01 Emergency Pediatric Triage Program Manual PDF

Emergency Pediatric Triage Program Manual (2013)
Created & Complied By:

Saleem Diknash
RN, BSN, DipEdu
(2013)
1
Acknowledgement:
This manual would not have been prepared and conducted without all the efforts
of many professionals who shared their wisdom, knowledge, and their professional clinical
experiences.
I am grateful to Dr. Milfi Onazi –Chairman of Pediatric area, Emergency Care Center in King
AbdulAziz Medical City, for his support and valuable advices to do this project. He is one of the best ED
consultants and always regards nurses as his colleagues.
I acknowledge my colleague Eyad Zafer – Registered Nurse in Triage area of Emergency Care
Center of King AbdulAziz Medical City for her support, encouragement and wise advice during the
processing of this manual.
And finally, I am grateful to following colleagues for their support:

Anecita Talampas – Clinical Resource Nurse in Emergency Care Center of King AbdulAziz Medical City for
her effort, support and her excellent and accurate editing skills for this manual, also Sami Diyab for his
support, efforts and active inputs in this manual, and all Course Coordinators in the Post Graduate
Educational & Academic Affairs, King Saud Bin Abdulaziz University for Heath Sciences for her coordination
and facilitation efforts academically.
Saleem Diknash, 2013
2
Contents
Section’s No. Topics Pages
01 Overview of triage
02 Pediatric Triage Assessment
03 Canadian triage ED & Acuity Scale – Revised 2011
04 Documentation
05 Pediatric Legal issues
06 Customer service
07 Cultural and religious considerations
08 Violence
09 Child abuse & neglect
10 Expectations of all health workers in pediatric triage area
 References
 Triage Oral Test Format
 Course Evaluation Tools
 Examples of Pediatric Triage Guidelines and Protocols
3
PEDIATRIC TRIAGE CONCEPTS
Each section provides a basic foundation on which to build your skill as a triage nurse or physician.
Triage is much more than taking vital signs and asking the patient what is wrong. Many other skills are
required of the triage health professional (nurse or physician). Understanding these areas will enable you to
function competently and effectively in various roles that are all part of triage. Specific areas covered are:
 Overview of triage
 Pediatric Triage
 Pediatric Canadian triage ED & Acuity Scale
 Documentation
 Pediatric Legal issues
 Customer service
 Cultural and religious considerations
 Violence
 Expectations of all health workers in triage area
Ability to function effectively in the triage role requires a basic foundation of knowledge, skill, and
flexibility. As you study each chapter in this section, ask yourself how it applies to your current work situation.
Work with your preceptor to mold these concepts to your needs and to the department in which you work.
Use the information to build a knowledge base that makes the move to more complex clinical concepts a
smooth journey.
4
SECTION ONE: TRIAGE OVERVIEW

PURPOSE:
 Determine the essential facts related to the conceptual foundation of triage.
OBJECTIVES:
o Define the term" Triage “

o Discuss the main triage historical data.
o Explain the main triage development and classification.
o Identify the main triage concepts and terms.
o Discuss the main triage historical data in Emergency Department.
o Describe the main functions of triage.
o Explain the Principles of triage.
o Discuss the main goals of triage.
o Review the triage process based on Canadian Emergency Triage Guidelines.
o Identify the patient Disposition based on Canadian Emergency Triage Guidelines.
o Identify the main roles and responsibilities for the triage room nurse.
o Review the main functions of triage physician.
o Describe the items related to care giver and patient satisfaction.
o Explain the main triage pitfalls.
o Explain the main skills needed for developing the Critical Thinking.
o Develop the ability of judgment and critical thinking skills. (Case scenarios / Presentation)
RESOURCES
 Patient flow diagram showing the process from arrival to disposition

 Institutional statistics for emergent, urgent, and nonurgent patient visits
 Triage-related policies: Triage, mission statements, triage acuity categories, waiting room
reassessment, infection control, telephone advice, nurse calls, workers' compensation insurance,
nonemergency screening procedures
 Triage protocols
 Maps and telephone lists
 Patient teaching resources
 Performance improvement monitoring tools, reporting mechanisms, and policies related to these
activities at triage
5
INTRODUCTION
The process of triage recognized as a foundation of emergency nursing, is an integral process in the
ED. Triage requires both simple and complex knowledge and advanced practitioners as well. The process
may be simple and straightforward for some patients but complicated and even controversial for others.
This section provides an overview of triage concepts, definitions, and roles to establish a common language
to be used as you progress through this program.
The term "triage" is derived from the French verb "trier" that refers to sorting or choosing. Simply put,
triage is the process of sorting or classifying patients according to urgency of condition or compliant.
Effective triage gets the patient to the right place at the right time with the right care provider. Triage is the
first decision point in care of the emergency patient. The patient presents to the ED where information is
elicited to determine the nature of the problem as well as the urgency with which the problem should be
evaluated and treated. A priority of care is assigned to the patient, and the patient is then sent to the
appropriate area or provider for further evaluation and treatment. Incorrect identification of the patient's
problem can delay treatment and may adversely affect outcome. For example, a patient who complains
of jaw pain may be incorrectly sent to the dental clinic if the nurse does not consider other causes of this
pain, such as myocardial infarction.
During World War I, triage was used to separate soldiers with the most salvageable injuries from
those who required more extensive care. This process allowed rapid treatment for those who could be
treated and quickly returned to the battlefield. Triage enabled military personnel to focus resources on
soldiers who were most likely to survive and could return to battle. Triage appeared in civilian hospitals
during the late 1950s and early 1960s in response to increasing volume of patients and use of the ED for
treatment of nonurgent conditions (Rund & Rausch, 1981). In the civilian arena, triage was used to identify
patients with an immediate threat to life or limb. As the population increases and number of ED visits
continues to climb, problems with overcrowding only highlight the need for an effective triage system.
Today, triage can be divided into two basic categories: Nondisaster and multicasulty (or disaster).
Both types include classification and acuity systems for treatment and transport; however, the purpose of
each type is very different.
 Nondisaster triage is used to provide the best care for each patient
 Multicasulty/disaster triage is designed to provide the most effective care for the greatest
number of patients. Disaster triage, or military triage, is primarily oriented for use in the
prehospital arena. Delayed transport is used to prevent overloading the ED and to maximize
use of available resources.
EMERGENCY DEPARTMENT TRIAGE SYSTEMS
Triage systems are as varied as the EDs that use them. These systems are designed to meet the
needs of the user and to function effectively in rapidly changing health care institutions. Triage systems may
differ in staffing, documentation, triage categories, assessment parameters, reassessment guidelines, and
treatment protocols. Despite these variations, triage systems generally fall into three common types iden-
tified by Thompson and Dains (1982) (Table 1-1)
6
Table 1-1 ED Triage Systems

Type and Name Staffing Urgency Categories Protocols and
Treatment
I. Traffic Director Nonprofessional Two: Emergent or urgent None
II. Spot-Check RN or MD Three: Emergent, urgent, delayed

