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Triage
Author: Pamela Dugle

 

Triage | Copyright © 2010 CEUFast.com


Course Contents

 

Purpose/Goals

The purpose of this course is to help nurses develop the competency to distinguishing the five levels of triage and differentiate between first responder and first receiver triage.

 

Course Objectives

After completion of this course the learner will:

1. identify the need for triage
   
2. demonstrate the ability to distinguish between first responder and first receiver triage
   
3. demonstrate the ability to categorize patients in the ESI and ENA triage classifications

 

Introduction

Triage began with the military during World War I. The military leaders needed a process they could use to determine which soldiers could return to duty and when, and the concept of triage was born. At the time, no scientific method of triage existed.

Triage is a French word that emphasizes the context of sorting, or sifting. It was on the battlefields of France that the practice of triage first became formalized, with an effort to systematically sort the wounded into those who could be saved by medical interventions, and those who could not.
(Peterson, et al., 2003)

As the healthcare system evolved, Emergency Departments (ED) became an important source of care for the community. As the patient census increased, ED staff soon realized that a system was needed to assess the acuity of the patients in order to provide the best and most efficient care. Through the years, many methods have been studied to determine the best system for triaging patients.

When the threat of a swine flu pandemic prevailed in 2009, facilities began taking a closer look at their triage systems and planning for a surge of patients. They also began looking at the ethical ramifications of a large increase in patient population and how they could best serve the patient's needs.

Recent statistics released by the Centers for Disease Control (CDC) indicate that ED visits reached 119.2 million in 2009. These same statistics revealed that 40.5% of the population visits the ED. In addition, 13% of the ED visits resulted in a hospital admission and 1.9% resulted in a transfer to a different facility. The median ED visit is 2.6 hours (unknown, 2010). With these statistics one can easily understand the need to sort through these patients and determine who is a priority for the doctor to evaluate. The triage assessment should be completed in two to five minutes, but one study revealed this is only accomplished 22% of the time (Travers, 1999).

 

Triage

Triage is the first assessment in patient care. When an incident of major trauma occurs, the most common chain of events brings a 911 call to local police and emergency services. Bystanders who are present at the site usually make the call for aid and often provide initial response and rescue efforts to injury victims up to and including initiation of basic life support. With the arrival of trained emergency personnel, a more organized rescue effort is established and advanced life support services provided when needed. Key to effective management of the injured, especially when multiple victims are present, is the ability for rapid identification of those individuals who most need and can best benefit from the limited available care.

The triage area in most facilities serves as the front door of the hospital. This area is where life and death decisions are made, and these decisions are based on the knowledge and experience of this trained ED triage nurse.

Reliable triage is critically important; it helps ensure patient safety and accurate identification of the patient's needs. Assessing the airway, breathing, circulation, and disability of any patient arriving in triage assures the proper disposition of the patient. As with any patient, addressing the ABCs are the primary concern, but determining the disability of the patient aids the triage nurse in upgrading any triage disposition decision. Therefore, observing the patient and doing a visual survey is the first step in the process.

As with other aspects of nursing, triage has rights. The four rights of triage include: getting the right patient to the right resources in the right place at the right time. Following the four rights will always lead to accurate triage.

 

Triage Assessment

Triage begins with a general assessment of the patient. The nurse must look at the patient and take note of the patient's condition as he or she approaches the triage desk. For example, the method of movement, noting whether the patient is ambulatory and how the gait is, also not whether the patient is using an assistive device, is the patient in a wheelchair, is the patient alone, or with a crowd must be considered in the general assessment. The most important question to consider is: does the patient look sick.

Three other aspects of triage include obtaining a good history of the patient's presenting symptoms, obtaining a good medical history of the patient, and completing an assessment that is based on the presenting complaint. After the history and assessment have been completed, the triage nurse can make a disposition decision.

While completing the history, the triage nurse should determine if the patient has any allergies to drugs or foods. Make sure to ask about the onset of symptoms. Ask female patients about their menstrual cycle.

Assessing whether or not the patient is in distress is a significant part of triage. Many families wish to do all the talking for the patient. Having the patient answer the questions allows the triage nurse to determine if the patient is able to speak in complete sentences as well as assess his or her cognitive level.

