Siddiqui, Emaduddin

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eCommons@AKUDepartment of Emergency Medicine Medical College, PakistanAugust 2012Emergency Triage: Extend of our knowledgeEmaduddin SiddiquiAga Khan University, emaduddin.siddiqui@aku.eduFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_emerg_medRecommended CitationSiddiqui, E. (2012). Emergency Triage: Extend of our knowledge. journal of Pakistan Medical Association, 62(8), 839-842.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_emerg_med/70Triage is derived from the French word TIER, "tosort/separate or select". A process of determining the severityof patients and prioritizing them according to their medicalurgency, initially used to sort agricultural products, duringdisaster, in the battle field and even on telephonic advice,however presently it is exclusively used in specific healthcare context1 like hospital EDs (emergency department), andin ambulatory medical services.Dominique Jean Larrey, was the first to own most ofthe triage ideas during the Napoleonic Wars. Triage was thenformalized during World War I to treat the injured solders inbattlefields. Historically, there has been a broad range ofattempts to triage patients, and differing approaches andpatient tagging systems were used in different countries.Since the last century, triage is modified withscientific and modern approaches and more logicallydependent on physiological needs and assessment findings ofpatients. Assess, Categorization/transport are the bases of alltriage.2 Different types of triage are functional at present i.e."Simple triage", used at the scene of a mass-casualty, to sortpatients who need critical attention and continuous integratedtriage, it has 3 subtypes. Other types are: "Group (Global)Triage (e.g.; M.A.S.S. triage)", when Medical disasteroverwhelms the ability of a given area or community to meeta demand for health care. "Individual Triage. e.g. S.T.A.R.T.(Simple Triage and Rapid Treatment)", process of firstresponders to effectively and efficiently evaluate all of thevictims during a mass casualty incident. Developed in 1983by Newport Beach Fire Department, California.and HospitalTriage (e.g. E.S.I. or Emergency Severity Index v 4.0)3 this isbased on visual assessment, person perception and predictedresources used. Advanced Triage", resource dependent, triagestaff may decide to divert the present resources to a morestable patient, having more chance of survival with little orexisting resources. This has significant ethical implications,thus confined to serious disaster and battle field.3 "Reversetriage", Modern hospital triage based on appropriate use ofED space and resources to ensure that all patients presentingto the ED shall have access to care according to theirrespective needs. ESI (Emergency Severity Index) v 4.04 is a five-levelemergency department (ED) triage system that providesVol. 62, No. 8, August 2012 839Emergency Triage: Extend of our knowledgeEmaduddin SiddiquiAga Khan University Hospital, Karachi.Email: emaduddin.siddiqui@aku.eduShort CommunicationFigure-1: Establishing a mass casualty management system 1995 PAS, WHO, 2001.clinically relevant stratification of patients into five groupsfrom 1 (most urgent) to 5 (least urgent) on the basis of acuityand resource needs since 1990's by Richard Wuerz andcolleagues. Designed and evident to be very effective instratifying and sorting patients according to their clinicalneeds and recourses available to improve critical care anddecrease the risk of patient deteriorating in the waiting area.5Triage assignment based on visual assessment, triage staffperception, his experience and objective measures(vitals/pain scale). Goal is to provide every patient the rightresources, at the right place and the right amount of time.Triage area location must be immediately accessibleand clearly sign-posted. Triage structure should be designedfor quick patient examination, while keeping the privacyintact. Behavioral and psychiatric patients should beprioritized as per policy. On the other hand strategies toprotect staff is utmost important. Basic structure of triage forbusy ED must have at least 04 areas including a separatepaediatric bay for acute and non acute patients.Level 1 Resuscitation (Priority {P} 1): Immediateattention with maximal utilization of resources to prevent lossof life, limb, or vision. Level 2 Emergent (Priority {P} 2): High risk forrapid deterioration, loss of life, limb, or eyesight if treatmentor interventions are delayed. Level 3 Urgent (Priority {P} 3): Symptoms and riskfactors for serious disease do not indicate a likelihood ofrapid deterioration in the near future. Abnormal vitals signsfor these grey area patients may upgrade or downgrade thepriority. Level 4 Less Urgent (Priority {P} 4): Chroniccomplaints, medical maintenance, or medical conditionsposing no threat to loss of life, limb, or eyesight. Level 5 Non Urgent (Priority {P} 5): Patients in thiscategory are currently stable and require no resources such aslabs or x-ray.The goal of triage is to rapidly identify serious andwith life threatening conditions, and to adjust them in mostappropriate treatment area and to reduce ED congestion/rushin ED, along with ongoing patient's assessment. Provision ofadequate and timely information about the management andadministrative plan to the patients is also the responsibility oftriage staff.6Paediatric triage, needs more vigilance andexperience, children not only require quick assessment, butthe assessment