General Triage Guidelines
The triage nurse should have rapid access or be in view of the registration and waiting areas at all times.
- Greets client and family in a warm empathetic manner.
- Performs brief visual assessments.
- Documents the assessment.
- Triages clients into priority groups using appropriate guidelines.
- Transports client to treatment area when necessary.
- Gives report to the treatment nurse or emergency physician, documents who report was given to and returns to the triage area.
- Keeps patients/families aware of delays.
- Reassesses waiting clients as necessary.
- Instructs clients to notify triage nurse of any change in condition.
Accurate assignment of triage levels is based on:
- Practical knowledge gained through experience and training.
- Correct identification of signs or symptoms.
- Use of guidelines and triage protocols.
A triage level must be recorded on all patients, during all shifts. This includes all ambulance patients.
When the triage nurse has categorized more than 3 urgent patients, it is his/her responsibility to prioritize these patients for the treatment nurse/ emergency physician.
Triage is a dynamic process: A patient’s condition may improve OR deteriorate during the wait for entry to the treatment area.
The Triage Process: Primary survey vs Primary Nursing Assessment:
There can be confusion about the amount of detail required to assign a triage level. A short primary survey may be necessary to ensure patient flow and reduce delays to first contact with a health provider. In many REHCF’s and at certain times in larger ED’s, the initial triage assessment may be a more detailed “primary nursing assessment”. The need to meet time objectives for triage assignment within 10 minutes of arrival means that the triage assessment may be limited to 2 minutes unless there are other operational policies like bringing on more triage personnel. The “primary nursing assessment” is more detailed and more accurately determines the patients need for care.
- All patients should be assessed (at least visually) within 10 minutes of arrival.
- Full patient assessments should not be done in the triage area unless there are no patients waiting to be seen. Only information required to assign a triage level should be recorded.
- A primary survey (rapid assessment) should be used when there are 2 or more patients waiting to be triaged. After all patients have had some assessment done, level IV and V patients that have been sent to the waiting area should have a more complete assessment done by the triage personnel or treatment nurse. .
- The priority for care may change following a more complete assessment or as patient’s signs and symptoms change. There should be documentation of the initial triage as well as any changes. The initial triage level is still used for administrative purposes.
- Level I, II, patients should be in a treatment area and have the complete primary nursing assessment done immediately.
The triage assessment:
- Chief complaint: patient’s statement of the problem
- Validation and assessment of chief complaint:
- When did it start (be exact with time)? What were you doing when it started?
- How long did it last?
- Does it come and go?
- Is it still present?
- Where is the problem? Describe character and severity if painful (Pain scale).
- Aggravating or alleviating factors?
- If pain is or was present: Character and intensity (pain scale) to be documented.
- Previous history of same? If yes, what was the diagnosis?
Objective: this part of the triage assessment may be deferred to the treatment area if the patient requires rapid access to care / interventions (Level I, II, III).
- Physical appearance – color, skin, activities
- Degree of distress: severe distress; NAD (no acute distress)
- Emotional response: anxious, indifferent
- Complete Vital Signs if time allows or necessary for assignment of triage level (Level III, IV, V).
- Physical assessment
- Medications – List by name, if available. List by category if patient doesn’t know name: B/P, heart, stomach, nerve, etc
Triage is not a static process.
It is important to remember that triage is a dynamic process and patients may move up or down on the urgency continuum while waiting for access to treatment areas, physician assessment, results of investigation or response to treatment. Triage systems should be accompanied by protocols on:
- How quickly a patient is to be seen by the health care provider for specific complaint types?
- How often patients in each triage category will be reassessed and where that information should be documented?
- How patients with defined signs and symptoms are categorized i.e., chief complaint.
- What types of interventions are expected to be initiated in triage?
- What types of reassessments should be done? The options vary from a quick overview of the waiting room patients, to a repeat primary survey and repeat vital signs.
- Designating time frames and methods of reassessment in your guidelines provides a framework for evaluating quality / outcomes and preventing patient deterioration.
Objectives for time to Nursing reassessment is related to triage level
||Every 15 minutes
||Every 30 minutes
||Every 60 minutes
||Every 120 minutes
- There should be a nursing reassessment on all patients at the time intervals recommended for physician assessment. That is: Level I patients should have continuous nursing care, Level II every 15 minutes, Level III every 30 minutes, Level IV every 60 minutes and Level V every 120 minutes. This is to ensure that patients are reassessed to confirm that their status has not worsened.
- When patients have a medical diagnosis or are considered “stabilized”, the frequency of nursing assessment and care will depend on the existing care protocols or MD orders.
- When patients have exceeded the time objective for MD assessment for their triage level they should be up triaged to avoid unfair bumping and long delays to MD assessment.
