Page 605 - ACCCN's Critical Care Nursing

582 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

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sort and analyse relevant information. This foundation
enables an emergency nurse to communicate appropri- TABLE 22.1 Australasian triage code
ately with other members of the healthcare team, and to
implement appropriate independent and collaborative Code Descriptor Treatment acuity
nursing interventions. Assessment is an important element
of emergency care; other chapters provide detailed infor- 1 Resuscitation Immediately
mation on the evaluation of critically ill patients. 2 Emergency Within 10 minutes
Emergency nurses are specialists in acute episodic nursing 3 Urgent Within 30 minutes
care, and their knowledge, skills and expertise encompass 4 Semiurgent Within 1 hour
almost all other nursing specialty areas. Emergency nurses
therefore possess a unique body of knowledge and skill- 5 Non-urgent Within 2 hours
sets to manage a wide variety of presentations across all
age groups; this includes familiarity with general physical
and emotional requirements of each age group as these included a time-based scale and different colours on the
1,7,8
relate to their presenting health needs. ED nurses work medical record to indicate priority. Subsequent modi-
2-4
cooperatively with prehospital emergency personnel, fication and refinement led to the Ipswich Scale in the
1,2,4,5,7
doctors and other healthcare personnel and agencies in 1970s–80s. These early triage systems reinforced the
the community to provide patient care. 2,3,5 Roles in the concepts developed by Larrey, and established a process
ED include triage, direct patient care, expediting patient for patients’ presentations to be seen in order of clinical
flow, implementing medical orders, providing emotional priority rather than time of attendance. In the 1990s the
support during crises, documenting care, and arranging impact of community expectations and national health
for ongoing care, admission to the hospital, transfer policy led to further enhancements of triage systems in
to another healthcare facility, or discharge into the Australia, and the Ipswich triage scale was adapted into
community. 5,6 the national triage scale (NTS). The NTS was subsequently
tested and demonstrated to have the essential character-
TRIAGE istics of utility, reliability and validity. 1,2,4,5,7,9-11 In 1993,
the NTS was adopted by the Australasian College for
7
Central to the unique functions of an ED nurse is the role Emergency Medicine (ACEM) in its triage policy, and
of triage; perhaps the one clinical skill that distinguishes subsequently renamed the Australasian triage scale (ATS)
an emergency nurse from other specialist nurses. Triage as it was implemented in most EDs in Australia and New
4
literally means ‘to sieve or sort’, and is the first step in Zealand (see Table 22.1).
any patient’s management on presentation to an ED. 1-3 The ATS is now a world-leading, reliable and valid triage
classification system for emergency patients, with demon-
HISTORY OF TRIAGE strated predictive properties for severity of illness, mortal-
Triage was first described in 1797 during the Napoleonic ity and the need for admission. 5,7,9-11 When properly
wars by Surgeon Marshall Larrey, Napoleon’s chief applied, presenting patients should receive the same
7
medical officer, who introduced a system of sorting casu- triage score no matter which ED they present to. 5,9,11
alties that presented to the field dressing stations. His
aims were military rather than medical, however, so the THE PROCESS OF TRIAGE
highest priority were given to soldiers who had minor All patients presenting to an ED are triaged on arrival by
wounds and could be returned quickly to the battle lines a suitably experienced and trained registered nurse. 2,10
with minimal treatment. 1,8 This assessment represents the first clinical contact and
The documented use of triage was limited until World the commencement of care in the department. The ideal
War I, when the term was used to describe a physical area features of a triage area are: a well-signposted location
where sorting of casualties was conducted, rather than a close to the patient entrance; ability to conduct examina-
description of the sorting or triage process itself. Triage tion and primary treatment of patients in privacy; a close
8
continued to develop into a formalised assessment physical relationship with acute treatment and resus-
process, with subsequent adoption for initial categorising citation areas; and appropriate resources including an
of patient urgency and acuity within most civilian EDs. 1,7,8 examination table, thermometer, a sphygmomanometer,
stethoscope, glucometer and pulse oximetry. 2,4,10
DEVELOPMENT OF TRIAGE PROCESSES IN As the first clinician in the ED to interview the patient,
AUSTRALIA AND NEW ZEALAND the triage nurse gathers and documents information from

Australia is a world leader in the development of emer- the patient, family and friends, or prehospital emergency
personnel. Professional maturity is required to manage
gency triage and patient classification systems. In the late the stress inherent in dealing with an acutely ill patient
1960s patients presenting to ‘casualty’ departments in and family members (under significant stress themselves),
Australia were not always triaged, 1,2,4,5 with many EDs while rapidly making informed judgement on priorities
using random models of care; ambulance presentations of care for a wide range of clinical problems. 10
were given priority and the ‘walking wounded’ seen in
order of arrival. In the mid-1970s, staff at Box Hill Hos- The triage nurse receives and records information about
pital in Melbourne developed a five-tiered system that the patient’s reason for presentation to the ED, beginning