Variable
III. Comprehensive RN Four: Immediate, Stable – ASAP, Driven by
Stable – No distress. protocols
Five: Immediate, Emergent, Urgent,
Less Urgent (Semi-Urgent), Non-
Urgent.
Thompson and Dains (1982)
Type I: Traffic Director or Non-Nurse Triage
Non-nurse triage is the most basic system used. Non-licensed personnel, such as a secretary,
department clerk, registration clerk, technician, or nursing aide, obtain minimal information—usually the
patient's name and chief complaint. An impression of how sick the patient looks is used with this information
to determine if the patient has an emergent or urgent condition. There are no established standards or
protocols for care, and documentation is very limited. Inherent problems with this system relate to superficial
assessment of potentially serious problems as well as violation of applicable regulatory mandates in
Northern America. With non-licensed personnel making first contact, there is greater risk that the patient
may be asked financial questions before completion of the MSE.(ENA, 2001).
Type II: Spot-Check Triage
A "quick look" by a registered nurse (RN) or physician is the basis of this system. This system is also
called advanced triage because licensed professional personnel perform this rapid assessment. Limited
subjective, objective, and historical information is obtained prior to making a determination of acuity. The
goal of this system is to ensure that patients with the most serious illness or injury are treated first. Three
primary triage categories are used: emergent, urgent, and nonurgent. Protocol use varies from institution to
institution. Formal assessment criteria and documentation requirements also vary by facility (ENA, 2001).
Type III: Comprehensive Triage
This system encompasses all aspects of the triage process. It is the most advanced of the common
ED triage systems and for example is supported by ENA's Practice Standard for Triage. Registered nurses
with appropriate education and experience assess and prioritize patients using various data and
predetermined guidelines. Subjective and objective data considered in concert with past medical history,
health status, psychosocial components, and health behaviors are used to identify physiological,
educational, and primary health needs (Thompson & Dains, 1982). Four or five categories may be used for
patient prioritization (ENA, 2001).
One advantage of this system is consistency. Using protocols and written standards for assessment
and documentation minimizes variability between users. Written standards for assessment, planning, and
intervention are used to guide the triage process. Protocols are used to initiate diagnostic tests, select
treatments, and re-evaluate the patient and this is what CTAS are based on.
7
PREHOSPITAL TRIAGE
Paramedics in the prehospital fields are managing patients, categorized the patient’s injury severity
and need for medical treatment following their own protocols and standards, while in arrival to the hospital;
this is often handed over to the triage nurse.
Trauma triage
Globally, a validated criterion is used to triage injured patients. These triage decisions influence to which
hospital patients are transported. Many Emergency Medical Service (EMS) districts have well-defined triage
criteria that determine which accident victims need the services of a trauma center and which can be
cared for at a local facility. Each EMS jurisdiction may use different criteria, but most use a combination of
the following:
 Mechanism of injury
 Anatomic criteria
 Medical criteria
Currently, physicians too often send trauma patients unnecessarily to trauma centers. Debate has
ensued over cost/benefit issues related to this trend.
TRIAGE CONCEPTS
Various labels may be used to identify the triage nurse including triage officer, triage agent, and
triageur; however, the preferred term is triage nurse. Just as ENA recommends a specially educated RN
(ENA, 1999) perform triage; use of the term triage nurse is also encouraged. Therefore, throughout this text,
the term triage nurse identifies the RN who performs triage. Aspects of triage such as vital signs, visual acuity
examination, and patient transport may be delegated to other appropriately trained staff; however, the
triage nurse is still responsible for the patient. State practice acts and institutional policies determine what
tasks can be delegated and to whom they can be delegated. Critical thinking skills enable the triage nurse
to assimilate data from various sources and set priorities for patient care based on particular circumstances
of the patient and ED at that time.
Triage requires the triage health professional (nurse or physician) to have clinical knowledge as well
as the ability to manage multiple tasks. The triage health professional (nurse or physician) affects not only
those patients in the waiting area, but also patient flow through the entire department. These complex and
diverse requirements make triage daunting to those without experience. Specific objectives of the triage
system are highlighted in Table 1-2. Time-tested principles that assist the triage nurse in accomplishing these
objectives include the following:
 Greet patients and identify yourself as the triage health professional (nurse or physician).
 Maintain patient confidentiality in all interactions.
 Maintain visual access of incoming patients even while interviewing others.
 Ensure flow of information between triage personnel and patients in the waiting area as well as
between the triage and treatment areas.
 Know the institution's triage system and your own limitations. Remember the primary objectives of
the triage role.
 Use available resources to maintain the appropriate standard of care.
 Control flow of patients through an emergency department by accurately assigning acuity for
treatment
 Security within the triage area.
8
Table 1-2. Primary Objectives for ED Triage Systems

 Identify patients who require immediate care.
 Determine the appropriate area for treatment.
 Facilitate patient flow through the ED and avoid unnecessary congestion.
 Provide continued assessment and reassessment of arriving and waiting patients.
 Provide information and referrals to patients and families.
 Allay patient and family anxiety.
 Enhance public relations.
(ENA, 1992)
ACUITY CATEGORIES AND REASSESSMENT
Patients are assessed by the triage nurse then sorted by patient acuity. Acuity refers to severity of
illness or injury as well as the potential for complications related to the illness or injury. Complications include
adverse physical outcomes and undue suffering. The primary goal of triage is to identify patients who
require immediate treatment for life-threatening conditions. The triage nurse's second goal is to sort or
prioritize patients according to identified acuity. Determination of acuity is made using a system of two to
five acuity levels. A number, letter, or name may identify a specific level. Specific criteria for each level
include the degree to which the complaint is life-threatening, risk for short-term complications, time
parameters for requisite treatment, amount of patient or family suffering, and availability of treatment areas
and providers (ENA, 2001).
Key Concept
The primary goal of triage is to identify life Threatening conditions. The second goal is to prioritize patients according to
acuity.
There are many rating systems used for triage acuity. In the annual ENA survey of EDs in 1996, managers
reported the type of triage acuity scales used in their departments. 64% used a 3-level scale, 6% used a 4-
level scale, 10% used a 5-level scale, and 20% didn't respond to the question or had no triage rating system
(ENA, 1996).
For example, 3-level and 5-level triage scales are presented here. In 3-level triage, the primary
acuity categories are emergent, urgent and nonurgent.
 Emergent: Involves an immediate threat to life, vision, or limb

