MODULE 2:

TRIAGE:
EMERGENCY MEDICINE
ADMISSION AND ASSESSMENT

Course/Program: Triage: Emergency Medicine Admission and Assessment

Course Description:

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.

Intended Audiences: Staff Nurses/ED Personnel

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

After studying this chapter, you will be able to:

1. Classify cases as Emergent, Urgent and Non-urgent.
2. Classify patient as Covid/Covid Suspect or Non-covid (Covid related cases) for
their designated area of assignment in the ED.
3. Rapidly assess patients requiring emergency treatment.
4. Include in the assessment pertinent patient data, history and taking initial vital
signs.
Introduction

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 ED triage nurse will evaluate the patient's

condition upon arrival and complex decision making
is needed to evaluate which cases need priority
intervention and treatment. This nurse will evaluate
the patient's condition, as well as any change in
status upon arrival and should refer high priority
cases immediately to the triage physician.

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.

According to Centers for Medicare and Medicaid 2016, it is

important hat 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. Figure 2-2 shows the MDH
Emergency Triaging reception with the Triage Physician.

A major factor contributing to the triage decision is available

Figure 2-2. MDH Emergency Triage Physician hospital bed space. The triage hospitalist must determine, in
conjunction with a hospital's "bed control" and admitting team,
what beds are available for optimal utilization of resources in order to provide safe care to all patients.

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.

As part of providing comprehensive and important information for customers, an Emergency

Department Brochure is made available. It contains vital information on triage categories, proper
behavior while inside the Emergency Department, and important information that should be provided
to the adminstrative staff.
ED Brochure, 2021
 Triage Classification

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.

CATEGORIES ACTION REQUIRED:

AFTER TRIAGE:

EMERGENCY CASES Immediate treatment

PRIORITY CASES Rapid attention

NON-URGENT CASES Wait turn in the queue.

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.

Performing Triage in the Emergency Department

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
interpreters, either in person or via
phone, when language barriers exist
6. Request that family members and other
visitors to leave the room as necessary to
maintain privacy
7. Review patient’s medication
8. Assess the patient’s pain, using self-
report and if any, using self-report and a
The Wong–Baker Faces Pain Rating
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
10. Assign acuity level based on the triage
classification. Endorse to the Emergency
department team and notify treating
physician.
11. Provide nursing treatment within the
scope of nursing practice
12. Implement the prescribed treatments
per physician’s orders.
13. Dispose the used materials according to
facility protocol.
14. Remove PPE, discard appropriately, and
perform hand hygiene.
15. Update the patient’s plan of care, as
To prevent the filtering of information from the
patient due to language barrier.
To provide privacy to the patient, as well as to
limit the people in the area.
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.
To provide comfort to the patient, as well as
prevent anxiety that can be experienced by the
patient.
To identify the magnitude of illness and how well
the body is coping with the resultant physiologic
stress.
To identify patients needing immediate
resuscitation, thereby prioritize care among the
patient’s care.
To identify the nursing competency and nurse’s
core abilities which are required in fulfilling their
roles, as well as prevent the overlapping of
responsibilities among the healthcare team.
To follow the orders from a licensed physician
who has an expertise to understand the best
treatment options.
To reinforce the creation of a worker-safe,
patient-safe, and environmentally-safe
workplace.
To maintain a safe environment for everyone by
reducing the risk of the potential spread of
disease.
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.

Contingency Plan for Sudden Influx of Patients at DEMS

Guidelines on Overcrowding and Surge Protocol

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

Guidelines for Emergency Room Officers During Activation of Code White

1. The decision to declare CODE WHITE is the discretion of the ER Consultant-on-duty

 This is mainly guided by our rule of greater than 10 patients from the same accident
 This may also apply to other situation where the DEM resources will be overwhelmed and we
will need the help of other personnel from the hospital
2. Once declared, the ER Consultant makes sure the Nurse Supervisor (Initial Incident Commander)
has been informed who must consequently inform the Hospital and Medical Director (assume
Incident Command on arrival) of the situation.
3. Inform the DEM Chair of the CODE WHITE activation
4. The DEM Consultant-on-duty will be the Treatment Area Supervisor or Team Leader
5. Gather all staff present at the DEM and brief them of what is going to happen

Code White, Influx and Mass Casualty Incidents

Code White is the MDH DEM code for Mass Casualty Incident. An example of this incident ca be seen in
Figure 2-3. It depicts the 2018 Fire Incident at Manila Pavilion which is just beside the Manila Doctors
Hospital.

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

Level of Consciousness Assessment

An important skill that every nurse should know when assessing a patient in a triage. It assists in the
identification of the patient’s triage classification, and the proper management suitable for the patient.
Assessment of level of consciousness is done using Glasgow Coma Scale and can be done in cases such
as:
 Routine screening examination
 A change in mental status is observed (e.g. drug overdose, alcoholic intoxication, sepsis)
 Post- head injury/ Traumatic brain injury (e.g. after a fall, road traffic accident)
 Stroke (e.g. ischemia and bleed)
 Post- seizures

Glasgow Coma Scale

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.

Spontaneous – open with blinking at baseline 4

Opens to verbal command, speech, or shout 3
Best Eye Opening ( E )
Opens to pain, not applied to face 2
None 1
Oriented 5
Confused conversation, but able to answer questions 4
Best Verbal Response (V) Inappropriate responses, word discernable 3
Incomprehensible speech 2
None 1
Obeys commands for movement 6
Purposeful movement to painful stimulus 5
Withdraws from pain 4
Best motor response (M)
Abnormal (spastic), flexion, decorticate posture 3
Extensor (rigid) response, decerebrate posture 2
None 1

Performing Level of Consciousness Assessment

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.

Special Instructions in Performing Conscious Level Assessment

 CLC should not be used solely as a tool for neurological assessment
 Nurses need to be cautious when assessing patient with possible aphasia which will not present
accurate verbal response. Patient who had high cervical injuries will also be unable to provide an
accurate Motor response
 Avoid using LED/ laser light to assess pupil size and reaction as it can potentially cause damage
to the retinas.

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
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Emergency Nurses Association (ENA). (1999). Emergency Nurses Association Scope of Emergency
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