TRIAGE AND TRANSPORT

Dr.Suresh Babu Chaduvula

Professor

Department of Obstetrics & Gynecology

King Khalid University

Abha, Saudi Arabia

TRIAGE:

Triage is the term derived from the French verb trier meaning ‘to sort’ or ‘to choose’

It’s the process by which patients are classified according to the type and urgency of their conditions to get the

Right patient to the Right place at the Right time with the Right care provider

AIM To treat the patients in the order of their

clinical urgency appropriately and timely

TYPES

Non disaster: To provide the best care for each individual patient.

Multi casualty/disaster: To provide the most effective care for the greatest number of patients.

DISASTER: Definition: an incident, either natural or

human-made, that produces patients in numbers needing services beyond immediately available resources. May involve a large no. of patients or a small no. of patients requiring significant demand on resources.

The key to successful disaster management is to provide care to those who are in greatest need first. Correct triage is essential to accomplish this goal.

OBJECTIVES -1:

1. Identify patients requiring immediate care.

2. Determine the appropriate area for treatment

3. Facilitate patient flow through the ED and avoid unnecessary congestion.

OBJECTIVES -2: 4. Provide continued assessment and reassessment of arriving and waiting patients.

5. Provide information and referrals to patients and families.

6. Allay patient and family anxiety and enhance public relations.

TRIAGE AREA Immediately accessible Sign posted Allow for patients examination Privacy Staff security Fully equipped with Emergency

equipment Communication services

TRIAGE TIME Should be completed in 10 minutes If it is going beyond 15 minutes call for

additional nurse. Accurate triage is key to the efficient

operation Effective triage – is based on

knowledge, skills and attitude of the triage nurse.

Pediatric cases – record vital signs every 30 mts and others – 60 mts during reassessment.

Triage is an essential function of EDs Urgency refers to the need for time –

critical intervention. Patients who are not critical with low

acuity categories –safe to wait for assessment and treatment but still require admission.

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

know!”

GOALS OF TRIAGE1. Rapidly identify patients with urgent

life threatening conditions2. Assess/ determine severity and acuity

of the problem3. Ensure that patients are treated in

order of clinical emergency4. Ensure that treatment is appropriate

and timely5. Allocate the patients appropriate and

treatment area6. Reevaluate who are in waiting area

ADVANTAGES OF TRIAGE1. Streamlines patient flow2. Reduces risk of further injury/

deterioration3. Improves communication and public

relations4. Enhances team work5. Identifies resource requirements6. Establishes national benchmarks

TRIAGE AREA INCLUDES The triage team

Triage of Victims- first victims to arrive are frequently not

the most seriously injured. They are

1. Critical patients

2. Fatally Injured Patients

3. Non critical patients

4. Contaminated patients

TRIAGE ACUITY SYSTEM [ATS ] Are divided into 5 levels or

categories depending on following acuity determinants

1. Chief complaint2. Brief triage history3. Injury/ illness4. General appearance5. Vital signsThe most urgent clinical feature that is identified will determine ALS category

TRIAGE ACUITY SYSTEM OR LEVELS

Level 1- Resuscitation

Level 2- Emergent

Level 3- urgent

Level 4- less urgent

Level 5- Non urgent

LEVEL I – IMMEDIATE : Resuscitation -- threat to life

Time to nurse assessment IMMEDIATE Time to physician assessment IMMEDIATE

Cardiac and respiratory arrest Major trauma Active seizure Shock Status Asthmatics

LEVEL II - EMERGENT Potential threat to life, limb or function Nurse Immediate , Physician <10 minutes

Decreased level of consciousness Severe respiratory distress Chest pain with cardiac suspicion Over dose (conscious) Severe abdominal pain G.I. Bleed with abnormal vital signs Chemical exposure to eye

LEVEL III - URGENT

Condition with significant distressTime Nurse < 15min, physician < 30

min

Head injury without decrease of LOC but with vomiting

Mild to moderate respiratory distress G.I. Bleed not actively bleed Acute psychosis

LEVEL IV – LESS URGENT

Conditions with mild to moderate discomfortTime for Nurse assessment < 30 minutes Time for physician assessment < 1hour

Head injury, alert, no vomitingChest pain, no distress, no cardiac suspicion.Depression with no suicidal attempt

LEVEL V – NON URGENTConditions can be delayed, no distressTime for nurse 60 minutesPhysician assessment more than 2h or

120 minutes

Minor trauma Sore throat with temperature < 39

degree centigrade Chronic medical illnesses. Alcoholics

BASIC COMPONENTS OF TRIAGE An “across-the room” assessment

The triage history

The triage physical assessment

The triage decision

AN “ ACROSS THE ROOM ASSESSMENT”

To identify obvious life threat conditionsGeneral appearance

Air wayBreathing

Circulation

Disability(neurogenic)

ACROSS THE DOOR ASSESSMENT

• The triage nurse must scan the area where patients enter the emergency door, even while interviewing other patient.