 Urgent: Requires prompt care, but will not cause loss of life, vision, or limb if untreated for several
hours
 Nonurgent: Requires evaluation and treatment, but time is not a critical factor
Table 1-3 provides an overview of these categories. Several time-critical situations and general
examples are included; however, these examples should not be considered all-inclusive or the standard for
each level. It is also important to remember that a change in the patient's condition may require change in
the acuity level.
Table 1-3 Triage Acuity System Using Three Levels (Emergency Nurses Association (2001))
Acuity Reassessment Examples
Emergent Continuous Cardiopulmonary arrest, severe respiratory distress, major burns, major
or multisystem trauma, massive hemorrhage, coma, crushing
substernal chest pain, anaphylaxis, high-risk needle stick requiring post
exposure prophylaxis
Urgent Every 30 to 60 Abdominal pain, multiple fractures, asthma, open fracture, renal
minutes calculi
Nonurgent Every 1 to 2 Rash, cystitis, sprains, minor lacerations, chronic headache, vaginal
hours discharge, sexually transmitted disease
9
Five-level triage scales are widely used in Australia, Canada and the United Kingdom (Australasian
College for Emergency Medicine, 1997; Beveridge, Ducharme, Janes, Beaulieu, & Walter, 1999; Manchester
Triage Group, 1997). Research in Australia and Canada indicate that the scales have excellent reliability
(consistent assignment of triage categories across nurses) and validity (strong association of triage levels
with outcomes and resource use) (Jelinek & Little, 1996; Beveridge, Ducharme, Janes, Beaulieu, & Walter,
1999). The Canadian Triage and Acuity Scale (CTAS), although independently derived, is based on time
objectives similar to the Australian National Triage Scale (NTS), and includes the following categories: level 1
(resuscitation), level 2 (emergent), level 3 (urgent), level 4 (less urgent) and level 5 (non urgent). The
National Emergency Nurses Affiliation (NENA) and the Canadian Association of Emergency Physicians
(CAEP) have endorsed the CTAS as the standard for ED triage. Canadian hospitals must use the CTAS data
element for mandatory reporting of all ED visits to the Canadian government (CAEP, 2001). Table (1 – 4)
CTAS Categories.
Table (1 – 4) CTAS Categories

