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DEM Module 2
DEM Module 2
TRIAGE:
EMERGENCY MEDICINE
ADMISSION AND ASSESSMENT
This training module is an integral part in developing clinical judgement and prompt decision-
making in ED nursing staff. This module will equip the nursing staff with the necessary knowledge and
skills using the right attitude in clients coming into the doors of the Emergency Department.
Teaching Strategy:
Lecture
Return Demonstration/Role Playing
Video Presentation
General Objective
This module will guide nurses develop prompt clinical judgment and decision-making in
categorizing patients according to priority and need.
Specific Objectives
This module will help the nurses develop the skills related to triaging the patients coming into
the doors of ED.
Triage is an essential tool in classifying patients according to their priority need. Triage nurse
and physician sort patient by emergent, urgent and non-urgent. Training in triaging patients is crucial in
the development of critical thinking skills in emergency nurses.
This module will also discuss the nursing assessment tool that is frequently used in triaging
patients.
It is important to provide quality and timey patient care in the Emergency Department (ED).
Patients often return to the ED with the same medical condition within a short period of time as a result
of receiving fragmented discharge services and lack of patient adherence to prescribed follow-up
Triage
The first stage on arrival at the emergency
department is assessment by the hospital triage
nurse. Figure 2-1 shows the MDH Emergency
Department entrance and tent.
The triage physician will also either field requests Figure 2-1. MDH Emergency Department Tent, 2020
for admission from the ER physician on patients
needing admission or from physicians they were
referred and can be transferred under their care (i.e. intensive care unit or if patient is stable for the
medical floor). This helps patients flow more efficiently in the hospital.
Assignment of degrees of urgency from wounds or trauma to illness complaints is decided upon the
triage system, especially in cases of mass casualties. Patients presenting in a critical condition are coded
RED and immediately admitted to the emergency room. Patients classified as less critical but whose
condition may worsen, with signs of physiological instability, are also admitted to the emergency room.
Triage is the process of rapidly examining patients when they first arrive in order to place them in one of
the following categories:
Those with EMERGENCY SIGNS who require immediate emergency treatment.
Those with PRIORITY SIGNS who should be given priority in the queue so they can be rapidly
assessed and treated without delay.
Those who have no emergency or priority signs and are NON-URGENT cases. These patients can
wait their turn in the queue for assessment and treatment.
After these steps are completed, proceed with a general assessment and further treatment according to
priority.
Ideally, all patients should be checked on their arrival by a person who is trained to assess
status. The triage nurse and physician decide whether the patient will be seen immediately and
receive life-saving treatment, or will be seen soon, or can safely wait for his or her turn to be
examined.
Triage should be carried out as soon as the patient arrives, before any administrative procedure such as
registration. This may require reorganizing the flow of patients in some locations.
Triage can be carried out in different locations, e.g. in the queue. Emergency treatment can be given
wherever there is room for a bed or trolley for the patient, enough space for the staff to work, and
where appropriate drugs and supplies are accessible. If a patient with emergency signs is identified in
the queue, he or she must quickly be taken to a place where treatment can be provided immediately.
It is important that nurses who led triage in EDs were able to focus on care specific to the patient, had
good communication skills, were concerned for the patient, and were competent when treating the
patient’s condition. It was also vital that nurses were available and visible, spoke using terms the patient
could understand, gave the patient a chance to ask questions, and were able to answer them. Patients
were generally satisfied when nurses led triage in EDs and would be willing to see the same professional
again. Case management (CM) in the ED can assist in reducing inappropriate utilization of emergency
services, verify that patients receive needed services, improve patient quality of life, and decrease
overall healthcare cost
Also take note that TIME is of essence when triaging patients in the Emergency Department. The initial
triage should take only 5 minutes without compromising patient safety.
Steps Rationale
1. Perform hand hygiene and don PPE as To prevent cross-transmission of microorganisms
necessary
2. Identify the patient, introduce yourself, To perform the correct procedure to the right
and establish privacy as appropriate to patient.
the patient’s medical condition.