ACROSS THE ROOM ASSESSMENT Air wayAbnormal airway sounds, strider, wheezing

gruntingUnusual posture e.g.. Sniffing position,

inability to speak, drooling or inability to handle secretion

BreathingAltered skin signs, cyanosis, dusky skin, tachypneabradypnea, or apnea periods, retractions, use accessory muscles, nasal flaring, grunting, or audible wheezes

ACROSS THE ROOM ASSESSMENT

CirculationAltered skin signs, pale, mottling, flushingUn controlled bleeding

Disability (neuro.) LOC Interaction with environment Inability to recognize family members Unusual irritability

Response to pain or stimuli Flaccid or hyper active muscle tone

TRIAGE NURSE SHOULD HAVE

Extensive knowledge to emergency medical treatment

Adequate training and competent skills, language, terminology

Ability to use the critical thinker process

Good decision maker

DUTY OF A TRIAGE NURSE Greet patients and identify your self. Maintain privacy and confidentiality Visualize all incoming patients even while

interviewing others. Maintain good communication between triage

and treatment area maintain excellent communication with waiting

area. Use all resources to maintain high standard of

care. Crowd control. Telephone. Communicate with team leader and seek feed

back on decisions.

RETRIAGE Reassess the patient within 1-2hours

of initial triage and continue to reassess on a regular basis, patients who may have presented without cardinal signs of severe illness may develop them during long waits.

Patients who appear intoxicated actually may have life threatening problems such as DKA, and should not be permitted to keep it off in the waiting room.

KEY POINTS The last person in along line at triage

may have a serious medical problem that requires immediate attention

Patient should wait no longer than 10

minutes for triage

If in doubt about a category, choose the higher acuity to avoid under triaging a patient

SPECIAL CONSIDERATIONS FOR TRAUMA AND PREGNANCY

With a trauma call involving a pregnant patient, you have two patients:

The womanThe unborn fetus

Any trauma to the woman has a direct effect on the fetus.

SPECIAL CONSIDERATIONS FOR TRAUMA AND PREGNANCY

Pregnant women may be the victims of:

AssaultsMotor vehicle crashesShootingsDomestic abuse

Pregnant women also have an increased risk of falls.

SPECIAL CONSIDERATIONS FOR TRAUMA AND PREGNANCY

Pregnant women have an increased amount of overall total blood volume and a 20% increase in heart rate.

May have a significant amount of blood loss before you will see signs of shock

Uterus is vulnerable to penetrating trauma and blunt injuries.

SPECIAL CONSIDERATIONS FOR TRAUMA AND PREGNANCY

When a pregnant woman is involved in a motor vehicle crash, severe hemorrhage may occur from injuries to the pregnant uterus.

Trauma is one of the leading causes of abruptio placenta.

Significant vaginal bleeding is common with severe abdominal pain.

SPECIAL CONSIDERATIONS FOR TRAUMA AND PREGNANCY

Cardiac arrestFocus is the same as with other patients.Perform CPR and provide transport.Notify the receiving facility personnel

that you are en route with a pregnant trauma patient in cardiac arrest.

SPECIAL CONSIDERATIONS FOR TRAUMA AND PREGNANCY

Follow these guidelines when treating a pregnant trauma patient:

Maintain an open airway.Administer high-flow oxygen.Ensure adequate ventilation.Assess circulation.Transport the patient on her left

side.

CULTURAL VALUE CONSIDERATIONS

Some cultures may not permit a male health care provider to assess or examine a female patient.

Respect these differences and honor requests from the patient.

A competent, rational adult has the right to refuse all or any part of your assessment or care.

DETERMINE PRIORITY OF PATIENT CARE AND TRANSPORT

The Golden Period is the time from injury to definitive care.

Treatment of shock and traumatic injuries should occur.

Aim to assess, stabilize, package, and begin transport within 10 minutes (“Platinum 10”).

DETERMINE PRIORITY OF PATIENT CARE AND TRANSPORT

DETERMINE PRIORITY OF PATIENT CARE AND TRANSPORT

Rapid scan assists in determining transport priority.

High-priority patients include those with any of the following conditions:

Difficulty breathingPoor general impressionUnresponsive with no gag or cough

reflex

DETERMINE PRIORITY OF PATIENT CARE AND TRANSPORT

High-priority patients (cont’d):Severe chest painPale skin or other signs of poor perfusionComplicated childbirthUncontrolled bleeding

DETERMINE PRIORITY OF PATIENT CARE AND TRANSPORT

High-priority patients (cont’d):Responsive but unable to follow

commandsSevere pain in any area of the body Inability to move any part of the body

DETERMINE PRIORITY OF PATIENT CARE AND TRANSPORT

Transport decisions should be made at this point, based on:

Patient’s conditionAvailability of advanced careDistance of transport

PRIMARY ASSESSMENT Transport decision

Provide rapid transport for pregnant patients who: Have significant bleeding and pain Are hypertensive Are having a seizure Have an altered mental status

PRIMARY ASSESSMENT AT ACCIDENT AREA

Circulation If there are signs of shock, control

bleeding, give oxygen, and keep the patient warm.

Transport decision If delivery is imminent, prepare to

deliver at the scene. If delivery is not imminent, prepare the

patient for transport.

Thank You