Level I Level II Level III Level IV Level V
IMMEDIATE EMERGENT URGENT LESS URGENT NON URGENT
(SEMI URGENT)
Continuous Within 15 Within 30 Within 60 Within 120
care minutes minutes minutes minutes
(Emergency Nurses Association (2001))
The Manchester Triage Scale, from Great Britian, is also five levels, with categories as follows: level 1
(immediate- red), level 2 (very urgent- orange) level 3 (urgent-yellow) level 4 (standard- green), and level 5
(non-urgent-blue). The system is organized by chief complaint. The triage nurse selects the appropriate
presentational flow-diagram (complaint algorithm) and proceeds to take the patient through a series of
predetermined questions that are specific to that complaint. For example, a level II chest pain patient is
one with severe chest heaviness, and a level VI chest pain patient is one with mild chest pain for several
days. So that we will try to use and utilize the five levels categories in this course mainly (ENA, 2001).
However, a new 5-level triage acuity and resource scale called the Emergency Severity Index (ESI),
has been developed in the United States. The ESI stratifies patients into five explicitly defined, mutually
exclusive categories: from level 1 (dying patient) to level 5 (simple problem, stable patient). Two
emergency physicians, Richard Wuerz and David Eitel, are responsible for the conceptual breakthrough
and the flowchart- based triage algorithm that exists today (Gilboy, Travers & Wuerz, 1999). Unlike other
triage systems ESI categorizes emergency patients by both acuity and expected resource needs. Acuity is
defined in terms of the stability of the patient's vital functions (for example, the ABC's of airway, breathing
and circulation) (ENA, 2001)
ESI Categories and Destination Diagnosis
10
Protocols
Protocols are used to assign categories like Ottawa Ankle Rules, direct diagnostic orders, and initiate
therapeutic interventions. Referrals to specific treatment areas and/or providers may also be determined by
protocols. Use of protocols minimizes variability by providing consistency from one provider to another.
Protocols used in triage include, but are not limited to, administration of antipyretics in febrile patients,
ordering x-rays for sprains and fractures, and ordering a urinalysis for patients with primary urinary symptoms
or abdominal pain (ENA, 2001).
HISTORY OF TRIAGE IN THE EMERGENCY DEPARTMENT
Historically, triage of newly arrived patients is part of the routine daily operation in nearly every ED in
the country. In large urban hospitals, two or more triage health professionals (nurse or physician) may work
together, depending on the time of day and number of patients waiting to be triaged. In smaller
community hospitals, nurses with other duties who immediately become available to perform triage for the
few patients that arrive per hour may perform triage must have knowledge of laws and bylaws to work
within such as EMTALA in USA.(ENA, 2001).
Triage specificity and sensitivity increases as a function of time spent performing triage on each
individual patient. Although some ED physicians believe a brief visual assessment can be performed
accurately, the specificity and sensitivity of this type of triage are low. Some teaching hospitals in large
urban areas have divided ED areas, such as adult medicine, pediatrics, surgery, trauma, and obstetrics and
gynecology. Patients initially may present to a common triage area (ENA, 2001).
Triage in the ED is high risk, yet it does not receive the attention, funding, or continuous quality
improvement reviews that would reflect its status as a high-risk activity. A major problem in large hospitals is
the pressure triage nurses feel from long lines of patients, which may cause them to perform triage too
quickly to perceive subtle signs of high-risk disease.
Also, the responsibilities assigned to the triage health professional (nurse or physician) vary from
institution to institution. One ED may require the triage nurse to make follow-up calls to emergency patients
seen the previous day, while another ED may expect the triage nurse to do chart audits. Geraci (1994)
identified 29 physical activities and 26 telephone activities performed by triage nurses in a comprehensive
triage setting. Despite these numerous tasks, the triage nurse must always focus on the primary activity or
role. In general, most triage nurses are faced with clinical and nonclinical duties. These duties may be
clearly identified in a formal job description or they may only be understood as part of the job that is
expected by management, colleagues, and patients. Clinical duties include performing the actual triage
process, administering medication, assisting patients from cars, and, on occasions, performing
cardiopulmonary resuscitation and attending first aid treatment. Nonclinical duties vary among facilities,
but the most common nonclinical duties are discussed below.
Public Relations
The ED is considered the window to the hospital. For most facilities, it is the only entrance after hours.
The triage nurse is often the first health care professional that patients encounter. For the patient, at that
moment, the triage nurse represents the ED, the hospital, and often the health care system. A negative
experience with the triage nurse can affect how the patient and his or her family view the rest of the visit.
The triage nurse must juggle multiple tasks while welcoming new arrivals in a professional, friendly manner.
This can be particularly challenging during times of high acuity or high census; however, in today's
competitive health care environment, this is an essential function of the triage nurse (ENA, 2001).
11
Traffic Director
Not every person who presents to the triage desk is seeking treatment in the ED. Individuals may
need directions to other areas of the hospital or want information about a current patient. The triage nurse
must manage these situations while maintaining contact with new arrivals. Viewing the position of triage
nurse as the gatekeeper for the ED illustrates the impact that triage has on overall flow through the
department. Posting effective, universal signs and maps can make this aspect of the triage nurse's role
easier (ENA, 2001).
Teacher
Patient teaching may begin at triage and can include basic health concepts, illness and injury
prevention, use of the emergency care system, and self-care skills such as first aid for extremity injuries. The
triage nurse first determines how receptive the patient and/or family is and then provides appropriate
education in a positive, constructive manner. Lectures or judgmental statements should be avoided
Infection Control
Screening patients at triage for potentially infectious diseases and providing appropriate isolation
measures hinders disease transmission. The triage nurse uses basic techniques to prevent the spread of
infection, including hand washing, use of personal protective equipment when indicated, and terminal
cleaning of the triage area as appropriate includes keeping an infectious people separated from non
infectious and the public areas.
Telephone
Telephone activities can tax even the most experienced triage nurse when patient census is high or
the number of telephone calls is excessive. The triage nurse may be required to receive telephone calls
from patients, physicians, and the public as well as to make telephone calls to these same people.
Requirements include taking physician orders, notifying physicians or families of patient arrival, and
answering questions from patients previously seen in the ED. Managed care organizations may call with
authorization information for visits. Despite these problems, the goal of the triage nurse is always to
determine patient acuity. Care must be taken when communicating over the telephone not to give out
patient information or medical advice, the triage nurse must direct the caller to seek medical advice at the
nearest appropriate place.
Crowd Control
Arrival of patients and families in great numbers may require the triage nurse to implement crowd
control measures. The triage nurse should maintain a calm, professional demeanor while directing families
to registration or asking individuals to move to another location. Situations can quickly escalate in the
presence of alcohol, drugs, or uncontrolled anger. It is imperative that the triage nurse knows the layout of
the triage area and how to quickly summon help. Panic buttons, security personnel in the ED, and a
separate area for grieving families can decrease anxiety related to this issue (ENA, 2001).
Team Member
The triage nurse does not work in a vacuum. As a team member, the triage nurse is responsible for
making and communicating triage decisions and interventions. Consultation with colleagues when
appropriate is also part of triage. Essential skills for triage nurses are also essential skills for teamwork:
communication and leadership. Providing feedback about the triage process to appropriate personnel
and groups is another aspect of teamwork required of the triage nurse.
12
TRIAGE FUNCTIONS
Triage is an essential function in ED where many patients may present simultaneously. Triage aims to
ensure that patients are treated in the order of their clinical urgency and that their treatment is
appropriately timely. It also allows for allocation of the patient to the most appropriate assessment and
treatment area, and contributes information that helps to describe the departmental case mix. Urgency
refers to the need for time-critical intervention - it is not synonymous with severity. Patients triaged to lower
acuity categories may be safe to wait longer for assessment and treatment but may still require hospital
admission.
PRINCIPLES OF TRIAGE
1. Early patient assessment ensures that patients are given the appropriate priority of the treatment
according to the urgency of their illness/ injury.
2. A brief overall patient assessment can reliably assist in determining the priority of care required.
3. The determination of urgency for care assist in reducing delays in treatment, reducing the risk of
further injury/ deterioration and promotes the efficient use of facilities and staff resources.
4. Documentation of triage findings promotes continuity of care for the patient through
communication of the urgency of each case to other staff.
5. Control of patient flow through the emergency settings promotes optimal care and efficient
utilization of resources.
6. Initiation of therapeutic measures assists in reducing the severity of some conditions and enhances
the effectiveness of interdisciplinary team.
7. Promotion of good public relations through timely and accurate information gathering enhances
the reputation of the hospital and promotes co-operation from the public /community.
(KAMC - R, 2006)
TRIAGE NURSE’S ROLES
1. Greet patients / family in a warm and empathetic manner and introduces herself / himself.
2. Performs brief visual assessment and interview.
3. Documents the assessment.
4. Triages patient into priority category using the appropriate triage guidelines.
5. If necessary transports patient to treatment area when necessary and gives report to the treatment
nurse or emergency physician or a nurse from the area collects the patients for the waiting room.
Documents, reports and return to triage area.
6. Communicates with families and visitors regarding patient status and when there are delays.
7. Reassesses waiting patients as necessary.
8. Instruct waiting patients to notify triage nurse of any change in condition.
9. Facilitates patient flow in emergency care setting by assigning appropriate patient acuity.
10. Control and monitors safety in the waiting room.
11. Provides health education for patients and families as time permits.
12. Acts as liaison with families regarding transfers and delays.
13. Documents clients leaving without being seen.
14. Provides first aid when necessary, comfort measures, fever care etc.
15. Direct patients to appropriate care if not within the ED.
(KAMC - R, 2006)
13
THE TRIAGE RECEPTION DESK RESPONSIBILITIES
1. Directly observe and inspect the patient through across the room assessment.
2. Greet all patients at the Triage Front Desk.
3. Assessment will take no longer than 3 - 5 minutes. If patient is for less acuity area per existing
guidelines, they go straight to that area without passing through the registration desk and then
will add a new visit for the patient.
4. Patients with complaints that categorized as level I or II will be directed immediately into the
high acuity area either in ED or to appropriate treatment area in the hospital that’s needs critical
care management and the paper work and registration will be completed at bedside or asking
one of the relatives to accomplish it.
5. For the complaints that categorized as level III, IV, or V:
a. The triage reception nurse will write the patient’s name at the appropriate place and fill out
the top of the triage assessment form indicating the patient’s chief complaint. Then the nurse
will send the patient to registration.
b. Triage nurse has to feel the patient's pulse at least and for all children you have exposed
their chest for quick assessment.
c. Some patients who are transferred from other health agencies and have acceptance to be
treated in ED, you need to receive an appropriate handover from the paramedics.
d. Patient signs consent for treatment within the department.
(KAMC - R, 2006)
THE NURSES OF TRIAGE ASSESSMENT ROOM ROLES AND RESPONSIBILITIES
1. The nurses will call the patient from the waiting room in order of priority.
2. The nurse will then take more detailed history, vital signs, including the weight and height of the
patient if applicable, and complete the remainder of the triage assessment form.
3. If the patient requires a level I or II, the nurse may re-triage and send patient to the high acuity area.
4. If the patient is deemed to be stable enough to sit in the waiting room, they will and the paperwork
will then be given to the CHARGE in treatment area.
5. All level IV and V patients will be given to the triage physician for review and possible triage away to
a more appropriate facility other than an emergency department.
6. Weigh all children if indicated. (Infants & neonates to be fully undressed)
7. Assess any wounds for inflammation, infection, dehiscence etc;
8. Assess all lung sounds, respiratory effort, use of accessory muscles, checking for wheezes, crackles,
decreased air entry;
9. Assess females in more private environment (veils off as necessary), privacy must be your priority;
then checking for color, diaphoresis, hydration.
10. Check females for PV loss if they state there is PV Bleeding.
11. Check peripheral pulses and circulatory status to distal limbs.
14
12. Check for lacerations, abrasions, bruises, deformities etc.

