Page 606 - ACCCN's Critical Care Nursing

Emergency Presentations 583

with a clear statement of the complaint in the patient’s TRIAGE ASSESSMENT
own words, followed by historical information and Patient assessment at triage has three major components:
related relevant details, such as time of onset, duration of quick, systematic and dynamic. Speed of assessment is
symptom/s, and what aggravates or relieves the symptom/s. required in life-threatening situations, with the focus on
A brief, focused physical assessment including vital signs airway, breathing, circulation and disability (A,B,C,D),
may be undertaken to identify the urgency and severity and a quick decision on what level of intervention is
of the condition, and may be collected as part of the required. A systematic approach to assessment is used for
triage process to inform decision making. 5,10,11 Triage all patients in all circumstances, to ensure reproducibility.
assessment generally should be no longer than 2–5 Finally, the triage assessment must be dynamic, in that
11
minutes, balancing between speed and thoroughness. several aspects can be undertaken at once, and acknowl-
From the information collected, the triage nurse deter- edging that a patient’s condition can change rapidly after
1-3
mines the need for immediate or delayed care, and initial assessment. Various assessment models are avail-
assigns the patient a 1–5 ATS category in response to the able, but fundamentally they all include components of
statement: This patient should wait for medical assessment observation, history-taking, primary survey and second-
and treatment no longer than … . 11 1-3,4,6,11,12
ary survey.
Patients with acute conditions that threaten life or limb
receive the highest priority while those with minor illness
or injury are assigned a lower priority. It may not be pos- Patient History/Interview
sible to categorise the patient correctly in all instances, The triage interview provides the basis for data gathering
but it is better to allocate priority on a conservative basis and clinical decision making regarding patient acuity.
and err on the side of a potentially more serious After an introduction, the triage nurse asks person-specific
problem. 3,8,10,11 Importantly, a triage allocation is dynamic open-ended questions. Use of close-ended questions or
and can be altered at any time. If a patient’s condition summative statements enables clarification and confir-
5-8
changes while waiting medical assessment/treatment, or mation of information received, and to check under-
if additional relevant information becomes available that standing by the patient. Privacy is important to ensure
12
impacts on the patient’s urgency the patient should be that the patient is comfortable in answering questions of
re-triaged to a category that reflects the determined a personal nature. Most EDs need to balance providing
urgency. 11,12 Frequent, ongoing observation and assess- an area that is private and accessible, yet safe for staff to
ment of patients is therefore routine practice following work in relative isolation.
the initial triage assessment.
A large component of the triage assessment may be based
on subjective data, which are then compared and com-
bined with the objective data obtained through the senses
Practice tip of smell, sight, hearing and touch to determine a triage
category: pulse, blood pressure, respiratory rate and char-
The aims of triage are to deliver the right patient to the right acteristics, oxygen saturation, capillary return, tempera-
treatment area at the right time. Triage decisions must be accu- ture, blood glucose level. One aspect of the history that
rate, ensure the patient’s safety and be reproducible across is difficult to quantify is intuition. This is that ‘sixth sense,
clinicians and departments. or gut feeling’ that tells us that something not yet detect-
able is wrong with the patient. This unexplained sense is
difficult to outline or apply scientific research models to,
but it has an important role to play in patient assessment
and should be acknowledged when something ‘doesn’t
The premise for a triage decision is that utilisation of feel right’. 6,11,12
valuable healthcare resources provide the greatest benefit
for the neediest, and that persons in need of urgent atten-
tion always receive that care. 1,2,4,5,11,12 Triage encompasses
the entire body of emergency nursing practice, and nurses Primary Survey
complete a comprehensive triage education program While taking a patient history, the triage nurse also
prior to commencing this role. A formal national triage simultaneously conducts a primary survey. As noted
training resource has been developed that provides the earlier, airway, breathing, circulation and neurological
essential education components to promote consistency function (deficit) is observed. If any major problem
in application of the ATS. 11,12 is observed, the interview is ceased and the patient
is transferred immediately to the acute treatment or
TRIAGE CATEGORIES resuscitation area. 8
After triage assessment is undertaken on arrival, patients
are allocated one of five triage categories using the
Australasian triage scale (ATS) (see Table 22.2). Prompt Secondary Survey and Physical Examination
assessment of airway, breathing, circulation and disability A secondary survey, involving a concise, systematic
remains the cornerstone of patient assessment in any physical examination, is conducted after the patient
clinical context, including triage. history and primary survey have been completed. The