1. TRIAGE Mary Corcoran RN, BSN, MICN

2. EMTALA: Emergency Medical Treatment and Labor Act Requires a hospital to provide an appropriate medical screening exam to any person who comes to the emergency department and requests treatment or an examination for a medical condition. If the examination reveals an emergency medical condition, the hospital must also provide either necessary stabilizing treatment or appropriate transfer to another medical facility

4. EMTALA imposes financial penalties on physicians and hospitals

8. If a patient is lying on the sidewalk outside of the parking garage, is the emergency department required to evaluate and treat the person?

10. 3 Common Triage Systems Traffic Director- simplest, non clinical employee greets patient and directs them to treatment area or wtg room based on initial impression- by 2002 obsolete Spot-check triage- appropriate for low volume, ED. Registration greets patient and pages triage nurse. The RN performs basic assessment Comprehensive triage- supported by ENA. Triage done by competent RN. The RN determines priority of care based on physical, developmental and psychosocial needs

11. Triage Acuity In 2003, 2 hospitals had EMT’s and RN’s complete triage’s on 5 scripted patients and then were asked same scenarios 6 weeks later and only 24% of participants assigned the same ratings both times The goal is to develop a standardized acuity system in order for everyone to have the same understanding of each level assigned

12. Trends Affecting ED Wait Times The American Hospital Association (2002) revealed 90% of ED’s perceive they are operating over capacity. The avg time to see ED physician in 2001 (49 min) which was an 11% increase over 1997 And increased to 56min in 2006 Factors contributing to increased ED volumes:- * decrease in ED’s, aging population, longer ED stays, inability to move admissions, increase in the uninsured, po0r access to primary care, nursing shortage

13. The Interview Introduce Yourself Confirm the Patients Identity (IMPORTANT) Obtain a Chief Complaint/Reason for visit Gather Subjective & Objective Data Including LMP, VS, Weight, History, Mechanism etc Perform a rapid, concise, focused assessment, with quick primary and secondary survey

15. Pediatric Patients Use the CIAMPEDS format to triage pediatric patients C- Chief complaint- primary problem I- Immunizations- UTD, NUTD A- Allergies M- Medications – Name, last dose, how much? P- PMH Parents impression of child’s condition E- Events surrounding illness/injury D- Diet- bottles, ounces D- diapers S- Symptoms associated with illness, injury

16. Pediatric Patient Use Similar A-I Assessment criteria as adults A- Airway; patency, positioning, audible sounds B-Breathing; inc or dec WOB. AMU, nasal flaring C-Circulation; color of skin, cap refill D- Disability; activity level, response to environment E-Exposure; identify underlying injuries F- Fahrenheit G- Get VS, including weight in kg H- Head to Toe Assessment; quick related to cc I- inspect the back and isolate; observe for hidden injuries, communicable illness Be cognizant of legal issues related to abuse/neglect and the difference between adults and children

17. OB Patients Most OB patients can be transferred to L&D via wheelchair, Usually patients 20 weeks gestation and greater are evaluated in L&D or by OB physician. EMERGENT OB-A patient with a “presenting part” must be delivered in ED. Prepare for delivery if patient is multigravida, completely dilated, had SROM, or c/o rectal pressure Urgent OB- Patients in active labor- ( contractions 2 minutes apart lasting 60-90 sec, presence of “bloody show”, ROM Non-urgent OB- Patients not in active labor- per hospital policy Legal Considerations-Important to know who can transport patients to L& D

18. Geriatric Population Important points to remember when triaging geriatric patients: Altered pain perception common Delayed presentation common Upper abdominal pain, an ill appearance, abnormal VS= RED FLAG Consider etiology of falls Consider elder abuse Older patients are uniquely prone to delirium

19. Psychiatric Patients All patients exhibiting aggressive and/or agitated behavior are considered violent unless proven otherwise Never turn your back on these patients When speaking to psychiatric patient be simple, direct, clear and concise Do not overlook physical injuries or illnesses in psychiatric patients

20. What do you think? 40 y/o old female c/o epigastric pain, vomiting 50 y/o male with a ripping sensation in his chest? 23 y/o with RLQ pain and fever? 19 y/o post partum, hypotensive & fever? 2 y/o, vaccines NUTD, drooling & fever? 4 week old male, vomiting after every meal? 80 y/o with abdominal pain, vomiting bilious? 4 m old diff breathing, congestion- winter months?