13. Assess abdominal region for pain, location, tenderness, radiation etc.
Document all findings on the Triage Form and Report any abnormalities/concerns to the Triage
Nurse for possible prioritization.
(KAMC - R, 2006)
REGISTRATION DESK - PROCEDURE
1. On arrival to the registration desk, the clerk will register the patient on the computer and produce
an armband (depending in your organization policy).
2. All paperwork will then be stamped with the addressograph.
3. If there is a red sticker on the chart – the registration clerk will process that patient first.
EMERGENCY MEDICAL SYSTEM (EMS) AREA ROLES
PARAMEDICS
1. Their major role is to assist in the management of patients that present to the ED by private car and
by local ambulance.
2. They will perform, if needed such tasks as spinal immobilization, splinting of limbs, and intubation of
patients if needed in appropriate area.
3. They will also respond to some “codes” throughout the hospital.
(KAMC - R, 2006)
EMERGENCY MEDICAL TECHNICIANS
1. Their role is to assist the Paramedic in the management of patients that present to the ED.
(KAMC - R, 2006)
15
TRIAGE NURSE CHARACTERISTICS IN ED
 Be able to work in stressful situations.

 Possess leadership characteristics.
 Thinks critically when asking questions and making decisions.
 Professionalism and punctuality.
 Flexible and open minded.
 Effective communicator.
 Expert clinical emergency nurse.
 Can participate in organizational enhancement efforts.
 Enough clinical experiences in triage area.
 Master the learning outcomes of the triage program.
 To deliver a coast effective care.
 Well versed in triage guidelines. (KAMC - R, 2006)
TRIAGE NURSE DUTIES IN ED
 To work collaboratively in a multi - displinary team.

 To promote professional development.
 To performs the initial/ continual patient assessment.
 To minimize the immediate risks to patients 'care.
 To advocate for the improvement of care delivery system.
 To assists with first aid (eye irrigation, C-Spine Immobilization, limb splinting etc).
 To report his /her concerns respecting the chain of command.
 To manage the data electronically or as per agency.
(KAMC - R, 2006)
TRIAGE PHYSICIANS
The Triage Physician primary role is to assess patients to determine the need for admission into the
Main Emergency Department. Patients that are evaluated not to be in need of Emergency Care, shall be
referred or directed to a more appropriate facility (e.g. PHU, Health Care Centers or where eligible). All
Triage decisions are to be made in strict accordance with the enclosed triage guidelines (KAMC – R, 2006).
Patients initially presenting to the Emergency Department will be seen at the front desk by a triage
reception Nurse. The patient will be brought in directly to the Emergency Room if he/she is in obvious
distress. Otherwise a Triage sheet will be initiated and the patient will be sent to the Triage Assessment
Room. The nurse in the Triage Assessment Room will take the vital signs and the Triage Physician will acquire
a history and do a focused examination. He/She will not provide care to the patient but only be
responsible for redirecting the patient to the most appropriate facility, whether it is our Emergency
Department or an outside health care center (KAMC – R, 2006).
TRIAGE PHYSICIANS ROLES AND RESPONSIBILITIES
1. Greet all patients

2. Take focused patient history
3. Note any other Medical problems;
4. Note any regular medications;
5. Note any allergies;
6. Assess patients’ complaints
7. Prioritize those requiring immediate treatment and co-ordinate with the Charge Nurse.
8. Take those patients requiring priority treatment to the Trauma Bay.
9. Provide discharge / educational instructions for all patients / relatives that are being referred to
other facilities.
16
10. The Triage Physician must notify the reception nurse any time he/she is taking a break. Coverage for
the break period must be coordinated with the physician in the Triage Extension. It is the
responsibility of the Triage Physician to ensure that the Triage Room has continuous coverage.
(KAMC – R, 2006)
The ED- triage physicians must assess the following:
 Chief complaint - High acuity, high risk, true emergency

 Vital signs - Grossly abnormal
 Mental status - Evidence of abnormalities
 General appearance - Patient looks sick, patient's skin looks poorly perfused, patient shows signs of
dehydration
 Ability to walk - Patients who cannot walk are at high risk for true emergency medical conditions.
 Focused physical examination (i.e. an examination appropriate to the organ system referred to in
the chief complaint). For example, patients who have complained of earache must have an
examination of the ear. Patients with a sore throat must have their throat examined. Those who
have grossly abnormal findings are clearly at risk for an emergency medical condition and must be
examined in the ED. (KAMC – R, 2006)
All data collected whether by a nurse, physician, or physician's assistant, must be recorded on the
patient's medical record, which then becomes a permanent part of the hospital's medical computerized
record system. (KAMC – R, 2006).
17
SECTION TWO: PEDIATRIC TRIAGE ASSESSMENT
PURPOSE:
 To develop the ability of the systematic triage assessment of pediatrics in Emergency Department.
OBJECTIVES:
o Explain the term “Triage process”.

o Describe the goals of triage assessment.
o Identify the critical components of triage assessment.
o Apply the four critical components of triage assessment.
o Review the main specific considerations in pediatric triage assessment.
o Apply the pediatric triage assessment
o Discuss the triage systems accompanied by protocols.
o Decide the main components of triage reassessment.
o Explain the main considerations related to the tips of triage interview.
o Describe the main facts related to pediatric trauma.
o Express the epidemiological studies related to pediatric trauma.
o Identify the main general considerations related to triage pediatric trauma.
o Explain briefly the differences of anatomy and physiology among pediatrics related to triage
trauma.
o Assess the pediatrics based on pediatric triage trauma guidelines.
o Demonstrate an understanding of the primary survey, resuscitation, and secondary survey as
it pertains to the pediatric trauma patient.
o Discuss injury patterns that frequently occur with children.
o Discuss the unique characteristics of the child as a trauma patient including type of injury,
pattern of injury, anatomic and physiologic differences compared to the adult and long
term effects of injury.
o Discuss ranges of normal vital signs for pediatric patients.
o Identify the emotional needs and methods of providing support to the pediatric patient and
family.
o Discuss appropriate medications, doses, and equipment sizes for resuscitation of pediatric
patients.
RESOURCES
 Policies related to vital signs, pediatric triage, geriatric triage, assessment guidelines, and
reassessment in the waiting area
 Diagram showing steps in the triage process for the department
 Pediatric vital sign charts with normal and abnormal ranges
 Chart showing average height and weight range for pediatric patients
18
PAEDIATRIC TRIAGE ASSESSMENT
Children are definitely not same adults. Variations in vital signs, anatomy, physiology, development
and psychosocial constructs make triage and treatment of pediatric patients a challenge. Table 2-1
presents unique aspects of pediatric anatomy and physiology that must be considered during triage.
Pediatric assessment should be tailored to the patient's developmental level and ability to communicate.
The ABCD approach is used for children with special attention given to differences in this population
(Canadian Association of Emergency Physicians, 2001).
Table 2-1. Anatomic and Physiologic Considerations in Pediatric Assessment
Parameter Description of Variations
Airway Infants are obligate nose breathers.

