EMERGENCY TRIAGE EDUCATION KIT TRIAGE QUICK REFERENCE GUIDE

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Recommended Triage Method

1 Patient presents for triage ~ Safety hazards are considered above all

2 Assess the following: Chief complaint General Appearance Airway Breathing Circulation

Yes Disability Environment Limited History Co-morbidities

2 Quick Evaluation ~ Is patient stable?

No 3 Differentiate predictors of poor outcome from other data collected during the triage assessment 5 Assign an appropriate ATS category in response to clinical assessment data

4 Identify patients who have evidence of or are at high risk of physiological instability

6 Allocate staff to patient, including brief handover to allocated staff member/s

7 ED model of care proceeds

Triage Method

ATS categories for treatment acuity and performance thresholds

ATS category Treatment acuity (maximum waiting time) Performance indicator (%)

1 2 3 4 5

Immediate 10 minutes 30 minutes 60 minutes 120 minutes

100 80 75 70 70

ATS Categories

Validated Methods for quantitative assessment of pain

Visual analogue scale: 100 mm line
(Nelson, Cohen, Lander, et al, 2004) Use a 100 mm line as shown below.

0 No pain Ask the patient to mark their level of pain on the line.

10 Severe pain

Application of a triage category

Descriptive terms to guide acuity for the ATS and validated methods for quantitative assessment of pain Descriptor Very severe Moderately severe Moderate Minimal ATS category 2 3 4 5

Reference: Australasian College of Emergency Medicine

Assessment of Pain

Abbey Pain Scale

For measurement of pain in people who cannot verbalise How to use scale: While observing the patients, score questions 1 to 6
Q1.Vocalisation eg: whimpering, groaning, crying Absent 0 Mild 1 Moderate 2 Severe 3 Q2. Facial expression eg: looking tense, frowning, grimacing, looking frightened Absent 0 Mild 1 Moderate 2 Severe 3 Q3. Change in body language eg: fidgeting, rocking, guarding part of body, withdrawn Absent 0 Mild 1 Moderate 2 Severe 3 Q4. Behavioural change eg: increased confusion, refusting to eat, alteration in usual patterns Absent 0 Mild 1 Moderate 2 Severe 3 Q5. Physiological change eg: temperature, pulse or blood pressure outside normal limits, perspiring, flushing or pallor Absent 0 Mild 1 Moderate 2 Severe 3 Q6. Physical changes eg: skin tears, pressure areas, arthritis, contractures, previous injuries Absent 0 Mild 1 Moderate 2 Severe 3

Add scores for 1 6 and record here Now tick the box that matches the Total Pain Score Finally, tick the box which matches the type of pain
02 No pain

Total Pain Score

37 Mild Chronic 813 Moderate Acute 14+ Severe Acute on Chronic

Reference: Jennifer Abbey, Neil Piller, AnitaDe Bellis, Adrian Esterman, Deborah Parker, Lynne Giles and Belinda Lowcay (2004) The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia, International Journal of Palliative Nursing, Vol 10, No 1.pp 6-13.

Pain Scale Abbey

FLACC Behavioural Pain Scale

0 Face Legs Activity Cry Consolability No particular expression or smile Normal position or relaxed Lying quietly, normal position, moves easily No cry (awake or asleep) Content, relaxed 1 Occassional grimace or frown, withdrawn, disinterested Uneasy, restless, tense Squirming, shifting, back and forth, tense Moans or whimpers; occasional complaint Reassured by touching, hugging or being talked to, distractible 2 Frequent to constant quivering chin, clenched jaw Kicking, or legs drawn up Arched, rigid or jerking Crying steadily, screams, sobs, frequent complaints Difficult to console or comfort

