REVIEW OF TRIAGE

AND DOCUMENTATION
Ns.M.FATHONI, S.Kep.,MNS
MASTER OF NURSING
FACULTY OF MEDICINE
UNIVERSITY OF BRAWIJAYA
04 th APRIL 2016
TRIAGE SYSTEM
 Review TRIAGE
• Triage (Trier = to sort out or choose): A process which places the right
patient in the right place at the right time to receive the right level of
care
• Triage: essential, effective system to reduce waiting time, and
patient receive the appropriate treatment (Nuttal; Bailey, Hallam & Hurst as
cited in McNally, 1996).
competence and
experience
• Dependent on the competence and experience
– Pengalaman klinis
– Penilaian yang baik dan kepemimpinan
– Tenang di bawah tekanan
– Keputusan
– Memiliki pengetahuan tentang sumber daya yang tersedia
– Pemecah masalah kreatif
– Tersedia
– Berpengalaman dan berpengetahuan tentang korban yang
diantisipasi
Categories of triage
• Daily triage
– To identify the sickest patients: assess and provide treatment to
them first, before providing treatment to others who are less ill.
– The highest intensity of care is provided to the most seriously ill
patients, even if those patients have a low probability of survival.

• Incidental triage
– ED: a large number of patients but is still able to provide care to
all victims utilizing existing agency resources.
– Additional resources are used but disaster plans do not have to
be activated.
– The highest intensity of care is still provided to the most critically
ill patients.
Categories of triage (cont’)
• Disaster triage
– A paradigm shift from “rapid, high tech care to
the most unstable or acutely ill”
– To “doing the greatest good for the greatest
number”
– To identify injured or ill patients who have a
good chance of survival with immediate care
that does not require extraordinary resources.
Categories of triage (cont’)
• Tactical-military triage
– Similar to disaster triage, only miliatary
mission objectives
• Special conditions triage
– Ex. epidemic: triage to prevent secondary
transmission
• Susceptible, exposed, infectious, removed,
vaccinated
Triage system
• Phone triage : Criteria Based
dispatch
• Scene triage : START&SAVE vs.
SIEVE & SORT
• ED triage : ESI v.4
 Star of Life
Detection

Transfer to Report
Definitive Care

Care in Transit Response

On Scene Care
 Emergency Department
“TRIAGE”

Emergency Severity Index - ESI

 Examples of Triage Acuity
Systems
2 levels 3 levels 4 levels 5 levels

Emergent Emergent Life-threatenin Resuscitation

g
Non-emergent Urgent Emergent Emergent

Non-urgent Urgent Urgent

Non-urgent Non-urgent

Referred
 In Hospital: Daily Triage
• Three-tier system
– Emergent Urgent Nonurgent
Class 1 Class 2 Class3
• Four-tier system
– Emergent Emergent Urgent Nonurgent
Class 1A Class 1 Class 2 Class3
• Five-tier system
– Emergent Emergent Urgent Nonurgent Nonurgent
Class 1A Class1 Class 2 ED care Ambulatory Care
Class3 Class 4
- ATS - CTAS - ESI - Manchester - etc
Prehospital and Disaster: Triage
• Simple Triage and Rapid Treatment
(START) system: for triaging adults

• JumpSTART system: for triage pediatric

• Start/Save: when the triage process must

be over an extended period of time
START system
• Can walk Delayed (GREEN)
• RPM (30-60 sec) (Resprsi, Perfusi, Mental status
– R > 30
– P > 2 seconds (CRT) Critical (RED)
– M = doesn’t obey command (PERINTAH)
– R < 30
– P < 2 seconds Urgent (YELLOW)
– M = obeys command
– R = not breathing Expectant: dead
or dying (BLACK)
 Start Triage Minimal
injury

No Is patient breathing? Yes

> 30 BPM < 30 BPM

Open Patient’s airway Yes Immediate Care
No Is radial pulse present?

No Control bleeding
Dead or Yes
Dying
No Assess mental status
Can patient follow commands?

