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GUIDELINES FOR NURSES PERFORMING TRIAGE IN EMERGENCY AT

NON-TERTIARY HOSPITALS

BACKGROUND

Triage is a central element of the delivery of care in Emergency Departments.


The range and breadth of presentations at any one time is a challenge to the
practitioner.
Underpinning the approach to patients is the rationale that timely access to
definitive care improves patient outcomes. Thus the triage role is central to
the efficient and effective operation of the Emergency Department.
Furthermore, triage quality is key to ensuring the quality of care provided is
commensurate to the clinical need.

it is acknowledged that personnel undertaking triage in non-tertiary hospitals


may have multiple roles. The triage nurse is the first contact for all people
entering the Emergency Department and the point at which care commences.
Triage is a brief clinical assessment that determines the clinical urgency of the
patient’s presenting complaint and allocates an Australasian Triage Score
category which defines the time and sequence in which care is provided.

A variety of triage training resources are available (outlined at close of policy).


This circular does not attempt to re-state or capture these. The aim of this
circular is to ensure that staff performing triage are appropriately trained and
deemed competent to do so and WA facilities ensure that staff are adequately
supported to do so.

SCOPE

This policy applies to all WA public non-tertiary hospitals providing emergency


services.
The policy excludes major disaster situations, mental health services and
community services.

KEY POLICY ITEMS

Policy regarding patient care


• All patients presenting to emergency departments must be triaged on
initial presentation against the Australasian Triage Scale (ATS). If their
condition alters prior to assessment by a medical officer or nurse
practitioner, patients must be re-triaged. If re-triaged the reason, time
and re-triaged ATS and appropriate measures undertaken needs to be
documented. When initiated, the early recognition and response criteria
(RRCD programme) and corresponding escalation process may be an
appropriate reference.

• Refer to OD 0333/11 for further policy on triaging and clinical indicators


which require referral to or discussion with a doctor, emergency nurse
practitioner or registered nurse deemed competent in triage by their
employing hospital. In addition to the items described, advice should be
sought for any other concern relating to the health or safety of a patient.
• All patients must be triaged, have an ATS allocated and a more complete
nursing and/or medical assessment done before discharge.
• Resuscitation measures and treatment protocol as per nursing guidelines
are to be followed until medical advice is available.

Policy regarding documentation


• Documentation of the patient’s admission (including triage notes) should
make reference to the following:

o Date and time of assessment


o Name of attending triage nurse
o Presenting complaint
o Relevant history
o Relevant assessment findings
o Allocated triage category
o If re-triage is necessary the re-triaged ATS along with time &
reason for this.
o Assessment and any diagnostic, first aid or other treatment
measure provided
o Discharge plan if the patient is discharged from triage or
emergency

• Managing and documentation of telephone advice:


o Where a telephone call requesting medical advice is received, the
caller should be redirected to HealthDirect.
o Rural callers requesting mental health advice should be redirected
to Rural Link, the specialist after hours mental health telephone
service for the rural communities of Western Australia.
o Pregnant women booked into local maternity units will commonly
be instructed to contact the maternity unit directly.
o Where a member of staff has sought medical advice by telephone,
it and the reason for seeking advice, the person providing the
advice, time and the nature of the advice must be documented in
the MR1 or patient notes.
o Where a telephone consultation has occurred with an external
medical practitioner this information must be provided to the site
where care is being delivered for review and inclusion in the
patient’s medical record.
Policy regarding nurse scope of practice - triage

• Registered nurses performing triage must be appropriately trained and


have demonstrated competency in triage. Staff being trained to
undertake triage must be adequately supervised by one who has
demonstrated competency in triage.

• Triage should not be performed by enrolled nurses, midwives who are


not also registered nurses, allied health or administrative staff.

• WA facilities must ensure staff performing triage are appropriately trained


and deemed competent by their employer (or in case of staff in training,
adequately supervised) to do so.

Evaluation
• WA facilities should ensure that audits are undertaken to assess triage
competency at annual intervals.

• WA facilities should ensure that accuracy and system evaluations are


periodically undertaken to review the triage allocation against guidelines
and triage category for certain clinical indicators.

• Some WA facilities offer emergency care but do not have on-site 24 h


medical coverage and so must ensure that arrangements are in place to
ensure personnel undertaking triage and assessment to obtain advice
from medical personnel or emergency nurse practitioner or registered
nurse deemed competent to perform triage by their employer.
ADDITIONAL REFERENCES AND RESOURCES

WACHS resources: update with link on WACHS intranet

Department of Health and Aging: Emergency Triage Education Kit


http://www.health.gov.au/internet/main/publishing.nsf/Content/5E3156CFFF0
A34B1CA2573D0007BB905/$File/Triage%20Education%20Kit.pdf

Department of Health WA: Remote Area Nursing Emergency Guidelines,


2005.
http://www.nursing.health.wa.gov.au/docs/reports/Remote_Area_Nursing_Em
ergency_Guidelines.pdf

Australian College of Emergency Medicine:


http://www.acem.org.au/media/policies_and_guidelines/P06_Aust_Triage_Sc
ale_-_Nov_2000.pdf

http://www.acem.org.au/media/policies_and_guidelines/G24_Implementation_
_ATS.pdf

http://www.acem.org.au/media/policies_and_guidelines/patient_right_accessc
are.pdf

http://www.acem.org.au/media/policies_and_guidelines/P44_Prov_of_ED_Tel
.pdf

http://www.acem.org.au/media/policies_and_guidelines/responsibility_care.pd
f

http://www.acem.org.au/media/policies_and_guidelines/Access_Targets.pdf

College of Emergency Nursing Australasia: http://www.cena.org.au/