3. Perform a primary assessment to identify To identify the emergent and urgent problems of
if the patient is in need of immediate the patient based on the patient’s circulation,
attention. Use the mnemonic CABDE. airway, breathing, disability, or exposure.
a. Circulation: Check for pulse and blood
pressure, any bleeding, skin color,
capillary refill time, heart rhythm
b. Airway: Patency of airway
c. Breathing: Rate and depth of
respirations, breath sounds,
movement of the thorax, trachea
location
d. Disability: Assessing level of
consciousness, pupil reactions, gross
motor and sensory function
e. Exposure and environment: Check for
any injuries or exposure to extreme
heat or cold
4. Perform a secondary assessment using To support the data obtained from the primary
the mnemonic PQRSTT after completing assessment, as well a provide the healthcare
the primary assessment. This includes team an idea on how the patient’s problems can
both objective and subjective be properly managed.
information:
a. Provocative/palliative: Symptom
provocation and best treatment
b. Quality/quantity: Patient’s subjective
statement on how it feels and how
often it takes place
c. Region/radiation: Location of
symptom and radiation if any
d. Severity: Rate on a scale from 1–10
e. Timing: Duration and occurrence of
symptoms
f. Treatment: Prior treatment and
outcome
5. Use professional certified medical To prevent the filtering of information from the
interpreters, either in person or via patient due to language barrier.
phone, when language barriers exist
6. Request that family members and other To provide privacy to the patient, as well as to
visitors to leave the room as necessary to limit the people in the area.
maintain privacy
7. Review patient’s medication To identify the present comorbidities of the
patient based on his medications, and foresee
any potential adverse reaction to the medical
intervention that will be provided to the patient.
8. Assess the patient’s pain, using self- To provide comfort to the patient, as well as
report and if any, using self-report and a prevent anxiety that can be experienced by the
The Wong–Baker Faces Pain Rating patient.
Scale which shows a series of faces
ranging from a happy face at 0, or "no
hurt", to a crying face at 10, which
represents "hurts like the worst pain
imaginable".
9. Check vital signs To identify the magnitude of illness and how well
the body is coping with the resultant physiologic
stress.
10. Assign acuity level based on the triage To identify patients needing immediate
classification. Endorse to the Emergency resuscitation, thereby prioritize care among the
department team and notify treating patient’s care.
physician.
11. Provide nursing treatment within the To identify the nursing competency and nurse’s
scope of nursing practice core abilities which are required in fulfilling their
roles, as well as prevent the overlapping of
responsibilities among the healthcare team.
12. Implement the prescribed treatments To follow the orders from a licensed physician
per physician’s orders. who has an expertise to understand the best
treatment options.
13. Dispose the used materials according to To reinforce the creation of a worker-safe,
facility protocol. patient-safe, and environmentally-safe
workplace.
14. Remove PPE, discard appropriately, and To maintain a safe environment for everyone by
perform hand hygiene. reducing the risk of the potential spread of
disease.
15. Update the patient’s plan of care, as To provide an accurate reflection of nursing
appropriate, and document performing assessments, change in clinical state, care
the triage in the patient’s medical record. provided, and pertinent patient information to
Including the following information: support multidisciplinary team to deliver great
Date and time the triage was care.
performed
Acuity rating
Patient’s main symptoms
Any allergies
Vital signs
All current medications
Patient’s response to the triage process
Patient/family member education,
including topics presented, response to
education, and plan for follow-up
education.
Objectives:
1. To define overcrowding and surge protocol for MDH DEM
2. To define levels of overcrowding and action plans for each
3. To define patient flow during times of overcrowding
4. To update patient flow during surges of patients
Definitions:
1. Overcrowding occurs when there is no space left in the ED to mee the timely needs of
the next patient requiring emergency care.
2. Surge Capacity is the maximum number of patients the Emergency Department can
handle depending on the type of patients and resources available
10 patients of the same incident or nature of injuries or illness
6 ICU/Critical Care and Resuscitation patients
20 urgent cases
50 non-urgent or ambulatory patients
The trigger for the hospital is 10 cases coming from the same site or same nature of illness with
probability of more patients coming in. It is used to cascade measures to prepare the whole hospital and
has a set of hospital policy for implementation in this kind of incident.
Figure 2-3. 2018 Fire Incident at Manila Pavilion Figure 2-4. Area of patient categorization based on
severity
Code
white is
declared
when it
exceeds
the MDH
ED
capacity
of:
10
Critical
or RED
patients
20 Urgent or YELLOW patients
100 Ambulatory or GREEN Cases
Figure 2-4. MDH DEM Triage Tags in Mass
Figure 2-4 shows the area of patient categorization
Casualties
during the 2018 Fire Incident at Manila Pavilion as
the Emergency Department caters patient affected
by the said tragedy. On the other hand, Figure 2-5
shows the triage tags being used for patients during
a Code White situation. An additional BLACK tag is
used to mark deceased patients.
The following information are being obtained using the said triage tags:
Patient Number (this is used to quantify the number of patients identified from the incident)
Major injuries
Hospital destination
Level of Consciousness (whether oriented, disoriented, or unconscious)
Time, with the corresponding pulse rate, blood pressure, and respiratory rate measurement.