Yes
Delayed care
 Triage assessment exercise
Type of injury Pertinent information Triage category

Compound fracture of Respirations: < 30

the left femur Radial pulse: absent
Mental status: confuse

Dislocated right Respirations: < 30

shoulder Radial pulse: present
Mental status: conscious

Sucking chest wound Respirations: > 30

Radial pulse: present
Mental status: unconscious
Nursing practice during a disaster

• Assess situation
Safe life
• Assess victims
• Call for help Safe limp
• First aid Safe function
• Transfer
Assess situation:
• Scene safety: self, patient, other
• Aware of risk, hazards, environment
(second bomb)
• Recognize nature of problem: medical or
trauma, number of patients, do you need
more help?
• Always use basic safety instruction (BSI):
gown, gloves, glass, mask
Assess victims:
• Initial assessment: general impression:
cause, severity, mental status, airway,
breathing, circulation, set priority (Triage)
• History and physical examination
• Detail physical examination
• Ongoing continue assessment
• Communication and documentation
Nursing assessment
• A: Assess Airway
• B: Breathing
• C: Circulation, V/S, shock
• Burn assessment
• Pain assessment
• Trauma assessment head to toe
• Mental status assessment
• Know indications for intubation
• IV administration (Fluid therapy)
• Emergency medication
Nursing therapeutics
• Concepts of basis first aid
• Triage and transport & transfer
• Pain management
• Management of hypovolumia and fluid replacement
• Suturing
• Blast injuries/ tissue loss
• Eye lavage
• Decontamination of chemical exposure
• Fractures/immobilization of fracture
• Management of hemorrhage
• Stabilization of crush injuries
• Movement of patients with spinal cord injury
Competencies for RN related
to mass causality incidents
• Critical thinking
• Assessment
• Technical skills
• Communication
• Ethics
• Human diversity

Stanley, 2005
 Critical thinking
• Use an ethical and nationally approved
framework to support decision making and
prioritizing needed in disaster situations
• Use clinical judgment and decision making
skills in assessing the potential for appropriate,
timely individual care during an MCI

Stanley, 2005
Assessment
• General
– Assess the safety issues for self, the response
team, and victims in any given response situation,
in collaboration with the incident response team
– Identify possible indicators of a mass exposure
– Describe the essential element included in an MCI
scene assessment
• Specific
– Focus health history
– Assess the immediate psychological response
– Perform health assessment: airway,
cardiovascular, integumentary (wound, burn,
rash), pain, injury from head to toe, GI,
neurologic, musculoskeletal, mental status
spiritual emotional
Stanley, 2005
 Technical skills
• Demonstrate safe administration of medications
• Demonstrate safe administration of immunizations
• Assess the need for and initiate the appropriate
isolation and decontaminated procedures
• Demonstrate knowledge and skill related to
personal protection and safety
• Demonstrate the ability to maintain patient safety
during transport through splinting, immobilizing,
monitoring
Stanley, 2005
Communication
• Describe the local chain of command and
management system
• Identify one’s own role
• Demonstrate appropriate emergency
documentation of assessments, intervention,
nursing action, and outcomes
• Identify appropriate resources for referring
• Describe appropriate coping strategies to
manage self and others

Stanley, 2005
Ethics
• Identify and discuss ethical issue
related to MCI event
• Describe the ethical, legal,
psychological , and cultural
considerations when dealing with the
dying and etc.

