EMS Triage Systems (Nursing)

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Introduction to Pre-Hospital Care

The Emergency Medical Services (EMS) system

BASIC AMBULANCE CARE (BAC) COURSE

INTRODUCTION TO PRE-HOSPITAL CARE SYSTEMS Monday, December 24, 2007

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Development of towns and cities

In newly developing towns and cities, the first hospitals were established. Patients must be brought in to these hospitals.

Patients brought to medical care Ambulance services still did not exist yet

Medical Care brought to

patients

Patients brought to Medical Care



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Baron Dominique-Jean Larrey1766 – 1842

‘The worthiest man I have ever met’ – Napoleon Bonaparte

1797 – Napoleon’s Army Italian Campaign Ambulance Volante “Flying ambulances” Casualties reached within 15 minutes, treated on site and transported back to base hospital.



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Baron Dominique-Jean Larrey1766 – 1842

Introduced the concepts of triage that are still used today

The best plan that can be adopted in such emergencies, to prevent the evil consequences of leaving soldiers who are severely wounded without assistance, is to place the ambulances as near as possible to the line of the battle, and to establish headquarters, to which all the wounded, who require delicate operations, shall be collected to be operated upon by the surgeon-general. Those who are dangerously wounded should receive the first attention, without regard to rank or distinction. They who are injured in a less degree may wait until their brethren-in-arms, who are badly mutilated, have been operated and dressed, otherwise the latter would not survive many hours; rarely until the succeesing day. Besides with a slight wound, it is easy to repair to the hospital of the first or second line, especially for the officers who generally have means of transportation. Finally, life is not endangered by such wounds



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Ambulances bringing patients

Horse-drawn ambulances had to contain a defined set of equipment, including ample brandy.

Typical horse-drawn ambulances



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Developments in ambulance

The Electric Ambulance

Rolls-Royce ambulances



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Today’s

Still serving the same function of bringing the patient to medical care

Is this correct?Are we just transports??



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The importance of TIME 1960’s and 1970’s

Emergency Medicine emphasized the importance of medical care to be given as early as possible

Heart attacks and road traffic accidents were major killers

Outcomes could be improved if treatment started in time

A few minutes makes a lot of difference in survival

Role of ambulances changed Patients often cannot wait until reaching

hospital to start receiving emergency care Care had to be brought to the patient



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Role of the modern ambulance service

Transportation Respond quickly Reach early Transport rapidly Refer accurately

Emergency Care Start medical care Time-related

interventions Assessment of

patients Documentation



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The Pre-Hospital Environment Pre-hospital environment poses difficult

circumstances– Difficult to find– Unaccustomed personnel– Unusual environment– Limitations with equipment– Dangerous scenes and people– No support from others– Transportation difficulties– Time pressures



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Scene Safety Precautions Some scenes are DANGEROUS

Violence / Crime / Mob Environment and Terrain Persisting dangers Hazardous Materials

Scene Safety is most important Assess scene safety from FAR (rule-of-thumb) Approach only when deemed safe Park the ambulance safely Look around for persisting dangers Get information Ask for help / advice

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Techniques to reduce traffic hazards

Let the experts guide you

Position “fend-off” position

Establish staging area and ambulance loading area

Use equipment to slow traffic and divert away from safe zone

Use only essential warning lights; position them properly so as not to blind incoming traffic

Wear high-visibility clothing



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Call for assistance / Call for help Suspicion and Identification of

Products Identification of Zones

– Red (Hot) Contaminated– Yellow (Warm) Control– Green (Cold) Safe

Hazardous Materials (HazMat)

Wind Direction



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Personal Protective equipment (PPE)– Don’t be a dead hero!!– Do not enter a contaminated site

without adequate Hazmat PPE– Levels A, B, C, D

Decontamination– Dry powder– Liquid– Gaseous

Hazardous Materials (HazMat)

A

B

CD



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EMT well-being Basic physical fitness Exercise and nutrition Habits and Addictions Body Substance Isolation (BSI) Back Safety Vaccination Decontamination of Equipment Post-Exposure Prophylaxis



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Body substance isolation (BSI) Assume that all body fluids and blood is

