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Riflessioni sulla porta del Pronto Soccorso Triage, code e See and Treat

Riflessioni sulla porta del Pronto Soccorso Triage, code e See and Treat. Guardiamoci intorno…. Grande variabilità in USA (codice di priorita’ fra 2 e 5 livelli) ‏ Attuale “trend”per l’uso di 5 livelli ENA e ACEP joint assessment in favore del sistema a 5 ( 2003) ‏

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Riflessioni sulla porta del Pronto Soccorso Triage, code e See and Treat

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  1. Riflessioni sulla porta del Pronto Soccorso Triage, code e See and Treat

  2. Guardiamoci intorno… • Grande variabilità in USA (codice di priorita’ fra 2 e 5 livelli)‏ • Attuale “trend”per l’uso di 5 livelli • ENA e ACEP joint assessment in favore del sistema a 5 ( 2003)‏ • Aumentano le evidenze in favore dei 5 livelli

  3. Guardiamoci intorno… • Australasian Triage Scale (ATS)‏ • Manchester Triage Group (UK ,Canada)‏ • Canadian Triage and Acuity Scale (CTAS)‏ • Emergency Severity Index ( USA)‏

  4. Australia National Triage System Sistema numerico bilanciato Attenzione all’emergenza – urgenza Derivazione inglese

  5. CanadaCodici di priorità Codice Tempo Definizione 1 0 Emergenza 2 20’ Urgenza 3 24 ore Non Urgente 4 Indef. Inappropriato 5 Indef. Programmato

  6. CanadaCodici di priorità Codice Tempo Definizione 1 0 Rianimazione 2 0 Emergenza 3 30’ Urgenza 4 60’ Urgenza minore 5 120’ Non urgenza

  7. Canada Canadian Triage and Acuity Scale Sistema numerico bilanciato Attenzione al dolore Ottima diffusione e controllo qualità

  8. USA 100 milioni di accessi nel 2000 Realtà disomogenea Rinnovata attenzione al triage

  9. USA ENA 2001 National Benchmark guide ED 4000 ED survey Triage globale 63%, di bancone 24%

  10. USA Tre livelli 66% (emergent, urgent, non urgent) (red, yellow, green) Quattro livelli 11% Cinque livelli 3%

  11. USA Gold standard ENA five level priority Gli infermieri che usano un sistema a cinque non tornerebbero a quello a tre o quattro livelli di priorità

  12. ESI: Emergency Severity Index Presented By: Duane A. Young-Kershaw RN, BSN Emergency Dept BIDMC, Boston Massachusetts, USA

  13. What is Triage? 1: the sorting of and allocation of treatment to patients and especially battle and disaster victims according to a system of priorities designed to maximize the number of survivors 2: the sorting of patients, in an emergency room, according to the urgency of their need for care

  14. Purpose of Triage Right person Right place Right time Right reason

  15. How has it been done? 3 Tier acuity rating system

  16. What is wrong with a 3 or 4 Level Triage System Does not tell us much about needed assets Subjective inconsistencies with multiple Triage Nurses decisions

  17. The need for Change ED volume increasing beyond resources for immediate care Emergency Dept becoming primary care for many patients In the united States there are greater than 100 million Emergency department visits each year. Why this Large number?

  18. The need for a better System With a greater stress on the Emergency Department Resources a better system was adapted and designed to better allocate these resources. The Emergency Severity is designed with asset allocation in mind.

  19. Emergency Severity Index

  20. ESI Based on Resources Needed Admission rates ED Resource Consumption ED length of stay Mortality Research has shown that patient acuity can accurately predict:

  21. What does the ESI do for us Greater emphasis on asset allocation Better places the patient In the right place In the adequate amount of time For the right reason

  22. What Information Is Necessary An organized radio report is important and inclusive of: Prehospital unit or company Base hospital/receiving facility Request to speak to MD or Nurse Patient acuity level Location of incident Age, weight, sex Problem/chief complaint/injury Mechanism of injury/LOC Pertinent history related to primary/secondary survey, including meds Current vital signs

  23. Triage: Repetitive Or Necessary? “ Do the nurses at triage need the same information again?” Yes and for several reasons: To verify the radio report, document changes that occurred en route, define a patient acuity level, ensure appropriate patient placement in the department and resources change.

