TRIAGE:

TRIAGE:

Is a process used to determine severity of illness or injury for each patient who enters the emergency department 

Putting the patient in the right place at the right time to receive the right level of care facilitates allocation of appropriate resources to meet the patient’s medical need.

The registered nurse as the appropriate person to perform patient assessment, which is essential for the triage process.

INTRODUCTION

• The use of advanced triage may become necessary when medical professionals decide that the    medical resources available are not sufficient to treat all the people who need help.
• This has happened in disasters such as volcanoes, thunderstorms, and rail accidents.
• In these cases some percentage of patients will die regardless of medical care because of the severity of their injuries. Others would live if given immediate medical care, but would die without it. 

TRIAGE

• is a system of sorting patients according to need when resources are insufficient for all to be treated. The term comes from the French tri (meaning sort).
• is process of assessing patients to determine management priorities.
• is used to sort patients into groups based on the severity of their health problems and the immediacy with which these problems must be treated.

TRIAGE CATEGORIES:

Patients are triaged into 4 categories: Red, yellow, green and Black.

These colours are typically intended to delineate injury severity. 

• Patients categorized as RED will die soon without intervention. They need immediate care.
• Patients categorized as YELLOW are seriously injured but can wait.
• Patients categorized as GREEN are typically the “walking wounded”. These patients have minor injuries.
• Patients categorized as BLACK are either dead or their injuries are not compatible with life and must be left.

The JumpSTART System

• R-Respirations: 15-45 is considered good. If not breathing, reposition, check P-pulse. If pulse, 5 rescue breaths. If continued apnea tag BLACK.
• A respiratory rate <15 or >45 is tagged RED.
• With a rate of 15-45, assess circulation. Assess a distal pulse for quality. If the distal pulse is weak or absent, tag RED.
• M-Mental status is based on AVPU. If the child is Alert, responds to Verbal or Pain, tag YELLOW. If unresponsive, tag RED.

URGENCY CATEGORIES

EDs use various triage systems with differing terminology, but all share this characteristic of a hierarchy based on the potential for loss of life.

Emergent patients have the highest priority– their condition are life-threatening and they must be seen immediately.

Urgent patients have serious health problems but not immediately life-threatening ones; they must be seen within 1 hour.

Non-urgent patients have episodic illnesses threat can be addressed within 24 hours without increased morbidity.

LANGKAH-LANGKAH PERANCANGAN TRIAGE

The goal of the triage process are to gather sufficient data for determining acuity, identify immediate needs, and establish rapport with the patient and family.

Use of the nursing process provides the necessary framework for a consistent approach for every patient.

1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation

Assessment

This is defined as a rapid systematic collection of data relevant to each patient.

Subjective data provide information disclose by the patient or family whereas objective data are observable, measurable information.

The triage nurse must focus his or her investigation on history of the complaint and related symptoms and signs.

The “PQRST” mnemonic is one example of a systematic approach to patient assessment. 

COMPONENT	SAMPLE QUESTIONS
P (provokes)    Q (quality)    R (radiant)    S (severity)    T (time)	What provokes the symptoms? What makes it better? What makes it worse? What does it feel like? Where is it? Where does it go? Is it in one or more spots? If we gave it a number from 0 to 10, with 0 being none and 10 being the worst you can imagine, what is your rating? How long have you had the symptom? When did it start? When id it end? How long did it last? Does it come and go?

DIAGNOSIS

• Diagnosis is defined as analyzing information collected in the assessment phase to determine acuity needs.

PLANNING

• Planning is defined as determining a course of action for identified needs to meet the expected outcome
• The triage nurse differentiates urgency of problems and prioritizes care by assigning acuity level, designating an appropriate treatment area, communicating to other team members, and identifying interventions to meet the expected outcome

IMPLEMENTATION

• is defined as carrying out the plan of care
• Nursing interventions, performs diagnostic procedures and treatments defined in established protocols, communicates to the patient and family, mobilizes necessary additional resources and documents all activities in the patient’s medical record.
• Examples of these activities include splinting, ice application, dressing, etc.

EVALUATION

• Evaluation is defined as interpreting the patient’s response to interventions.
• The triage nurse reassesses the patient; evaluates effectiveness of interventions; and revises the plan of care, expected outcomes, and acuity based on new or changing patient data.

THE EMERGENCY TEAM

The emergency department (ED), emergency room (ER), emergency ward (EW), accident & emergency (A&E) department or casualty department is a hospital or primary care department that provides initial treatment to patients with a broad spectrum of illness and injuries, some of which may be life-threatening and requiring immediate attention.

The staff in emergency departments:

1. Doctors,
2. Physician assistants (PAs)
3. Nurses with specialized training in emergency medicine
4. Paramedics 
5. Emergency medical technicians
6. Respiratory therapists
7. Radiology technicians
8. Healthcare Assistants (HCAs)
9. Volunteers

• Other support staff who all work as a team to treat emergency patients and provide support to anxious family members.
• Other specialities can be added depending on the nature of the injury, for example a neurological surgeon will attend if there is a serious head injury.