standard operating procedure for the initial assessment of ... · triage is a system of clinical...

Chair: Elaine Baylis, QPM

Chief Executive: Andrew Morgan

Standard Operating Procedure for the Initial

Assessment of Patients in Minor Injury Units

(MIU)/Urgent Care Centres (UCC) and “Safe To Wait”

Procedure in Out of Hours Services

Reference No: G_CS_91

Version 1

Ratified by: LCHS Trust Board

Date ratified: 9th January 2018

Name of originator / author: Laura Dilley

Name of responsible committee / Individual Effective Practice Assurance Group

Date issued: January 2018

Review date: November 2019

Target audience: All Staff

Distributed via Website

Chair: Elaine Baylis, QPM

Chief Executive: Andrew Morgan

Standard Operating Procedure for the Initial Assessment of Patients in Minor Injury Units

(MIU)/Urgent Care Centres (UCC) and “Safe To Wait” Procedure in Out of Hours Services

Version Control Sheet

Version Section / Para /Appendix

Version /Description ofAmendments

Date Author / Amendedby

1 New Policy 31/08/2017 Laura Dilley234567891011121314151617181920

Copyright © 2018 Lincolnshire Community Health Services NHS Trust, All Rights Reserved. Not to be reproduced inwhole or in part without the permission of the copyright owner.

3

Standard Operating Procedure for the Initial Assessment of Patients in

Minor Injury Units (MIU)/Urgent Care Centres (UCC) and “Safe To Wait”

Procedure in Out of Hours Services

Contents

Version Control Sheet Page 2

Introduction Page 4

Safe To Wait Page 5

Triage Page 9

Triage Categories and Definitions Page 10

Physiological Observations Page 10

Temperature

Pain

Other Observations

Documentation Page 11

Analgesia Page 12

Patients Younger Than 16 Years Page 12

Patients Aged 16 Years or Over Page 13

General points to consider when prescribing analgesics Page 13

Intuition Page 14

Reassessment Page 14

When to Escalate Patients Page 15

Training Page 15

4

Audit Page 15

Key aims Page 15

Flowchart Page 17

Overcrowding Escalation Plan Page 18

Parameters Page 18

Actions Page 20

References Page 20

Appendix A Summary of Safe to Wait Guidance Page 21

Appendix B General Discriminators Page 24

Appendix C UCC/MIU Patient Flow Page 25

Introduction

The Urgent Care Centres in Lincolnshire Community Health Services (MIU at Spalding

and Gainsborough, MIIU at Peterborough, WIC at Lincoln, and UCC at Louth and

Skegness) currently see and treat hundreds of patients per week. They do not operate an

appointment system and as such, Practitioners and GP assess patients using a “first

come, first served” basis.

Although the scope of the UCC is to see “minor” illnesses and injuries, patients often either

do not realise how serious their illness is, or simply do not understand where they should

attend. Consequently, a variety of patients will attend the UCCs and it is important that any

potentially time-critical, acutely unwell patients are prioritised, treated promptly, and

transferred to acute hospitals if needed.

Triage is a system of clinical risk management employed to manage patient flow safely

when clinical need exceeds capacity. There needs to be a robust, methodological and

auditable procedure for triaging and prioritising our patients.

The Manchester Triage Group was formed 20 years ago, and produced a book of

flowcharts to aid clinicians in A&E departments around the country. These are still used

today, and are relevant for use in our UCCs. It sets out a set of comprehensive flowcharts

5

that can be used quickly and easily to assess patients. Using these, triage can safely be

performed by not only practitioners, but also HCAs with relevant training.

There are two steps to the triage process in the UCCs. Firstly, the patient attends the

service and is booked in by the reception team. In some cases, the reception is manned

by a Health Care Assistant, but in majority of cases, they will be non-clinical staff. As such,

the receptionist should highlight to the clinical team those patients who need assessment

to see if they are “safe to wait”. This process is highlighted below.

The second step is triage by a clinical member of the team. This can be carried out by any

member of staff who is familiar with the Manchester Triage Tool and is competent in its

use. The triage process is also detailed below.