When performing the triage assessment, the triage nurse must actually lay hands on the patient and perform a quick head to toe assessment while focusing on the presenting complaint. Much information can be obtained when executing the triage assessment in this manner. For example, touching the patient tells the nurse the temperature of the skin, the moisture of the skin, the regularity or irregularity of the pulse, and the status of skin tenting. The quick head to toe assessment in the process of performing the focused assessment also tells the nurse if there are signs of abuse or neglect and other problems that could be associated with the primary complaint.

Example: The 30-year-old female that arrives in triage with a chief complaint of abdominal pain must be assumed to be pregnant until proven otherwise. She has bruises in various stages of healing and is accompanied by her boyfriend. At this point it would be imperative to separate the girlfriend and boyfriend to determine if the bruises were a result of abuse by the boyfriend. It must be assumed that she would not discuss the abuse if the boyfriend were present in the room. If abuse is suspected by the nurse, or abuse is reported by the patient, the nurse is obligated to report this. Each ED should have policies and procedures in place for whom to contact when these situations occur.

All patients must be screened for abuse and neglect. Hovering family members often times makes this a difficult assessment to make. Many triage nurses feel uncomfortable asking patient's family members to step outside for a few minutes, and these nurses often have a level of discomfort asking the patient if he/she feels safe in the current living arrangements. These are necessary assessments to make to prevent future occurrences of abuse or neglect. The triage nurse must realize the significance of these questions and treat all the patient's needs.

Screening the patient for signs and symptoms of tuberculosis (TB) occurs in triage to prevent further spread and exposure. Make sure to ask the patient if he/she has had recent unexplained weight loss, night sweats, fever, or coughing.

The focused triage assessment of the presenting complaint must be done by an experienced nurse to help differentiate between possible diagnoses. Bearing in mind that only doctors and midlevel providers have the ability to diagnose illnesses, the experienced triage nurse must be able to anticipate these diagnoses in order to make the proper disposition of the patients.

Regardless of the triage method used by your facility, all patient assessments must include certain key factors such as: onset of symptoms, allergies, associated symptoms, treatment prior to arrival, vital signs, and a description of pain including the PQRLS.

  P=Pain
   
  Q=Quality
   
  R=Radiation
   
  L=Location
   
  S=Severity

Two factors to keep in mind when triaging patients: all chest pain is considered cardiac until proven otherwise and all women of child bearing age are considered pregnant until proven otherwise.

Once the initial triage assessment is completed and the disposition decision is complete, the triage nurse must monitor those patients sent to the waiting room. These patients will need reassessment during their stay in the waiting room. The acuity of the patient's in the waiting area can change, and the acuity level must be advanced based on the reassessment by the triage nurse.

 

Initial Treatment

Treatment begins in triage. Treatment consists of more than just the basic life support expected of all healthcare professionals. The patient coming in with an active bleeding wound will need to have a pressure dressing applied. If the patient is reporting neck pain after falling down and hitting his/her head, the nurse should apply a cervical collar. Hysterical family members will require comfort measures to assist them when a relative is ill or injured.

 

Triage Barriers

Many barriers exist for the triage nurse. Age can be one of the biggest barriers. The very young and the older individuals generally present the most difficulty for the inexperienced nurse. The older individuals frequently have multiple co-morbidities thus magnifying presenting complaints. The younger patients bring a heightened level of psychosocial needs strictly based on their age.

The triage nurse may also over triage, and the treatment area becomes full. Individuals arriving later are under triaged perhaps inappropriately - because there is no room in the treatment area.

 

Pediatric Triage

Pediatric patients present with a different set of problems than adults do regardless of their presenting complaints. One must take into consideration the psychosocial aspects of the pediatric patient. Pediatric patients have a fear of strangers, their perception of the event leading to the need to go to the emergency department, and they have parents who may be hysterical therefore amplifying the patients' anxiety.