21. Recommended by the ENA (Emergency Nurses Association) and ACEP (American College of Emergency Physicians) ESI 5 level Triage System

22. Introduction Level 1- Resuscitation 0 minutes Level 2- Emergency 10 min Level 3- Urgent 30 minutes Level 4- Semi urgent 60 minutes Level 5- Non-urgent 120 minutes

23. Level 1 Requires Life Saving Intervention? Yes No High Risk Situation Or Confused/Lethargic/ Disoriented Or Severe pain/Distress Level 2 Yes How Many Resources are Needed? None One Many yes Level 3 Dangerous Vital Signs? Level 4 Level 5 No

25. Airway, breathing, circulation

26. Potential for life, organ or limb threat

27. How soon the patient needs to be seen

28. Expected resource assessment

30. Mutually exclusive

31. Allows for rapid sorting

32. Differs from a complete assessment

33. Gather sufficient information to assign an ESI level

35. Experienced emergency department nurse at triage

37. Yes Is this patient dying? A 1 No

39. Obstructed or partially obstructed

40. Unable to protect their own airway

41. Breathing

42. Apneic

43. Intubated pre-hospital

44. Severe respiratory distress

46. Pulseless, or concerned about rate, rhythm or quality?

47. Drugs

48. Hemodynamic interventions

50. Examples:

51. Hypoglycemia needs glucose

52. Heroin overdose needs Narcan

54. Intubation

55. -Surgical airway

56. -CPAP, BiPAP

57. -Bag valve mask ventilation

58. Defibrillation

59. External Pacing

60. Chest needle decompression

61. Significant IV fluid resuscitation

62. Blood administration

63. IV medications

64. vasopressors

65. Control of major bleedingResuscitation Hemodynamics

66. What are NOT life saving interventions? ECG Laboratory studies Oxygen Monitor IV access ASA Nitroglycerine Pain medications Antibiotics Heparin Diagnostic Tests Medications

67. No Yes Can not wait? B No 2

68. High risk situation? or Confused/lethargic/disoriented? or Severe pain/distress? B Yes 2 No

70. Does not require a full set of vital signs

71. Unsafe for the patient to wait

72. Suggestive of a condition that could easily deteriorate

73. Symptoms of a condition where treatment is time sensitive

75. Rule out PE

76. Newborn with a fever

77. Rule out ectopic pregnancy

78. Neutropenia with a fever

79. Suicidal/homicidal

80. New Onset Confusion in elderly

81. Adolescent found confused and disoriented

82. Patients in SEVERE pain

84. Pain intensity rating

85. Chief complaint

86. PMH, medications

87. VS, physical assessment findings

88. Assign ESI level 2 if and only if

89. Self-reported 7/10 or greater

90. AND

91. RN cannot intervene and they require immediate intervention

93. Burn victim

94. Oncology patients

95. Possible dislocated shoulder

97. Based on the standard of care

99. Mean Resources Used Per Triage Category Mean # of resources used ESI Triage Level

100. Resources: Count number of different types of resources, not individual tests or x-rays (ex: CBC, electrolytes, and coags equal one resource; CBC plus chest x-ray equal two resources.

102. Examples:

103. Healthy 10 year old with “poison ivy”

104. Healthy 52 year old who ran out of his blood pressure medicine yesterday

105. 22 year old, involved in a car accident 2 days ago, wants to be checked. Nothing hurts.

107. Care by mid-level providers in fast track or express care setting

109. Healthy 19 year old with sore throat and fever.

110. Healthy 29 year old with a UTI, denies vaginal discharge.

111. Healthy 43 year old with stubbed toe who states “I think I broke it!”.

113. Require in-depth evaluation

114. Long length of stay

117. Danger zone vitals? HR RR SaO2 <3 m >180 >50 <92% 3m-3y >160 >40 <92% 3-8y >140 >30 <92% >8y >100 >20 <92% Level 3

119. 1 to 3 months of age: consider assigning ESI 2 if temp >38.0c (100.4F)

122. Vaginal Bleeding/ Abdominal Pain 23 y/o female presents to triage with a CC of moderate vaginal bleeding and generalized abdominal cramping (5/10) for 2 hours. Her LMP was 8 weeks ago. She is G1P0. Her skin is warm and dry. Her vital signs are: BP 110/80, T 98.6, HR 84, RR 20

124. PNA A 70 year old male arrives by ambulance from a nursing home. The nursing home reports a non-productive cough since he choked on his lunch today. His baseline mental status is unchanged, although he is normally confused. Skin is warm and moist. His vital signs are: BP 135/80, T 100.2, HR 94, RR 20, SpO2 94% on RA

125. Laceration A tearful 5 year old is carried in by her father who reports is daughter was trying to help set the dinner table and broke a glass. You notice a 3 cm laceration on her left hand. The bleeding is controlled. No history, allergies or meds. Her vital signs are: BP 98/64, T 97.8, HR 108, RR 24

127. Trauma Notified by EMS you are receiving an 8 y/o female hit by a bus. Witnesses state she was thrown across the street. VS= HR=148, RR=36, BP=70/palp, O2 sat=91%.

128. What if they Leave? LWBS Pts who are LWBS (Left Without Being Seen), are more common in high volume ER’s Most patients are frustrated with the long wait times Discuss the LWBS policy with your specific facilities

129. Triage Nurse Qualifications Triage Nurses are the Gate Keepers to the ER, if they Over-triage they can use up vital beds in the ER, if they Under-triage they can delay vital care Triage Nurses must be knowledgeable, experience, temperament, and qualifications necessary to function in a high stress roll Most facilities require at least 6mo- 1year of ER experience before allowing nurses to triage

130. Questions?