The document also covers the overcrowding escalation plan, which is to be utilised by staff

to support safe patient management when there are potential overcrowding issues in the

Urgent Care Centres.

Safe To Wait

When patients present to UCCs and OOH Services, the first point of contact will usually be

the reception staff.

The Safe To Wait Guidance will ensure that reception staff are aware of “Red Flag Signs”

and symptoms that indicate that someone presenting at the unit may require immediate or

urgent attention.

“Major bleeding” involves a loss of a large amount of blood, and “severe pain” is defined if

the patient is in visble distress. Reception staff do not need to assess wounds, etc or

assess pain using pain scales, but should make a quick assessment based on how the

patient looks and what they tell staff. The clinical staff (Health Care Support Worker,

Practitioner or Doctor) will then either triage the patient or make a full clinical assessment.

When documenting in the record, reception staff should document “SAFE TO WAIT

NEEDED” adjacent to the usual information about the complaint. For example “Head Injury

– SAFE TO WAIT NEEDED”. The staff will then easily be able to identify these patients

and prioritise them. If the patient is presenting with a condition that needs assessing

immediately (see below), then they should inform a clinician by directly speaking to them

6

(NOT via the instant messaging system as there is no way to know that they have seen

the message). Out of Hours staff will need to inform clinical staff as soon as possible of

ANY “safe to wait” patients. These patients should not attend OOH regularly, as those with

appointments will have been triaged, but clinical conditions can deteriorate, so it is

possible.

Patient’s Condition Identifiable Signs Action for staff

Acute/Major Burns Deep or large burns/scalds

Any burns to special areas

(Face, Neck,

Groin/Genitals)

Difficulty breathing or

swallowing

Document in

“Presenting

Complaint” section

Immediately inform

any clinician of

patient’s attendance

if any difficulty

breathing, talking or

swallowing

Anaphylaxis Sense of impending doom

Swelling of throat, mouth

or face

Difficulty in swallowing or

speaking

Reported fast heart rate

Severe asthma

Abdominal pain, nausea

and vomiting

Sudden feeling of

weakness

Collapse and

unconsciousness

Document in

“Presenting


Immediately inform

any clinician of

patient’s

attendance

Major Limb Injury Any apparent limb

deformity

Severe Pain

Major bleeding

Any apparent amputation

Document in

“Presenting


Altered Consciousness Any level of altered

consciousness

Document in

“Presenting


7

Immediately inform

any clinician of


Asthma/Breathing

Difficulties

Unable to talk in full

sentences

Chest pain or palpitations

Agitation

Confusion

Noisy breathing

Cyanosis (blue lips or

fingers, etc)

Document in

“Presenting


Immediately inform

any clinician of

patient’s

attendance

Chest Pain Looks unwell

Shortness of breath

Pale/clammy

Nausea/vomiting

Document in

“Presenting


Immediately inform

any clinician of

patient’s

attendance

Facial Wounds Gross facial swelling

Bleeding from the

ear/nose/mouth

Visible deformity

Patient struggling to talk

due to injuries

Document in

“Presenting


Immediately inform

any clinician of

patient’s

attendance if any

gross facial

swelling, visible

deformity, or if

patient struggling to

talk due to injuries

Generally Unwell Adult or

Child

Pale/Clammy

Feeling of “impending

doom”

Feeling faint

Severe pain

Persitent vomiting

Document in

“Presenting


Immediately inform

any clinician of

patient’s

8

Unable to pass urine (urine

retention)

Distressed/inconsolable

child

attendance

Major Bleeding/Wounds Deep or large wounds

Major bleeding

Loss of function or

sensation to limb/hand/foot

Large foreign body in

wound (nail, large piece of

glass, etc)

Document in

“Presenting


Immediately inform

any clinician of

patient’s

attendance if any

major bleeding or

patient feels unwell

Major Head Injury Any level of altered

consciousness

Persistent vomiting

Confusion

Unable to walk (new onset)

Document in

“Presenting


Immediately inform

any clinician of

patient’s

attendance

Overdose/Poisoning Any overdose or poisoning Document in

“Presenting


Pregnancy Problems Severe pain

Heavy bleeding

Document in

“Presenting


Sick/Distressed Child Cyanosis (blue lips or

extremities)

Not responding normally to

parents/carers

Parents/carers report child

is very hot

Any breathing difficulty or

noisy breathing

Report of “non-blanching

rash”

Document in

“Presenting


Immediately inform

any clinician of

patient’s

attendance

9

Neck stiffness


child

Severe pain

If there is any doubt or concern about a patient, even if not covered in the above table,

always consult the Practitioner in Charge.