of severity of disease might bemissed/delayed and they may deteriorate rapidly. Theymanifest non specific symptoms, and are uncooperativeduring examination, and may be presumed to have agespecific diseases.4 In this context triage staff should carry outa 3-step assessment before categorizing the severity of illnessi.e. initial impression of illness severity, evaluation of thepresenting complaint, assessment of behaviour and age-related physiological measurements.5 Timely and adequatelyinvolving paediatric physician in difficult and grey cases canreduce the morbidity and mortality. There are many different5 level triage acuity based on the disease and clinical acuity,like Emergency triage and treatment guidelines, Australiantriage scale (ATS), Canadian Triage and acuity scale (CTAS),Manchester triage level, Cape Triage group, other than ESI. The ESI triage depends on visual assessment; personperception and experience, hence the need of equipmentsare reduced. This makes ESI a more acceptable triagesystem for low income countries with higher burden ofpatients coming to EDs with limited available resources.Still triage staff needs some facilities like hand-washing,gloves, adequate communication devices (telephone and/orintercom etc), record register/computer. Vital monitoringequipments like HR, RR, BP, Temp, O2 saturation isrequired in ESI triage acuity. ECG machine, medication bin(temperature and pain relieving medications) andexamination area with adequate provision of privacy arefew of the necessities of adequate triage.Triage can be done by a physician or an experiencednurse supported by a nursing attendant. Only the experiencednurse can anticipate the probable recourse needed for anindividual patient and importance of age specific vital signs.Continuous training and protocols will keep triage stafffamiliar with the triage assessment. This pedigree must bemodified for rush hours and in disaster with at least 02 RN ora physician with a RN. Visual triage is preferred duringdisasters. The triage nurse should have rapid access to or be inview of the registration and waiting area at all times. He/sheshould greet patients and families in a warm and empatheticmanner. Brief visual assessments and documenting relevantvital signs and assigning triage level, reassessment of patientsin waiting, and notifying patients and families of delays, andnotify any change in their condition to the patient/attendant.Shifting the patients to treatment areas where necessary alongwith the triage slips and reports to the treatment nurse oremergency physician is also important.Reassessment after initial triage should be doneaccording to the triage policy, ESI recommendation is moreor less same for reassessment, i.e. level II should bereassessed within 15 minute, while Level III in 60 minutes,Level IV in 120 minutes and Level V in 180 minutes.However physician’s discretion should be superceded as perhis experience and clinical perception. In case of Disaster, natural or man made, whenseverity and magnitude of resources go beyond the scope ofwhat normally can be handled through routine procedures840 J Pak Med Assocand resources. Main objective is to provide immediate care tothe needy. In case when ED is in full potential capacity orduring Disasters, Priority 3 (P3), Priority 4 (P4) and Priority5 (P5) patients can be diverted to other hospitals or clinics.All Priority 1 (P1) and Priority 2 (P2) patients should be dealtwith preference. Ambulatory or Emergency Medical Servicesnumber like 1122 as functional in some areas of Pakistan playan important role in sorting and diverting thepatients/ambulances directly from the field to the immediateaccessible and available vicinity with adequately vacantresources. Role and preparation of ED triage and staff duringdisaster should be planned before. ED reception/Triage desk,other than triaging should facilitate to evacuate theemergency area, prepare triage and trauma team, start visualtriage and color assignment, Minor injuries and ambulatorypatients may be diverted to the area previously assigned formanaging such cases or referred to some other premise. Insuch cases this would be better option to identify patientsseverity and outcome with color tags like:2Red: Immediate care / life-threatening Yellow: Delayed urgent care / can delay up to one hour(Serious) Green: Minor delayed care/can delay up to three hours(Minor injuries)Black: Deceased victim is dead or mortally wounded / nocare required.There are few common problems and hindranceslike: Overcrowding, which is the most serious andcommonest. Availability of beds, limited access to primarycare or specialist physicians, increased complexity ofpatients are few other common problems at triage otherthan lack of alternative health facilities. Overcrowdingcreates a workload and dissatisfaction amongst triage staffsand patient. Left without being seen, aggression,inadequate patient care, prolonged delays in the treatmentsand diversions all adversely affect the patient's satisfactionand staff contentment. Staff-related outcomes, manifest asdecreased productivity, poor morale, and jobdissatisfaction. Morbidity and mortality cases are alsoattributed to delays in diagnosis and treatment. Shortagesof trained and experienced staff (nurse/doctors) docontribute while most of remaining prefers to work parttime. Dissatisfied patients may comment on demerits oftriage system and may give personal comments, but usuallyover look the significance of the system for the society ingeneral who visit