Triage in Emergency Department Triage Waiting room Team leader.
Triage Lecture Dr F Mesa Gaerlan
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Transcript of Triage Lecture Dr F Mesa Gaerlan
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TRIAGETRIAGE
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The best for the most with the The best for the most with the least by the fewest.least by the fewest.
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HISTORYHISTORY
The word “triage”, arising from the French “trier” meaning “to sort” has its origins in Latin.
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DEFINITIONDEFINITION
Triage is a brief clinical assessment that Triage is a brief clinical assessment that determines the determines the time and sequencetime and sequence in which in which patients should be seen in the ED or, if in the patients should be seen in the ED or, if in the field, the field, the speed of transportspeed of transport and and choice of choice of hospital destinationhospital destination
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PRIMARY OBJECTIVESPRIMARY OBJECTIVES
Promptly identify patients requiring Promptly identify patients requiring immediate, definitive careimmediate, definitive care
Determine the appropriate area for treatmentDetermine the appropriate area for treatment Facilitate patient flow through the ED and Facilitate patient flow through the ED and
avoid unnecessary congestionavoid unnecessary congestion
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Provide information and referrals to patients Provide information and referrals to patients and familiesand families
Allay patient and family anxietyAllay patient and family anxiety Enhance favorable public perceptions of and Enhance favorable public perceptions of and
experiences with emergency servicesexperiences with emergency services
PRIMARY OBJECTIVES PRIMARY OBJECTIVES
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Triage is not only a necessity, but Triage is not only a necessity, but a major component of the a major component of the Emergency Medical SystemEmergency Medical System
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TYPES OF ED TRIAGE TYPES OF ED TRIAGE SYSTEMSSYSTEMS
Very diverseVery diverse Developed according to the institution’s and Developed according to the institution’s and
department’s needsdepartment’s needs Should be tailored to meet the common goals Should be tailored to meet the common goals
of triageof triage
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TYPES OF ED TRIAGE TYPES OF ED TRIAGE SYSTEMSSYSTEMS
# of patients and severity of injuries < # of patients and severity of injuries < resourcesresources Life threatening injuries are treated firstLife threatening injuries are treated first
# of patients and severity of injuries > # of patients and severity of injuries > resourcesresources Patients with greatest chance of survival are Patients with greatest chance of survival are
treated firsttreated first
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TYPES OF ED TRIAGE TYPES OF ED TRIAGE SYSTEMSSYSTEMS
Type I: Traffic Director-TriageType I: Traffic Director-Triage most basic typemost basic type greeting or traffic directing is performed by a non-greeting or traffic directing is performed by a non-
professionalprofessional how “sick” the patient looks determines how “sick” the patient looks determines
classification as emergent or nonurgentclassification as emergent or nonurgent
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TYPES OF ED TRIAGE TYPES OF ED TRIAGE SYSTEMSSYSTEMS
Type II: Spot-check TriageType II: Spot-check Triage ““quick look” systemquick look” system RN or MD obtains info and limited RN or MD obtains info and limited
subjective/objective data related to chief complaintsubjective/objective data related to chief complaint emergent, urgent, delayedemergent, urgent, delayed
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Type III: Comprehensive TriageType III: Comprehensive Triage most advanced system of triagemost advanced system of triage assessment and prioritization performed by an assessment and prioritization performed by an
experienced RNexperienced RN use of sophisticated triage categoriesuse of sophisticated triage categories standards followed for assessment, planning and standards followed for assessment, planning and
interventionintervention
TYPES OF ED TRIAGE TYPES OF ED TRIAGE SYSTEMSSYSTEMS
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COMPREHENSIVE TRIAGE COMPREHENSIVE TRIAGE GOALSGOALS
Identification of patients with life-threatening Identification of patients with life-threatening problemsproblems
Regulation of patient flowRegulation of patient flow Efficient use of resources and spaceEfficient use of resources and space
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APPLICATIONSAPPLICATIONS
TRAUMATRAUMA DISASTERDISASTER PREHOSPITAL PREHOSPITAL OUTBREAKSOUTBREAKS EMERGENCY DEPARTMENTEMERGENCY DEPARTMENT
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START SYSTEMSTART SYSTEM
Simple Triage and Rapid Treatment Simple Triage and Rapid Treatment Created in the 1980”s by Hoag Hospital and Created in the 1980”s by Hoag Hospital and
the Newport beach CA Fire Departmentthe Newport beach CA Fire Department Allows rapid assessment of victimsAllows rapid assessment of victims It should not take more than 15 seconds/ It should not take more than 15 seconds/
patientpatient
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START SYSTEMSTART SYSTEM
Classification based on 3 categories:Classification based on 3 categories: RespirationRespiration PerfusionPerfusion Mental statusMental status
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Medical Screening ExaminationMedical Screening Examination
Chief complaintChief complaint - High acuity, high risk, true - High acuity, high risk, true emergency emergency
Vital signsVital signs - Grossly abnormal - Grossly abnormal Mental statusMental status - Evidence of abnormalities - Evidence of abnormalities General appearanceGeneral appearance - Patient looks sick, patient's - Patient looks sick, patient's
skin looks poorly perfused, patient shows signs of skin looks poorly perfused, patient shows signs of dehydration dehydration
Ability to walkAbility to walk - Patients who cannot walk are at - Patients who cannot walk are at high risk for true emergency medical conditions.high risk for true emergency medical conditions.
