This course prepares nurses to apply a specific triage system.
On completion of this educational activity, the learner will be able to:
Assessment helps the patient care team to understand a situation, in order to identify the problem, the source of the problem, and the consequences of the problem. The purpose of an assessment is not to identify an intervention, but to find out whether an intervention is needed.
Triage Assessment, as stated by the Emergency Nurses Association (ENA), is about getting the right patient to the right place, at the right time, and to see the right provider (Gilboy et al 2012). The triage process must be done swiftly, yet competently and effectively. The process includes (ICRC, 2008):
The triage assessment must be done by a registered nurse as the scope of practice calls for an RN. A licensed practical nurse, nursing assistant or healthcare tech are not qualified to do the triage assessment (Bemis, 2007).
Triage systems were initiated by the military (started in France, WWI) in an effort to sort through soldiers that were injured into categories of life threatening or high risk injuries as opposed to those that could be treated in the field (Iserson and Moskop, 2007). Triage was further adapted by hospitals and transitioned into use by emergency departments (Rockwill, 2005).
The purpose of the Emergency Severity Index (ESI) Triage system in emergency departments today is to allow the triage nurse to effectively:
The two main goals of the ESI Triage system are patient urgency and patient sorting. The ultimate intent is to meet standards of care by ensuring safety for patients and staff, meeting the patient needs at the appropriate level through standardization of practice with the appropriate use of resources (AHRQ, 2011).
The 4 Rs of Triage are Right patient, Right resources, Right place and Right time.
Rpaid ABC Assessment
Think about abnormal airway sounds, abnormal posture, abnormal breathing pattern
Think about accessory muscles, cool, diaphoretic, cyanotic or dusky skin, Tachypnea, bradypnea or apneic periods. Note nasal flaring, expiratory grunting, and prolonged expiratory phase with use of pursed lips, diminished or absent breath sounds.
Think about tachycardia, bradycardia, irregular pulse, pulseless, cool, hot, mottled, diaphoretic or flushed skin. Note pale mucous membranes or cyanotic nail beds. Evaluate for delayed capillary refill, diminished pulse quality, hypotension, muffled, distant, variable or adventitious heart tones, obvious bleeding.
Example: A patient enters the emergency room (ER) and states, I need to see a doctor. As the triage nurse approaches the patient, she is visually inspecting the patient from head to toe for an over-all presentation. Does the patient appear:
The nurse touches the patients hand and asks his/her name, and why the patient needs to see a doctor. Is the hand warm or cool or hot, dry or clammy? Can the patient tell you his name? Is his speech clear or slurred? Can the patient elaborate on his need to see a physician? Does the presentation match the complaint? Are they alone or with family?
By now, the nurse will have determined if the patient is alert and oriented times 4, short of breath, diaphoretic, circulation effective, and whether or not the complaint matches the presentation, or if what the patient genuine needs are different from what the patient complaints.
The chief complaint should be written as a "direct quote from the patient or significant other, stating the MAIN symptom that brought the patient to the ER for treatment (Bianco, 2006). If the patient gives you a monologue of complaints and symptoms, use only part of the whole quote. The chief complaint is usually 3-5 words, not always the first words of the patient. Some investigation may be needed to determine the reason the patient came to the ER.
It is the responsibility of the nurse to ensure that patient needs and patient complaints are met to the best of their ability; by, working with the doctor and the patient. The complaint and need may differ from each other.
The 10 most common reasons for an ER visit (English, 2012)
The patients identity, chief complaint, and level of emergency or urgency are determined by the FIRST interview (Rapid ABC Assessment). The patients need for treatment cannot be prioritized based on only the patients chief complaint. The chief complaint is one aspect of the information required to meet the objectives of triage. A detailed assessment is started. Further detailed information is needed: the who, what, when, where, why and how now need to be assessed by the emergency room nurse (Bemis, 2007).
Remember to get AMPLE History: (Bemis, 2007)
The patient in the emergency department is in an ever changing state. The patient will improve with treatment or need further treatment to make improvements or prevent decompensation. The disposition is considered at the START. Will the patient be treated and discharged, admitted, transferred, or requires significant resources from the emergency room staff to stabilize? Patients need frequent reassessment for:
Do not be surprised if the complaint changes from the time of presentation to ER or that the nurse changes the complaint, based on the patients real needs (Bemis, 2007). As an example: Patient complains of left shoulder pain and feeling weak, but his heart rate (HR) is 145 and, after getting an electrocardiogram (ECG), reflects new onset atrial fibrillation (A Fib).