the ED in need.Patients left without being seen (LWBS),7 leaveprior to being seen by a physician for assessment andtreatment, because of ''tired of waiting,8 childcare or othercommitments, transports, dissatisfaction with nursing andphysicians, improvement of symptoms, safety concerns inthe waiting room, difficulties with ED staff and aperception that the department is very busy are few otherreasons of LWBS. Triage staff should be careful of under triage, this willend up with legitimate action against the staff and hospitaladministration but on the other hand this may cause seriousmorbidity and mortality. Over triage is the process ofoverestimating the level, acceptable rates of up to 50% in aneffort to avoid under triage, might be fruitful.5Aggression at triage is common all around the world.Aggressive people are either patients or the relatives orfriends.9Aggression may provoke or magnify by some factorslike delays, pain, frustration of not been seen, fear, stress,drugs/alcohol or mental instability. Feeling of perceivedprejudice may also aggravate aggression and may lead to arisk of harm for the triage nurse and other reception staff.In order to minimize aggression, anticipation andimmediate action and involvement of management andseniors all may help to reduce anxiety. At times security maybe required. Hospitals should have assault/threat(verbal/physical) policy, which may be implemented firmlyas needed. There are some strategies to calm down aggressivepatients like verbal, physical and pharmacological in case ofpsychiatric illness. Ethical implications are the serious concern. Healthcare plan for different pandemic might raise these issues inVol. 62, No. 8, August 2012 841Figure-2: A 5 level triage categorization ESI v4.4future regarding the triage of patients and the rationale of care.Triage work load can be curtailed by reducing thewaiting time by: One problem per person strategy, triageliaison physician option, Rapid assessment team (RAT),10development or by multidisciplinary assessment at triage.Redesigning ED patient flows: Application of Lean thinkingto health care are possible other options.Debriefing sessions for staff is of utmost importantafer a disaster, patients death and humiliation/assault in ED.Staff working at triage needs to be shuffled and rotated fromtime to time to get some space and time out for them to reviveand energize themselves from a robotic, nauseating and nonrewarding job. For mental and psychological grooming,debriefing sessions are necessary to eliminate the thoughtsnegativism, while physical debriefing needs additionalvacations and day out. Triage Staff training is a continuous training exercise.Accuracy of correct triage can only be maintained byrepeated training, and its ongoing assessment needs. Recommendations:The health burden on emergency services all overthe world is increasing, patient expectations are at a rise,and ED has to cope with the problems of increasingdemand, financial pressures, paucity of experienced staff,and to apply more complex medical management in orderprevent mortality. The future challenges are to establisheffective triage systems, for early detection of those whorequire immediate, focused and best emergency responsewith limited resources.ConclusionOur aim at triage is to maintain a safe workenvironment, establish and maintain a positive client-patientfocus relationship and to minimize the risk of escalation ofaggression through practical knowledge gained throughexperiences and training with corrects identification of signsor symptoms and acknowledging the key information fromthe presenting complaint and relevant history with the use ofapproved guidelines and triage protocols. References1. Iserson KV, Moskop JC. Triage in medicine, part I: concept, history and type.Ann Emerg Med 21007; 49: 275-81.March 2007;Vol 49, No. 3: 275-2812. Establishing a mass casualty management system Pan American HealthOrganization; 1995. (Online) 2012 (Cited 2011 May 9). Available from URL:http://helid.digicollection.org/en/d/Jph24ee/5.2.2.html.3. Triage. (Online) 2012 (Cited 2011 May 1). Available from URL:http://en.wikipedia.org/wiki/Triage.4. Emergency Severity Index. (Online) 2011 (Cited 2011 May 2). Available fromURL: http://www.ahrq.gov/research/esi/.5. Shelton R. The Emergency Severity Index 5 level triage system. Dimens CritCare Nurse 2009; 28: 9-12.6. The Australian Triage Scale adopted by Australian College of EmergencyMedicine, 2000. (Online) (Cited 2011 May 3). Available from URL:http://www.docstoc.com/docs/31860308/TRIAGE-IN-THE-EMERGENCY-DEPARTMENT.7. Kennedy M, Mac Bean CE, Brand C, Sundarajan V, McD Taylor D. Reviewarticle: Leaving the emergency department without been seen. Emerg MedAustr 2008; 20: 306-13.8. Brand C, Kennedy M, Mac Bean C, Sundararajan V, Taylor D. Patients who'leave without being seen' (LWBS) from an emergency department. Literaturereview commissioned by the Department of Human Services. The RoyalMelbourne Hospital Grattan Street Victoria: June 2005.9. Royal Perth Victoria Hospital. Division of Critical Care. Zero tolerance topatient and visitor initiated workplace aggression at Royal Perth HospitalEmergency Department. Perth: Royal Perth Hospital; 2003.10. Grant S, Spain D, Green D Rapid assessment team reduces waiting time. EmergMed 1999; 11: 72-7.842 J Pak Med Assoc

Emergency Triage: Extend of our knowledge

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Emergency Triage: Extend of our knowledge

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