01.02 Triage in the ER

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Outline

Overview

Triage is the process of sorting patients as they come into the ED in order to determine who needs immediate attention and who can wait. It requires expert clinical judgement by an experienced nurse.

Nursing Points

General

The current reccomendation from ACEP and the ENA is the use of a 5-level triage system. The Emergency Severity Index is the standard of care in the United States and is based on severity of symptoms and resource utilization.

Assessment

  1. Walking through the door
    1. Across the room assessment
      1. Look
      2. Listen
      3. Smell
    2. Triage Interview
    3. Triage Vitals
    4. Objective assessments
  2. Triage Severity Rating
    1. Emergency Severity Index (ESI)
    2. 5-Levels
      1. 1 – Immediate (Intubated, apneic, pulseless)
      2. 2 – Not as immediate (But still in pretty bad shape)
      3. 3 – You can wait, but you are gonna need some stuff
        1. Two of more resources or vitals in the “danger zone”
      4. 4 – You can also wait because you are going to need one specific thing
        1. Only needs one resource (An x-ray, an oral antibiotic, etc)
      5. 5 – Please have a seat (Or head to the urgent care center down the block)
        1. No resources needed
    3. Resources:
      1. Labs (blood, urine)
      2. ECG, x-rays, CT, MRI, Ultrasound
      3. IV fluids
      4. IV, IM or nebulized meds
      5. Speciality consultation
      6. Simple procedure =1 (Lac repair, foley)
      7. Complex procedure =2 (conscious sedation)
    4. Not resources:
      1. H&P
      2. Point of care testing (Finger stick, Urine Preg)
      3. Heplock
      4. PO meds, Script refils
      5. Phone call to PCP
      6. Simple wound care (dresssing, wound check)
      7. Crutches, splint, sling
  3. START Triage
    1. When things get sideways
    2. Greatest good for the greatest number
    3. Dreaded black tag

Nursing Concepts

  1. Clinical Judgement
  2. Ethical and Legal Practice
  3. Prioritization

Patient Education

  1. Get the patient to the Emergency Department.
  2. Be thorough with information you tell the triage nurse.

Transcript

Hello everyone and welcome to our lesson on Triage in the Emergency Department. Today we are going to discuss what happens when a patient first comes through the door of the ED. 

We have probably heard the line, “Nurses are the frontline of healthcare”. Well nowhere is it more of a literal translation then in ED triage. The nurse truly is the first person that a patient will see when they walk through the door. 

In case you were wondering where modern medical triage started, it was the French. Specifically, a surgeon named Dr Larrey, who during the Napoleonic wars treated the wounded according to what he saw. How badly they were injured and how quickly they needed treatment were what guided his process. Don’t worry, were not going to test you on this, but every once in awhile it is nice to know where the things we do actually came from. Moving on.

Triage is a process. The first step is a visual, or across-the-room assessment. This is what we do when the patient walks through the door.

The second step is the triage interview, where we actually talk to the person, and the third step is to collect vital signs and perform a quick objective assessment. So let’s dive a little deeper into this. 

So your patient just came through the door….what happens. Well, you probably look up, or you hear them screaming as they walked in. Either way, at that moment, triage has started. The across-the-room assessment is just that, when you look up..what do you see? At this point, a triage decision can be made. If there is a knife sticking out of someone’s chest, or they are holding their severed left arm in there right hand….they get to go right in… probably a level 1. If someone comes in and says there dad is having a stroke and you can see the man is drooling on himself and the entire left side of his face is drooping…Boom…right in. And yes…i put smell up there. And i can attest to this one. a young woman was brought into the ED semi-conscious, GCS of 12. That alone means we could up her triage level at the least, a 3 but most likely a 2 or 1. But as she rolled in, we smelled the strongest odor of gas we had ever smelled. It was on her clothes, her hair, we didn’t even have to get that close. In an instant, before she was even through the doors, this changed from a fairly routine case for us, to a full blown level 1 Haz-Mat incident complete with the nomex suits and full decontomanation. Turns out she was using a space heater that was leaking kerosene into her apartment and she had been inhaling it for most of the day. 

So lets say your next patient is not a kerosene snorting stabbing victim. For most of our patients, we can get to the second step in triage, which is the triage interview. This is usually the first interaction a person has with the ED and it really can set the tone for the whole visit. Triage nurses not only have to be detectives and researchers, but counselors and social workers as well. Listening to a patient’s story, obtaining the important details and putting aside the extra stuff, and trying to determine the course of treatment options all happens in minutes in the triage booth. The nurse will do their best to get a history and one of the ways to do that is top use the SAMPLE mnemonic:

Signs and symptoms

Allergies

Medications

Past pertinent medical history

Last oral intake

and Events leading up to the current situation. 

Once we have an acceptable history (may not be the best, but we are pressed for time), we move on to our objective assessments. First we try to get a full set of vital signs. The patient’s vital signs can actually change their triage level, which we will get in to. The we try to make some objective physical assessments. We are not doing a full head-to-toe exam in triage, but if they say they cut their arm, we want to look at the wound and document.