It is the clinician’s responsibility to make a clinical assessment of the patient (triage) and

decide whether or not they are safe to wait to be fully assessed and treated. It must be

remembered that reception staff are not usually clinicians, and therefore it is safer to ask

for a patient to be prioritised and triaged, and deemed to be safe to wait, rather than

remain unassessed in the waiting room and become very unwell.

Triage

The first stage of the triage process is to identify the problem, so the clinician can decide

which flowchart to use. This is normally done using the presenting complaint. Multiple

charts may be relevant, so all options should be evaluated but only one selected. They

should all create a similar outcome.

All patients who attend UCCs staffed than more than two registered professionals must be

triaged. For those units who run with two practitioners and usually operate with a short

waiting time, triage should not be standard practice, but should be implemented if the

waiting time exceeds 30-45 minutes (at practitioner-in-charge’s discretion). If no other

chart is relevant, the “unwell adult” or “unwell child” charts should be used.

Questions should be used to ascertain if the patient has any key discriminators. The

assessment is carried out by finding the highest level at which the answer is posed by the

discriminator question is positive.

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Triage Categories and Definitions

Number Name Colour Maximum time to

full assessment by

Practitioner or

Doctor (mins)

1 Immediate Red 0

2 Very Urgent Orange 10

3 Urgent Yellow 30

4 Standard Green 120

5 Non-urgent Blue 240

The “Urgent” category’s maximum time to assessment has been adapted from 60 minutes

(as suggested in Emergency triage) to 30 minutes, as in an Urgent Care setting these

patients should be assessed and referred if needed within a short time frame.

If a patient is assessed as “non-urgent”, they have had the condition for four weeks or

more, and it remains unchanged, then they could be advised to attend their own GP

surgery for assessment and treatment as needed. All patients who streamed directly from

triage, or who decide not to wait for further assessment/treatment, should be recorded on

a separate paper form.

Patients assessed as “Immediate” or “Very Urgent” will generally need a 999

emergency ambulance requesting immediately and should not wait to have the full

assessment carried out, as they will need rapid transfer to secondary care.

Physiological Observations

Temperature

Temperature is used as a general discriminator and accurate measurement of the

temperature should be part of the triage process. If the skin feels very hot, then the patient

is clinically said to be very hot and corresponds to a temperature of 41 degrees Celsius or

more; a patient with skin that feels hot is clinically said to be hot and would have a

temperature of 38.5 degrees Celsius or more. A patient with warm skin goes with a

temperature of less than 38.5 degrees Celsius.

11

Patients with cold skin can be said to be clinically cold – a core temperature of less than

35 degrees Celsius.

Pain

Pain is a major factor in determining priority. Pain should be assessed using pain ladders

or scores, and the corresponding discriminator documented. Pain relief should be offered

to the patient, and the pain score should be reassessed after 30 minutes (and then an

hour if relevant) of taking analgesia.

Other Observations

Clinicians must document the observations that are contained within the flowcharts in

order to rule out the discriminators.

Clinicians should also complete a full set of observations (respiratory rate, pulse

rate, oxygen saturations, blood pressure and temperature) for all patients with chest

pain, abdominal pain, shortness of breath or head injury, and in any unwell patient

that the clinician is concerned about. In addition to this, observations should be

taken as per the Paediatric Observation Priority Scoring criteria.

Documentation

Documentation is vital, and shows that the triage procedure was carried out accurately.

Clinicians must document which flowchart has been used, which discriminator defines the

category, and which category has been selected. If the patient has been referred to a

practitioner, then this should also be documented. All observations should be carried out

and recorded accurately.

Any allergies should also be documented.

If any medication is given at triage, then this must be documented.

