TRIAGE

NURSING

Introduction. . .

T-R-I-A-G-E originates from the French word “trier”, which means to sort out or choose

a universal term applied to methods of allocating treatment prioritizations for casualties from disasters or in warfare

helps a medical team to treat urgently casualties to defer those whose treatment is less urgent and to provide care and comfort for those with fatal injuries.

determined who should be transferred to medical facilities and who were critically injured with little chance of survival.

The World War Ito sort out casualties on the battlefields for the primary purpose of providing quick treatment to soldiers who could return to battle

Military Classification of Triage:Minimal care: little or no treatment is required; minor injuries

Immediate care: immediate life or limb-saving measures are required; receives highest priority

Delayed care: treatment is required but the injury is not life or limb-threatening; treatment can wait for a short period of time

Expectant care: major injuries requiring extensive time and supplies; these victims would most likely expire even with immediate treatment.

Triage CategoriesA. Emergent I

• requires immediate medical interventions; potentially life or limb threatening

• Airway compromise• Cardiac arrest• Severe shock• Cervical spine injury• Multisystem trauma• Altered LOC• Eclampsia

B. Urgent II• patient with stable condition but

requires medical intervention within a few hours; no immediate threat to life or limb of these patients

• Fever• Minor burns• Minor musculoskeletal injuries• Dizziness• Lacerations

C. Non-emergent III

• patients with chronic or minor injuries; no danger to life or limb by having these patients wait to be seen; no obvious signs of distress noted

• Chronic low back pain• Routine medical refills• Dental problems• Missed menses

Types of Triage System•Nonprofessional determination of priority of care – assessment and prioritization are carried out by the registration clerk according to how sick the patient appears.

•Basic triage – a quick assessment is done by an RN, LPN, or physician to ensure that the most seriously ill or injured patients are treated first; a chief complaint is determined with little or no collection of other data; little to no documentation is done.

•Comprehensive triage – assessment and prioritization are done by an educated, experienced ED RN; standards are developed and followed for assessment, prioritization, and plan of care, immediate nursing action, and documentations. This type utilizes established triage categories.

Qualifications of a Triage NurseExperienced in emergency nursing: minimum of 6 monthsEmergency nursing clinical knowledge and assessment skills; demonstrated clinical competenceAbility to prioritize appropriatelyLeadership skillsAssertivenessAbility to solve problemsAbility to make quick decisions using good judgment

Good verbal communications skillsCommon senseAbility to empathize with patients, family, and colleaguesAbility to act as a patient advocate and public relations representativeAbility to document accurately and conciselyOrganizational skillsHigh tolerance of stress

Responsibilities of a Triage NurseBe aware of arriving patientsMaintain contact with patients in the waiting roomHave a warm and caring manner of all patientsBe in ongoing communication with the charged nurseAssigned patient to treatment rooms or notify the charged nurse of patients who need emergent or urgent treatmentDemonstrate understanding of patient and family requests and concernsDetermine priorities of care Determine how non-emergent patients are brought in or called into the ED proper for treatment

Triage Inservice Trainingthe triage function must be an important part of the ED orientation process

a new ED RN should spend at least four shifts in triage with an experienced RN before being allowed to triage alone

the nursing staff who will be assigned to the triage function should attend educational classes to prepare them for the role

the purpose of triage, rapid assessment and prioritization of presenting patient problems according to established standards and categories or levels of patient acuity, required documentation, policies, resources, and a specific triage procedure

should have the authority to decide what patient is to be brought directly in for treatment

her decision should not be challenged by peers, because the triage nurse is the initial assessor of the patient and is the only person aware of the patient’s degree of illness

must empathize with co-workers and only bring those patients who require immediate attention directly into the treatment area during time of high activity and ED overload

Standards and Priorities of Carea triage manual should be developed and kept in the triage area, so that it can be referred to by the triage nurses at any time

established triage procedure for the individual hospitalsupplies and equipment to be maintained in the triage areadefinitions of category termsan index of patient complaints or problems with specific levels of priority; the index makes up most of the manual. 

Comprehensive Triage NursingThe patient is greeted by a professional, which helps establish immediate communication, rapport, and an appearance of sensitivity to the patient and family needs. It also enhances the public relations image of the hospital.

When a nurse has immediate contact with the patient, patient stress is alleviated.

Initial communication with hospital (or ED) does not concern insurance or ability to pay.

Treatment of patients requiring immediate care is expedited by se of an acuity category system.

Immediate assessment and documentation of patient problems are provided for.

Certain diagnostic procedures and/or treatments can be initiated without delay.

It provides for continuous reassessment of patients waiting in the waiting room.

It provides for continued communication with family in the waiting room.

Setting Up the Triage AreaDeskOne chair for the triage nurse and one chair for the patientTelephoneIntercom to the nurse stationOral and rectal thermometersSphygmomanometer with three cuff sizes: adult, extra large, child

Ice packsSplintsBandages, dressings, tapeBasinsIrrigating water: a sink if possibleSpecimen containersPhlebotomy suppliesSupplies and fluids for emergency IV infusionAirways, Ambu bagWheelchairBulletin board

Triage formsED nursing documentation formReferral formsReferral services and agenciesCatchment area listsBeeper listHospital telephone directoryTriage manualComputer terminal in EDs with computerized registration

Triage Procedureto ensure prompt evaluation of all patients within 2-3 minutes of their arrival at the EDall patients are to be assessed within 15 minutes of arrivalwhen the number of patients waiting to be triaged at one time is more than one triage nurse can manage, an additional nurse to assist temporarily should be requestedEDs with patient visits over 200 often have more than one nurse assigned to triage at all timesa list of established hospital or public health clinics and services should always be available 

the triage nurse introduces her- or himself to the patient

asks about the name, the problem, a brief history of the presenting problem, and if he has a private physician

name and sex; race, birth date, and ageassessment: subjective and objective (with vital signs)allergieslevel of acuity: emergent, urgent or non-urgentplan: send directly to the treatment area or waiting room or what medical service he will be assigned tonursing interventions: ice packs, splint, elevation, cleaning and dressing of a wound; neuro check; patient teaching; referralre-evaluation of patient waiting

Referneces:Buschiazzo, L. (1987). The Handbook of Emergency Nursing Management. Maryland: Aspen Publisher, Inc.Lippincott, J.B. The Lippincott Manual of Nursing Practice. 6th Ed. Philadelphia: Lippincott-Raven PublishersBlack, J.M. & Hawks, J.H. (2004). Medical-Surgical Nursing: Clinical Management for Positive Outcomes. 7th Ed., Vol 2. Singapore: Elsevier Pte. Ltd.Macpherson, G. (2002). Black’s Medical Dictionary. 40th Ed. London: A&C Black Publisher Limited