REVIEW OF TRIAGE

AND DOCUMENTATION
Ns.M.FATHONI, S.Kep.,MNS
MASTER OF NURSING
FACULTY OF MEDICINE
UNIVERSITY OF BRAWIJAYA
03 th MAY 2012
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
Clinically experience
Good judgment and leadership
Calm and cool under stress
Decision
Knowledgeable of available resources
Sense of humor
Creative problem solver
Available
Experienced and knowledgeable regarding anticipated casualties
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
 Emergency Department
TRIAGE

Emergency Severity Index - ESI

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

Emergent Emergent Life- Resuscitation

threatening
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)
R > 30
P > 2 seconds Critical (RED)
M = doesnt obey command
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 Patients Yes Immediate
airway Care No Is radial pulse
present?
No Control
Dead or bleeding 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
Assess victims
Safe life
Call for help Safe limp
First aid
Transfer
Safe function
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 ones 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
individuals response to an MCI
Discuss the diversity of emotional,
psychological and socio-cultural
response

Stanley, 2005
 ASSESSMENT &
PRIORITY SETTING

33 Triage - SOAP
 Objectives

To list the steps of the SOAP process

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

34 Triage - SOAP
 Assessment Guide

History from patient/relative/others

The 5 senses including Common
Sense

35 Triage - SOAP
 Use the Five Senses

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

36 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

37 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

38 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
39 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

40 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

41 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

42 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?

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

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

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

45 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
46 Triage - SOAP
P - PLAN
Establish your priority & direct to appropriate
area.

Triage - SOAP 47
 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
48 Triage - SOAP
 SUMMARY
Perform a systematic triage process
Collect sufficient subjective and objective
data
Assess according to patients acuity
Plan interventions appropriately
Document completely

49 Triage - SOAP
 DOCUMENTATION IN
TRIAGE

50 3-May-12 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

51 3-May-12 Documentation
 Goals of Documentation

To support the triage decision

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

52 3-May-12 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

53 3-May-12 Documentation
 Key Points
Describe chief complaint as accurately as
possible
Document patients expectations
Document obstacles e.g. language barrier
Document any conflict between subjective and
objective data

54 3-May-12 Documentation
 Pain Assessment
Acronym PAIN
P Place or site of pain
Ask patient to point to actual site

55 3-May-12 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

56 3-May-12 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

57 3-May-12 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

58 3-May-12 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

59 3-May-12 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

60 3-May-12 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

61 3-May-12 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.

62 3-May-12 Documentation
63 3-May-12 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 patients pain at the worst
or when it is relieved.

64 3-May-12 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 cant use the
other 3 pain scales
Assess each category
Add all scores for the 5 categories to get
the pain intensity score

65 3-May-12 Documentation
FLACC Scale
Scale Categories Behaviour Score Patients Score
0 1 2 e.g.
F Face No particular Occasional grimace or Withdrawn, 0
expression or is frown. Frequent to disinterested
smiling constant quivering of
chin, clenched jaw
L Legs Normal position or Uneasy, restless, tense Kicking, or legs 0
is calm and drawn up,
relaxed voluntary
immobility or
extremely restless
A Activity Lying quietly Squirming, shifting back High-pitched cry or 0
Normal position and forth scream when
Moves easily touched or moved
Disturbed sleep of
cannot sleep at all
C Cry No cry (awake or Moans or whimpers, Crying steadily, 0
asleep) occasional complaints screams, sobs,
frequent
complaints
C Consolability Content, relaxed Reassured by occasional Inconsolable 0
touching, hugging or
talking to, easily
distracted
Overall score 0

66 3-May-12 Documentation
 Assignment
1 week due date 14/5/2012

1. Each student proposes 2 research

/academic article and analyze

2. Sent to :
mfathony@yahoo.com
THANK YOU
VERY MUCH