Emergency Department Triage System

By Jamal Wahadneh Rn MPH and Ms Aida Salahat Rn Al-Makassaed Emergency department

Objectives
Define Triage Define Triage system Identify different systems Describe emergency severity index Function of triage system

History of Triage
Definition Origin

Informal triage

Goals of Triage
Primary
Secondary

Category of triage
In hospital triage
Multi casualty disaster triage

Types of triage methods

Three level
Four level Five level

Function of triage
Identify life-threatening conditions and determine acuity level of each patient

Reassessment in triage
Level Level Level Level Level 1 2 3 4 5 =Continuous = every 15 min = every 60 min = every 60 to 90 min = every 2 hours

Five level system

Origin of 5 level Identify different levels

Emergency Severity Index

Definition
Advantages disadvantages

ES I
M E R G E N C Y

EN VD EE RX I T Y

Is patient dying ?

Yes Level I

No Level II, III, IV, V

Can patient wait ?

Yes Level III, IV, V No Level II

How many resources ?

TWO Level III ONE Level IV NON Level V

What are resources ?

Resources
Labs ECG-X-rays C-T MRI IV Fluids /hydration IV /IM Medication Specialty consult

Not resources
HX and physical exam. Point of care testing Saline or Hep lock PO. Medication Simple wound care (dressing check /recheck) crutches ,splints,slings.

Simple procedure Complex procedure

Key concepts
Acuity level change Choose higher acuity when in doubt

Basic triage components

Across the room assessment
Triage history Physical assessment Triage decision

Key concept
Discontinue assessment and transport the patient immediately to the treatment area if immediate care is needed. Do not delay treatment to finish the assessment

Triage process
Establish priorities
Scientific method Importance of time

Nursing process in triage

Assessment time
Vital signs Pain scale Nursing diagnosis

Key Concept
Never assume the accident caused the presenting condition. The presenting condition may have caused the accident.

Interview methods
Open ended Close ended Communication style Use of five sense attitude

How do I triage?
Across the room General appearance Abcd Subjective and objective (AMPLE) Focused assessment Pains scale (Pqrst)

Triage decision
Step1- visual Step 2- chief complaints Step3- focused assessment Step 4- pose hypothesis Step 5- determine acuity Step 6- reassess the acuity

Remember That:
Effective triage gets the patient To the right place. At the right time. With the right care provider.

Questions