Other things to consider:
ESI is a standardized triage system that is supported by both ENA, and ACEP (American College for Emergency Physicians), and provides validity and consistency of a rating system amongst medical institutions across the United States (Briggs & Grossman, 2006).
ESI permits the RN to have a means for quick, effective and accurate sorting of patients, which begins as soon as the nurse sees the patient. This allows the nurse to identify patients who are in immediate need of life saving interventions or those who are less critical (Trimarchi, 2012). This further allows the emergency room physician to have a guideline for determination of thresholds for diversions or natural disaster events.
ESI levels 3-5 are determined by the number of resources utilized. Resources include:
Count the different type of resources, not the individual tests. (i.e. all labs count as one resource, all x-rays count as one resource) (Eitel et al, 2001). Prediction of number of resources utilized is initiated immediately, starting with the first encounter of the patient by the triage nurse (Trimarchi, 2012). The triage nurse will use information obtained from the subjective and objective aspects of the triage assessment, the patients medical history, medications, age and gender.
The very young (< 3 months) and the very old (>75yrs) may increase the patients ESI category up a level simply based on their age and complaint (i.e. fever, elevated heart rate, sob, dehydration) (AHRQ, 2011). Co-morbidities may increase the patients ESI category up a level (Gilboy et al). These co-morbidities may be: smoker, ETOH abuse, drug abuse, immunosuppressed, HTN, sedentary life style. If a person presents looking age 85, but is age 70, he/she may very well be the age 85 health wise.
All child bearing age females are considered pregnant until proven otherwise.
Chest pain is considered cardiac in nature until ruled out.
Level 5: Requires no resources and may be a Nurse only visit.
Level 4: One resource
Level 3: Two or more resources
Level 2: Does NOT require immediate lifesaving intervention, but is CRITICAL for recovery of the patient and would place the patient on a high risk status.
Level 1: REQUIRES immediate LIFE SAVING intervention
Determining between level 1 and 2:
The patients ESI level may change from the triage time to time of disposition (Briggs & Grossman, 2006). It may increase or decreased depending upon the outcome of the diagnosis and what is revealed during the exam as the nurse and doctor work together to determine the patients needs. The patient may different aspects to different healthcare team member as the patient recalls or is prompted to provide additional information.
Regardless of the ESI level, depending on a patient's specific medical condition, the emergency room physician will admit the patient to the hospital, discharge the patient home or transfer the patient to a more appropriate medical facility (Gilboy et al). Remember, demographics, living arrangements, ability to pay for medications, primary care physician (PCP), must also be considered for final disposition.
ANY high risk situation can rapidly develop into a life threatening situation which requires lifesaving intervention, thereby upgrading a level 2 to a level 1.
High risk situations: (AHRQ, 2011)
|NEUROLOGICAL||Acute mental changes such as loss of consciousness, meningitis, history of multiple CVAs, acute onset ischemic stroke, < 2hrs, severe headache with change in mental status, head injuries especially with anticoagulation therapy.|
|ABDOMEN||Gastro intestinal Bleed, abdominal pain in the elderly or the very young, abdominal pain or vaginal bleeding in pregnant females, mesenteric ischemia, ectopic pregnancy, appendicitis, galls stones, duct obstruction (cholelithiasis versus cholecysititis), diverticulitis versus diverticulosis, pancreatitis, small bowel obstruction, perforated ulcer.|
|CARDIAC||Chest pain, acute coronary syndrome, history of angioplasty with chest pain, Cardiac Arrhythmia.|
|RESPIRATORY||Acute respiratory distress, Shortness of breath (SOB), upper airway distress, pneumothorax, toxic, smoke inhalation, facial burns, allergies|
|GENITOURINARY||Acute renal failure, or urinary retention, testicular torsion, anuria, polyuria, urethra obstruction, priapism, kidney stones with obstruction|
|GYNECOLOGICAL||Ectopic pregnancy, spontaneous abortion, placenta previa, abruptio placenta, imminent delivery, gestational hypertension, gestational diabetes, sexual assault|
|MENTAL HEALTH||Suicidal or homicidal ideation, combative, hostile, hysterical|
|GENERAL||Immuno-compromised, oncology patients, transplant patients, hyper, hypoglycemic, DKA, Electrolyte disturbances, chemotherapy patients with a fever.|
|OCULAR||Eye trauma, sudden partial or full loss of vision, floaters, pain, or chemical exposures|
|TRAUMA||MVA with or without loss of consciousness, Burns, Bleeding, Active Arterial Bleeding, Compromised Neurovascular function in an extremity, Amputations (complete or partial), acceleration or deceleration injuries, Fractures (hip, pelvis, femur) Trauma may fall under level 1 or level 2, depending on the severity of the injury or extent of the injury.|
|ENVIRONMENTAL OR TOXICOLOGICAL EMERGENCIES||Intentional Overdose of medication or substances, especially with Suicidal Ideation, Accidental Overdose of medication, ETOH, , Poisonous Snake Bites, Exposure to Organophosphates, Chemical spills, allergic reactions|
The Rule of Nines helps the nurse to quickly estimate the size of a burn. This method divides the body's surface area into percentages.