Instructions Patients who are awake: Observe for at least 2-5 minutes. Observe legs and body uncovered. Reposition patient or observe activity, assess body for tenseness and tone. Initiate consoling interventions if needed. Patients who are asleep: Observe for at least 5 minutes or longer. Observe body and legs uncovered. If possible reposition the patient. Touch the body and assess for tenseness and tone. Each category is scored on the 0-2 scale which results in a total score of 0-10 Assessment of Behavioral Score: 0 = Relaxed and comfortable 1-3 = Mild discomfort 4-6 = Moderate pain 7-10 = Severe discomfort/pain

Reference: Merkel S,Voepel-Lewis T, Shayevitz JR, et al: The FLACC: A behavioural scale for scoring postoperative pain in young children. Pediatric Nursing 1997; 23:293-797 Printed with permission 2002, The Regents of the University of Michigan

Pain Scale FLACC

Wong-Baker FACES Pain rating scale

Developed for young patients to communicate how much pain they are feeling.

NO HURT

HURTS LITTLE BIT

HURTS LITTLE MORE

HURTS EVEN MORE

HURTS WHOLE LOT

HURTS WORST

Instructions Explain to the child that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Face 0 Face 1 Face 2 Face 3 Face 4 Face 5 is very happy because he doesnt hurt at all. hurts just a little bit. hurts a little more. hurts even more. hurts a whole lot more. hurts as much as you can imagine, although you do not have to be crying to feel this bad.

Ask the child to choose the face that best describes how he/she is feeling.

Reference: Hockenberry MJ, Wilson D, Winkelstein ML: Wongs Essentials of Pediatric Nursing, ed. 7, St. Louis, 2005, p. 1259. Used with permission. Copyright, Mosby.

Pain Scale Wong-Baker

The ABCs of obstetrics

Urgency Urgency Indicator Reason for caution

Airway

Any potential compromise Increased nasal congestion

Often difficult intubations due to: increased patient size difficulty with patient positioning different induction agents required Increased vascularity of nose and airways causes difficulty in breathing Progesterone may be responsible for increased drive to breathe One third of pregnant asthmatic women experience a deterioration in their condition Progesterone causes widespread vasodilatation Oestrogen may contribute to increases in blood volume Diastolic BP 617mmHg BP lowest during second trimester Cardiac output (CO) by 3050% Hyperdynamic flow High volume and dynamic flow may cause cerebral heamorrhage, especially subarachnoid haemorrhage (SAH) during pregnancy Sudden and serious deterioration of their condition Changes in coagulation system associated with pregnancy

Breathing Circulation

Asthma Palpitations Headache Sudden drop in BP Symptoms of pulmonary embolus

Obstetrics

The ABCs of obstetrics (continued)

Points to remember

Hyperdynamic physiological changes occur as early as 68 weeks gestation. An assessment of urgency must be made on the basis of both the woman and the foetus. An elevated BP is an ominous sign: the higher the BP the more urgent the review. At 20 weeks the weight of the uterus compresses the inferior vena cava if the woman is lying on her back a compromise to foetal wellbeing. The risk of many conditions is higher in pregnant women than non-pregnant women of childbearing age. These conditions include: cerebral haemorrhage or cerebral thrombosis severe pneumonia atrial arrythmias venous thrombosis cholelithiasis pyelonephritis spontaneous arterial dissections, e.g. splenic and subclavian dissections, with no previous medical history. Domestic violence is more prevalent during pregnancy. This can mean increased complications for mother and adverse neonatal outcomes. In the setting of trauma, maternal signs may remain stable even when loss of one-third of blood volume may have occurred. The best initial treatment for the foetus is the optimum resuscitation of the mother.

Assessment of dehydration levels in infants

Signs Mild General condition Pulse Anterior fontanelle Eyes Tears Mucous membranes Skin turgor Urine Weight loss Thirsty, restless, agitated Normal Normal Normal Present Slightly dry Normal Normal 45% Moderate Thirsty, restless, irritable Rapid, weak Sunken Sunken Absent Dry Decreased Reduced, concentrated 69% Severity Severe Withdrawn, somnolent or comatose; rapid deep breathing Rapid, weak Very sunken Very sunken Absent Dry Decreased with tenting None for several hours >10%

Source: Health Information for International Travel. Chapter 8: Traveling Safely with Infants and Children. USA: Centers for Disease Control and Prevention [Online] 2005 [Cited 2007 March 24].