Airway is smaller but increases in size as the patient grows.
Tongue is larger in proportion to mouth.
Soft neck framework easily obstructed by positioning.
Breathing Infants are more reliant on the diaphragm for effective ventilation.
Ribs are horizontal, soft, and cartilaginous.
Chest wall is thin and respiratory muscles are poorly developed.
Fatigue occurs quickly with respiratory distress.
Normal respiratory rates decrease as age increases.
Greater oxygen requirement because of increased basal
metabolic rate (BMR).
Circulation Normal pulse rates decrease as age increases.
Brachial or apical sites are used for infant pulse checks.
Circulating blood volume is 85 ml/kg in neonates, 80 ml/kg in
infants, and 75 ml/kg in children.
Functional murmurs are often present in infants.
Cardiac output is greatly influenced by heart rate.
Hypotension is a late sign of shock and may not appear until
volume loss is 24 to 40%.
Cervical Head in infant and child is significantly larger and heavier in
spine relation to body size.
Laxity of cervical spine ligaments, shallow facet joints, and poorly
developed musculature make the cervical spine more elastic and
mobile.
Disability Anterior fontanel normally closes at 18 to 24 months.
Pain response is expressed according to age (e.g., kicking and
jerking in infants, verbalization in school age children)
Exposure Larger body surface area (BSA) to weight ratio increases ambient
heat loss.
Infants cannot shiver because of neuromuscular immaturity.
Temperature control is not fully developed in infants, so
hypothermia occurs more quickly.
F Extremities may feel cold because of peripheral vasoconstriction
despite presence of high fever.
Get vital Vital signs vary significantly with age.

signs Sinus tachycardia is a common response to many stressors.
Bradycardia in a child is an ominous sign.
(Emergency Nurses Association (2001)
Working with infants and children takes patience and experience. It is important to remember that
parents and child should be treated as a unit. Avoid separation. Parents know their child better than
anyone else. When a parent says the child is not acting right, this is essential information and should not be
19
casually dismissed. Additionally, the child should not be ignored. Involve the child in the discussion to obtain
as much information as possible. When treating children, always be honest and tell them what you are
going to do and if it will hurt. Explain the procedure in terms they can understand and in ways that do not
frighten them. For example, describing a little magic machine that makes noise when put in the ears and a
penlight that can be blown out are less frightening than using medical terms (Magid,1993).Older Children
are very conscious of their bodies, and they may be very shy at certain ages. Protect their modesty and
respect their privacy. As you triage the pediatric patient, also assess the parent. Consider how the parent
and child interact and what stress is created by the specific situation. Consider the possibility of abuse and
neglect when the patient's history does not match the physical findings. Cardinal indicators of abuse
include cigarette burns, and bruises with a distinct pattern such as a belt buckle (Canadian Association of
Emergency Physicians, 2001).
Sick children present unique challenges to health care professionals. Assessment and treatment of sick
children are unique because children's perceptions may be radically different from those of adults. In a
busy emergency department (ED), professional health workers(physicians, nurses and paramedics) may not
always take the time to realize that children brought in for care are likely to be scared at the sight of
strangers and the unknown "hurts" that lie ahead(ENA, 2003). Furthermore, depending on age, children may
or may not be able to say what is bothering them. Patience and understanding are key to overcoming or
averting these problems (ENA, 2003). Communicating with a child and the family is a three-way process
involving the professional health worker, child, and parent. For the most part, information about the child is
acquired by direct observation or is communicated to the professional health worker by parents. Usually, it
can be assumed that close contact with the child makes information imparted by the parent reliable.
Assessment requires input from the child (verbal and nonverbal), information from parents, and the
professional health worker’s own observations of the child and interpretation of the relationship between
child and parent. The following outlines guidelines for communicating with children are (ENA, 2003):
 Assume a position eye-level with the child.

 Allow time for the child to get acquainted with the nurse.
 Avoid sudden advances toward the child or immediate removal from parents.
 Include the parent in questions, especially if the child is initially shy.
 Speak clearly, using simple terms.
 Offer choices where they exist.
 Be honest.
In most cases, parents should stay with the child during all phases of the visit. Approach the child
slowly while asking questions of the parent or caregiver. Fear and uncertainty surrounding the child's
condition, coupled with a loss of control of the situation, add to the stress. Positive, caring interactions with
the child and parent help alleviate stress and facilitate assessment of the child. (ENA, 2003)
Most emergency nurses, regardless of practice area, will encounter a sick child at some stage in
their career. The ability to intervene in critical situations requires a strong foundation of knowledge and
assessment skills. This manual provides an overview of pediatric assessment and common emergencies
including pediatrics with trauma and abuse conditions.
SPECIAL CONSIDERATIONS FOR PEDIARTIC TRIAGE:
The triage process sets the tone for the reminder of the emergency department visits. The triage
health professionals must be aware how he or she approaches the parents and child. The following table
shows the Approach to child and family during the triage process.
20
Concept Considerations
There is diversity in family  Respect diversity.
composition, including single  Don’t assume anything.
parent, divorced, and same-sex  Observe and assess the family’s strengths,
parent. The caregiver’s of family’s weaknesses and resources while conducting
values vary and may conflict with the interview.
normal or accepted values.  Be non-judgmental in approach.
The anxiety of the caregiver or  Reassure the caregiver honestly with your
parent will affect the interaction. triage findings:” I know your baby sounds like
he is having trouble breathing, but he is
moving air well and his color is good”
 Explain briefly what you are doing and what
will happen next: “I am going to have you sit
across from my desk where I can observe
you, the nurse will come to take you to room
soon”.
 Listen to the caregiver because he or she
knows the child better than else.
 Ask “What do you think the problem?”
The anxiety of the child will affect  Approach the child slowly.
the examination.  Sit down if possible, and allow the parents to
hold the child.
 Speak to the child directly, no matter the
age.
 Anticipate tat the child will be fearful and
use distraction techniques such as stickers
and toys.
Data from: Engle, 1993; Scidel & Henderson, 1997
DIFFICULT PARENTS:
Because parents who bring their children to the ED are often under stress, worried about their child
or angry about the wait, they may become difficult. ”Difficult” may describe those parents who angry,
confrontational, demanding, or hysterical. These parents must be handled in a calm manner to prevent
them from disrupting the entire ED and patient care. Often the triage health professional may be able to
deal with the situation quickly by recognizing the concern, but he or she may have to involve other staff
members, including the senior health care professionals or social services or patient relation. The following
tips may help when it is necessary to manage a crisis with s difficult parents (Walker & Joseph, 1997):
 Intervene early.
o Don’t avoid confrontation in hopes that it will go away.
o Deal with the problem as soon as it presents.
o Involve the senior health professionals if necessary.
o Take the parents into a private area if you need a time to calm him or her.
 Have one person take charge.
o Allow one person to interact with the parents. This may have a claiming effect, having to
repeat the story to several different people may increase the parent’s frustration and
honesty.
 Gather complete data.
o Find out what the parents is upset about and listen without being judgmental.
 Listen First.
o Listen to the parents without arguing.
 Be aware that information doesn’t always solve the problem.
o The situation may be exacerbated by an excess of facts because an angry or frightened
parent may be not be able to process what is being said.
21
 Use plain language.

