Triage in emergency department

Triage in emergency departmentLye Meng HonIntroductionDefinitionFrench noun derived from the verb trier, which means to sift or sort.the methods used to assess patients severity of injury or illness within a short time after their arrival, assign priorities, and transfer each patient to the appropriate place for treatment.

Problems Faced in EDThe volume of admissions to a given emergency department cannot be predicted with any great accuracy.Only a certain proportion of the patients have life endangering or medically urgent conditions.Patients with life-threatening injuries or illnesses need to be reliably identified within minutes of arrival.Patient overcrowding.The demand for medical treatment significantly outstrip available resources.A study done in HUSM in year 2000 showed that 55% of ED visits were inappropriate (problems which can be treated in in the primary care services in the community).

AimTo ensure that the patient receives the level and quality of care appropriate to clinical need (clinical justice). Reduce unnecessary delay of treatment.Departmental resources are most usefully applied (efficiency).

Triage in Emergency DepartmentED triage systems Designed to identify the most urgent (or potentially most serious) cases.To ensure that they receive priority treatment, followed by the less urgent cases. First-come, first-served basis

Triage officers routinely assess all patients who present for treatment to sort and prioritize them.Types of Triage in ED3-level triage system:Level 1 = emergentLevel 2 = urgentLevel 3 = non-urgent Lack of specificity and prone to subjectivity

5-level triage systemsEg: Australian Triage Scale (ATS), Manchester Triage Scale (MTS), Canadian Triage Acuity Scale (CTAS), Emergency Severity Index (ESI)

Art of TriageComplex and dynamic processObtaining adequate and relevant information in a short amount of timeDecisions are made in a time-sensitive environment with limited manpower and information.Decision made based on pre-existing guidelines and patients condition.Roles of Triage OfficerAllocate triage category bases on patient assessmentInitiate appropriate nursing interventionsFirst aidInitiation of organizational guidelines, eg: x-ray, analgesia.Liaise with members of the public and other healthcare professionals.Escort patient and pass over relevant informationProvide patient and public education where necessarydocumentationProcess of TriageMain complaint and brief historyVital signsPhysical findings seen, heard, felt or smeltSetting the priority status of the patientDecision of preliminary diagnostic testing should be doneDecision whether treatment should be started at triage

SOAP SystemLarry-Weed SOAP systemS (Subjective) main complaint and brief historyO (Objective) physical finding and vital signsA (Assessment) setting of the priority status based on subjective and objective findingP (Plan) preliminary diagnostic and treatment

Malaysian Triage CategoryMTC is designed for use in hospital emergency services throughout Malaysia.A scale for rating clinical urgency.Directly relates triage category with a range of outcome measures (inpatient length of stay, ICU admission, mortality rate) and resource consumption (staff time, cost).Provides an opportunity for analysis of a number of performance parameters in the Emergency Department.MTCCritical (RED)Critical (RED)Patients with life threatening injuries or illness which require immediate attention.Assessment and treatment simultaneously within 5 minutes.Subcategories:R1 (immediate life-threatening)R2 (life-threatening)Clinical DescriptionsCode arrest (cardiac/ respiratory) or impending arrestHypoventilation: RR< 10/minShock state SBP < 80 (adult)or severely shocked child/infantAirway compromise or immediate risk to airwaySevere respiratory distress. Tachypnoea and/or dyspnoea with SpO2 120 with systemic symptoms Chest pain visceral, non-traumatic associated with parasympathetic and sympathetic symptomsAcute MI/ unstable angina diagnosed by referralAcute abdomen, hemodynamically unstableHyperglycemia or hypoglycemia with altered conscious level or neurological/ systemic deficitBaby< 3 months with fever > 38COther life threatening conditionsObstetric emergency (Hamodynamically unstable)

Semi-Critical (YELLOW)Semi-Critical (YELLOW)Assessment and treatment starts within 30 minutes.Usual presentation:Unable to walk but airway is secure, hemodynamically stable and on trolleysClinical DescriptionsAltered conscious level but not comatose. Head injury = 14/15 or GCS full but pupils unequalFractures of long bones of lower limbs/ pupilsOpen fracture of upper limbsSpine injuries (not in shock, no neurological deficit)Eye injury with loss or impaired visonDislocation of major jointsLimb amputation: total or/ near-total (haemodynamically stale)Burns 15-25% of BSA regardless of depth and/or 10-20% 3rd degree burns with no compromise to airway and circulationVascular injuries but hemodynamically stablePatients with acute abdomen but hemodynamically stableChemical exposure involving eyesAlleged poisoning/ drug overdose patient conscious and need no interventionSevere pain:Trauma: pain score: 8-10Non-trauma: pain score 4-7/10Allergic reaction moderateMild to moderate dyspnoea with saturation >95% and/or rate 38CInfant < 1 month regardless of any symptomsSignificant per vaginal bleed with hemodynamically stableOther medical urgencies requiring intravenous intervention and intermittent monitoring only:Dehydration, diarrhea with vomiting, pyrexia >40C, signs of infection, dialysis problem, acute psychotic episodes, chemotherapy or immunocompromised, acute urinary retention.Non-Critical (GREEN)Non-Critical (GREEN)Assessment and treatment starts within 90 minutesUsual presentation:Airway secure, hemodynamically stable patients not in any distress and ambulantSubcatagories:G1 (fast line)G2 (require initial management or first aid before seen by doctor)G3 (patients who can wait)G4 (triage away to primary care or another center)G5 (not seen in ED)Non-Critical (GREEN)G1 (Fast Lane)Children < 2 years oldSenior citizen > 65 years oldAcute pain (trauma): pain score