INFECTIOUS Always use PPE whenever you are treating any

patient Protective gloves (wearing and removing technique) Masks and Eye protections N-95 masks, if needed Disposable water-proof gowns Safety boots Resuscitation barriers



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Back Safety Good back posture Proper body weight Avoid ego; ask for help Position load as close to body as possible Keeps palms upward Bend your knees; keep your chin up “Lock in” spine and abdo muscles Don’t twist or turn Use leg muscles, not back muscles Exhale during lift; don’t hold your breath Push, not pull

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Scheme of Pre-Hospital CareHow we do our work



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General scheme of Pre-hospital care

Scene Size-Up

Initial Assessment

Trauma Medical

Focused History and Physical Examination


Detailed Physical Examination

On-going Assessment



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Scene size-up Scene Safety Determine need for assistance Determine need to report in Determine mechanisms of

Injury Determine nature of Illness Determine number of patients Request additional assistance

when Multiple casualties Expanding scene / scope Hazmat or Rescue situation Dangerous (violent, weapon, mass

LOOKSAFE?HOW?HELP?



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General scheme of Pre-hospital careScene Size-Up

Initial Assessment

Trauma Medical




On-going Assessment



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Initial Assessment - Check the ABCs

Mental status Airway Breathing Circulation Identify the Priority Patients Manage the Priority Patient first



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Form a general impression of the patient

Does the patient appear to have a life-threatening condition?

Was it trauma? Does he need spinal immobilization?

Is it a medical problem?

Is the patient conscious and coherent? Can he answer questions and obey commands?

Is this a priority patient? Will this patient need to be transported urgently?



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ParamedicEyes Ears Touch Monitors

PatientSymptoms Signs

SKILL



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Scene Size-Up

Initial Assessment

Trauma Medical




On-going Assessment

TRAUMA



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Trauma patientsFocused History and Physical examination

Reconsider the Mechanism of Injury– Decide if significant mechanism of injury exists, or

not

– Significant Mechanism of Injury Golden Hour Concept extremely important Rapid trauma assessment and tranport

– No Significant Mechanism of Injury More time for assessment More time for interventions More time for transport



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Significant Mechanisms of Injury

Ejection from vehicle Death in same passenger compartment Significant intrusion into patient compartment Intrusion more than 12 inches in lateral impact Fall greater than 15 feet Vehicle roll-over mechanisms Vehicle – pedestrian collision Motorcycle crash Unresponsive patient or altered mental status Penetrating injury to head, chest or abdomen



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Significant Mechanisms of Injury – what to do

Rapid Trauma Assessment (complete within 5 mins)– Continue Spinal Immobilization– Assess for DCAP-BTLS in head, neck, chest, abdomen,

pelvis, extremities, back (log-roll)– Full spinal immobilization– Baseline vital signs and SAMPLE history

Packaging and Rapid transport (complete within 10 mins)

Followed by Detailed Physical Examination on the way to the receiving hospital

Deformity, Contusions, Abrasions, Penetrating, Burns, Tenderness, Lacerations, Swelling



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No significant mechanisms of injury

Focused assessment (based on chief complaint)

Full physical examination Baseline vital signs and SAMPLE history Transport Documentation



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Scene Size-Up

Initial Assessment

Trauma Medical




On-going Assessment

MEDICAL



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Medical Patients Evaluate responsiveness again Unresponsive

– Rapid Medical Assessment– Baseline Vital signs and SAMPLE History– Transport

Responsive– History of Illness with SAMPLE History– Focused Physical Examination based on chief complaint– Baseline vital signs – Transport decision to re-evaluate



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Actions for Medical Patients

Depends on history and clinical findings Provide Oxygen Monitor breathing (and oxygen saturation) Monitor pulse (and vital signs) Monitor conscious levels (talk to the patient) Reassurance and Comfort



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General scheme of Pre-hospital care

Scene Size-Up

Initial Assessment

Trauma Medical




On-going Assessment



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On-going assessment Continued assessment of the patient

To detect any changes / deterioration in patient’s condition

To detect any new findings / injuries Adjust care provided if needed

A Assess

I Intervene

R Re-assess



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What can we assess on the Mental Status

Responsiveness Irritability, agitation

Airway patency and Breathing effort

Listen for abnormal sounds Look for effort of breathing

Pulse and Skin Rate and volume Peripheries warmth, capillary refill Signs of Shock

M A P



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Tarik Nafas

!!