Documentation in SystmOne

To document the category in SystmOne, right click on the patient attendance, go to “triage”

and “assign triage category”. A box will then appear to document the triage category, the

time it was carried out (it defaults to the current time but can be amended), and who they

12

were triaged by. Confirm by clicking “ok”. This will then document the triage

colour/category on the main attendance screen.

Analgesia

If the patient has any pain, then it should be assessed using pain ladders or scores as

detailed in the relevant NICE guidance. The patient should be asked if they have already

taken any analgesia before attending the department (over the counter or prescribed), the

time of the last dose, how many doses in the past 24 hours, and its effect if any.

Appropriate pain relief should be offered to the patient using the guidance below, and the

pain score should be reassessed after 30 minutes (and then an hour if relevant) of taking

analgesia. If the triage is carried out by a Health Care Support Worker, then they should

ask a registered clinician to assess the patient, and prescribe analgesia (via independent

prescribing or via a valid Patient Group Direction, PGD). This should be administered by a

registered clinician as per the LCHS medicines management policy (the same clinician if

using PGDs).

Patients Younger Than 16 Years

Prescribe either paracetamol or ibuprofen alone. Both are suitable first-line choices

for treating mild-to-moderate pain in children.

If the child does not respond to the first analgesic:

o Check their adherence, and that an appropriate dose is being taken.

o If paracetamol has been used, switch to ibuprofen alone.

o If ibuprofen has been used, switch to paracetamol alone.

If the child has not responded sufficiently to appropriate doses of either drug alone,

consider alternating paracetamol and ibuprofen.

Add a dose of the second drug (for example, 2-3 hours after the first drug), provided

that the parents/carers are confident to do this.

Paracetamol is usually given every 6 hours and ibuprofen every 8 hours. Care

needs to be taken not to exceed the maximum dose of each drug in a 24-hour

period.

If the child is still in pain or more than short courses of analgesics are required,

consider seeking specialist advice.

The following treatment options are not recommended for children in primary care:

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o Administering paracetamol and ibuprofen at the same time.

o Naproxen.

o Diclofenac.

o Aspirin.

o Weak opioids.

Patients Aged 16 Years and Over

A stepwise strategy for managing mild-to-moderate pain in adults is recommended:

Step 1 - Paracetamol. This is a suitable first-line choice for most people with mild-

to-moderate pain.

• Increase to the maximum dose of 1 gram four times a day, before switching

to (or combining with) another analgesic.

Step 2 - Substitute the paracetamol with low-dose ibuprofen (400 mg three times a

day). If necessary, increase the dose of ibuprofen to a maximum of 2.4 grams daily,

except where this is contraindicated.

• If the person is unable to take a nonsteroidal anti-inflammatory drug

(NSAID), use a full therapeutic dose of a weak opioid (such as codeine 60

mg every 4 to 6 hours; maximum 240 mg daily).

Step 3 - Add paracetamol (1 gram four times a day) to low-dose ibuprofen (400 mg

three times a day). If necessary, increase the dose of ibuprofen to a maximum of

2.4 grams daily.

• If the person is unable to tolerate an NSAID, add paracetamol to a weak

opioid.

Step 4 - Continue with paracetamol 1 gram four times a day. Replace the ibuprofen

with an alternative NSAID (such as naproxen 250 mg to 500 mg twice a day).

Step 5 - Start a full therapeutic dose of a weak opioid (such as codeine 60 mg up to

four times a day; maximum 240 mg daily) in addition to full-dose paracetamol (1

gram four times a day) and/or an NSAID.

General points to consider when prescribing analgesics

The underlying cause of the pain should be treated, whenever possible.

People who experience continuous pain should receive regular analgesia following

a full clinical assessment.

14

Ensure a full therapeutic dose is used before considering switching to a different

analgesic.

For people who are at an increased risk of gastrointestinal adverse effects, consider

prescribing an alternative to an oral NSAID.

If an NSAID is necessary, prescribe low-dose ibuprofen (400 mg three times a day)

with a proton pump inhibitor.

For people with underlying heart or circulatory conditions, prescribe low dose

ibuprofen (400 mg three times a day). Avoid doses of 2.4 grams or more in this

group of people.