  24. EMS Report/ED Nurse Charting The triage note taken from the EMS report includes the following: Verification of those things reported in the radio call Time of arrival Mode of transportation Condition on arrival History/meds/allergies Prehospital interventions/results Any evidence of violence experienced by patient

  25. ED Triage Note, cont’d Current vital signs Results of primary/secondary survey from the field Next of kin information Collection of rhythm strips or labs drawn in field with appropriate labeling and documentation of such is very important

  26. Inghilterra L’impatto della normativa 1992 “…prima valutazione entro 5’ dall’arrivo in A&Ed…” 1997 “Manchester Triage System” La diffusione nel mondo

  27. MANCHESTER TRIAGE SYSTEM The Essential Concept Jill Windle Lecturer Practitioner in Emergency Nursing Chair Faculty of Emergency Nursing

  28. Manchester Triage System Manchester Triage Group First published 1997 UK wide coverage Eire, Portugal, Holland, Belgium, Sweden NZ, Australia, Japan, Canada

  29. The System Components Developed via consensus view Presentation flow charts Series of General and specific discriminators To reach patient clinical priority

  30. Manchester Triage System 50 presentations 186 discriminators General Specific 5 priorities

  31. RED Y Discriminators N Y Discriminators ORANGE N Y Y N Discriminators Discriminators YELLOW GREEN N BLUE

  32. The Evidence Growing body of evidence of accuracy, reliability, reproducibility of the system Internal and external validity Estimated 8 million patient’s per annum (in the UK) triaged using MTS

  33. Documentation Specific & guided What to include & what not Prevents negative reporting Legally powerful

  34. Computer Decision Support Units with CDSS are more likely to achieve higher accuracy rates CDSS illustrates the system so every triage assessment = familiarization Reducing nurses ability to make arbitrary decisions improves accuracy and reduces risk of inappropriate decision making

  35. Do’s and Don’ts

  36. Do Treat MTS as a whole system You need all the components for optimum efficiency Use flow charts as they were designed Pain assessment integral to the decision making process

  37. Do Not Mistake MTS as a Protocol MTS guides the decision making process for safe allocation of patient priority Cannot replace the assessment skills required of Emergency Nurses Still need to ask the right questions Nurses require assessment skills, ED experience and triage training to make accurate decisions

  38. Don’t forget PAIN General Discriminator Most cited error for inappropriate priority Most common patient complaint Match patients pain with priority Analgesia at triage

  39. MTS is Dynamic Not limited to ED front door Continues from arrival to admission or discharge Re-assessment is a key principle

  40. System Countries Levels Patient should be seen by provider within Australasian Triage Scale (ATS) (formerly National Triage Scale of Australia)‏ AustraliaNew Zealand 1 - Resuscitation2 - Emergency3 - Urgent4 - Semi-urgent 5 - Nonurgent Level 1 - 0 minutesLevel 2 - 10 minutesLevel 3 - 30 minutesLevel 4 - 60 minutesLevel 5 - 120 minutes Manchester EnglandScotland 1 - Immediate (red)2 - Very urgent (orange)3 - Urgent (yellow)4 - Standard (green) 5 - Nonurgent (blue)‏ Level 1 - 0 minutesLevel 2 - 10 minutesLevel 3 - 60 minutesLevel 4 - 120 minutesLevel 5 - 240 minutes Canadian Triage and Acuity Scale Canada 1 - Resuscitation2 - Emergency3 - Urgent4 - Less Urgent 5 - Nonurgent Level 1 - 0 minutesLevel 2 - 15 minutesLevel 3 - 60 minutesLevel 4 - 120 minutesLevel 5 - 240 minutes Five-level Triage Systems Australasian College for Emergency Medicine, 2002 ; Canadian Association of Emergency Physicians, 2002 ; Manchester Triage Group, 1997