Tips for the Triage Interview
Open ended questions help elicit feelings and perceptions along with information. Closed questions (with yes or no answers) are useful for obtaining facts. In general, initial questions should be open-ended (subjective assessment), whereas closed questions (objective assessment) can be used to validate information. Triage providers develop interview techniques that suit their communication style, the clientele, and the environment. Many factors influence effective communication at triage: language barriers, age, pain level, hearing disability, mental competency. Non-verbal information is also an important source of information.
Physical assessment accompanies the triage interview, chiefly through observation. Assessment may begin with the observation that the patient can speak and therefore has a patent airway. Physical assessment must be rapid, concise, and focused. In some patients objective measures such as vital signs and/ or O2 saturation may be reasonable while in others it would be a description of physical signs.
Effective triage requires the use of sight, hearing, smell and touch. There are many non-verbal clues: facial grimaces, cyanosis, fear… Listen to what the patient is saying and pay attention to questions they are reluctant or unable to answer. Listen for a cough, hoarseness, laboured respiration… Touch the patient; assess heart rate and skin temperature and moisture. Notice odours such as the smell of ketones, alcohol, or infection.
Remember that the purpose of the triage interview is to gather enough information to make a clinical judgment for priority of care, not a final medical diagnosis. Often, the most time consuming task of triage is to allay patient and family anxiety.
Attitude and empathy are important aspects of the triage nurse’s demeanor. Remaining consistent and non-judgmental toward all patients is important. Difficult patients such as those who are intoxicated and combative require special care. Any element of prejudice, leading to a moral judgment of patients, can increase patient risk due to incorrect assignment of triage levels, to low care needs priority. Do not to prejudge patients based on appearance or attitude.
Assessment: -subjective/ objective data
- 2 – 5 minute interview
- Not a head to toe assessment (treatment nurse should complete).
- Need enough critical information to determine patient acuity and any immediate care needs.
Vital signs (VS) will be done on patients if required for categorization or if time permits. Otherwise VS are the responsibility of the treatment nurse. Any patient presenting to the ED who is Level I or II will be taken immediately to an appropriate treatment area. It is the treatment nurse’s responsibility to do a full assessment (primary nursing assessment) including VS.
Should be attempted on all patients with pain. It is used, in conjunction with the presenting complaint, to assign patients with similar complaints, to different triage level. Pain scales are not absolute, but do allow the patient to communicate the intensity of a problem from their
perspective. The more intense the pain (8-10/10) the more the care provider should be concerned about the need to identify or exclude serious illnesses and attempt to offer empathy or interventions that will diminish unnecessary pain and suffering. Because pain perception is very individual and may be influenced by age and cultural differences, it would be unwise to exclude serious problems when pain is not described as severe (Oh nurse it’s not a pain, just a discomfort…but dear its just a heart attack!). It is also true that severe pain can be associated with benign processes. The scales are less helpful (or reliable) at the extremes of age.
The consistent use of pain scales is an extremely important component of the triage scale. This also allows for confirmation of improvement that both provider and patient can understand.
Continued severe pain should lead to a reconsideration of the diagnosis and treatment. Pain scales are dependent on previous painful experiences. The first pain someone has may be by definition10/10, if the question is asked as the worst pain you have ever had (as opposed to the worst pain imaginable).
Providers should never assume that a patient’s pain is not severe. On the other hand, patients reporting high pain levels (>7/10) with minor injuries or problems might be assigned a triage level of III or IV, with consideration of standing orders or verbal review with the physician to administer minor analgesics, while awaiting formal physician assessment.
Nursing Diagnosis: assigned according to priority of care needs
Planning: Responsible for planning nursing interventions and medical/ diagnostic procedures/protocols (e.g. Use of ice, immobilization, EKG…)
Implementation: Responsible for placing patient in treatment area and for providing appropriate information to the receiving health provider (MD/ nurse).
Evaluation: All waiting patients require reassessment, according to assigned triage levels and type of problem.
Documentation: Patient assessment information, Triage level assignment, Vital signs where appropriate, allergy status/ medications, reassessment
- Date and time of triage assessment.
- Nurse’s name.
- Chief complaint or presenting concerns.
- Limited subjective history: onset of injury/symptoms
- Objective observation.
- Triage Level
- Location in the department.
- Report to treatment nurse.
- Diagnostic, first aid measures, therapeutic interventions.
Triage Nurse Qualifications
- Communication skills are crucial. Provider must interact with patient – family – police – EMT – visitors.
- Must have tact, patience, understanding, and discretion.
- Organizational skills – patient line-ups, inquiries, etc. (Constantly under patient scrutiny)
- Able to perform in hectic situations.
Can recognize who is sick. (Depends on experience, skill and expert clinical judgment.)