Are You REALLY Sick?
Concepts of effective triage
JHS EDUCATORS
Objectives
1. Define Triage
2. Recognize the role of the Triage nurse
3. Discuss current Triage classification systems
4. List the benefits of a five level system
5. Practice using the Emergency Severity Index
System
Welcome to the Emergency room?
What is Triage?
• Triage – is a French word meaning “ to sort” or “to
choose”
• The triage process is an essential component of
safe emergency care
• Triage sounds simple but it is really complex
• The triage process is an essential component of
safe emergency care
– Knowing who is the sickest is crucial.
What is Triage?
• Triage is a method:
– The purpose is to prioritize care
delivery based on rapid
assessment.
• A Triage Nurse should be
able to rapidly and accurately
identify the small percentage
of patients requiring
immediate -vs- delayed care
Triage Nurse
• Triage assessment should be timely and
brief. Enough information to determine acuity.
Average time of 5 minutes.
– This timeframe is met only 22% of the time.
Triage Nurse
• The Triage of Pediatric and Geriatric population
may take longer.
– Barrier or challenges such as developmental
stage may increase assessment time.
Triage Nurse
• The Triage Interview starts with the
introduction.
• The initial greeting sets the tone of the
whole visit.
• People skills count.
• What an ER nurse may think of as minor, it
maybe stressful and a crisis for families or the
patients
Triage Nurse
The Nurse determines the chief complaint
and history of the present injury or illness.
– Based on these findings the nurse conducts a
focused assessment of the problem and measures
vital signs. Only then can a severity be
determined
– Line of questioning should use open ended
questioning, Example…What seems to be the
problem?
Triage Nurse
• Triage is the front line:
– Triage serves as the gatekeepers:
• Careful not to over triage (which does not put the
sickest patients where they need to be
or
• under triage (which compromises patient safety)
Triage Nurses Role
• The Triage Nurse ensures that the right
person is put in the right place at the
right time for the right reasons
– Which eventually:
• Improve throughput
• Maximize patient care and outcomes
• Improve patient satisfaction
Triage Nurse
• Triage Nurse should also be able to:
– Complete across the room assessment
– Multitask: Multitasking is essential
++++Triage Nurse
Variety of tools exist for gathering
Patient data
Triage Process
• Triage Interview
– Interviewing Tools (Mnemonics):
• Adult: AMPLE
• Pediatrics: CIAMPEDS
– chief complaint, immunizations/isolations, allergies, medications, past medical
history, events, diapers/diets, symptoms
• The W questions (who, what , when, where, and why)
• PQRST
• Objective Data
• Assess only parameters pertinent to chief
complaint or patient presentation.*
Triage Process
• Triage Documentation
– Clear, Concise, and support the
assigned acuity level
– Can use “SOAPIE” to write narrative notes
S: Subjective assessment
O: Objective assessment
A: Analysis of data ( acuity and dx)
P: Plan of care
I: Implementation
E: Evaluation or reassessment
Triage System
• The Triage system serves as a language for
communicating patient severity
• If data is collected correctly, the information
can be used to analyze and trend various
patient outcomes and compare ED’s.
• Initial categorization is crucial. Large
percentage of ED’s frequently report
functioning, at or over capacity
Types of Triage Systems
• Type I ( not endorsed by ENA)
– non-nurse triages and determines acuity
• Type II (used in low volume ED)
– quick look/spot check by RN or MD
– limited subjective and objective data
• Type III comprehensive
– Nurse triages & gathers data
• Two Tiered Triage Systems
– 1st RN quick look & Screening
– 2nd Nurse complete comprehensive
assessment on stable patients
Types of Triage Acuity systems
• Two level system
– Sick
– not sick
• The definitions of emergent,
urgent and non-urgent are
unclear
• Three level
– non-urgent
– urgent
– Emergent
• Four level
–
–
–
–
non-urgent
Urgent
Emergent
Life-threatening
• Five level
– Uses 5 tiered approach
• Standardized use is not uniform
and are often hospitals and nurse
dependent
– Emergent: Immediate Care
– Urgent: Prompt care, may wait
several hours
– Non Urgent: Can wait safely
• ENA encourages and endorses
the 5 tiered approach
5 tiered Severity Rating System
• Validity
– Accuracy of the triage rating
– Do the triage levels truly reflect differences in
severity
• Reliability
– Degree of consistency or agreement among those
using the system
– Will different triage nurses assign the same patient
the same severity level
EMERGENCY SEVERITY INDEX (ESI)
ACUITY LEVELS
When using the ESI Algorithm you should ask yourself ?
LEVEL ONE
Patient is dying.
Patient requires life-saving interventions.
LEVEL TWO
Patient has a risk-risk situation.
Patient is acutely confused/lethargic/disoriented.
LEVEL THREE
Patient requires two or more resources.
LEVEL FOUR
Patient requires one resource
LEVEL FIVE
Patient requires no resource.