Paediatric Dehydration

Paediatric physiological discriminators (PPD)

Category 1 Immediate
Airway Obstructed Partially obstructed with severe respiratory distress

Category 2 Category 3 Category 4 Category 5 Emergency Urgent Semi-urgent Non-urgent Within 10 minutes Within 30 minutes Within 60 minutes Within 120 minutes
Patent Partially obstructed with moderate respiratory distress Respiration present Moderate respiratory distress, e.g. moderate use accessory muscles moderate retraction skin pale. Circulation present Patent Partially obstructed with mild respiratory distress Respiration present Mild respiratory distress, e.g. mild use accessory muscles mild retraction skin pink. Circulation present Respiration present No respiratory distress no use accessory muscles no retraction. Respiration present No respiratory distress no use accessory muscles no retraction. Patent Patent

Breathing
Circulation s/s dehydration LOC/activity cap refill <2 sec dry oral mucosa sunken eyes tissue turgor absent tears deep respirations thready/weak pulse tachycardia urine output

Absent respiration or hypoventilation Severe respiratory distress, e.g. severe use accessory muscles severe retraction acute cyanosis. Absent circulation Significant bradycardia, e.g. HR <60 in an infant Severe haemodynamic compromise, e.g. absent peripheral pulses skin pale, cold, moist, mottled significant tachycardia capillary refill >4 secs. Uncontrolled hemorrhage

Circulation present

Circulation present

Moderate hemodynamic compromise, e.g. weak/thready brachial pulse skin pale, cool, moderate tachycardia capillary refill 24 secs. >6 s/s dehydration

Mild haemodynamic compromise, e.g. palpable peripheral pulses skin pale, warm mild tachycardia.

No haemodynamic compromise, e.g. palpable peripheral pulses skin pink, warm, dry.

No haemodynamic compromise, e.g. palpable peripheral pulses skin pink, warm, dry.

36 s/s dehydration

<3 s/s dehydration

No s/s dehydration

PPD

Paediatric physiological discriminators (continued)

Category 1 Immediate
Disability GCS<8

Category 2 Emergency Within 10 minutes

GCS 912 Severe decrease in activity, e.g. no eye contact, decreased muscle tone.

Category 3 Urgent Within 30 minutes

GCS >13 Moderate decrease in activity, e.g. lethargic eye contact when disturbed.

Category 4 Category 5 Semi-urgent Non-urgent Within 60 minutes Within 120 minutes

Normal GCS or no acute change to usual GCS. Mild decrease in activity, e.g. quiet but eye contact interacts with parents. Mild pain, e.g. patient/parents report mild pain skin, pink, warm no alteration in vital signs requests analgesia. Normal GCS or no acute change to usual GCS. No alteration to activity, e.g. playing smiling.

Severe pain, e.g. patient/parents report severe pain skin, pale, cool alteration in vital signs requests analgesia. Severe neurovascular compromise, e.g. pulseless cold nil sensation nil movement capillary refill.

Moderate pain, e.g. patient/parents report moderate pain skin, pale, warm alteration in vital signs requests analgesia. Moderate neurovascular compromise, e.g. pulse present cool sensation movement capillary refill.

No or mild pain, e.g. patient/parents report mild pain skin, pink, warm no alteration in vital signs declines analgesia.

Mild neurovascular No neurovascular compromise compromise, e.g. pulse present normal/ sensation normal/ movement normal capillary refill.