Caution is needed with long-term use of weak opioids (tolerance and dependence

can occur). It may be necessary to reduce the dosage gradually to prevent

withdrawal symptoms.

Be aware that the capacity to metabolize codeine can vary considerably between

individuals; there is a marked increase in morphine toxicity in people who are ultra

rapid metabolizers, and reduced therapeutic effect in poor codeine metabolizers.

Use an alternative analgesic in these people.

If weak opioids are prescribed for elderly people, start with a lower dose and titrate

up slowly. Elderly people are more susceptible to the adverse effects of opioids.

Effervescent preparations should be avoided (due to their high salt content),

particularly in people with hypertension .

Combination analgesics should be avoided as first-line treatment. Prescribing single

constituent analgesics allows independent titration of each drug

Intuition

Intuition is linked with expertise and experience, and should never be ignored. It is usually

a result of previous experience, and is a valuable in the decision making process. If in

doubt about a patient, speak to an adavnced clinical practitioner or doctor.

Reassessment

Patients who have not had a full assessment commenced by a Practitioner or Doctor in the

maximum time as per the table above should be reassessed using the Manchester Triage

Tool, and escalated as appropriate.

15

When to Escalate Patients

If patients are categorised as “immediate” or “very urgent”, then the clinician carrying out

triage should verbally inform a registered clinician for them to commence a full assessment

as soon as they can (or delegate the person who is available first). If they are conducting

an assessment/examination on a lower priority patient, and it is appropriate to do so, then

they should pause the examination (whilst explaining to the patient/relatives the reasons

behind their actions) to assess the priority patient.

Training

All clinicians undertaking triage should have a clear understanding of the triage process,

which clinical observations to perform, and when to escalate patients.

Although the triage process should be simple, clinicians should be orientated to the

flowcharts, with case studies used during training (either on a one to one basis or as a

group session), and then using direct and indirect supervision by a competent clinician

until they have been assessed themselves as being competent. The amount of supervision

and training will vary between clinicians, but it is imperative that they understand the terms

used in all flowcharts and are competent to carry out physical observations.

Audit

The most effective audit continuously assesses clinicians for accuracy and is linked by

reflective practice and, if necessary, additional training to improve performance. The

method outlined below is suggested by the Manchester Triage Group and is designed to

audit the quality of decision making against the Manchester Triage System standard, along

with standards of escalation and documentation.

Key aims:

All triage clinicians are identified

All episodes of triage are identified

2% of episodes per practitioner (minimum of 10 episodes) are randomly selected

Episodes are assessed by a senior clinician, experienced in triage

Completeness of episodes is expressed as a simple proportion

Accuracy of episodes is expressed as a simple proportion

16

Number of incomplete episodes is fed back to the clinician

Overall accuracy is fed back to the clinician

Any causes of inaccurate triage are fed back to the practitioner

10% of episodes assessed are performed independently by a second senior

clinician and any differences moderated by discussion

Monthly audits should be performed on the introduction of triage to an area, but this

frequency can be reduced to 3-6 monthly once a consistent high standard is

demonstrated.

Criteria Yes No Comments

Correct use of presentational flow chart

Specific discriminators correctly selected (record as seen on triage

record)

Pain score recorded

Correct triage category assigned (based on

patient presentation and discriminators)

Demonstrated ability to navigate the

computerised triage system

Triage record documented accurately and

correctly

Re-triaged where necessary

Completeness: An episode is complete if all the steps necessary to reach the

conclusion have been undertaken. The method requires that

the clinician excludes all the discriminators in any higher

priority. Thus if SpO2 appears as a discriminator in the chart

selected, then the episode would be incomplete if no result was

recorded. The most common error is to fail to record a pain

score.

Accuracy: An episode is recorded as accurate if both the presentation and

discriminator selected are appropriate. It is important to realise

that there may be appropriate alternatives; thus audit should be

carried out by a clinician with sufficient experience to make this

judgement.

17

Flowchart:

Select 2% (min

10 records)

↓

A Total

↓

Presentation → No →B Inaccurate

appropriate?