Decision Point A:
Is the patient dying?
ESI level I constitute < 5% off all ED patients. Patient is
taken immediately to the treatment area and resuscitation
efforts are initiated.
LIFE THREATENING
INTERVENTIONS
AIRWAY/BREATHING
LIFE-SAVING
NOT LIFE-SAVING
BVM Ventilation
Oxygen administration via nasal canula
Intubation
Oxygen administration via non-rebreather
Surgical Airway
Emergent CPAP
Emergent BIPAP
ELECTRICAL THERAPY
Defibrillation
Emergent Cardioversion
External Pacing
Cardiac Monitor
LIFE THREATENING
INTERVENTIONS
PROCEDURES
HEMODYNAMICS
LIFE-SAVING
NOT LIFE-SAVING
Chest needle decompression
EKGs
Pericardiocentesis
Labs
Open thoracotomy
Ultrasounds
Intraosseous Access
Cat Scans
Significant IV fluid resuscitation
IV access
Blood for acute blood loss
Saline Lock
Control of major bleeding
Central line placement
Decision Point B:
Once the triage nurse determines that the patient does not met the
criteria for ESI level 1, the nurse moves to decision point B.
.
Can the patient wait? NO Would you give this patient your last bed? YES
•
Examples:
–
Active chest pain
–
A needle stick in a health care worker
–
Rule-out ectopic pregnancy
–
Suicidal or homicidal
–
Acute Altered mental status
Decision Point C:
Resources
ESI level 3 patients are predicted to require 2 or more resources
ESI level 4 patients are predicted to require 1 resource
ESI level 5 patients are predicted to require no resources
ESI Resources
• To identify resource needs the Triage nurse must be familiar with
the emergency department standards of care.
• The triage nurse must be knowledgeable about the concept of
“prudent and customary”.
• One easy way to think about this concept is to ask the question “
Given this patient’s chief complaint or injury what resources is the
emergency physician is likely to utilize?
ESI Resources
Resources
Not Resources
Labs (blood, urine, cultures)
History & Physical ( including pelvic)
Point-of -care testing
Diagnostic Exams (X-ray, EKG, CT)
IV fluids (hydration)
Saline or Heplock
IV or IM medications
PO meds
Tetanus Immunization
Prescription refills
Specialty consultation
Phone call to PCP
Simple procedure=1
(Lac repair, Foley cath)
Complex procedure=2
(conscious sedation)
Simple wound care
(dressing, recheck)
Crutches, splints, slings
ESI Resources
• ESI level-3 patients make up the majority of patients seen in the
emergency department.
• They often require a more in-depth evaluation but are felt to be
stable in the short term, and certainly may have a longer length
of stay in the ED.
.
ESI Resources
• ESI level 4 and ESI level 5 make up between 20% and 35% of
ED volume. High proportion of these patients have a traumarelated complaint, these patients could safely wait several hours
to be seen
• Mid-level providers could care for these patients in a fast-track
or express care setting.
Danger Zone Vital Signs
• Experience in ER is key at certain decision points. Look
at the whole picture- presentation, vital signs,
assessment
• Vital signs are needed when patients do not meet al high
level of acuity but will meet at least 2 resources
• Review vital signs and determine level 2 or 3
– Clinical judgment and knowledge influences acuity decisions
– Danger zone vital signs may warrant an “up triage”
Decision Point D:
Vital Signs: Before assigning a patient to ESI level 3, the nurse
needs to look at the patient's vital signs and decide whether they are
outside the accepted parameters for age
Pediatric Fever Considerations
•
•
•
1 to 28 days temp >38 - ESI 2
1 to 3m consider ESI 2 temp >38
3m - 3yrs consider ESI 3 temp >39
or incomplete immunizations, or no
obvious source of infection
Consider upgrading to an
ESI level 2 based on vital
sign abnormalities
ESI vital signs criteria
ESI
Level
Complete set of
V/S at Triage
(Yes/No)
Evaluation Plan
1
NO
Requires definitive care . V/S are either part of the secondary
survey or are done simultaneously when a multimember team
responds to the patient with a life-threatening condition
2
NO
Requires definitive care. V/S are either part of the secondary
survey or are done simultaneously when a multimember team
responds to the patient with a high-risk condition
3
YES
Nurse considers patient’s HR, RR, SaO2 and Temp(Children<2)
to decide if up triage is necessary
4
NO
Patient has a single system problem requiring one or none of
the defined resources,
5
NO
Patient has a single system problem requiring 1 or none of the
defined resources, V/S are not necessary for triage level
assessment but are part of the treatment area evaluation
2,3,4,5
Returning to
waiting room
YES
Vital assessment is necessary to ensure patient safety
Case Scenario
• 80 y/o female with HTN slipped and fell
in bathroom c/o severe right hip pain.
