoid additional
discomfort or possible lost opportunity to
obtain specimens.
O The blood tubes collected will be labeled
and then held in an appropriately secured
area until orders for testing are made or the
patient is released from the ED.
Temperatures
O Pediatric patients less than 3 months of
age, who present with a chief complaint of
fever, or head injury (even if no fever at
triage) MUST have the initial examination
done by a physician.
Temperatures
O Rectal temperatures will be obtained on the
following types of patients
O Children under the age of 1 year old having
complaints of fever or any related infectious
process
O Patients with a fever greater than 102
O Unconscious patients
O Any patient PRN as ordered by the physician
Elevated Temperatures
O Remove any excessive clothing, blankets, etc.
O Undress and gown loosely
O Ask the physician for antipyretic for
temperatures greater than 101 degrees (unless
the patient had fever at home, received an
antipyretic and fever is reducing)
O **always ask the dosage that was given at
home**
O Encourage cooling liquids po (fluid challenges,
popsicles, etc.) to help bring the patient’s
temperature down.
Weights
O All patients under the age of 18 must have
weight taken and documented in kilograms,
on the triage record.
O Estimated weights must be documented on
anyone older than 18 years of age, on the
triage record.
O All patients to receive weight based
medications, need an actual weight taken
and documented on the record.
OB Patients
O All pregnant patients greater than 12 weeks
gestation will have Fetal Heart Tones (FHT’s)
assessed, no matter that patient’s chief
complaint.
Pediatrics
O Under 3 months of age with a c/o fever or
head injury, must have initial examination
done by a physician
O Any child under 2 years old with trauma,
head injury or sustaining a fall MUST have
an initial examination done by a physician
O All pediatric molestations MUST be treated
by a physician
Chest pain greater than 25
years old
O Order
O Portable chest x-ray
O STAT EKG/ Obtain an old EKG and hand deliver to the
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physician for immediate STEMI determination
CBC
Troponin
PT
BMP
O2, Cardiac Monitor, Post Rhythm Strip on the chart
Saline Lock
Continuous Pulse Oximeter
Obtain a second EKG in 5 minutes if active chest pain
Greater than 50 years old
O Obtain an EKG for
O Chest pain
O Dizziness
O Syncope
O Dyspnea
O Arm pain
O Weakness
O Neck or Jaw pain
O Back pain
O Abdominal pain in women
Greater than 80 years old
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Obtain and EKG for
Chest pain
Dizziness
Syncope
Dyspnea
Arm pain
Weakness
Neck or Jaw pain
Back pain
Abdominal pain in women
Nausea or vomiting
Possible TIA or CVA
O Refer to the stroke protocol
Trauma
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Call the physician to the bedside
Type and screen (hold)
CBC
Hepatic Function Panel
PT
PTT
UA with Culture Reflex
Alcohol
Rapid Drug Screen
BMP
Undress the patient completely
O2, Cardiac Monitor, Post Rhythm Strip on chart
Saline lock (one or two accordingly)
Continuous pulse oximeter
Shortness of Breath/
Respiratory Distress
O Notify MD ASAP if in distress
O Place on cardiac monitor, obtain rhythm strip and
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record on chart
Obtain a baseline air pulse oximeter, unless the
patient is in respiratory distress.
Place the patient on oxygen at 2 lpm via nasal
cannula, or as indicated to keep the patient’s pulse
oximeter greater than 93 %
Start a saline lock and draw blood for, but not
necessarily order the following: CBC, Basic Chemistry.