↓ ↑

Yes

↓

C Incomplete ← No ← Sufficient information? ↑

↓

Yes

↓ ↑

Discriminator → No

appropriate?

↓

Yes

↓

D Accurate

Check that A = B+C+D

% incomplete = C/A x 100

% accuracy = D/A x 100

Targets:

0% episode incomplete

95% accuracy

95% agreement between assessors

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If these targets are not met, then feedback must be given to the clinician, and the audit

should be repeated monthly.

Overcrowding Escalation Plan

Overcrowding occurs when it is assessed that there is not enough capacity in the

department to meet demand. Time of day (in relation to changes in staffing levels or

closing times) is an important factor when analysing the situation.

The decision on whether a department is overcrowded should only be made by the ACP in

charge of the shift, and then escalated to the On Call LCHS Urgent Care Duty Manager as

appropriate. The On Call Urgent Care Duty Manager will then take the appropriate action.

Parameters

Ratio of Patients to Staff

in Department

Category Action

Less than or equal to 3

patients to 1 registered staff

member

Green Normal Working

4 patients to 1 registered

staff member

or

3 or more patients in the

department who have a

triage category of Urgent

(Yellow) or above

Amber Monitor and Observe

Situation

Between 5 and 6 patients to

1 registered staff member

or

4 patients to 1 registered

staff member, with 3 or

more patients in the

department who have a


(yellow) or above

Red Escalate to LCHS On Call

Urgent Care Duty Manager

7 or more patients to 1

registered staff member or

Black Escalate to LCHS On Call


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Between 5 and 6 patients to

1 registered staff member,

with 3 or more patients in

the department who have a


(yellow) or above

In addition to this table, the following actions should be taken:

Staffing Level Category Action

Normal Staffing Green No Extra Action

1 Clinical Staff Member Less

Than Normal

Amber Monitor and observe

situation, if not affecting

ratios of patients to staff

2 Clinical Staff Members

Less Than Normal

Red Escalate to LCHS On Call


3 or more Clinical Staff

Members Less Than Normal

Black Escalate to LCHS On Call


Where the department normally has a specialist type of clinician (e.g. minor injury

specialist practitioners at PMIIU or Grantham OOH, or doctors) and these are essential to

the running of the department, the LCHS On Call Urgent Care Duty Manager must be

informed if there is any reduction in numbers.

Time Until Closure of

Department/Change in

Staff Numbers

Category Action

3-4 hours Green No Extra Action

2-3 hours Amber Monitor and observe

situation if patient ratios are

“green”. Otherwise, Escalate

to LCHS On Call Urgent

Care Duty Manager

1-2 hours Red Escalate to LCHS On Call


Less than an hour Black Escalate to LCHS On Call


20

Actions

If as the ACP in charge you feel that the department is at risk of becoming overcrowded,

please undertake the following actions:

Undertake assessment using the attached tables as guidance

Contact the on-call duty manager guided by the tables. If you are concerned but the

tables do not flag a priority category, please contact the on-call duty manager

Discuss options for the functioning of the department

Contact A&E as appropriate to inform them of reduced capacity due to

overcrowding

Ensure on-call duty manager has contacted the CCG as appropriate and escalated

internally their actions

References

Emergency Triage: Manchester Triage Group (2013)

NICE Cliniical Knowledge Summary – Mild to Moderate Pain (2015)

https://cks.nice.org.uk/analgesia-mild-to-moderate-pain

21

(Appendix A) Summary of Safe to Wait Guidance

Patient’s Condition Identifiable Signs Action for staff

Acute/Major Burns Deep or large burns/scalds

Any burns to special areas

(Face, Neck,

Groin/Genitals)

Difficulty breathing or

swallowing

Document in

“Presenting


Immediately inform

any clinician of


if any difficulty

breathing, talking or

swallowing

Anaphylaxis Sense of impending doom

Swelling of throat, mouth

or face

Difficulty in swallowing or

speaking

Reported fast heart rate

Severe asthma

Abdominal pain, nausea

and vomiting

Sudden feeling of

weakness

Collapse and

unconsciousness

Document in

“Presenting


Immediately inform

any clinician of

patient’s

attendance

Major Limb Injury Any apparent limb

deformity

Severe Pain

Major bleeding

Any apparent amputation

Document in

“Presenting


Altered Consciousness Any level of altered

consciousness

Document in

“Presenting


Immediately inform

any clinician of


22

Asthma/Breathing

Difficulties

Unable to talk in full

sentences

Chest pain or palpitations

Agitation

Confusion

Noisy breathing

Cyanosis (blue lips or

fingers, etc)