The triage nurse must adjust the approach and assessment based on the chronological and emotional age of the child. Children have feelings and emotions just as adults do and are perfectly capable of expressing themselves.
Assessing infants and children present challenges, but these pediatric patients should be assessed just as an adult would be assessed. One exception would be assessment of the pulse. The pulse of the infant would be assessed at the brachial artery rather than at the radial artery. Assessing respiratory quality, rate, and effort would be the same in both children and adults. Most triage assessments are completed in a head to toe fashion. With pediatric patients, the assessment should begin with the chest and abdomen. This will allow for a thorough assessment prior to upsetting the child. A child that is upset might cry or scream and assessing the chest and abdomen would be difficult. One trick used frequently with children to allow for the complete assessment is distraction with a small bubbles wand. This nurse carries a heart shaped bubble necklace filled with liquid bubbles when assessing children. This serves as a distraction and allows the triage nurse to assess respiratory strength and effort while the child blows the bubbles.

The pediatric patient's vital signs must not be forgotten. Knowing the normal ranges for children is vital to making disposition. Table 6 shows the normal range of vital signs for all ages. Overcrowding in the hospital and ED can present triage problems. Limited space in the treatment area can cause the triage nurse to under triage a patient, and patients who should be seen may be sent to the waiting room.

 

Triage Nurse Qualifications

The Emergency Nurses' Association (ENA) recommends that all triage nurses have a minimum of six months ED nursing in addition to completing a triage course which includes a didactic component and a clinical orientation with an experienced preceptor. The ENA also recommends that triage nurses be current in Basic Life Support (BLS), Advanced Life Support (ACLS), Trauma Nursing Core Curriculum (TNCC), Emergency Nursing Pediatric Course (ENPC), and they also prefer to have the triage nurse successfully complete their Certified Emergency Nurse (CEN) examination (Hoyt & Selfridge-Thomas, 2007).

The triage nurse must possess strong interpersonal skills in addition to having the ability to perform focused assessments. The triage nurse must also have the ability to work autonomously and make precise decisions based on the focused assessment. Triage presents a chaotic challenge on many occasions and the triage nurse must possess the ability to work calmly under duress. He or she must maintain control of the waiting room when patients insist on being seen prior to another patient. The triage nurse must be able validate his/her triage decisions and to field questions based on the acuity of the patients (Hoyt & Selfridge-Thomas, 2007). The triage nurse will wear many hats: counselor, nurturer, decision maker, public relations officer, and safety officer, to name a few.

 

Protocols vs. Standing Orders

EDs historically have triage nurses using standing orders for particular diagnoses. The Joint Commission (JC) recommends that no standing order include administration of medications because this calls for the nurse to make a diagnosis and would result in the nurse working outside the scope of practice. The JC realizes having nurses not use standing orders would cause EDs nationally to come to a screeching halt. Their recommendation is to have standing protocols and for them to be based on symptoms rather than diagnoses. The symptom-based protocols allow the nurse to facilitate treatment by ordering diagnostic interventions. This speeds the treatment process and improves stake holder satisfaction (Briggs & Grossman, 2006).

 

Triage Systems

No uniform triage system exists in the United States (US). This creates an injury rating scale dilemma, with each region and emergency service network utilizing its own, perhaps unique, triage method of choice.

The lack of a uniform system in the US is in contrasts with other industrialized nations such as Canada and Australia. In the US, the most common triage practice is a 1-2-3 classification assignment system. This system is initiated at the time of patient entry into the ED. Allocation of care resource decisions are made on an as needed basis, often by an experienced nurse, with the emphasis on ensuring that unstable or potentially unstable patients be seen rapidly while those deemed not likely to deteriorate wait for care. Ever more rapid response by emergency medical services (EMS) and their need to make field decisions according to the acuity of trauma victims has shown that the traditional 1-2-3 triage system is finding great difficulty stretching to encompass site-of-event trauma scenes (Carley, S. and Mackway-Jones, K. 2005). However, studies have created the five-level triage which is currently in use in many hospitals across the country.

The growing trend of EMS involving hospital services in the initial on-scene assessment of major trauma provides a great advantage by supplying the receiving facility with information that will allow preparation for the trauma victim, which in turn, prompts high levels of time effective treatment. Forming methods which integrate field and hospital needs would support an emergency medical service system that provides better continuity of care, as displayed in the following model.