Summary of adult physiological predictors (APP) for the ATS

Category 1 immediate Category 2 10 minutes Category 3 30 minutes Category 4 60 minutes Category 5 120 minutes

Airway Breathing

Obstructed/partially obstructed Severe respiratory distress/absent respiration/ hypoventilation Severe haemodynamic compromise/absent circulation Uncontrolled haemorrhage

Patent Moderate respiratory distress

Patent

Patent

Patent No respiratory distress

Mild respiratory distress No respiratory distress

Circulation

Moderate haemodynamic compromise

Mild haemodynamic compromise

No haemodynamic compromise

No haemodynamic compromise

Disability

GCS <9

GCS 912

GCS >12

Normal GCS

Normal GCS

Risk factors for serious illness or injury These should be considered in the light of history of events and physiological data. Multiple risk factors = increased risk of serious injury. The presence of one or more risk factors may result in allocation of triage category of higher acuity.

Developed by a project team for the Consistency in Triage Project (2001). Contributors: Emergency Nurses Association,Triage Working Party and Royal Childrens Hospital emergency nursing staff.

APP

Risk factors for serious illness or injury

These should be considered in the light of history of events and physiological data. Multiple risk factors = increased risk of serious injury. The presence of one or more risk factors may result in allocation of triage category of higher acuity. Mechanism of injury, e.g. penetrating injury fall >2 height MCA >60 kph MBA/cyclist > 30 kph pedestrian ejection/rollover prolonged extrication (>30 minutes) death same car occupant explosion. Co morbidities, e.g. Hx prematurity respiratory disease cardiovascular disease renal disease carcinoma diabetes substance abuse immuno-compromised congenital disease complex medical Hx. Age <3 months and febrile acute change to feeding pattern acute change to sleeping pattern Victims of violence, e.g. child at risk sexual assault neglect. Historical variables, e.g. events preceding presentation to ED apnoeic/cyanotic episode seizure activity decreased intake decreased output red current jelly stool bile stained vomiting. Parental concern. Other, e.g. rash actual/potential effects of drugs/alcohol chemical exposure envenomation immersion alteration in body temperature.

Risk factors

Summary of ophthalmic emergency predictors (OEP) for the ATS

Category 1 Immediate Category 2 10 minutes Category 3 30 minutes Category 4 60 minutes Category 5 120 minutes

Penetrating eye injury Chemical injury Sudden loss of vision with or without injury Sudden onset severe eye pain

Sudden abnormal vision with or without injury Moderate eye pain, e.g. blunt eye injury flash burns foreign body

Normal vision Mild eye pain, e.g. blunt eye injury flash burns foreign body

Normal vision No eye pain

OEP

Mental health triage tool

Triage code Treatment acuity 1 Immediate Description Definite danger to life (self or others) Australasian Triage Scale1 states: Typical presentation Observed
Violent behaviour Possession of weapon Self-destruction in ED Extreme agitation or restlessness Bizarre/disoriented behaviour

General management principles*

Continuous visual surveillance 1:1 ratio (see denition below)

Supervision

Severe behavioural disorder with immediate threat of dangerous violence

Alert ED medical staff immediately Alert mental health triage or equivalent Reported Provide safe environment for patient and others Verbal commands to do harm to Ensure adequate personnel to provide self or others, that the restraint/detention based on industry standards person is unable to resist Consider (command hallucinations) Calling security +/- police if staff or patient Recent violent behaviour safety compromised. May require several staff to contain patient 1:1 observation Intoxication by drugs and alcohol may cause an escalation in behaviour that requires management.

Action

MH Triage tool

Mental health triage tool (continued)

Triage code Treatment acuity 2 Emergency Within 10
minutes

Description Probable risk of danger to self or others AND/OR Client is physically restrained in emergency department AND/OR Severe behavioural disturbance Australasian Triage Scale1 states:
Violent or aggressive (if): Immediate threat to self or others Requires or has required restraint Severe agitation or aggression

Typical presentation Observed

Extreme agitation/restlessness Physically/verbally aggressive Confused/unable to cooperate Hallucinations/delusions/paranoia Requires restraint/containment High risk of absconding and not waiting for treatment Attempt at self-harm/threat of self-harm Threat of harm to others Unable to wait safely

