Triage Basics

By Kane Guthrie FCENA

Learning Points

• Triage- What is it• The Australian Triage Scale• Triage assessment• Predictors of poor outcome• Red flags at triage• Assigning appropriate ATS

Triage

Trier= to sort.

Triage= establishing priorities of patient care for urgent treatment while allocating limited resources.

Triage

Timely response to abnormal clinical findings reduce morbidity & mortality.

National Triage Scale (1993-1997)

Australasian Triage Scale (1997-present)

The ATS

An assessment tool allowing for:

– Timeliness– Fairness– Consistency– Time to treatment– Performance appraisal

Time-2-Treatment

Physiological Predictors

Looking for the @Risk

• Risk Factors for serious injury/illness

Waiting is Bad

Access Block

• Hospital wide issue• Burden is with ED• ∧Morbidity & Mortality

• Huge impact at triage– Ramping– WR management

Predictors of Bad Outcomes!

• Physiological abnormalities• Failure to recognise & treat• Age >65

Know Your Environment

Making Decisions @ Triage

Interpret

∨

Discriminate

∨

Evaluate

Assessment @ Triage

Its all about:• Airway• Breathing• Circulation• Disability• Exposure/Environment

The Approach

Airway

Always check patency– Consider C-Spine precautions

• Occluded or compromised airway=

ATS 1

The C-Spine

NexusMOI with 1 Criteria:

• Cervical tenderness• Signs of intoxication• Altered Mental state• Significant distracting injury• Focal neurological deficits

Canadian• Only use when GCS 15

Breathing

Assessment includes:– Resp Rate– Work of Breathing

• Detecting hypoxia is paramount!

Circulation

Assessment includes:– Heart rate– Pulse & pulse characteristics– Cap refill

• Signs of haemodynamic compromise=

ATS 1 or 2

Disability

Assessment includes:– Use AVPU or GCS

• Signs of altered level of consciousness=

Important indicator of serious injury/illness

Environment

Assessment Includes:– Assess Temperature

• Hypo/hyperthermia are important indicators of serious illness!

PAIN

“The eye’s don’t see what the mind doesn’t know!”

General Appearance

Look for:– Observe mobility– Does the patient look sick?– Behaviour

– Ability to use vending machine

The Eyes

Some Pearls &

Pitfalls

“Trust your instincts not the paramedics!”

Extremes of Age

• Be aware:

• Physiological differences, limited reserves

High Risk Features

• Chronic Illness• Cognitive impairment• Co-morbidities• Poisonings• Severe pain

• Use caution allocate higher ATS

High Risk Alerts

Trauma Patients

• Look at MOI:– Vehicle rollover– Death in same vehicle– Ejection– Fall from >3 meters

• Use trauma criteria = ATS 1 or 2

The Rashes

When Multiple Patients Arrive!

• Look for compromised A,B,C• Get SJA to triage themselves• Do a mini triage & priorities

Managing the WR

• Use clinical rounding– Reassess and retriage if need– Treat pain– Manage the families

Patient 1

Patient 2

• 80 male• Post fall- GCS 15• On Pradaxa

Patient 3

• BIBP –intoxicated-homeless• Obstructive & belligerent

PEARL

• “Alcoholics were put here to burn triage

nurses”

Patient 4

• 20 male• Playing with nail gun• Got nailed!

Patient 5

• 60 Male• COPD• RR30, Sp02 95%, HR 110

Questions

Take Home Points

• ID & Manage risk to self & patients• 1st impressions count• “Does the patient look sick?”• ID time critical interventions required• Use the Duty consultant & SCO

• The waiting room is your enemy!

Thank you