  
 

 

START System

 One effective triage assessment system for mass trauma that is gaining in popularity is the Simple Triage and Rapid Treatment (START) system. START originated during the 1980s at Newport Beach, California from a system cooperatively developed by local fire department and hospital personnel. The START system, like all successful triage methods, helps organize and prepare emergency personnel for the best use of their resources when faced with multi-casualty events. It emphasizes rapid classification of injury victims by senior on-site personnel. The senior personnel use rapid assessments, under one minute per victim, and colored, highly visible priority tags to minimize confusion at the scene. The START system categorizes patients into four groups: Red, Yellow, Green and Black.

  Red (Immediate): Patients are critically injured, with problems that will require immediate intervention to correct
   
  Yellow (Delayed): Patients are injured and will require some medical attention, yet will not die if care is delayed for other patients. Individuals placed in this category have respirations under 30 per minute, capillary refill of less than 2 seconds and can follow simple commands. Yellow patients are not ambulatory and will require a stretcher for transportation
   
  Green, or Ambulatory: Patients are not critically injured and can walk and care for themselves, but they require minor treatment
   
  Black: Patients, are deceased or have such catastrophic injuries that they are not expected to survive transport

The following algorithm is a visual representation of the START system.

  
 

For purposes of this course, triage will be divided into two main groups. Group one will be the first responder (pre-hospital) triage and group two will be the first receiver (hospital) triage.

First responder triage commences when the EMS personnel arrive on the scene. In the event of a large event the START method of triage takes place. In the state of Florida the new START tag was adopted several years earlier. This tag includes the four triage classification colors in addition to the contamination strip. When a hazardous chemical exposure is involved the EMS crew will initiate the gross decontamination process. Once a patient has gone through gross decontamination, the contamination strip is removed along with the unnecessary triage classification strips. The patient is then transported to the first receiver hospital where fine decontamination is performed. Patients arriving at the first receiver hospital are re-triaged once they arrive and have gone through fine decontamination. Triage classification at this point can change. For example: Mr. Jones was at the scene of the hazardous exposure event and during pre-hospital triage he was classified as a yellow patient because he had injuries requiring medical treatment but his mental status was within normal limits and his vital signs were also within normal limits. Upon arrival to the first receivers he was noted to have a change in his mental status and his vital signs were beginning to go outside the normal range. His respirations were counted at 35 respirations per minute. His respiration increase to greater than 30 has now moved him into the red category. Therefore, his triage classification was upgraded to a red.

Group two triage is the first receiver hospital triage. For many years hospitals enlisted the three level triage classification system: Immediate life threatening, urgent, and less urgent (Blanco, n.d.). This system functioned quite nicely for many years, but as hospitals closed EDs and more patients use the ED as their primary care provider, facilities felt the need to move to a more accurate method of triage and began using a five level triage. The five level triage system has proven to be the most effective and provides the triage nurse with more accuracy and consistency for the triage process (Briggs & Grossman, 2006).

 

Five level Triage System

The ENA adopted and promoted the five level triage system in 2002. The Veterans Healthcare System Emergency Field Advisory Committee adopted the Emergency Severity Index (ESI) five level triage system as the official triage system for the VA EDs nationally.

The ENA five level triage demonstrates assessment criteria and nursing considerations for each level. The five levels are: level one-critical; level two-high risk; level three-moderate risk; level four-low risk; and level 5-lower risk. Table 1 demonstrates how the acuity assessment coordinates with the nursing considerations.

Table 1

Acuity/Assessment Level Nursing Considerations
Level 1-Critical Resuscitation
Level 2-High Risk Emergent
Level 3-Moderate Risk Urgent
Level 4-Low Risk Semi Urgent
Level 5-Lower Risk Non Urgent
(Briggs & Grossman, 2006)

The ESI is a five level triage program used in many EDs throughout the United States as well as in Korea and the Netherlands. The ESI was studied by a group of physicians in the American College of Emergency Physicians (ACEP) and the ENA. The ESI has proven to be a favorite triage classification system with EDs because it is based on both acuity and resources. Benefits of the ESI triage include a quick sorting of patients, discrimination of patients who do not need to be seen in the ED but can be triaged to Urgent Care (UC) or Fast Track (FT), and determination of the thresholds for diversion of patients.