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METHODSMETHODS
The majority of US Emergency Departments use 3-level triage: Emergent– requires immediate evaluation &
treatment Urgent–can tolerate a period of time in the waiting
room Non-urgent–minor illness/injury that can be
treated within six hours
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EmergentEmergent
Life and limb threatening conditionsLife and limb threatening conditions Immediate care within secondsImmediate care within seconds cardiac arrest, acute severe chest pain, massive cardiac arrest, acute severe chest pain, massive
vomiting of blood, sudden loss of vomiting of blood, sudden loss of consciousness, and major trauma with consciousness, and major trauma with hypotensionhypotension
Reassessment is continuousReassessment is continuous
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UrgentUrgent
Requires prompt care but will not cause loss of Requires prompt care but will not cause loss of limb or life if left untreated for hourslimb or life if left untreated for hours
acute dyspnea, acute abdominal pain, acute acute dyspnea, acute abdominal pain, acute chest pain, acute confusion, and severe pain. chest pain, acute confusion, and severe pain.
abdominal pain, high fever, acute back pain, abdominal pain, high fever, acute back pain, serious extremity injuries, and large or high-serious extremity injuries, and large or high-risk lacerationsrisk lacerations
Reassessment is every 30 minutes Reassessment is every 30 minutes
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Non-urgentNon-urgent
Disorders are chronic, minor, or self-limiting. Disorders are chronic, minor, or self-limiting. medication refill, acne, mild adult upper medication refill, acne, mild adult upper
respiratory tract symptoms, mild sore throat, respiratory tract symptoms, mild sore throat, blood pressure check, and lumps and bumps. blood pressure check, and lumps and bumps. Keep in mind that no matter how minor, these Keep in mind that no matter how minor, these patients may still require an MSE if they patients may still require an MSE if they request treatment or evaluationrequest treatment or evaluation
Reassessment is every 1 to 2 hoursReassessment is every 1 to 2 hours
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Who should do triage?Who should do triage?
Early studies showed little difference in Early studies showed little difference in predicted outcomes of patients when predicted outcomes of patients when physicians, as opposed to nurses, perform physicians, as opposed to nurses, perform triagetriage
However, more recent studies suggest that However, more recent studies suggest that experienced emergency medicine (EM) experienced emergency medicine (EM) physicians and EM nurses actually may physicians and EM nurses actually may provide the best triage provide the best triage
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PitfallsPitfalls Failure to recognize and attend to a patient Failure to recognize and attend to a patient
who complains of severe painwho complains of severe pain Failure to recognize or acknowledge high-risk Failure to recognize or acknowledge high-risk
chief complaints chief complaints Failure to take adequate vital signs Failure to take adequate vital signs
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PitfallsPitfalls Failure to adequately document the triage Failure to adequately document the triage
and/or MSE and/or MSE Failure to retriage patients initially assigned to Failure to retriage patients initially assigned to
the waiting room: Patients assigned to a the waiting room: Patients assigned to a waiting room should have vital signs retaken waiting room should have vital signs retaken every 2 hoursevery 2 hours
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CASESCASES
Case 1: A 36-year-old man presented Case 1: A 36-year-old man presented to the ED with severe chest pain. His to the ED with severe chest pain. His vital signs were blood pressure, vital signs were blood pressure, 140/90 mm Hg; pulse, 120 beats per 140/90 mm Hg; pulse, 120 beats per minute (bpm); respiration, 20 breaths minute (bpm); respiration, 20 breaths per minute (bpm); and temperature, per minute (bpm); and temperature, 99°F. Although the patient's pulse was 99°F. Although the patient's pulse was 120, his respiratory rate was normal, 120, his respiratory rate was normal, and he looked well. and he looked well.
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Case 2: A 43-year-old man presented to the Case 2: A 43-year-old man presented to the ED, complaining of a severe headache. The ED, complaining of a severe headache. The patient had normal vital signs except for a patient had normal vital signs except for a temperature of 39°C. The ED was very busy temperature of 39°C. The ED was very busy and crowded. and crowded.
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Case 3: A 65-year-old man Case 3: A 65-year-old man presented to the ED presented to the ED complaining of groin pain. complaining of groin pain. He said the pain was He said the pain was severe and he did not feel severe and he did not feel well. His vital signs were well. His vital signs were blood pressure, 150/95 mm blood pressure, 150/95 mm Hg; pulse, 108 bpm; Hg; pulse, 108 bpm; respiration, 22 bpm; and respiration, 22 bpm; and temperature, 38°C. temperature, 38°C.