The triage severity rating is the level we give each patient to determine the urgency in which they need to be seen. In most hospitals today, we are using a 5-level triage system based on the Emergency Severity Index. The ESI is a combination of 2 things. The severity of the situation, or the potential for life, limb, or organ threat, and the predicted resource consumption, which we will talk about on the next slide. 

So the 5 levels go from 1, most severe, to 5, not severe at all. Level 1 needs immediate treatment., This is very commonly determined when they walk through the door. No interview necessary. Anyone intubated….level 1. No pulse… Level 1. Severe Trauma … Level 1. In some facilities, if a Code Stroke is called from triage… Level 1. Level 2 is just behind. Are they disoriented, acutely lethargic, in severe pain, respiratory distress, less severe traumas, or vital signs in the “danger zone”, they need to be a level 2. As far as the vitals go…we consider an adult in the “danger zone if they have a heart rate over 100 and respirations over 20 and an 02 sat of less than 92% without comorbidities. 

Level 3 is where we start to think more about resource utilization. If we anticipate they will need several resources, they are a 3. Like the young man with flank pain and no history of traumas. We are thinking kidney stone so we know they will need IV meds, labs, and a CT. Level 3. 

Level 4 probably needs one resource. A recurrent asthmatic who just needs a nebulizer treatment. Could be a level 4. The young man who thinks he may have broken his finger and needs an x-ray… Level 4. The mom who cut herself on her hand with a kitchen knife and may need a few stitches…Level 4. All using 1 resource. 

Level 5 is everything else. Point of care testing, like a pregnancy test, or a flu swab. Wound checks, stitch removals, script refills, these are all Level 5 cases. These patients, unfortunately are probably going to wait. The recent explosion of urgent care centers around the country is helping to alleviate some of these level patients but they will still come to us. And by the way, if you are wondering if you can tell a patient to just go to an urgent care center if you know the wait is going to be long, check out our lesson on EMTALA and legality in the ED. (And in case you were wondering….you can’t do that).

SO we talked alot about resources, so what is a resource and what is not. 

Resources are materials or items that if used in excess, could put a train on the ED. Things like labs, radiology (and we include all radiology here, X-Ray, CT, MRI, Ultrasound). IV fluids, IV, IM or nebulized meds, any calls to specialists. and procedures. A laceration repair is one resource. A laceration repair with x-rays and a call to ortho is actually 3 resources. 

So what is not considered a resource. Well we mentioned some of them, point of care testing like pregnancy tests, flu swabs, finger sticks. Oral meds or script refills. Simple wound care or basic sprain or strain care like crutches or splints, are all not considered resources. Much of triage is based on how we use our resources. 

Simple Triage and Rapid Treatment, or START, is a little different. This is the triage process we use in disasters or mass casualty incidents. Basically when everything starts to go sideways, we are gonna pull out our special triage tags like this one and get to work. The important thing to remember with START is that we are here to do the greatest good for the greatest number of people. We need to accept the fact that in these situations we can not save everyone and if we focus all our resources on one patient who is on the edge of death, we will be limiting the work we can do for all of the other victims. The START process involves making a rapid assessment (less than 1 minute) of every patient in the event. We then determine which of the 4 triage categories they fit into and then visually identify them with color coding. 

Green tag – walking wounded. These patients have relatively minor injuries. I have been at incidents where the medical commander will actually say for everyone to hear “If you can hear my voice, and you can stand and walk, i need you to come over to this area and see the nurse” Anyone who can do that is considered a green tag until proven otherwise. 

Yellow Tag – or delayed treatment. These patients need to be transported, but they can wait. They have some significant injuries, but we don’t anticipate them getting worse over 24 hours. Simple fractures, lacerations in which bleeding is controlled, stable vital signs, alert and oriented. Things like this.

Red tag or immediate. These are the patients that we believe we can treat but they need rapid transport and treatment. We know that we can help them if we get them to advanced treatment within 60 minutes. Compromises to the ABCs fall in this category. Things like bad fractures, head injuries who are conscious but altered, respiratory distress, burns, all fall as red tags.

Black Tags or expectant. No one ever wants to tag someone with a black tag but it is necessary. These victims are unlikely to survive due to the severity of their injuries or the level of available care. No pulse…black tag. Open head wound with visible brain matter and unresponsive. Multiple gunshots and unresponsive. We do not do CPR during START triage. To CODE someone in these situations would deny many other patients that could benefit from our help. Its not pretty and I hope none of you ever have to make this call, but it is a reality of our profession and the time we live in.

OK guys, so triage is all about judgement. The experienced nurse can make them in minutes and set the tone for all the care they are going to receive. 

We have to be careful about what we do in triage and how we treat all our patients. we really can’t turn anyone away (and we really shouldn’t).

And of course, triage is about prioritization. Who needs to be seen and who can wait. 

A few key points:

Triage starts when they walk in the door. We first use our senses to make our assessments…look, listen, smell and make some decisions.

Who is the worst? The stroke is going to get seen before the abdominal pain. And the abdominal pain is going to get seen before the flu patient. 

You have to know the resources of your department and how they can be used.

And while we never use it, we need to know the basics of START triage. I suggest if you ever know of a disaster drill being performed, get yourself involved in it. 

Once again, thanks so much for tuning in guys. Pease check out all our other lectures in our Emergency Medicine series and as always…

HAPPY NURSING!