Document in

“Presenting


Immediately inform

any clinician of

patient’s

attendance

Chest Pain Looks unwell

Shortness of breath

Pale/clammy

Nausea/vomiting

Document in

“Presenting


Immediately inform

any clinician of


Facial Wounds Gross facial swelling

Bleeding from the

ear/nose/mouth

Visible deformity

Patient struggling to talk

due to injuries

Document in

“Presenting


Immediately inform

any clinician of


if any gross facial

swelling, visible

deformity, or if

patient struggling to

talk due to injuries

Generally Unwell Adult or

Child

Pale/Clammy

Feeling of “impending

doom”

Feeling faint

Severe pain

Persitent vomiting

Unable to pass urine (urine

retention)


child

Document in

“Presenting


Immediately inform

any clinician of

patient’s

attendance

23

Major Bleeding/Wounds Deep or large wounds

Major bleeding

Loss of function or

sensation to limb/hand/foot

Large foreign body in

wound (nail, large piece of

glass, etc)

Document in

“Presenting


Immediately inform

any clinician of


if any major bleeding

or patient feels

unwell

Major Head Injury Any level of altered

consciousness

Persistent vomiting

Confusion

Unable to walk (new onset)

Document in

“Presenting


Immediately inform

any clinician of


Overdose/Poisoning Any overdose or poisoning Document in

“Presenting


Pregnancy Problems Severe pain

Heavy bleeding

Document in

“Presenting


Sick/Distressed Child Cyanosis (blue lips or

extremities)

Not responding normally to

parents/carers

Parents/carers report child

is very hot

Any breathing difficulty or

noisy breathing

Report of “non-blanching

rash”

Neck stiffness


child

Severe pain

Document in

“Presenting


Immediately inform

any clinician of

patient’s

attendance

If there is any doubt or concern about a patient, even if not covered in the above table,

always consult the Practitioner in Charge.

24

(Appendix B) Table of General Discriminators

Discriminator Category Maximum time to full

assessment by

Practitioner or

Doctor (mins)

Airway compromise

Inadequate breathing

Exsanguinating

haemorrhage

Shock

Unresponsive child

Currently fitting

Immediate 0

Uncontrollable major

haemorrhage

New abnormal pulse

Altered conscious level

Very hot

Hot baby

Cold

Severe pain

Very Urgent 10

Uncontrollable minor

haemorrhage

History of unconsciousness

Warm newborn

Hot

Moderate pain

Urgent 30

Warm

Recent mild pain

Recent problem

Standard 120

None of the above Non-urgent 240

25

UCC/MIU Patient Flow

Patient Self Presents

Booked into department by reception

staff

“Safe to Wait” as necessaryShift Leader responsible for overseeing

departmental flow.

Oversees handover for ambulance patients

presenting to UCC.

Monitors stream and waiting times.

Proactively escalates concerns with flow and

waiting times as per procedure.

Monitors transfer issues, allocating resources

appropriately as escalates promptly.

Triage Stream. Clinician/HCSW

allocated

Using MTS allocate level, document

flowchart used, discriminator and

category selected

Escalate to shift lead/ACP if

Yellow/Amber/Red category

Triage flow.

Self-care advice. i.e. Chemist,

phone GP

Treat and discharge, i.e. simple

dressing reviews.

Allocate Doctor/ACP review.

Allocate consultation room/waiting

area if applicable

See and Treat Workflow.

Doctor and/or Advanced Clinical

Practitioner review.

History and Examination.

Allocate/request interventions/

treatments.

Discharge to appropriate services.

Admit to definitive care/GP

review/Treatments complete.

Departure UCC

standard operating procedure for the initial assessment of ... · triage is a system of clinical...

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