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Case 4: A 55-year-old man Case 4: A 55-year-old man presented to the ED presented to the ED complaining of abdominal complaining of abdominal pain. He stated that he pain. He stated that he thought his condition was thought his condition was secondary to eating too secondary to eating too much greasy fast food too much greasy fast food too rapidly. His vital signs rapidly. His vital signs were blood pressure, were blood pressure, 150/100 mm Hg; pulse, 150/100 mm Hg; pulse, 100 bpm; respiration, 22 100 bpm; respiration, 22 bpm; and temperature, bpm; and temperature, 37°C. 37°C.
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Case 5: A 22 year old Case 5: A 22 year old female came in due to acute female came in due to acute onset diarrhea. She had onset diarrhea. She had about 6 episodes and had about 6 episodes and had severe epigastric pain. BP: severe epigastric pain. BP: 120/80, HR: 89 and RR: 23.120/80, HR: 89 and RR: 23.
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Case 5: A five year old Case 5: A five year old female came in due to fever female came in due to fever and chills of five days and chills of five days duration. HR: 110, RR: 30 duration. HR: 110, RR: 30 and T: 40and T: 40°C. The patient °C. The patient had maculopapular rashes had maculopapular rashes all over.all over.
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TRIAGE TRIAGE EXAMINATIONEXAMINATION
YEAR LEVEL VIYEAR LEVEL VI
20072007
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36/F 36/F fell from a ladder on fell from a ladder on outstretched handoutstretched handwith gross deformity, with gross deformity, L forearmL forearm
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40F, smoker40F, smoker
CC: Vaginal CC: Vaginal bleeding bleeding
VS: VS: BP 80/50BP 80/50
HR 90HR 90
RR 24 RR 24
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55M, hypertensive, 55M, hypertensive, smokersmoker
CC: Chest pain CC: Chest pain
VS: VS: BP 90/50BP 90/50
HR 90HR 90
RR 24 RR 24
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56M, cook56M, cook
CC: difficulty of CC: difficulty of breathing breathing
VS: VS: BP 130/80BP 130/80
HR 90HR 90
RR 28 RR 28
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58M, smoker58M, smoker
CC: LLQ painCC: LLQ pain
VS: VS: BP 120/80BP 120/80
HR 100HR 100
RR 24 RR 24
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19M, vendor19M, vendor
hit-and-run victimhit-and-run victim
unconscious unconscious
VS: VS: BP 130/80BP 130/80
HR 90HR 90
RR 24 RR 24
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22F, student22F, student
CC: R shoulder pain CC: R shoulder pain
VS: VS: BP 120/80BP 120/80
HR 80HR 80
RR 20 RR 20
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36M, non-smoker36M, non-smoker
CC: low back pain CC: low back pain
VS: VS: BP 130/80BP 130/80
HR 88HR 88
RR 22 RR 22
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44M, smoker44M, smoker
CC: amputated CC: amputated index finger index finger
VS: VS: BP 130/80BP 130/80
HR 90HR 90
RR 24 RR 24
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41M, smoker41M, smoker
CC: foreign body CC: foreign body sensation R eye sensation R eye
VS: VS: BP 130/80BP 130/80
HR 90HR 90
RR 24 RR 24
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56M, laborer, 56M, laborer, smokersmoker
CC: unconscious CC: unconscious
VS: VS: BP 130/80BP 130/80
HR 90HR 90
RR 24 RR 24
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40M, carpenter, 40M, carpenter, HPNHPN
CC: fall CC: fall
VS: VS: BP 100/80BP 100/80
HR 90HR 90
RR 24 RR 24
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25M, student25M, student
CC: dog bite CC: dog bite
VS: VS: BP 120/80BP 120/80
HR 80HR 80
RR 20 RR 20
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30M, bodybuilder30M, bodybuilder
CC: chest pain CC: chest pain
VS: VS: BP 130/80BP 130/80
HR 94HR 94
RR 26 RR 26
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40M, smoker40M, smoker
CC: electrocuted/fall CC: electrocuted/fall
VS: VS: GCS 15GCS 15
BP 130/80BP 130/80
HR 90HR 90
RR 24 RR 24
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43M, smoker43M, smoker
CC: numbness, CC: numbness, lower extremities lower extremities
VS: VS: BP 130/80BP 130/80
HR 90HR 90
RR 24 RR 24
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40M, smoker40M, smoker
CC: epigastric pain CC: epigastric pain
VS: VS: BP 140/80BP 140/80
HR 92HR 92
RR 20 RR 20
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12M, vendor12M, vendor
CC: side-swiped by CC: side-swiped by a truck a truck
VS: VS: BP 120/80BP 120/80
HR 90HR 90
RR 24 RR 24
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40M, jockey40M, jockey
CC: fall CC: fall
VS: VS: BP 130/80BP 130/80
HR 90HR 90
RR 24 RR 24
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QUESTIONS?QUESTIONS?
The process we understand as triage was first described by Baron Dominique Jean-Larrey
First systematic description in civilian medicine was from E. Richard Weinerman in Baltimore in 1964