EKG
Portable chest x-ray
Abdominal Pain/ Flank Pain
Female (child bearing age)
O CBC
O Hepatic Function Panel
O Lipase
O HCG urine
O BMP
O UA with Culture Reflex
O Saline Lock
O Obtain catheter urine if no urine is available
within 30 minutes
Abdominal Pain/ Flank Pain
Males
O CBC
O Hepatic Function Panel
O Lipase
O BMP
O UA with Culture Reflex
O Saline Lock
O Obtain catheter urine if no urine available
within 30 minutes
Sepsis
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Portable chest x-ray
STAT EKG/ obtain old EKG
CBC
Lactic Acid
Hepatic Function Panel
BMP
2 blood cultures from different sites
UA with Culture Reflex
O2, Cardiac Monitor, Post Rhythm Strip on Chart
Saline Lock
Continuous Pulse Oximeter
Psychiatric/ Overdose
O Undress the patient totally and remove all clothing and
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belongings from the room
STAT EKG/ Obtain old EKG
Alcohol
Hepatic Function Panel
CBC
Rapid Drug Screen
BMP
Suicide Precautions
O2, Cardiac Monitor, Post Rhythm Strip on Chart
Saline Lock
Continuous Pulse Oximeter
GI Bleed
STAT EKG and obtain old EKG
Type and Screen (on hold)
CBC
Hepatic Function Panel
PT
BMP
O2, Cardiac Monitor and Post Rhythm Strip on
Chart
O Saline Lock (one or two accordingly)
O Hemoccult
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Seizures
O CBC
O UA with Culture Reflex
O BMP
O Seizure Precautions
O Continuous Pulse Oximeter
O Saline Lock
O O2
Syncope / Dizziness
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STAT EKG and obtain and old EKG
CBC
Troponin
If older than 25 years of age HCG serum
qualitative in females of child bearing age
FSBS
BMP
O2, Cardiac Monitor and post Rhythm Strip on
Chart
Saline Lock
Continuous Pulse Oximeter
Vaginal Bleed - Pregnant
O ABO Cell and RH Panel
O CBC
O BMP
O HCG Quant
O UA with Culture Reflex
O Saline Lock
O NPO
Vaginal Bleed – Not Pregnant
O HCG Qualitative
O CBC
BMP
Sore Throat
O Strep Reflex
STD - Male
O UA with Culture Reflex
O GC/Chlamydia swab at bedside
O Swabs available in the room
STD - Females
O HCG urine
O Set up for Pelvic Exam with appropriate
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tubes
GC/Chlamydia swab at bedside
Trichomonas swab at bedside
UA with Culture Reflex
Obtain catheter urine if no urine is available
within 30 minutes
Hypoglycemia
O CBC
O BMP
O UA with Culture Reflex
O FSBS
O Saline Lock
Hyperglycemia
O CBC
O Acetone
O BMP
O UA with Culture Reflex
O FSBS
O Saline Lock
Eyes
O Remove contact lenses if has not already been
done
O Obtain visual acuity on all patient that present
with any type of eye complaint with glasses or
lenses in
O Ask physician for 2 drops of Tetracaine into the
affected eye(s) when pain or photophobia
present, no allergy, bleeding or obvious open
globe rupture
O If chemical injury, instill Normal Saline irrigation
to the affected eye(s).
Burns
O Apply cool, moist, sterile compresses to small
burns to address the patient’s pain relief until
the doctor can assess the patient. AVOID ICE
O Keep the extremity moderately elevated if
possible.
O In the case of severe discomfort or patient has
sustained more than 5% of body surface area
(for example ½ of the arm or ½ of the leg),
consider starting saline lock in order to be able
to give IV pain medication as soon as the
physician has seen the patient
Extremities
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When assessing complaints involving extremities, palpate and assess
one joint proximal and distal to the injury for pulse and discoloration
Remove all potentially constrictive clothing and/or jewelry from the
involved extremity.
Apply ice, but not directly to the skin, x20 minutes then off for 20
minutes. Keep replenishing the ice packs until the patient is
dispositioned.
Keep the extremity elevated.
Consider splinting the extremity when there is obvious deformity to
address the patient’s pain/comfort issues
Ask the physician for pain medication
For any injuries in which there is obvious deformity, place a saline lock
in order to be able to administer IV pain medication as soon as the
physician sees the patient. NPO if surgical candidate.
Have the patient mark on the skin with a marker, areas in which they
are experiencing pain.
Extremities
O Indications to order x-rays
O Painful with history of trauma
O Swelling, deformity or bruising secondary to
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trauma
Point tenderness secondary to trauma
Crush injuries
To rule out foreign body
Pain, swelling and/or redness, without history
of trauma
Extremities
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The following x-rays are to be ordered as indicated:
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Shoulder
Humerus
Elbow
Wrist
Hand/wrist (when having pain proximal to the MP joint)
Fingers (when pain is distal to the MP joint, specify which finger is to be x-rayed)
Knee
Lower Leg (Tibia/Fibula)(when pain is localized over the medial malleolus)
Lower leg and Ankle (when the patient is experiencing any pain in the lower leg and
the ankle)
Ankle (when pain is localized over the lateral malleolus)
Foot (when pain is proximal to the metatarsal)
Toes (when pain is distal to the metatarsal)
Hip/AP Pelvic Order 1 view CXR for obvious fracture, (i.e. shortening and/or external
rotation of the lower extremity
Extremities – care of
amputated parts
O Rinse with room temperature 0.9 % sterile
Normal Saline to remove gross
contamination
O Wrap the part in sterile gauze, which has
been moistened with room temperature
0.9% sterile Normal Saline and place it in a
sealable plastic bag, then into an emesis
basin and then place the basin on (NOT IN)
ice.
References
O Please refer to the following policies and
training for complete information
O Triage
ES 710.57
O Surge Capacity ES 710.133
O Ambulance Diversion AD 4-4
O Emergency Severity Index Triage Training