  41. PRIMAVERA 1996 GRUPPO INTERDISCIPLINARE PER L’ ATTIVAZIONE DEL TRIAGE INFERMIERISTICO IN PRONTO SOCCORSO DI ALCUNE REALTA’ DELL’ EMILIA ROMAGNA, MARCHE, UMBRIA E SAN MARINO • FORMAZIONE • CORSI RESIDENZIALI • CORSI c/o AZIENDE • 1996  2004 circa 5.000 Infermieri e medici in tutta Italia • 1.300 dei quali negli 12 corsi residenziali • CONFRONTO STUDIO RICERCA • Contatti con le realtà operative • Relazioni a convegni • PUBBLICAZIONI • Sito internet • Articoli su riviste professionali • 1997 “Triage Infermieristico in Pronto Soccorso” “GFT news” • 2000 “Triage Infermieristico” • Consulenza per organi istituzionali (linee guida triage 1996 e 2001, direttive regionali) Infermieri, medici, capo sala, coordinatori OPERANTI IN PRONTO SOCCORSO MARCHE EMILIA ROMAGNA SAN MARINO UMBRIA TRENTINO PIEMONTE VENETO TOSCANA LIGURIA CAMPANIA FRIULI SARDEGNA SICILIA LAZIO LOMBARDIA MOLISE TR. BOLZ.

  42. REVISIONE LETTERATURA STRANIERA • E.N.A. • Manchester Triage Group • ESPERIENZA SUL CAMPO • Realtà all’ Avanguardia • Specifico Professionale • Esigenze Realtà Operative • Disposizioni Legislative MODELLO DI TRIAGE INTRAOSPEDALIERO G.F.T. TRIAGE GLOBALE ricerca esperienza applicabilità metodologie di valutazione clinica condivise in letteratura Strumenti Nursing Protocolli, pocesso di n., identificazione dei problemi assisten.,ecc. Tecniche Relazionalie di front-hoffice Clinicariguardante i quadri patol. Tipici del P.S.

  43. MODELLO CHE PREVEDE • OBIETTIVI • Definizione del Sistema di Triage • Definizione della metodologia di valutazione • Criteri per la stesura dei protocolli • Formazione • Implementazione

  44. IL PROCESSO DI TRIAGE LA VALUTAZIONE “SULLA PORTA” LA RACCOLTA DATI (VALUTAZIONE SOGGETTIVA E OGGETTIVA) LA DECISIONE DI TRIAGE LA RIVALUTAZIONE

  45. 1. VALUTAZIONE SULLA PORTA ASPETTO GENERALE A: PERVIETA’ DELLE VIE AEREE B: RESPIRO C: CIRCOLO D: EVIDENTI DEFICIT NEUROLOGICI O ALTERAZIONI DELLA COSICENZA

  46. 2. RACCOLTA DATI / VALUTAZIONE VALUTAZIONE SOGGETTIVA IL SINTOMO PRINCIPALE L’EVENTO PRESENTE  IL DOLORE  I SINTOMI ASSOCIATI LA STORIA MEDICA PASSATA • VALUTAZIONE OGGETTIVA • DATI OSSERVATI (come appare il paziente) • DATI MISURATI (parametri vitali) • DATI RICERCATI (esame fisico mirato) P = provocato/alleviato Q = qualità R = irradiazione/regione S = gravità T = tempo A = vie aeree B = respiro C = circolo D = deficit neurologici H = storia/esame completo E = esposizione F = febbre G = parametri vitali T = tetano E = eventi S = storia T = terapie A = allergie CONFERMA DEL SINTOMO PRINCIPALE

  47. 3. DECISIONE DI TRIAGE Sistema di codifica a quattro livelli di priorità CODICE GIALLO CODICE ROSSO Pazienti in pericolo di vita Vi è il cedimento di una o più funzioni vitali Pazienti in potenziale pericolo di vita Minaccia incombente di cedimento di una funzione vitale. CODICE BIANCO CODICE VERDE Pazienti che necessitano di prestazione medica differibile nel tempo senza rischi Patologie che non sottendono alcuna Urgenza

  48. Organizzazionedella Unita’ Operativa Età, sesso, handicap TRIAGE Protocolli della Unità Operativa CODICE DI PRIORITA’ Esperienza triagista Tipo di struttura ospedaliera Percorsi interni Gestione Sala d’attesa

  49. è prevista la rivalutazione continua dei pazienti in sala d’attesa 4. RIVALUTAZIONE • Tempi in base al codice di gravità assegnato • Necessità valutata dall’ operatore • A richiesta dell’ utente

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