Estimating burn size in an adult
Estimating burn size in babies and young children
The "rule of palm" is another way to estimate the size of a burn. The palm of the person who is burned (not fingers or wrist area) is about 1% of the body. Use the person's palm to measure the body surface area burned.
|Age||Heart Rate||Respiratory Rate||SaO2|
|≤ 3 months||≥ 180||≥ 50||≤ 92%|
|3 months to 3 years||≥ 160||≥ 40||≤ 92%|
|3-8 years||≥ 140||≥ 30||≤ 92%|
|≥ 8 years||≥ 100||≥ 10||≤ 92%|
|≥ 18 years||≥ 100||≥ 10||≤ 90%|
In conclusion, by completing a brief focused assessment, it allows the triage nurse to sort patients into five categories based on the patients need and acuity level. It allows the nurse to quickly and effectively determine which patients must be seen immediately and which patients can wait to be seen.
Having a standardized triage system that is accepted nation-wide allows for emergency departments across the United States to be able to function on the same page, so to speak. This permits nurses from emergency department to emergency department to be able to communicate the patients acuity level with a few simple words (Reiter & Scarletta, 2008). It doesnt take the place of a nurse to nurse report for details, but does allow the receiving nurse to get a mental picture of how complicated the patient may be.
Agency for Healthcare Research and Quality (AHRQ). Emergency Severity Index, Version 4 U.S. Department of Human & Health Services 30 June 2011
American College of Emergency Physicians Foundation (ACEPF). About emergencies: When Should I go to the Emergency Department. Retrieved 29 May 2012 from (Visit Source).
Bemis, P. Emergency Nursing Bible, 4th Edition, 2007.
Bianco, C. How Emergency Rooms Work. retrieved 29 May 2012 from (Visit Source).
Briggs, J and Grossman, V. Emergency Nursing 5-tier Triage Protocols, 2006. Philadelphia, Lippincott, Williams & Wilkins.
Eitel, D, Gilboy, N, Tanabe, P, and Travers, D. Making the Right Decision: A Triage Curriculum, 2nd Edition. Emergency Nurses Association 2001.
English, M., 10 Most Common Reasons for an ER Visit Retrieved 29 May 2012 from (Visit Source).
Gilboy, N., Tanabe, P., Travers, D., Rosenau, A. and Eitel, D. Emergency Severity Index, Version 4: Implementation Handbook. AHRQ publication no. 05-0046-2. 2012.
ICRC, Guidelines for Assessment in Emergencies, International Federation of Red Cross and Red Crescent Societies (ICRC), March 2008.
Iserson, K and Moskop, J., Triage in Medicine, Part I: Concept, History and Types March, 2007.
Reiter, M. and Scaletta, T., On Your Mark, Get Set, Triage Emergency Physicians Monthly, The Independent Voice for Emergency Physicians, August 31, 2008.
Rockwill, M., Agency for Healthcare Research and Quality. May, 2005.
Trimarchi. M., 10 Injury Treatment Priorities at the Emergency Room. retrieved 01 June 2012 from (Visit Source).