Table 2

Category Criteria Comments
1 Requires immediate life saving interventions Strictly based on acuity
2 High risk Based on acuity. This is the person you would give your last bed to.
3 Requires 2 or more resources Based on resources, but with this category, you must look at the Vital Signs (VS). If the VS are out of the normal range, this patient's classification moves up to a category 2. This patient could wait in the waiting room as long as the VS remain stable.
4 Requires 1 resource Based on number of resources only
5 Requires no resources Based on number of resources only

With the ESI, resources are not counted individually, but in a group. For example, labs constitute one resource, therefore a complete blood count (CBC), a basic metabolic panel (BMP), and prothrombin time (PT) on the same patient would be counted as one resource instead of three. If the provider adds a chest x-ray, the resources just increased to two and therefore the triage category just advanced to a minimal three. In the triage category three, the triage nurse then must look at the VS and determine if they are within the normal ranges. If the VS are normal, the patient remains a category three. If the VS move outside the normal range, the patient's triage classification advances to a category two. Examples of resources and non-resources are listed in Table 3 (Clancy, n.d.).

Table 3

Examples of Resources Not Considered to be Resources
• Labs
• X-Rays, CT, US
• EKG
• Medications (IV, IM, nebulizer)
• Procedures
• Consults
• Point of care testing
• Prescription refills
• Splints and assistive devices
• IV lock
• Medication (PO)
• Simple wound care
• Phone calls to the provider

Most patients in categories three, four, and five can wait in the waiting room. Categories four and five could be seen in UC or FT if the facility has these resources available. If a facility does not have an UC or FT, all patients must be medically screened prior to sending them away from the area in order to avoid an Emergency Medical Treatment and Active Labor Act (EMTALA) violation. The EMTALA Act was passed in 1986 after a woman in labor was turned away from an ED because she was unable to pay for hospital services (Miller, n.d.). The purpose of the EMTALA Act was to prevent patient dumping.

Triage does not serve as a medical screening. Doctors and midlevel providers are the only individuals qualified to perform the medical screening exam. Van Der Wulp, Sturms, Schrijvers, and Van Stel (2009) reported that their two year study of 117,740 patients who were triaged at two EDs showed that 22% of the patients were classified as an ESI level five. Of these 22%, 6.2% were admitted to the hospital. In their evaluation, they determined that the patients had been under triaged.

While the patients in categories three, four, and five wait in the waiting room, they must be monitored based on your facility's protocols. Many hospitals use the two hour window to reassess any patient waiting in the waiting room. During this waiting period, the patient's condition can change and when it is reassessed, the patient's triage classification must be re-evaluated. For example, the patient who comes in to triage with abdominal pain and the pain level was a three out of 10, VS were normal, and the patient had no other symptoms or complaints is classified as a triage category three and sent to the waiting room because the ED was busy and no beds were available to immediately place the patient. The triage nurse or triage technician checks on the patient two hours later and his pain level has increased to a nine, his VS show a blood pressure of 197/85, and his pulse rate has increased to 110. This patient still needs two or more resources, but because his VS moved outside the normal range, his triage classification should be changed from a three to a two. This patient must not be expected to wait more than an hour to be moved to an ED examination room. The triage nurse must now make adjustments to his or her list of patients and the order in which they are moved to the ED examination rooms. The danger vital signs are shown in Table 4 (Van Der Wulp et al., 2009).

  
 

 Table 5 demonstrates a comparison of the ESI five level triage and the ENA five level triage in reference to respiratory and cardiac situations. The table gives examples of the type of condition that would be included in the five different levels.

The 40-year-old male that arrives in triage and reports having heart palpitations for two days palpitations that have become worse today after using cocaine last night - would fall into the level two triage classification based on ENA and ESI criteria. He would not need immediate life saving interventions, but he would be a high risk patient. For the full description of the ESI follow the link to review version four: http://www.ahrq.gov/research/esi/.