Remember TRIAGE ??

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Today…………. Widely used Concept unchanged

To serve objectives Use of available resources

Objectives DIFFERENT Save lives Reduce further morbidity

Achieving the Triage Objectives Ensure that unstable or potentially unstable

patients are seen and treated urgently Ensure those who are not likely to

deteriorate could wait safely for care Concept of

prioritizing patients provide immediate critical care when needed do the most for the most with available

resources

Triage in different scenarios Trauma Triage

Sequence of transfer Mode and speed of transport Proper destination

Disaster Triage In mass casualties / disasters, the objectives include

doing the most for the most with available resources Hospital Triage

Determines time and sequence of treatment Enables proper functioning of Emergency Department

TRAUMA TRIAGE?

Sorting of patients based on injury severity and resource availability and time management

HOW DOES IT WORK?

Deliver the RIGHT patient to the RIGHT place at the RIGHT time.

GUIDELINES for TRAUMA TRIAGE

Patient assessment to look for immediate life threatening injuries Abnormal physiologic sign

Anatomic location of injuries

Mechanism of injury

Pre or co-morbid conditions

Measure vital signs & level of consciousness

GCS < 13Systolic BP< 90mmHgResp rate <10 or >29

STEP 1

yes No

To trauma centerAssess anatomic location

of injury (Step 2)

Penetrating injury to chest, abdomen, head, neck/groinFlail chest

Two or more proximal long bone #Burns >15%, face/airway burns

Pelvic #Limb paralysis

Amputation proximal to wrist/ ankle

Step2

YesNo

To trauma center

Evaluate for evidence ofMechanism of injury

Or high energy impact(Step 3)

•Ejection from automobile•Death in same passenger compartment•Extrication time > 20 min•Falls > 20 feet•Roll over accident•High speed auto crash•Auto-pedestrian injury with significant impact•Pedestrian thrown or run over•Motorcycle crash > 20 mph with separation of rider and motorcycle

Step3

yes no

To trauma center Step 4

Age < 5 or > 55 yearsKnown cardiac or respiratory disease

Diabetic taking insulin, cirrhosis, malignancyObesity, coagulopathy

Psychotics taking medication

Step4

yes no

Contact medical control andConsider transport to trauma center

Re-evaluate with Medical control

Hospital Triage Different objectives

Ensuring that unstable patients get immediate medical attention

Ensuring that potentially unstable patients receive prompt medical attention

Identifying patients who require time-related interventions (eg pain, poisoning)

Ensuring that those who are not likely to deteriorate can wait safely for care (with regular reassessment)

Hospital Triage

Essential for effective and efficient functioning of the Emergency Department

Provision of emergency medical care cannot be performed adequately if the system is overwhelmed by non-emergency cases

Hospital Triage Clinical assessment: brief but accurate

Limited time; not to make specific diagnosis

Aim: decide whether the patient needs to be seen earlier

Performed by experienced health care provider with years of clinical judgment & decision making

Triage System in the Emergency DepartmentPatient in Initial Encounter

Primary Triage

Urgent Treatment Required?

Critical

Semi-Critical

Non-Critical

Secondary Triage

Resuscitation (RED)

Intermediate (YELLOW)

Green Zone

Waiting Area

Under-triaged

Fast-Track

Primary Triage Assessment: What you can see What you can ask Aim: To identify patients that need to be seen

urgently (either yellow or red)

Secondary Triage Assessment: Further History Vital Signs, ECG, Initial wound care Aim: To screen for unstable patients Under-triaged Fast-track To provide initial care and investigations

Primary Triage – Assessment Phase See

General Condition: Airway, Breathing, Unconscious, Pale, Movement, Sitting up, Walking, Injuries

Ask Chief Complaint, Brief History to assess severity,

duration Mechanism of Injury and Circumstances of Injury

Primary Triage – Action Phase Do

Assist in patient transfer from vehicle onto stretcher, wheel chair if necessary

Provide further instructions for next phase of care (for patient and relatives)

Decide Urgent Triage Category

Critical (Red) Semi-Critical (Yellow)