She has also experienced Loss of
Consciousness. The vital signs are
stable. Physical exam reveals
shortened right leg with faint Distal and
popliteal pulses, when compared to the
left side
ESI algorithm
• ESI I
– Does this patient require a life
saving intervention? Yes or
NO
• ESI II
– Is this patient a high risk,
acutely confused/disoriented,
or in severe pain or distress
Answer of yes (ESI II), an answer
of no continue with ESI III, IV or
V utilizing resources
Case Scenario
• 22 year-old with right lower quad. Abdominal
pain since early am, +nausea, no appetite,
+rebound tenderness 9/ 10
T- 100.80 HR-101 RR16 B/P-116/74
– Intervention:
– Resources:
– ESI Level
Case Scenario
• High risk Appendicitis
• ESI Level: 2
Case Scenario
• 33-year-old female with c/o abdominal pain
5/10, vomiting & diarrhea x 3hrs. Patient
states she thinks she has food poisoning
T- 96.80 HR-86 RR16 B/P-136/74
– Intervention:
– Resources:
– ESI Level
Case Scenario
• ESI III two or more resources
– Patient not high risk or in severe pain
– Labs, IV Fluids, Meds (anti-emetics)
Case Scenario
• Healthy 19 year –old with sore throat and
fever
T- 100.80 HR-86 RR16 B/P-116/64
– Intervention:
– Resources:
– ESI Level:
Case Scenario
• Intervention: Needs an exam, throat culture,
prescription
• Resources: 1( lab)
• ESI Level: 4
Case Scenario
• Healthy 52 year-old male ran out of BP meds;
BP 150/90
•
T- 97.20 HR-76 RR16 B/P-156/94
– Intervention:
– Resources:
– ESI Level:
Case Scenario
• Intervention: Needs an exam and prescription
• Resources: None
• ESI Level:5
Case Scenario
• 45 year-old obese female with left lower leg
pain and swelling, started 2 days ago after
driving in car for 12 hours
– Intervention:
– Resources:
– ESI Level:
Case Scenario
• Intervention: Needs an exam, lab, lower ext.
non-invasive vascular studies
• Resources: 2 or more
• ESI Level: 3
Case Scenario
• Healthy 29 year-old female with c/o burning
on urination patient denies vaginal discharge
– Intervention:
– Resources:
– ESI Level:
Case Scenario
• Intervention: Needs an exam, U/A and urine
culture, maybe urine hCG and prescriptions
• Resources: 1 Labs
• ESI Level:4
Emergency Severity Index
• ESI is endorsed by the Emergency
Nurses Association (www.ena.org)
• ESI is a rapid patient stratification tool
(level 1-5)
• Categorizes patients by acuity and
resources
Emergency Severity Index
System
• Emergency physicians Richard Wuerz and
David Eitel developed ESI (Emergency
Severity Index System) in 1998.
• Paula Tanabe and Nicki Gilboy are nurse
researchers who have conducted several
studies that show ESI is both valid and
reliable
Education
• Receive a free copy of the Emergency
Severity Index, Version 4:
Implementation Handbook @
www.ahrq.gov
References
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Eitel DR, Travers DA, Rosenau A, Gilboy N, Wuerz RC (2003). The emergency severity index version 2 is reliable
and valid. Academic Emergency Medicine 10(10):1079-80.
Emergency Nurses Association (2000). In B.B. Jacobs and K.S. Hoyt (Eds.), Trauma nursing core course
(Provider manual), 5th ed. Des Plaines, IL: Author.
Tanabe P, Gimbel R, Yarnold PR, Kyriacou DN, Adams J (2004). Reliability and validity of scores on the
Emergency Severity Index version 3. Academic Emergency Medicine 11:59-65.
Tanabe P, Gimbel R, Yarnold PR, Adams J (2004). The emergency severity index (v. 3) five level triage system
scores predict ED resource consumption. Journal of Emergency Nursing 30:22-9.
Tanabe P, Travers D, Gilboy N, Rosenau A, Sierzega G, Rupp V, et al. (in press). Refining Emergency Severity
Index (ESI) triage criteria, ESI v4. Academic Emergency Medicine.
Travers D, Waller AE, Bowling JM, Flowers D, Tintinalli J (2002). Five-level triage system more effective than
three-level in tertiary emergency department. Journal of Emergency Nursing 28(5):395-400.
Wuerz R (2001). Emergency severity index triage category is associated with six-month survival. ESI triage study
group. Academic Emergency Medicine 8(1):61-4.
Wuerz R, Milne LW, Eitel DR, Travers D, Gilboy N (2000). Reliability and validity of a new five-level triage
instrument. Academic Emergency Medicine 7(3):236-42.
Wuerz R, Travers D, Gilboy N, Eitel DR, Rosenau A, Yazhari R (2001). Implementation and refinement of the
emergency severity index. Academic Emergency Medicine 8(2):170-6.