Stanley, 2005
Human diversity
• Discuss the cultural, spiritual, and
social issues that may affect on
individual’s response to an MCI
• Discuss the diversity of emotional,
psychological and socio-cultural
response

Stanley, 2005
 ASSESSMENT &
PRIORITY SETTING

34 Triage - SOAP
 Objectives

• To list the steps of the SOAP process

• To describe how to carry out each step of
the SOAP process

35 Triage - SOAP
 Assessment Guide

• History from patient/relative/others

• The 5 senses including Common
Sense

36 Triage - SOAP
 Use the Five Senses

SIGHT SMELL
• general appearance • alcohol
(head to toe) • ketone bodies
• obvious signs of • malaena stools
injuries
• body language

37 Triage - SOAP
 Use the Five Senses

HEARING
• listen attentively
• ? shortness of breath
• ability to talk in complete
sentences

TOUCH
• skin temperature
• palpate for quality of pulse,
tenderness, swelling

38 Triage - SOAP
 Assessment & Priority
Setting
Purpose of Triage
• not to diagnosis
• but to assess and plan intervention

SOAP System
• organized & systematic approach
• formulated by Larry Weed
• problem - orientated medical record system

39 Triage - SOAP
 SOAP System
• Gathers subjective and objective data for
quick assessment
• Enables accurate planning for nursing
intervention and immediate management
• Is a 2 minutes’ process
• Is effective for documentation of nursing
assessment
40 Triage - SOAP
 WHAT IS SOAP?
S - Subjective
Collect data from what patient tells you
O - Objective
What are you actually seeing?
Parameters
A - Assessment
Assess the situation
P - Plan
Establish a plan for the patient
Investigations
Interventions
Priority

41 Triage - SOAP
 Triage Process
S - SUBJECTIVE
Collect subjective data
• Ask open ended questions e.g.
“What is the reason you want to see a doctor?”
• Gather other relevant information
• Obtain brief one-line statements
• AMPLE if not
• SAMPLE

42 Triage - SOAP
 Questions To Ask
• What is the chief complaint?
• Time of onset, duration, frequency
• Use acronym PAIN for pain assessment
• Effects to other system and activities e.g. unable to
bear weight after twisting ankle
• Effort to treat
– GP/Polyclinic/other emergency departments
– self medicate
• Past travel history, medical history, & drug allergy

43 Triage - SOAP
 Trauma Cases
Mechanism of injury must be noted
1. Ask how the patient was injured
2. Other Questions
● When did the accident occur?
● How fast was the car travelling?
● Where were you sitting?
● Were you wearing a seat belt?
● Did you hit the dashboard and were you thrown
against another car?
● Did you lose consciousness?

44 Triage - SOAP
 O - OBJECTIVE
Collect objective data :
General
• Mode of arrival to ED
• Level of consciousness; GCS (Trauma Case)
• Patient’s general appearance using your senses

Vital signs
• temperature,pulse, respiration, BP, SpO2 & pain
score

45 Triage - SOAP
 A - Assessment
Assess and evaluate patient based on
subjective and objective data findings

46 Triage - SOAP
 A - Assessment
• Carry out further tests if required
– ECG
– Peripheral blood glucose
– Urine Combur 9
– Urine HCG
– X-ray

• Institute first aid management

– Immobilize fracture
– Put on cervical collar
– First aid dressing

47 Triage - SOAP
P - PLAN
• Establish your priority & direct to appropriate
area.

Triage - SOAP 48
 SUMMARY
• Obtaining information on the chief
complaint is the cornerstone of the
triage process
– Event leading to illness/injury & time of
onset
– Location of problem
– Mechanism of injury for trauma cases
– Progress of problem
– Any previous treatment and response
49 Triage - SOAP
 SUMMARY
• Perform a systematic triage process
• Collect sufficient subjective and objective
data
• Assess according to patient’s acuity
• Plan interventions appropriately
• Document completely

50 Triage - SOAP
 DOCUMENTATION IN
TRIAGE

51 7-Sep-18 Documentation
 Objectives
• To state the goals of documentation
• To describe what to document
• To understand the key point of documentation
• To describe the use of the acronym PAIN

52 7-Sep-18 Documentation
 Goals of Documentation

• To support the triage decision

• To communicate essential information to
other caregivers
• To meet medical legal requirements

53 7-Sep-18 Documentation
 What Must Be Documented?
1. Time of triage
2. Chief complaint & associated symptoms
3. Past medical history
4. Allergies
5. Vital signs
6. Subjective and objective assessment
7. Acuity category
8. Diagnostic tests ordered
9. Interventions rendered
10. Disposition
11. Re-evaluation and changes in condition