o Avoid medical jargon and tailor the explanations to the perceived educational level of the
parent.
 Don’t repetitious.
o Repeating what was said in louder voice will not be effective and may only inflame the
situation.
 Be aware that the parents may have serious psychopathology.
o Involve security if you suspect that the parent has an altered mental status or if the parent is
behaving inappropriately.
The principles of pediatrics assessment are the same as those for adult assessment; however, age
influences the pattern of presentation, assessment and management, as children are prone to rapid
deterioration. Consistency of triage is optimized for this population when age, historical data and clinical
presentation are all included in the triage assessment. History-taking in pediatrics relies on information
provided by primary careers and sometimes by the child or young person. It is important to develop a
rapport with the patient and the career in order to elicit the maximum amount of information in a relatively
short timeframe. Interpreting the meaning of the information provided by careers is an additional challenge
when triaging children, as the information that is given in this context will be influenced by the career's own
knowledge and experience. The importance of privacy for parents, children and young people at triage
should not be ignored (Australian Government Department of Health and Ageing – Emergency Triage
Educational Kit, 2007).
However, there are some of clinical indicators have been found to be significantly foretelling of
serious illness in infants and young children. Moreover, some of these indicators were mentioned and
explained by Henson & et al demonstrated the value of several easily assessed parameters in positively
identifying infants with serious illness, including activity levels, alertness, skin temperature, feeding patterns
and fluid output. In particular, the following parameters were predictive of serious illness:
 Decreased feeding (<½ normal intake in preceding 24 hours)
 Breathing difficulty
 Having fewer than four wet nappies in the preceding 24 hours
 Decreased activity
 Drowsiness
 Being pale and hot
 Febrile illness in a child under three months old.
Pediatric Physiological approach to triage assessment and decision-making

Triaging pediatrics requires a professional who have the capabilities to collect the clinical data and
make an appropriate decisions related to the pediatric situation and to follow a systematic way of thinking
in order to identify the priority or urgency of the conditions. So that you have to observe the general
appearance of the child by using your common senses (sight), then follow the ABC approach as in adult
patients with special considerations related anatomy and physiology, vital signs the common disease that
affect the pediatrics more than adult.
NORMAL VITAL SIGNS BY AGE
AGE Respiratory Rate/Minute Heart Rate/Minute Blood Pressure Systolic (mm Hg)
Preterm Newborn 55-65 120-180 40-60
Term Newborn 40-60 90-170 52-92
1 month 30-50 110-180 60-104
6 month 25-35 110-180 65-125
1 year 20-30 80-160 70-118
2 years 20-30 80-130 73-117
4 years 20-30 80-120 65-117
6 years 18-24 75-115 76-116
8 years 18-22 70-110 76-119
10 years 16-20 70-110 82-122
12 years 16-20 60-110 84-128
14 years 16-20 60-105 85-136
Adapted from Proehl, J.L. (1999). Secondary survey. In J.A. Proehl (Ed), Emergency nursing procedures (2nd ed., pp. 4-6).
Philadelphia, PA: WB Saunders.
22
PEDIATRIC TRIAGE PROCESS
The process of triage is used to establish priorities and determine urgency of need for emergency
care. Aspects of scientific method, diagnostic reasoning, critical thinking, personal style, and the art of
nursing are found in the triage process. The triage nurse does not attempt to determine the medical
diagnosis but evaluates patient condition and potential for decompensation or deterioration based on sub-
jective, objective, historical, and physical data. This information is obtained by systematically approaching
the patient within the context of the patient's current situation. Triage has four basic components:
1. Across the Room Assessment & initial Assessment

2. Pediatric triage History.
3. Pediatric Triage Physical Assessment
4. Triage decision and Rationale.
This process should take 3 to 5 minutes for most patients. Each component is addressed separately;
in reality, the triage nurse may need to simultaneously perform different components for multiple
patients.
1. ACROSS THE ROOM ASSESSMENT & INITIAL ASSESSMENT
The pediatric assessment triangles is an across The Room assessment or an As-You-Approach-The-

Child-Assessment. The triangle looks at the overall appearance of the child, work of breathing and
circulation to the skin. It is done on the child’s entry to the ED waiting area or the triage room. It consists of
the following (Figure 1):
 Overall appearance – including look, or gaze, speech, cry, and trying to answering the following:
how the child is dressed or hygiene does the patient look ill or toxic? Are posture and gait appro-
priate? Is the patient walking in a natural manner? Can the patient stand without assistance? Does
the patient clutch any part of the body? What is the patient's skin color and facial expression? Does
the patient appear angry, confused, fearful, or in pain? How does the patient interact with others
and the environment?
 Airway: Do you hear abnormal breathing such as stridor or wheezing? Are there signs of airway
obstruction? Do you hear high-pitched sounds or barking? Is there a cough? Is breathing labored?
 Breathing – including efforts being used, rate, and to have more clear picture about the child status,
you have to expose his chest as much as possible.
 Circulation –What is the skin color? Is the patient pale, dusky, ashen, gray, flushed, sallow, or
jaundiced? Do you see obvious bleeding? Is the skin mottled?
 Disability: Does the patient appear alert or sleepy? Irritable or angry? Can the patient stand and
walk erect without assistance? Does the patient respond appropriately to stimulation? Does the
patient appear limp or stiff? Is there obvious seizure activity?
Paediatrics: Critical Look

