emergency triage and bcls ,acls 2015

The Emergency Triage

Anusorn Karaker .Registered nurse (RN),MNS.

Rasisalai Hospital , Thailand

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Triage

• “triage” มาจากภาษาฝรงเศสทวา“trier” แปลวา to “sort” or “choose”.

• ระบบในการจำาแนกผปวยตามลาดบความรนแรงของโรค • ซงไดมการรเรมมาตงแตสมยสงครามโลกครงท 1• โดยนายแพทยชาวฝรงเศสชอ Dominique Jean Larrey



Triage


“ ” ในสมยนนการจำาแนกไดกระทาโดยการ เดา เปนหลก และเนนคดกรองเพอใหไดรบการรกษาอยางรวดเรวมากกวาความ

แมนยำา


Patient Classification


Johnson, 1984 : เปนระบบการจดผปวยใหเปนระดบชน และกลมตางๆ ตามลกษณะความเจบปวย โดยมวตถประสงคเพอใชเปนเครองมอจดทาระบบปฏบตการพยาบาลใหเปนมาตรฐาน โดยเฉพาะอยางยงในการประมาณการอตรากาลงบคลากรทางการพยาบาล

Gillies, 1994 : เปนการจดกลมผปวยตามปรมาณและความซบซอนของความตองการในการพยาบาล

Fagerstrom, Eriksson, & Engberg, 1999 : เปนการประเมนความตองการในการดแลเฉพาะบคคลตามชวงเวลา ซงจะแบงตามความตองการในการดแลและกจกรรมการพยาบาล

Faggestrom, Rainio, Rauhala, & Nojonen, 2000 : เปนการจดกลมโดยอาศยการประมาณความตองการการดแลในชวงเวลาใดเวลาหนง ตามการรบรความตองการการดแลผปวย ความรนแรงของความเจบปวย สานกการพยาบาล กระทรวงสาธารณสข (2547) : เปนการจดกลมผปวยในความดแลของพยาบาลในชวงเวลาใดเวลาหนง โดยวตถประสงคเพอการวางแผนการดแล คำานวณและวางแผนอตรากาลงและคำานวณคาใชจายของผปวยแตละกลม และหรอหนวยงาน/องคกร




"Who should be seen first ? ""How long can each patient safely

wait ?"Gilboy, Travers, & Wuerz, 1999; Wuerz, Milne,Eitel, Travers, & Gilboy, 2000




The American Hospital Association

Emergency Severity Index (ESI)


The American Hospital Association


Emergency Urgent Nonurgen

t

The 3-level acuity-rating scale•emergent, urgent, and nonurgent•unclear, not uniform and are often hospital dependent and nurse dependent


Emergency Severity Index (ESI)A Triage Tool for EmergencyDepartment Care version 4


5 ระดบ • ระดบ1 (most urgent) - ระดบ5 (least urgent)

• แบงตามacuity และ resource needs

•ESI concept in 1998


Emergency Severity Index (ESI)A Triage Tool for EmergencyDepartment Care version 4


Resuscitation Emergent Urgent Less-Urgen

t

Non-Urgen

t

ผปวยวกฤต เจบปวยรนแรง

เจบปวยปานกลาง

เจบปวยเลกนอย

เจบปวยทวไป


the Emergency Severity Index



Research on the EmergencySeverity Index

•improvements in ED operations•support for research and surveillance•for benchmarking

(Wuerz et al., 2000. ; Travers, Waller, Bowling, Flowers, &Tintinalli, 2002.; Eitel,Travers, Rosenau, Gilboy, & Wuerz, 2003 ; Tanabe, Gimbel, Yarnold, Kyriacou, & Adams, 2004 ; Worster et al., 2004 ; Durani, Breecher, Walmsley, Attia, & Loiselle, 2009)



The purpose of ED triage

• to prioritize incoming patients and to identify those patients who cannot wait to be seen

• to cope with overcrowding there is a critical need for a valid, reliable triage acuity rating system in order to sort these incoming patients more rapidly and accurately




• ESI (USA) • Canadian Triage and Acuity Scale (CTAS) • Australasian Triage Scale (ATS) • Manchester Triage Scale (U.K.)



EmergencySeverity Index



EmergencySeverity Index Is This a High-Risk Situation?



EmergencySeverity Index START TRIAGE

30 - 2 -Can do R-P-M

R = Respiration > 30 ครง/นาท..........เปนสแดง

P = Perfusion > 2 วนาท.................จดเปนสแดง

M = Mental status = ทาตามสงได ( Can do)จดเปนสเหลอง



EmergencySeverity Index

A. dying?B. shouldn't wait?C. many resources?D. vital signs?



NANDA Nursing Diagnoses

NOC Outcomes and Indicators NIC Intervention Label and select nursing activities

Risk for infection related to immunosuppression secondary to chemotherapy, inadequate primary defenses (central venous catheter), chronic disease (ALL) and developmental level.