Non-Urgent Category – proceed to secondary triage Normal (Green) Fast-track

Secondary Triage Aims

Second Screening to detect unstable patients based on further history, vital signs monitoring, ECG, initial wound assessment and clinical reassessment

Actions Review patients after registration Ask further history Perform vital signs, initial wound dressing, ATT,

ECG if necessary, splinting and bandaging. Identify under-triaged patients Identify fast-track patients Record onto clerking sheet

CURRENT TRIAGE SYSTEM: 3-tier emergency system Red: critical; response time 0 min Yellow: semi-critical; response time 10 mins Green: non-critical; seen within 60 mins Some mention a 4th level “non-emergency” which

ideally should not be seen within the ED (the well known ‘cold cases’)

Examples Triage RED Patients requiring Active Resuscitation Unstable Haemodynamics Potentially Unstable Haemodynamics eg myocardial

ischaemia, arrhythmias Polytrauma Acutely Breathless patients Patients requiring active monitoring Patients requiring aggressive oxygen therapy Patients requiring ventilation Patients requiring emergency procedures

Examples Triage YELLOW Stable haemodynamics All patients on stretchers except triaged RED. Patients unable to walk or sit upright Gross limitation of movement Unconscious but with stable haemodynamics All acute poisonings even if patient currently stable. Asthma patients (although usually separate area

with separate triage code)

Examples Triage GREEN Stable Patients Able to sit upright unaided Fully conscious Walking wounded Simple upper limb fractures and Minor injuries

Please note that Triaged Green patients are still Emergency cases, although they are NOT critical;

This should be differentiated from the Non-Emergency cases ie COLD cases

TRIAGE is a dynamic process need to reassess patient from time to time

(triage and re-triage) Ideal triage

Expedite care with accurate initial assessment Ensure appropriate prioritization depending

on severity of illness Improve patient flow within ED

IDEAL TRIAGE:

Triage process and rules must be: Easily understood & remembered Rapidly applicable to different age group,

illness/injury Provide a common language for all

emergency health care providers

LIMITATIONS TO TRIAGE:

Over-triage: burden existing resources & prevent patients with serious injuries from appropriate care

Under-triage: cause delays in treatment & transfer of patients with life/limb threatening injuries.

Over-triage and Under-triage concepts

Over-triage burdens the system, but under-triage maybe detrimental to the patient

Over-triage of up to 50% to achieve an under-triage rate of 10%

Under-triage

Over-triage

Increasing stringency of triage

Ideal level

10%

50%

CONCLUSION: Triage requires clinical experience & skill The need for a common standardized triage

system within a department A standard triage system will optimize clinical

care for patients with different severity of injuries/illness

A triage system is meant to meet the need of an Emergency Department; different departments therefore will have different needs, and therefore different triage systems.



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Short Break ?

Medical Services, Pulau Pinang 67

Disaster Triage and Field Operations

Medical Services, Pulau Pinang

Disaster Management Programme

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Why are Resources Important in Triage?

Disasters is commonly defined as an incident in which patient care needs overwhelm local response resources

Daily emergency care is not usually constrained by resource availability.



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START Triage Simple Triage And Rapid Treatment



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START: Step 1

Triage officer announces that all patients that can walk should get up and walk to a designated area

for eventual secondary triage.

All ambulatory patients are initially tagged as Green.



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START: Step 2

Triage officer assesses patients in the order in which they are encountered

Assess for presence or absence of spontaneous respirations

If breathing, move to Step 3 If apneic, open airway If patient remains apneic, tag as Black If patient starts breathing, tag as Red



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START: Step 3

Assess respiratory rate If ≤30, proceed to Step 4

If > 30, tag patient as Red



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START: Step 4

Assess capillary refill If ≤ 2 seconds, move to Step 5 If > 2 seconds, tag as Red



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START: Step 5

Assess mental status If able to obey commands, tag as

Yellow If unable to obey commands, tag as

Red



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Mnemonic

RPM

302Can do



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Summary

Triage• Prioritization

• For the good of the patient• For the good of most patients• For the good of the system

Field (Military) Triage Trauma Triage Hospital Triage Disaster Triage

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Emergency Medical Systems and Triage Systems

Thank You

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Documents

EMS Triage Systems (Nursing)