The Origins of Triage + Use of the ATS

Transcription

1 The Origins of Triage + Use of the ATS Jane Bebbington Senior Lecturer, The University of Auckland Nurse Educator, Auckland City Hospital Introduce myself Apologies - I am an ED nurse have done both paeds & adult (but out of date with paeds) My work setting might be very different to yours size / resources goodfellow april Function of Triage to ensure pts are treated in order of clinical urgency + treatment is appropriately timed allocation to most appropriate assessment + treatment area (+ contributes information that helps to describe departmental casemix) urgency refers to need for time-critical intervention - not synonymous with severity (ACEM, 2005) goodfellow april

2 goodfellow april Triage origins of the word French verb trier - picker or sorter Triage differentiated between high + low quality products In 1820s French coffee beans were sorted into three grades (Mezza, 1998): -best quality - middling -triage Military Origins Roman Wars Baron Dominique Jean Larrey ( ) WW I - resource availability / rationing (NATO, 1975) WW II Korea - greatest good for the greatest number Vietnam - staging options - good for everyone Military Hospitals goodfellow april Triage in NZ Emergency Departments Increasing use of emergency departments for urgent + non urgent problems Ipswich, NTS (Fitzgerald, 2000) The Healthcare Standards - all NZ EDs must use NTS + that all pts must be subject to triage on arrival (1994, p. A&E1) NTS replaced with Australian Triage Scale Australasian Triage Scale (last updated Nov 2005) goodfellow april

3 goodfellow april Use of ATS (2005) Use combination of presenting problem + general appearance (+/- physiological observations) Takes no longer than 2-5 mins Obtain enough info to determine urgency + immediate care needs Balance speed / thoroughness Triage not intended to make a diagnosis, although this may be possible Vital signs only if needed to estimate urgency, - time permits Safety Encounter whole spectrum of acute illness, injury, mental health problems & challenging behaviour may present there Aims - safety of: -patient -myself - staff - department - organisation (Bebbington, 2000) goodfellow april Stop the clock Usually it is "Time seen by doctor Can be nursing staff acting under clinical supervision (of a dr) - "Time seen by nurse If there is a documented, clinical pathway, protocol, or guideline approved by Director of Emergency Medicine - time of contact between pt & staff implementing pathway Emergency nurse practitioner. In the future.. Will be able to stop the clock without any medical involvement goodfellow april

4 goodfellow april Documentation stds Date / time of assessment Name of triager Chief presenting problem(s) Limited, relevant history Relevant assessment findings Allocated initial triage category Retriage category / time & reason Placement area Any diagnostics, first aid or treatment (ACEM, 2005) goodfellow april Paeds Same stds for triage apply to all ED settings where children are seen All 5 triage categories should be used in all settings Children should still be triaged according to objective clinical urgency (ACEM, 2005) goodfellow april

5 goodfellow april ATS 1 ATS 2 ATS 3 ATS 4 ATS 5 ATS Immediate Within 10 minutes Within 30 minutes Within 60 minutes Within 120 minutes Response Immediate simultaneous assessment & treatment ATS 1 Description Immediately Life-Threatening Conditions = threats to life (or imminent risk of deterioration) & require immediate aggressive intervention What are some clinical descriptors for triage category 1? goodfellow april Clinical descriptors Cardiac arrest Respiratory arrest Immediate risk to airway - impending arrest Respiratory rate <10/min Extreme respiratory distress BP< 80 (adult) or severely shocked child/infant Unresponsive or responds to pain only (GCS < 9) Ongoing/prolonged seizure IV overdose & unresponsive or hypoventilation Severe behavioural disorder with immediate threat of dangerous violence goodfellow april

6 goodfellow april Response Assessment & treatment within 10 mins (often simultaneous) ATS 2 Description Imminently life-threatening condition is serious enough / deteriorating with potential threat to life, or organ system failure Or Important time-critical treatment e.g. thrombolysis / antidote Or Very severe pain What are some clinical descriptors for triage category 2? Clinical descriptors Airway risk e.g. stridor / drooling Severe respiratory distress Circulatory compromise Clammy / mottled skin, poor perfusion HR< 50 or >150 (adult) Hypotension with symptoms Severe blood loss Shocked child / infant Chest pain (likely cardiac nature) Very severe pain BSL < 3 mmol Drowsy, decreased responsiveness (GCS< 13) Acute hemiparesis / dysphasia? Meningococcaemia continued goodfellow april Fever with signs of lethargy (any age) Acid or alkali splash to eye Major multi trauma Severe localised trauma - major fracture, amputation High Risk Hx Significant sedative or other toxic ingestion Significant/dangerous envenomation Severe pain suggesting PE / AAA / ectopic Behavioural/Psychiatric: violent or aggressive immediate threat to self or others requires or has required restraint severe agitation or aggression goodfellow april

