TRIAGE NURSING

General Objective:
After 2 hours lecture-demo the students will be able to

Specific Objectives:
After 2 hours lecture-demo the students will be able to:
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define Triage and Triage Nursing. enumerate the qualifications of a Triage Nurse. differentiate the two types of triage.

Triage
- from the French verb trier, meaning "to sort, sift or select."
-

is a process of prioritizing patients based on the severity of their condition so as to treat as many as possible when resources are insufficient for all to be treated immediately. Triage originated and was first formalized in WWI by French doctors treating the battlefield wounded at the aid stations behind the front.

TRIAGE NURSING

A point which emergency care begins.

A brief clinical assessment that determines the urgency of treatment and time and sequence in which patients are seen in the ER A tool for ensuring patients are seen in a timely manner, commensurate with their clinical urgency.

The Triage Nurse

A qualified RN who demonstrates and maintains clinical expertise in emergency nursing.

Initiate appropriate nursing interventions and organizational guidelines. Demonstrates critical thinking skills and abilities.

Types of triage
1. Simple triage

2. Advanced triage

Simple Triage

Used in a scene of mass casualty

This step can be started before transportation becomes available Categorization of patients based on the severity of their injuries Use printed triage tags or colored flagging.

A Triage Tag is a quick and easy way to communicate a patient's priority to others

Color-coded flagging tape can be used to mark patients in a triage situation.

TRIAGE COLOR CODE SYSTEM

RED
URGENCY

YELLOW
UrgentSecond Priority Injuries with systemic effects & complications
30-60 min.

GREEN
Third Priority Minimal injuries w/ no systemic complications

BLACK
Dying or Dead

Most UrgentFirst Priority Life threatening injuries

INJURY TYPE

Catastrophic injuries

MAY DELAY TREATMENT?

NO

No hope for Several Hours survival- no Tx

S.T.A.R.T. (Simple Triage and Rapid Treatment)

a simple triage system that can be performed by lightly-trained lay and emergency personnel in emergencies.
It is not intended to supersede or instruct medical personnel or techniques.

S.T.A.R.T. (Simple Triage and Rapid Treatment)

developed at Hoag Hospital in Newport Beach, California for use by emergency services.
field-proven in mass casualty incidents such as train wrecks and bus accidents, though it was developed for use by CERTs and firemen after earthquakes.

S.T.A.R.T. (Simple Triage and Rapid Treatment)

First: Separate the walking wounded- move to safe area- Evaluate later/GREEN Tag. Next: Three step evaluation of non-walking victims- ONE VICTIM AT A TIME Assess RESPIRATIONS > 30/min RED Tag Move to next victim None Reposition airway & reassess Within Normal Limits

Yes RED Tag Move to next victim

No BLACK Tag

Assess CIRCULATION

Delayed capillary refill RED Tag Move to next victim

Capillary refill WNL

Assess MENTAL STATUS

Cannot follow simple commands RED Tag Move to next victim

Can follow simple commands YELLOW Tag Move to next victim

ADVANCED TRIAGE (Hospital Triage)

Secondary triage is typically implemented by paramedics, battlefield medical personnel or by skilled nurses in the emergency departments of the hospital during disasters.
More complex than with simple triage. A trauma score is invariably taken when the victim first comes into hospital and subsequent trauma scores taken to see any changes in the victim's physiological parameters.

Advanced Triage
Categories of severity:
1. 2. 3. 4.

5.

Black / Expectant Red / Immediate Yellow / Observation Green / Wait (walking wounded) White / Dismiss (walking wounded)

Black / Expectant
- They are so severely injured that they will die of their injuries, possibly in hours or days (largebody burns, severe trauma, lethal radiation dose), or in life-threatening medical crisis that they are unlikely to survive given the care available (cardiac arrest, septic shock, severe head or chest wounds); they should be taken to a holding area and given painkillers as required to reduce suffering.

Red / Immediate
- They require immediate surgery or other life-saving intervention, and have first priority for surgical teams or transport to advanced facilities; they "cannot wait" but are likely to survive with immediate treatment.

Yellow / Observation
- Their condition is stable for the moment but requires watching by trained persons and frequent re-triage, will need hospital care (and would receive immediate priority care under "normal" circumstances).

Green / Wait (walking wounded)

- They will require a doctor's care in several hours or days but not immediately, may wait for a number of hours or be told to go home and come back the next day (broken bones without compound fractures, many soft tissue injuries).

White / Dismiss (walking wounded)

- They have minor injuries; first aid and home care are sufficient, a doctor's care is not required. Injuries are along the lines of cuts and scrapes, or minor burns.

Note

Some crippling injuries, even if not lifethreatening, may be elevated in priority based on the available capabilities. During peacetime, most amputations may be triaged "Red" because surgical reattachment must take place within minutes, even though in all probability the person will not die without a thumb or hand.

Reverse triage
In addition to the standard practices of triage as mentioned above, there are conditions where sometimes the less wounded are treated in preference to the more severely wounded. This may arise in a situation such as war where the military setting may require soldiers be returned to combat as quickly as possible, or disaster situations where medical resources are limited in order to conserve resources for those likely to survive but requiring advanced medical care. Other possible scenarios where this could arise include situations where significant numbers of medical personnel are among the affected patients where it may be advantageous to ensure that they survive to continue providing care in the coming days especially if medical resources are already stretched. In cold water drowning incidents, it is common to use reverse triage because drowning victims in cold water can survive longer than in warm water if given immediate BLS and often those who are rescued and able to breathe on their own will improve with minimal or no help.

References:
Burstein, J. L. & Hogan, D. E. (2007). Disaster Medicine (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
http://en.wikipedia.org/wiki/Triage

THANK YOU!