Emergency Department Triage

1. Ryan C. Mirano, MD, MHSA Emergency Department Triage

2. The Evolution of Triage • Purpose of ED triage: To prioritize incoming patients and to identify those who cannot wait to be seen • Three most common types of triage systems: • Traffic director • Spot-check • Comprehensive triage

3. Comprehensive Triage • The emergency staff triages each patient and determines the priority of care based on physical, developmental and psychosocial needs as well as factors influencing access to health care and patient flow through the emergency care system.

4. Principles of Triage • Urgency refers to the need for time-critical intervention – it is not synonymous with severity • Triage assessment is not necessarily intended to make a diagnosis • Patients triaged to lower acuity categories may be safe to wait longer for assessment and treatment but may still require hospital admission

5. Triage Acuity

6. Emergency Severity Index • “Who should be seen first?” • “How long can everybody wait?” • ESI triage is a rapid sorting into five groups with clinically meaningful differences in projected resource needs and therefore, associated operational needs. • Use of the ESI for this rapid sorting can lead to improved flow of patients through the ED.

7. ESI Conceptual Algorithm Patient dying? A Yes 1 No Shouldn’t wait? B Yes 2 No How many resources? None One Many C Consider Vital signs D No 3 5 4

8. Decision Point A: Is the Patient Dying? • Does the patient require immediate life-saving intervention? • Aimed at securing the ABC’s • Does the patient require an immediate airway, medication, or other hemodynamic intervention? (IV, supplemental O2, monitor, ECG or labs DO NOT count)

9. Decision Point A: Is the Patient Dying? • Does the patient meet any of the following criteria: • Already intubated • Apneic and pulseless • Severe respiratory distress • Acute mental status changes, or unresponsive

10. Examples of ESI Level 1 • Cardiac arrest/ Respiratory arrest • Critically injured trauma patient who presents unresponsive • Overdose with a respiratory rate of 6 • Severe respiratory distress with agonal or gasping type respirations. • Severe bradycardia or tachycardia with signs of hypoperfusion • Hypotension with signs of hypoperfusion

11. Examples of ESI Level 1 • Trauma patient who requires immediate crystalloid and colloid resuscitation • Chest pain, pale, diaphoretic, blood pressure palpatory • Weak and dizzy, heart rate < 50 • Anaphylactic reaction • Unresponsive with strong odor of ETOH • Hypoglycemia with a change in mental status

12. Decision Point B: Should the Patient Wait? • Is this a high risk situation? • patient you would put in your last open bed • Is the patient confused, lethargic or disoriented? • Is the patient in severe pain or distress? • determined by clinical observation and/or patient rating of greater than or equal to 7 on 0-10 pain scale

13. Examples of High-Risk Situation

14. Examples of High-Risk Situation

15. ESI Conceptual Algorithm Patient dying? A Yes 1 No Shouldn’t wait? B Yes 2 No How many resources? None One Many C Consider Vital signs D No 3 5 4

16. Decision Point C: Resource Needs? • What is typically done for the patient who presents to the emergency department with this common complaint? • Resources can be hospital services, tests, procedures, consults or interventions that are above and beyond the physician history and physical, or very simple emergency department interventions such as applying a bandage.

17. ESI Resources

18. Predicting Resources

19. Decision Point D: The Patient’s Vital Signs? • Before assigning a patient to ESI level 3, the staff needs to look at the patient's vital signs and decide whether they are outside the accepted parameters • Danger zone vital signs: • Adults(>8 years old) = Pulse <50 or >100 RR <10 or >30 BP <90/60 SaO2 <80%

20. ESI Conceptual Algorithm Patient dying? A Yes 1 No Shouldn’t wait? B Yes 2 No How many resources? None One Many C Consider Vital signs D No 3 5 4

21. Proposed Triage Flow

23. Practice Case 1 • A 44-year-old female is retching continuously into a large basin as her son wheels her into the triage area. Her son tells you that his diabetic mother has been vomiting for the past 5 hours and now it is “just this yellow stuff.” “She hasn't eaten or taken her insulin,” he tells you. No known drug allergies (NKDA). VS: BP 148/70, P 126, RR 24

24. Answer: ESI level 2: high risk. A 44-year-old diabetic with continuous vomiting is at risk for diabetic ketoacidosis. The patient's vital signs are a concern as her heart rate and respiratory rate are both elevated. It is not safe for this patient to wait for an extended period of time in the waiting room

25. Practice Case 2 • “I have this infection in my cuticle,” reports a 26-year-old healthy female. “It started hurting 2 days ago and today I noticed the pus.” The patient has a small paronychia on her right 2nd finger. NKDA, T 37.8° F, RR 14, HR 62, BP 108/70

26. Answer: ESI level 4: one resource. This young lady needs to have an incision and drainage of her paronychia. She will require no other resources.

27. Practice Case 3 • “My mother is just not acting herself,” reports the daughter of a 72-year-old female. “She is sleeping more than usual and complains that it hurts to pee.” VS: T 100.8° F, HR 98, RR 22, BP 122/80. The patient responds to verbal stimuli but is disoriented to time and place

28. Answer: ESI level 2: new onset confusion, lethargy, or disorientation. The daughter reports that her mother has a change in level of consciousness. The reason for her change in mental status may be a urinary tract infection that has advanced to bacteremia. She has an acute change in mental status and is therefore high risk.

29. Practice Case 4 • A 76-year-old male is brought to the ED because of severe abdominal pain. He tells you “it feels like someone is ripping me apart.” The pain began about 30 minutes prior to admission and he rates the intensity as 10/10. He has hypertension for which he takes a diuretic. No allergies. The patient is sitting in a wheelchair moaning in pain. His skin is cool and diaphoretic. VS: HR 122, BP 88/68, RR 24, SpO2 94%

30. Answer: ESI level 1: requires immediate lifesaving intervention. The patient is presenting with signs of shock-hypotensive, tachycardic, with decreased peripheral perfusion. He has a history of hypertension and is presenting with signs and symptoms that could be attributed to a dissecting aortic abdominal aneurysm. He needs immediate IV access, aggressive fluid resuscitation, and perhaps blood prior to surgery

31. Practice Case 5 • A 68-year-old female presents to the ED with her right arm in a sling. She was walking out to the mailbox and slipped on the ice. “I put my arm out to break my fall. I was lucky I didn't hit my head.” Right arm with good circulation, sensation, and movement, obvious deformity noted. PMH: arthritis, medications: ibuprofen, NKDA. Vital signs within normal limits. She rates her pain as 6/10.

32. Answer: ESI level 3: two or more resources. It looks like this patient has a displaced fracture and will need to have a closed reduction prior to casting or splinting. At a minimum, she needs x-rays and an orthopedic consult. Her vital signs are stable, so there is no need to up-triage her to an ESI level 2. Her pain is currently a 6/10.

33. ESI Triage Quality Indicators • Review of all negative outcomes which occurred due to a mis-triage • Measurement of time from patient arrival to being seen by a physician for each ESI triage category • Measurement of length of stay for each ESI triage category • Measurement of admission rates for each ESI triage category

34. Thank You