7 goodfellow april Response Assessment & treatment start within 30 mins ATS 3 Description Potentially life threatening condition may progress to life / limb threatening or lead to morbidity Situational Urgency i.e. potential for adverse outcome Severe pain / distress What are some clinical descriptors for triage category 3? Clinical descriptors Severe hypertension Moderately severe blood loss Mod SOB SAO % BSL > 16 Seizure now alert Fever if immunosuppressed Persistent vomiting Dehydration HI with LOC now alert Moderate pain continued goodfellow april Chest pain likely non cardiac Abdo pain without high risk features Mod limb injury deformity / severe crush / laceration Limb altered sensation, acute loss of pulse Trauma high risk Hx, no other high risk features Stable neonate Child at risk abuse /?NAI Behavioural / Psych (NB these do not match NZ MOH Mental heath triage guidelines) Very distressed / risk of self harm Acutely psychotic Deliberate self harm Agitated / withdrawn Potentially aggressive goodfellow april

8 goodfellow april Response Assessment & treatment start within 60 mins What are some clinical descriptors for triage category 4? ATS 4 Description Potentially serious i.e. condition may deteriorate or may have adverse outcome or symptoms moderate or prolonged Situational urgency i.e. potential for adverse outcome Significant complexity or severity Humane practice relief of discomfort or distress within 60 mins Clinical descriptors Mild haemorrhage FB aspiration Chest injury without rib pain / resp distress Difficulty swallowing nil resp distress Minor HI no loss of consciousness Moderate pain Eye inflammation / FB normal vision Minor limb trauma sprain,?#, uncomplicated laceration normal VS s / minor mod pain Non specific abdo pain Behavioural / psych Semi urgent mental health prob Under obs & no risk to self / others goodfellow april Response Assessment & treatment within 120 mins ATS 5 Description Less urgent Chronic or minor outcome not affected if treatment delayed 2 hours Clinico-administrative results review, med certs, prescriptions What are some clinical descriptors for triage category 5? goodfellow april

9 goodfellow april Clinical descriptors Minimal pain no high risk features Low risk Hx, asymptomatic Minor symptoms existing stable illness Minor symptoms of low risk conditions Minor wounds not requiring sutures Scheduled visit eg wound review Immunisation Behavioural / psych Known with chronic symptoms Social crisis, clinically well See ACEM - Infocentre, Policies and Guidelines Policy document ATS; Guidelines for implementation of the ATS Case scenarios 22 yr female, abdo pain 2 hours, R) lower quadrant, constant, LMP? 6/52 (unsure as often irregular), HR 110, a bit pallid What triage cat do you give her? Why? What factors may make her triage category higher or lower? goodfellow april yr old female Brought in by partner Following ingestion of 45 paracetamol tabs 35 mins ago alert and orientated Regretful of taking tabs, and does not want to cause you any more work..v apologetic What are your considerations in making the triage decision? goodfellow april

10 goodfellow april year old male, presents with a 2 cm lac to forehead, states he slipped on the stairs Nil other questions were asked but in order to triage this man.. What other information do you need? His GCS is 15 He was KO d He does not have c spine pain He also has some tenderness in his left wrist, nil other pain noted On further questioning it is not clear if he did fall - he may have collapsed What triage category will you allocate? What factors might make you allocate a higher or lower triage category? goodfellow april yr old female Presents with neck pain states turned to use telephone and became aware of v acute neck pain Now complaining of severe neck pain, headache Feeling very unwell What other info do you require to triage this woman goodfellow april

11 goodfellow april Woman Febrile temp 38.3 Hot and miserable Headache is v severe doesn t like bright light Now how would you triage her?? 44 yr old male, recent RTI C/O chest pain, left sided, localised, describes the pain as cutting, worse on coughing & movement On examination P 96, RR 18, to touch warm but not hot What triage category will you allocate? What factors might make you allocate a higher or lower category? goodfellow april year old male, has fallen from his skateboard OE obvious dinner fork deformity right wrist Not KO d Nil other injuries States it is very sore when he moves it What triage category will you allocate? What factors might result in a higher or lower category? goodfellow april

12 goodfellow april What factors would impact on the ability of your work setting to have a formal triage system? (Include telephone triage) What could be some possible solutions? goodfellow april