General management principles* Supervision Action

Continuous visual supervision (see denition below) Alert ED medical staff immediately Alert mental health triage Provide safe environment for patient and others Use defusing techniques (oral medication, time in quieter area) Ensure adequate personnel to provide restraint/detention Prompt assessment for patient recommended under Section 9 or apprehended under Section 10 of Mental Health Act. If defusing techniques ineffective, re-triage to category 1 (see above) Security in attendance until patient sedated if necessary Intoxication by drugs and alcohol may cause an escalation in behaviour that requires management

Reported

Consider

Mental health triage tool (continued)

Triage code Treatment acuity 3 Urgent
Within 30 minutes

Description Possible danger to self or others

Typical presentation Observed

General management principles* Supervision

Close observation (see denition below) Do not leave patient in waiting room without support person

Agitation/restlessness Moderate behaviour disturbance Intrusive behaviour Severe distress Confused Australasian Triage Scale1 states: Ambivalence about treatment Not likely to wait for treatment Very distressed, risk of self-harm Reported Acutely psychotic or Suicidal ideation thought-disordered Situational crisis Situational crisis, deliberate self-harm Agitated/withdrawn Presence of psychotic symptoms Hallucinations Delusions Paranoid ideas Thought disordered Bizarre/agitated behaviour

Action

Alert mental health triage Ensure safe environment for patient and others Re-triage if evidence of increasing behavioural disturbance i.e. Restlessness Intrusiveness Agitation Aggressiveness Increasing distress Inform security that patient is in department Intoxication by drugs and alcohol may cause an escalation in behaviour that requires management

Consider

Presence of mood disturbance

Severe symptoms of depression Withdrawn/uncommunicative and/or anxiety Elevated or irritable mood

Mental health triage tool (continued)

Triage code Treatment acuity 4 Semi-urgent
Within 60 minutes

Description Moderate distress Australasian Triage Scale1 states:

Typical presentation Observed

No agitation/restlessness Irritable without aggression Cooperative Gives coherent history

General management principles* Supervision Action

Intermittent observation (see denition below) Discuss with mental health triage nurse Re-triage if evidence of increasing behavioural disturbance i.e. Restlessness Intrusiveness Agitation Aggressiveness Increasing distress Intoxication by drugs and alcohol may cause an escalation in behaviour that requires management

Semi-urgent mental health problem Under observation and/or no immediate risk to self or others

Reported

Consider

Pre-existing mental health disorder Symptoms of anxiety or depression without suicidal ideation Willing to wait

Mental health triage tool (continued)

Triage code Treatment acuity 5 Non-urgent
Within 120 minutes

Description No danger to self or others

No acute distress No behavioural disturbance

Typical presentation
Cooperative Communicative and able to engage in developing management plan Able to discuss concerns Compliant with instructions

General management principles* Supervision Action

General observation (see denition below) Discuss with mental health triage Refer to treating team if case-managed

Observed

Australasian Triage Scale1 states:

Known patient with chronic symptoms Social crisis, clinically well patient

Reported

Known patient with chronic psychotic symptoms Pre-existing non-acute mental health disorder Known patient with chronic unexplained somatic symptoms Request for medication Minor adverse effect of medication Financial, social, accommodation, or relationship problems
Management Definitions2 Continuous visual surveillance = person is under direct visual observation at all times Close observation = regular observation at a maximum of 10 minute intervals Intermittent observation = regular observation at a maximum of 30 minute intervals General observation = routine waiting room check at a maximum of 1 hour intervals * Management principles may differ according to individual health service protocols and facilities. 1 Australasian College of Emergency Medicine (2000). Guidelines for the implementation of the Australasian Triage Scale (ATS) in Emergency Departments. 2 South Eastern Sydney Area Health Service Mental Health Triage guidelines for Emergency Departments Acknowledgements NICS acknowledges existing triage tools provided by Barwon Health