Personal information, which includes (only if it can be obtained)
Name
Address
City
Telephone Number
Gender
Age
Weight
The Glasgow Coma Scale (GCS) is used to objectively describe the extent of impaired consciousness in all
types of acute and trauma patient. The scale assesses patients according to three aspects of
responsiveness: eye-opening, motor, and verbal responses. The table below shows how to grade each of
the following dimension.
STEPS RATIONALE
1. Perform hand hygiene and dons PPE as To prevent cross-transmission of
appropriate microorganisms
2. Identify the patient. To perform the correct procedure to the right
patient.
3. Establish privacy by closing the door To create a trusting environment with respect to
to the patient’s room and/or drawing the curtain the patient which encourages the patient to
surrounding the patient’s bed seek care and be as honest as possible during
the course of a health care visit.
4. Introduce self to the patient and To be able to develop rapport with the patient
family member(s), if present; explains the and relatives, enhancing the connection
procedure Determine if the patient/family between nurse and patient, thus improving
requires special considerations regarding patient care.
communication (e.g., due to illiteracy, language
barriers, or deafness); makes arrangements to
meet these needs if they are present
5. When a language barrier exists, To prevent the filtering of information from the
follow facility protocols for using a professional patient due to language barrier.
certified medical interpreter, either in person or
via phone.
6. Assesses level of consciousness To describe the extent of impaired
using the Glasgow Coma Scale consciousness in all types of medical and trauma
Follows facility protocol for scoring under patients in all types of acute medical and trauma
special circumstances (e.g., correct procedure patients.
for scoring verbal response in a patient unable
to communicate due to intubation)
7. Asks the patient to state his/her full To assesses the patient’s orientation to person.
name (first explains that all patients are asked for
this information as part of standard assessment)
8. If the correct name is given, asks the patient to To assesses the patient’s orientation to place.
state where he/she is.
9. Then, asks what day, season, and To assesses the patient’s orientation to time and
year it is. Conclude by asking the patient to briefly situation.
describe his/her current situation
10. Performs the neurological To review the patient’s physical state and status,
assessment as part of a routine head-to-toe specifically check disorders of the central
assessment. Performs the examination in a nervous system.
symmetrical fashion with each area of the body
compared bilaterally to detect abnormalities
Observes the patient’s extremities for To assess the patient’s coordination, and station
symmetry of movement, muscle tone, and any and gait.
abnormal posturing
Performs the following as a simple test of To evaluate the muscle strength and identify
motor function degree of variations on muscle strength of the
Asks the patient to squeeze nurse’s patient.
fingers with their hands and then let go.
Holds the patient’s hands or wrists and
provides some resistance while the patient
tries to push the arms toward nurse and
then to pull them away
Asks the patient to dorsiflex and
plantarflex the feet against the palms of
nurse’s hands while nurse provides
resistance. Then asks the patient to
perform straight leg raises in the prone
position, with and without resistance
Observes pupil size, symmetry, reaction to
light, and presence of a consensual light reflex
Tests for pupil reactivity to light by shining a
flashlight in from the outer canthus of one
eye. Repeats the procedure with the other eye
11. Discards used procedure materials To reinforce the creation of a worker-safe,
and PPE; performs hand hygiene patient-safe, and environmentally-safe
workplace.
12. Updates the plan of care, if To reinforce the creation of a worker-safe,
appropriate, and documents the following patient-safe, and environmentally-safe
information in the patient’s chart. workplace.
References
Manila Doctors Hospital. (2020). Guidelines on Overcrowding and Crowd Control. In M.D.H.
Department of Emergency Medicine Policies and Procedures (Document No. DER-G 026):
Unpublished
Manila Doctors Hospital. (2016). Guidelines for Emergency Room Officers During Activation of Code
White. In M.D.H Department of Emegency Medicine Policies and Procedures (Document No.
DER-G-020):Unpublished
Manual for the Healthcare of Children in Humanitarian Emergencies. Retrieved June 7, 2021, from
NCBI Bookshelf: https://www.ncbi.nlm.nih.gov/books/NBK143755/
Gagliardi, A. R., & Nathens, A. B. (2015). Exploring the characteristics of high-performing hospitals that
influence trauma triage and transfer. Journal of Trauma & Acute Care Surgery, 78(2), 300-305.
doi:10.1097/TA.0000000000000506
Grinnon ST, Miller K, Marler JR, Lu Y, Stout A, Odenkirchen J, Kunitz S. National Institute of Neurological
Disorders and Stroke Common Data Element Project - approach and methods. Clin Trials. 2012
Jun;9(3):322-9.
Emergency Nurses Association (ENA). (1999). Emergency Nurses Association Scope of Emergency
Nursing Practice. Retrieved January 4, 2018, from http://www.nysena.org/
library/documents/scopePracticeNursing.pdf