Julie K. Briggs - Emergency Nursing 5-Tier Triage Protocols

xiii Acknowledgments

It has been an absolute pleasure working with Valerie again on the revision of Emergency Nursing: 5-Tier Triage Protocols, Second Edition. I truly appreciate how hard Valerie has worked on this, her friendship, and the tenacity in moving forward with this project in spite of many conflicting priorities in our personal and professional lives. I want to express my gratitude to Elizabeth Nieginski, whose belief in us helped to pave the way for this worthwhile project. Additionally, I want to thank my husband, Worth, and my family and friends for their support and understanding of the time-consuming nature of this project.

Julie K. Briggs

I am honored to have worked on this second edition with Julie, who has been a friend and mentor for many years. I am sincerely grateful for our Springer editor Elizabeth Nieginski, who is a true supporter of nurse authors and the role we play in our profession. My deepest appreciation goes to my daughters (Sarah and Nicole), my Dad (John), and my family, friends, and colleagues who support my passion for nursing and for nurses, and I am honored each time patients allow me to help them on their journey through the healthcare system.

Valerie Aarne Grossman xiv

Appendix A

Triage Program Development Triage Program Development for Emergency Department Nurses

Introduction

This appendix provides a comprehensive guide for the development of a formal triage program that can be used in larger urban EDs, smaller community hospitals, urgent care centers, and rural or remote healthcare centers. It can also be used in the development of a triage unit established in response to a multiple casualty event (MCE) caused by fires, utility failures, severe weather, pandemics, terrorist incidents, chemical spills, active shooter incidents, or any other event with a large influx of victims needing rapid triage to assess the severity of symptoms and need for timely care. In developing an effective triage program, the following issues should be addressed:

The triage area/station

Patient flow

Safety

Supplies and equipment

Rural and remote triage

Legal considerations

Maintaining quality

Training

Managing mass casualties and active shooter incidents

The Triage Area/Station

Establish a triage station that is clearly identified. On entering a facility, patients will generally seek out the first person they see unless there is clear signage to give specific direction where to go: Emergency patients see triage nurse with an arrow pointing to the triage station or Wait here for next triage nurse.

It is natural to go directly to a window or counter with a person who looks available to help. Some EDs place a registration person at the first contact point to enter patients into the computer system and then direct them to the triage nurse before any financial information is obtained.

The triage area should include a counter or window for the rapid triage or first encounter.

Establish a more private area for a more comprehensive triage assessment.

EDs seeing more than 30,000 patients a year will need at least two persons stationed at triage: either two triage nurses or one triage nurse and a technician.

The initial rapid triage station should provide seating for the nurse and for patients unable to stand at a counter.

The comprehensive triage area should provide seating for both the nurse and the patient. Some nurses prefer to use a stand-up computer terminal while assessing the patient.

If more than five patients are waiting for a comprehensive triage for more than 15 minutes, consider adding a second nurse and workspace to conduct the triage assessment. A patients condition could have deteriorated if waiting for an hour for a comprehensive assessment.

Establish a seating area adjacent to the initial rapid triage station to place urgent patients and others the nurse is concerned about so that the patient is always visible to the triage nurse. Some facilities require a reassessment for any urgent patient waiting for more than 60 minutes.

Develop a system for keeping track of where patients are in the triage process and the next step from triage to treatment. Some EDs use chart racks and move the chart from one rack to another as each phase of the process is completed, such as waiting for a comprehensive triage, registration, nurse-initiated/technician orders for treatment, laboratory or x-ray orders (per facility policy and procedures), and ready for next available treatment bed. This system can also be maintained on an electronic tracking system so that staff in the treatment area are also familiar with the flow of patients through triage.

Establish more than one exit route out of each triage station.

Patient Flow

Most EDs use a staged approach to triage including a rapid triage nurse, a comprehensive assessment nurse, a technician, and patient registration.

Rapid triage starts across the room when the person enters the facility. The RN obtains the patients name, date of birth (DOB), chief complaint, and time of arrival, and then makes a decision to move the patient to a treatment area for emergent care or the second stage, which may be registration or a comprehensive triage for a more thorough assessment. The rapid triage can occur at an open counter easily accessed by the patient. Rapid triage takes about 60 to 90 seconds and is a quick method to identify people at greatest risk of deterioration while waiting for the more in-depth triage.

Assess for potential life-threatening conditions.

Assess mobility: Does the person use an assistive device such as crutches, walker, cane, or wheelchair? Is his or her gait fast, slow, or weakened, or is the person unable to ambulate?

Assess facial expression or body language, which can indicate discomfort, fear, pain, facial drooping, signs of a stroke, or aggressive behavior.

Assess mental status: Is the person altered or impaired?

Assess airway/breathing: Is it labored, noisy? Does the person seem to have difficulty breathing, getting air in or out? Is the person drooling?

Assess circulation, note the color of the skin (pale, blue, red), is the person diaphoretic, is there obvious bleeding?

Assess neurologic status, note the level of responsiveness and upper and lower extremity movement and strength.

Assess signs of environmental exposure due to weather, chemicals, fire.

The comprehensive triage should occur in a more private area and includes vital signs including oxygen saturation, and a more comprehensive assessment to determine acuity and urgency for treatment.

If the RN is busy completing a comprehensive assessment, a technician can meet and greet the patient, determine the chief complaint, name, and DOB, and reassure the patient that the nurse will be available shortly. If the complaint seems urgent and the triage RN cannot be interrupted, an RN from the treatment area should complete the triage to determine if emergent care is appropriate.

Technicians can play a valuable role at triage. Responsibilities may include the following:

Measure vital signs

Help facilitate patient movement through the triage process

Collect some patient history

Perform laboratory testing per facility policy such as blood draws

Conduct EKGs per facility policy

Apply dressings or splints

Assist patients with mobility (i.e., assist in and out of cars, provide wheel chairs)

Keep the triage area stocked with supplies and equipment

Be familiar with conditions that often require immediate attention

Some EDs also utilize advance care providers at triage to help decrease waits and utilize the ED more efficiently. This role may be filled by an MD, NP, or PA who can provide a medical screening exam (MSE) at triage to determine that the person does not have an emergency medical condition and can be safely referred to other healthcare resources. (See Legal Considerations later in this appendix for additional information on the MSE.)