Table 5

Level ESI Respiratory ENA Respiratory ESI Cardiac ENA Cardiac
1 • Artificial ventilation required

• Absent or diminished breath sounds

• Oxygen saturation <90%
• Apnea

• Oxygen saturation <90%

• Unable to speak
• Significantly orthostatic

• Unable to control active bleeding

• Hemodynamically unstable

• Requires electrical therapy such as defibrillation

• Bradycardia in a pediatric patient
• Pulseless

• Non-responsive

• Symptomatic severe hypotension

• Central cyanosis
2 • Acute respiratory distress not requiring artificial ventilation

• Upper airway obstruction

• Pneumothorax

• Potential to decompensate

• Toxic or smoke inhalation

• Facial burns with burned nasal hairs
• Unable to speak in complete sentences

• Oxygen saturation <94%

• Severe stridor

• Moderate use of accessory muscles
• Acute chest pain

• History of angioplasty and chest pain
• Persistent chest pain after nitroglycerin dosing

• Severe chest pain

• Lightheaded

• >35 y.o. with palpitations

• Drug abuse in last 24 hours
 
3 • Productive cough
 
• Wheezing onset within past two hours, normal VS
• Wheezing onset within past two hours

• Frothy sputum

• Tight cough
• Recent chest pain

• Positive orthostatic VS (15 point difference in SBP or HR with position change)

• VS within normal limits
• <35 y. o with palpitations

• Family history of heart disease

• Moderate pain

• VS stable

• Stable rhythm
4 • COPD, having increased cough or shortness of breath and oxygen saturation >88%

• Symptoms consistent with pharyngitis
• Speaking in full sentences

• Fever >103o

• Productive cough

• > 60 y.o. with fever > 101o
• Recent injury  • Fever, cough and congestion

• Recent injury
5 • Non productive cough

• Cold or flu symptoms
• Oxygen saturation >95%

• Non productive cough

• Recent cold or flu symptoms
• Reproducible chest pain

• Pain increases with breathing or coughing

• Chronic pain
• Reproducible chest pain

• Pain increases with breathing or coughing

• Chronic pain
 

 

Table 6

Age Group Respirations Heart Rate Systolic Blood Pressure
Newborn 30-50 120-160 50-70
Infant (1-12 mo) 20-30 80-140 70-100
Toddler (1-3 y) 20-30 80-130 80-110
Preschooler (3-5 y) 20-30 80-120 80-110
School Age (6-12y) 18-25 70-110 85-120
Adolescent (13y +) 12-20 55-110 100-120
Adult 16-20  70-100 < 120
(Briggs & Grossman, 2006)

 

Conclusion

While triage can occur either outside the hospital setting in a mass casualty event or in the hospital for those individuals seeking medical care, the significant point is to remember that triage must be conducted by an experienced, licensed individual with the training and ability to make a rapid focused assessment and formulate an autonomous disposition decision based on this assessment.

 

References

Blanco, C. (n.d.). How emergency rooms work. Retrieved May 5, 2010, from http://www.howstuffworks.com

Briggs, J. K., & Grossman, V. G. (2006). Emergency nursing 5-tier triage protocols. Philadelphia: Lippincott Williams & Wilkins.

Clancy, C. (n.d.). Emergency severity index, version 4: Implementation handbook. Retrieved March 12, 2010, from http://www.ahrq.gov/research/esi/esinote.htm

Hoyt, K. S., & Selfridge-Thomas, J. (2007). Emergency nursing core curriculum (6th ed.). St. Louis: Elsevier.

Miller, G. L. (n.d.). EMTALA.com. Retrieved July 13, 2010, from http://www.emtala.com/

Tabery, J., & Mackett, C. W. (2008). Ethics of triage in the event of an influenza pandemic. Disaster Medicine & Public Health Preparedness, 2(2), 114-118.

Travers, D. (1999). Triage: How long does it take? How long should it take? Journal of Emergency Nursing, 25(3), 238-240.

unknown. (2010, January 18). Emergency department visits. Retrieved May 5, 2010, from http://cdc.gov

Van Der Wulp, I., Sturms, L. M., Schrijvers A, J., & Van Stel, H. F. (2009). An observational study of patients triaged in category 5 of the emergency severity index. European Journal of Emergency Medicine, 00(00), 1-6.

Van Der Wulp, I., Sturms, L. M., Schrijvers, A. J., & Van Stel, H. F. (2009). An observational study of patients triaged in category 5 of the emergency severity index. European Journal of Emergency medicine, 00(00), 1-6.