54 7-Sep-18 Documentation
 Key Points
• Describe chief complaint as accurately as
possible
• Document patient’s expectations
• Document obstacles e.g. language barrier
• Document any conflict between subjective and
objective data

55 7-Sep-18 Documentation
 Pain Assessment
Acronym “PAIN”
P – Place or site of pain
• Ask patient to point to actual site

56 7-Sep-18 Documentation
 Pain Assessment
Acronym “PAIN”
A – Aggravating factors
• Ask patient for onset of pain and whether it is
aggravated by physical activity
• Ask what ADL has been interrupted

57 7-Sep-18 Documentation
 Pain Assessment
Acronym “PAIN”
I– Intensity, Nature & Duration
• Verbal Numeric Scale
• Use Categoric Scale if patient fails to understand the
Numeric scale after 3 attempts
• Use the FLACC scale for children under 4 years /
patient is unable to give a self-report

58 7-Sep-18 Documentation
 Pain Assessment
• Ask patient what his/her acceptable level or score
would be
• Document the score as verbalised by the patient
• Ask patient to describe the pain using his/her own
words.
• Prompt with examples only if patient is unable to
provide a description
• Ask about the duration of pain and whether the
patient had previous experience of similar pain

59 7-Sep-18 Documentation
 Pain Assessment
Acronym “PAIN”
N – Neutralizing or Relieving Factors
• Ask how that pain was relieved e.g. by pharmacological or
non-pharmacological treatment.
• Ask about compliance to treatment orders – pharmacological and
non-pharmacological
• Ask about onset of relief from time of consuming the analgesics
and duration of relief experienced

60 7-Sep-18 Documentation
 PAIN SCALES
• Numeric Scale
– First pain scale for assessing pain intensity
– Ask patient to rate the pain using a number from 0
to 10, the bigger the number the more severe the
pain
– Explain the score as 0 being “No Pain” and 10
being the “Worst Pain Ever Imagined”
– Now PAIN as Fifth Vital Sign

61 7-Sep-18 Documentation
 Categoric Scale
• Ask patient to rate pain by using words such
as no pain, mild pain, moderate pain or
severe pain.
• Document the pain scores for the Categoric
Scale as follows:
• No Pain (0) =0
• Mild Pain (1-3) =2
• Moderate Pain (4-6) = 5
• Severe Pain (7-10) = 8

62 7-Sep-18 Documentation
 The Modified Wong-Baker Faces
Scale
• Used for children, the cognitively impaired or elderly
patients who are unable to rate pain using either the
Numeric or Categoric Scale
• Six faces are shown on a scale of 0 -10 placed at
equal intervals on a10-cm line.
• Each face depicts a picture to demonstrate the
intensity of pain
• The smiling happy face depicts No Pain at point 0
• The tearful face depicts the worst pain ever imagined
at point 10.
• The equal numbers 2, 4, 6 and 8 in between have a
corresponding face.

63 7-Sep-18 Documentation
64 7-Sep-18 Documentation
 The Modified Wong-Baker Faces Scale

• Use the Pain Ruler shown below to guide the

patient in selecting a face from the Scale that
represents his intensity of pain.
• Ask the patient to point to the face that would
best describe the patient’s pain at the worst or
when it is relieved.

65 7-Sep-18 Documentation
 The Modified Face, Legs, Activity, Cry and
Consolability Scale
(FLACC Scale)

• Used in children 4 years and below, the

cognitively impaired or elderly patients and
non-verbal patients who can’t use the
other 3 pain scales
• Assess each category
• Add all scores for the 5 categories to get
the pain intensity score

66 7-Sep-18 Documentation
FLACC Scale

67 7-Sep-18 Documentation
 Assignment
1 week due date 11/4/2016
1. Each student proposes 2 research
/academic article and analyze

2. Sent to :
[email protected]
THANK YOU
VERY MUCH