0702Immune Status Definition: Natural and acquired appropriately targeted resistance to internal and external antigens.1=severely compromised thru 5= not compromisedAbsolute WBC values WNL(within normal limits)1 2 3 4 5Differential WBC values WNL(within normal limits)1 2 3 4 5Skin integrity1 2 3 4 5Mucosa integrity1 2 3 4 5Body temperature IER( in expected range)1 2 3 4 5Gastrointestinal function1 2 3 4 51 2 3 4 5(NOC, 2008 p.399)

6550 infection protectionDefinition: Prevention and early detection of infection in a patient at riskActivities: Monitor for systemic and localized signs & symptoms of infection (central line site check every 4 hours.) Monitor WBC, and differential results (qod) Follow neutropenic precautions Provide a private room Limit number of visitors Screen all visitors for communicable disease Maintain asepsis Inspect skin and mucous membranes for redness, extreme warmth or drainage (q4 hours) Inspect condition of surgical incision (central line insertion site q 4 hours) Obtain cultures, as needed (Blood cultures prn T>38.3 C q 24 hours) (Drainage @ Central line site) Promote Nutritional intake (1500 kcal per day, Pt likes cereal) Encourage fluid intake (1225 cc per day, Pt likes orange Gatorade) Encourage rest (naps daily 1-3 PM, bedtime t 8:30 PM) Monitor for change in energy level/malaise Instruct patient to take anti-infective as prescribed (Bactrim po BID; Nystatin 5cc,swish & swallow, TID) Teach Family about s & symptoms of infection and when to report them to HCP-Teach patient and family how to avoid infections(NIC, 2008)



Gilboy N, Tanabe T, Travers D, Rosenau AM. Emergency Severity Index (ESI): A TriageTool for Emergency Department Care, Version 4. Implementation Handbook 2012 Edition. AHRQ Publication No.12-0014. Rockville, MD. Agency for Healthcare Research and Quality. November 2011



European Resuscitation Council Guidelines for Resuscitation

2015Section 1. Executive summary

BCLS & ACLS



1669



The chain of survival



1: Early recognition and call for help2: Early bystander CPR

3: Early defibrillation

4: Early advanced life support and standardised post-resuscitation care




1: Early recognition and call for help


Recognising the cardiac origin of chest pain, and calling the emergency services before a victim collapses, enables the emergency medical service to arrive sooner, hopefully before cardiacarrest has occurred, thus leading to better survival



2: Early bystander CPR


The immediate initiation of CPR can double or quadruple survival after cardiac arrest.

If able, bystanders with CPR training should give chest compressions together with ventilations.

CPR while awaiting the arrival of professional help.



3: Early defibrillation


Defibrillation within 3–5 min of collapse can produce survival rates as high as 50–70%. This can be achieved by public access and onsite AEDs.



4: Early advanced life support and standardised post-resuscitation care


Advanced life support with airway management, drugs and correcting causal factors may be needed if initial attempts at resuscitation are un-successful.



Adult BLS sequence



Look , listen and feel for Normal breathing

Alert emergency Service

Send someone to get AED.

Adult BLS sequence



Adult BLS sequence

Make sure you, the victim and any bystanders are self

Check the Victim for a response

Open the Airway



Start Chest Compression

Adult BLS sequence



Combine chest compression with recue breaths

If Untrained or Unable to do Rescue Breaths Continue compression only CPR

Adult BLS sequence



Switch on the AED and attach the electrode pad

Follow the spoken/visual directions

If Shock is indicated deliver Shock

If no shock is indicated continue CPR

Adult BLS sequence



Continue CPR

If unresponsive but breathing normallyIf you are certain the victim is breathing normally but still Unresponsive , Place in the recovery position

Adult BLS sequence



Foreign body airway obstruction (choking)

Suspect Choking Be alert to choking particularly if victim is eating

Encourage to coughInstruct victim to cough



Foreign body airway obstruction (choking)

Give Back Blows If cough becomes ineffective give up to 5 bag bows

Give abdominal thrusts If back blows are ineffective give up to 5 abdominal thrusts



In Hospital Resuscitation



ACLS



ACLS etc.



Quality During CPR and Treat Reversible Causes



Drowning chain of survival



Thank for attention


emergency triage and bcls ,acls 2015

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