Emergency Department

Triage Protocols

PolicyO 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.

PurposeO 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 InstructionsO 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 InstructionsO 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 InstructionsO 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 InstructionsO 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 LevelsO 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 LevelsO 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 LevelsO Level III

O A patient predicted to require two or more resources

ESI LevelsO Level IV

O A patient predicted to require one resource

ESI LevelsO 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 UsageO All rooms have O2 and Cardiac Monitors and therefore

can be versatile at any time patient treatment warrantsO Isolation rooms will be used for infectious disease

requiring negative pressureO Exam 20 and 40 will be utilized for patients who are

suicidal or a safety riskO Forensic Room for sexual assault victims or child

molestationO 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

ProceduresO 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 ASAPO Critically ill patientsO Unconscious patientsO Patients with unstable vital signs

IV AccessO 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.

TemperaturesO 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.

TemperaturesO Rectal temperatures will be obtained

on the following types of patientsO Children under the age of 1 year old

having complaints of fever or any related infectious process

O Patients with a fever greater than 102O Unconscious patientsO Any patient PRN as ordered by the

physician

Elevated TemperaturesO Remove any excessive clothing, blankets, etc. O Undress and gown looselyO 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.

WeightsO 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 PatientsO All pregnant patients greater than 12

weeks gestation will have Fetal Heart Tones (FHT’s) assessed, no matter that patient’s chief complaint.

PediatricsO 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 OrderO Portable chest x-rayO STAT EKG/ Obtain an old EKG and hand deliver to

the physician for immediate STEMI determinationO CBCO TroponinO PTO BMPO O2, Cardiac Monitor, Post Rhythm Strip on the chartO Saline LockO Continuous Pulse OximeterO Obtain a second EKG in 5 minutes if active chest

pain

Greater than 50 years old

O Obtain an EKG for O Chest painO DizzinessO SyncopeO DyspneaO Arm painO WeaknessO Neck or Jaw painO Back painO Abdominal pain in women

Greater than 80 years old

• 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 CVAO Refer to the stroke protocol

TraumaO Call the physician to the bedsideO Type and screen (hold)O CBCO Hepatic Function PanelO PTO PTT

UA with Culture ReflexO AlcoholO Rapid Drug ScreenO BMPO Undress the patient completelyO O2, Cardiac Monitor, Post Rhythm Strip on chartO Saline lock (one or two accordingly)O Continuous pulse oximeter

Shortness of Breath/Respiratory Distress

O Notify MD ASAP if in distressO Place on cardiac monitor, obtain rhythm strip and

record on chartO Obtain a baseline air pulse oximeter, unless the

patient is in respiratory distress. O Place the patient on oxygen at 2 lpm via nasal

cannula, or as indicated to keep the patient’s pulse oximeter greater than 93 %

O Start a saline lock and draw blood for, but not necessarily order the following: CBC, Basic Chemistry.

O EKGO Portable chest x-ray

Abdominal Pain/ Flank PainFemale (child bearing age)

O CBCO Hepatic Function PanelO LipaseO HCG urineO BMPO UA with Culture ReflexO Saline LockO Obtain catheter urine if no urine is

available within 30 minutes

Abdominal Pain/ Flank PainMales

O CBCO Hepatic Function PanelO LipaseO BMPO UA with Culture ReflexO Saline LockO Obtain catheter urine if no urine

available within 30 minutes

SepsisO Portable chest x-rayO STAT EKG/ obtain old EKGO CBCO Lactic AcidO Hepatic Function PanelO BMPO 2 blood cultures from different sitesO UA with Culture ReflexO O2, Cardiac Monitor, Post Rhythm Strip on ChartO Saline LockO Continuous Pulse Oximeter

Psychiatric/ OverdoseO Undress the patient totally and remove all clothing

and belongings from the roomO STAT EKG/ Obtain old EKGO AlcoholO Hepatic Function PanelO CBCO Rapid Drug ScreenO BMPO Suicide PrecautionsO O2, Cardiac Monitor, Post Rhythm Strip on ChartO Saline LockO Continuous Pulse Oximeter

GI BleedO STAT EKG and obtain old EKGO Type and Screen (on hold)O CBCO Hepatic Function PanelO PTO BMPO O2, Cardiac Monitor and Post Rhythm Strip

on ChartO Saline Lock (one or two accordingly)O Hemoccult

SeizuresO CBCO UA with Culture ReflexO BMPO Seizure PrecautionsO Continuous Pulse OximeterO Saline LockO O2

Syncope / DizzinessO STAT EKG and obtain and old EKGO CBCO TroponinO If older than 25 years of age HCG serum

qualitative in females of child bearing ageO FSBSO BMPO O2, Cardiac Monitor and post Rhythm Strip on

ChartO Saline LockO Continuous Pulse Oximeter

Vaginal Bleed - Pregnant

O ABO Cell and RH PanelO CBCO BMPO HCG QuantO UA with Culture ReflexO Saline Lock O NPO

Vaginal Bleed – Not Pregnant

O HCG QualitativeO CBC

BMP

Sore ThroatO Strep Reflex

STD - MaleO UA with Culture ReflexO GC/Chlamydia swab at bedsideO Swabs available in the room

STD - FemalesO HCG urineO Set up for Pelvic Exam with

appropriate tubesO GC/Chlamydia swab at bedsideO Trichomonas swab at bedsideO UA with Culture ReflexO Obtain catheter urine if no urine is

available within 30 minutes

HypoglycemiaO CBCO BMPO UA with Culture ReflexO FSBSO Saline Lock

HyperglycemiaO CBCO AcetoneO BMPO UA with Culture ReflexO FSBSO Saline Lock

EyesO Remove contact lenses if has not already

been doneO 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).

BurnsO 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

ExtremitiesO When assessing complaints involving extremities, palpate and

assess one joint proximal and distal to the injury for pulse and discoloration

O Remove all potentially constrictive clothing and/or jewelry from the involved extremity.

O 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.

O Keep the extremity elevated. O Consider splinting the extremity when there is obvious deformity to

address the patient’s pain/comfort issuesO Ask the physician for pain medicationO 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.

O Have the patient mark on the skin with a marker, areas in which they are experiencing pain.

ExtremitiesO Indications to order x-rays

O Painful with history of traumaO Swelling, deformity or bruising

secondary to traumaO Point tenderness secondary to traumaO Crush injuriesO To rule out foreign bodyO Pain, swelling and/or redness, without

history of trauma

ExtremitiesO The following x-rays are to be ordered as indicated:

O ShoulderO HumerusO ElbowO WristO Hand/wrist (when having pain proximal to the MP joint)O Fingers (when pain is distal to the MP joint, specify which finger is to be

x-rayed)O KneeO Lower Leg (Tibia/Fibula)(when pain is localized over the medial

malleolus)O Lower leg and Ankle (when the patient is experiencing any pain in the

lower leg and the ankle) O Ankle (when pain is localized over the lateral malleolus)O Foot (when pain is proximal to the metatarsal)O Toes (when pain is distal to the metatarsal)O 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.

ReferencesO Please refer to the following policies

and training for complete informationO Triage ES 710.57O Surge Capacity ES 710.133O Ambulance Diversion AD 4-4O Emergency Severity Index Triage

Training