1st step 2nd step
W
e
ra l
ea ra
nc
or
re
pp e
k
A en
Master
at
of
PRESENTING
G
hi
CRITICAL COMPLAINT
ng
LOOK list
Circulation
(Figure 1: Complaint Oriented Triage (2008), ppt. Slid # 206)
23
Initial Assessment:
In the triage setting, the initial assessment starts with a rapid primary assessment. Generally, the
assessment is focused on the chief complaint. Life threatening problems identified during the initial
assessment may require that the child be taken immediately to a treatment area. After the primary
assessment, the secondary assessment is completed. Modifications of this assessment may be necessary
because of space and privacy, and many components of the secondary assessment will have to be
completed after the child is taken to a room. The following signs and symptoms may be “red Flag” or
warning of a serious illness or injury (Fredrickson, 1994):
 Bradycardia  Apnea
 Decreased or absent peripheral pulse  Chocking
 Uncontrollable bleeding  Drooling
 Petechiae  Stridor
 Purpura  Grunting
 Change in mental status  Retractions
 Unresponsiveness  Use of accessory muscles
 New onset of seizure activity  Irrigular respiratory pattern
 Loss of consciousness  Wheezing
 Irritability  Bradypnea
 Bruising or injuries suggestive of child  Tachypnea
abuse  Change in color or skin temperature
 Contagious skin condition  Cyanosis
 Abnormal skin turger  Diaphoresis
 Tachycardia
24
Key Concept
Never assume that alterations in the across-the-room assessment are not life-threatening. If abnormalities are identified, act
immediately. Remember, if the patient looks sick, he or she probably is (Rice & Abel, 2005).
The across-the-room assessment is the first decision point for identifying obvious life-threatening
conditions. This assessment may be performed on an individual or on several patients simultaneously
entering the triage area. The triage nurse can adjust the pace of the triage process to accommodate
variations in flow into the triage area through use of the across-the-room assessment. This assessment is also
used to scan the waiting area and quickly survey new arrivals while interviewing other patients. Should any
patient appear in distress or trigger the triage nurse's antennae for trouble, the nurse can interrupt the
interview and investigate (Table 2 – 2).
25
Table 2-2. Across- the -Room Findings That

Indicate Emergent Conditions
Parameters Assessment Critical Findings

Airway  Apnea
 Choking
 Drooling
 Audible airway sounds
 Positioning
Breathing  Drooling or inability to handle secretions
Grunting
 Sternal retractions, increased work of breathing
 Irregular respiratory patterns
 RR>60 breaths/minute
 RR<20 breaths/minute for children less than 6 years of
age
 RR <15 breaths/minute for children less than 15 years
of age
 Absence of breath sounds
 Cyanosis
Circulation  Cool or clammy skin
 Tachycardia, brady cardia
 HR>200 beats/minutes
 HR<60 beats/minutes
 Hypotension
 Diminished or absent peripheral pulses
 Decreased tearing, sunken eyes
Disability  Altered level of consciousness
 Inconsolability
 Sunken or bulging fontanel
Exposure  Petechia
 Purpura
 Signs and symptoms of abuse
 Hypothermia
Full Set of Vital  Fever in an infant less than three months > 38°C
Signs (100.4°F)
 Temperature > 40.0°C to 40.6°C (104°F to 105°F) at
any age.
Give Comfort  Severe pain
History  History of a chronic illness
 History of a family crisis
 Return visit to ED within 24 hours
TRIAGE RED FLAGS: (Reference ENPC Guidelines (2004))
2. PEDIATRIC TRIAGE HISTORY (Eckle, Haley, and Baker, 1998):
Triage begins with the across-the-room assessment and builds from that point as more information is
collected. The triage history is obtained by the parents or the sick child , and triage physical assessment is
completed. Subjective and objective data are used during this part of the triage process. Elements are
often obtained concurrently but are presented separately for training purposes.
26
The CIAMPEDS mnemonic is a systematic way of obtaining important components of the pediatric
triage history (Subjective Assessment):
C Chief Complain
I Immunization or Isolation (Exposure to communicable disease)
A Allergies to food or medication
M Medication
P Past Medical History and Pain severity
E Events surrounding the illness or injury
D Diet or diapers (Bladder and bowel habits)
S Symptoms associated with the illness or injury
SUBJECTIVE ASSESSMENT
Subjective information is all data that is obtained that the patient or family tell you. The patient's
chief complaint, description of symptoms, and history are all subjective data obtained during triage.
Collecting this data requires a common language. If the patient does not speak English or is hearing-
impaired, an appropriate interpreter should be used.
CHIEF COMPLAINT: The chief complaint is a statement in the child’s or parent’s own words describing the
reason for seeking emergency care. Focus on the reason for the current ED visit. Identify the ptrimary health
problem and its duration. However, it may be necessary to ask the child or his parents with multiple
complaints to narrow the problem down to the main reason or most urgent problem that prompted the
visit. Even if the complaint is vague or seemingly insignificant, remain open to the possibility that an
emergency condition may be present and to gathers as much information as necessary to make the right
decision.
Determining chief complaint is the first step in obtaining an adequate patient history. While asking
questions is a good time to assess the patient for a medical alert bracelet or necklace. Questions to
determine chief complaint should be asked in a friendly, professional manner. Initial questions should be
open-ended statements. Asking the right question is not as easy as it sounds. Everyone hears and responds
to questions differently. Questions that begin with "Why" may sound accusatory and set the wrong tone for
the visit. Also, asking "What brought you today?" may prompt the patient to give you information about
transportation. Individuals who are very literal may think you are truly interested in their method of
transportation. The following questions are more effective:
 May I help you?
 What can we do for you?
 What is the matter?
 What is the reason you need to see the doctor today?
Once the chief complaint has been determined, the triage health professional (physician, nurse)
completes a focused assessment. Always address the patient first. Acknowledge children and address
appropriate questions to them. If the patient is unable to communicate, information may be provided by
significant others, bystanders, or EMS personnel. Use open-ended statements during the focused assessment
to allow the patient to describe symptoms. Lead the patient carefully. For example, after asking a patient
to describe his back pain, ask if he or she notices anything else rather than initially offering a list of
neurologic symptoms. Ask very specific questions when the patient cannot describe the problem. Notice
how the patient answers questions. This can be as telling as the actual answers (ENA, 2001).
Key Concept
The patient does not have to prove he or she is sick. You as the triage health professional (nurse, physician) must prove the
patient is not sick. Consider the worst-case scenario associated with that complaint, complete the assessment, and make
the decision based on your assessment, not assumptions (Turner, 2001).
27
IMMUNIZATION: Determine the child’s immunization status and /or potential need for further immunization
(e.g. Tetanus Booster). This helps to determine whether the child’s current health problem may be related to
inadequate immunization (e.g. respiratory illness in the young infant prior to the initial pertussis
immunization).
ISOLATION: Recent exposure to communicable disease (e.g. varicella) and assessment findings suggestive
of that disease may require that the child be isolated from chemotherapy or intirerjection medications to
prevent their exposure to other diseases.
ALLERGIES: Known medication, food and environment allergies should be document. Note the reactions to
the allergens.
MEDICATION: Elicit from the parent the names of prescribed and over the counter medications and herbal
products that the child is taking. This will help to prevent duplication of medication administration and to
determine the effectiveness of current medication. Note the medication’s name, dosage, route,
frequency, duration and effectiveness.
PAST MEDICAL HISTORY: For children younger than 2 years of age and children with disabilities, the health
history should include the birth history (maternal age, birth weight, discharge weight, gestational length,
complications, and medications). For all children, the health history should include prior hospitalization or
illness, ongoing chronic illnesses, or conditions (e.g. asthma, congenital heart disease); physical growth,
attainment of developmental milestones, and family health patterns.
PARENT’S IMPRESSION OF THE CHILD’S HEALTH CONDITION: Elicit from the parent what is different about the
child’s health that prompted the ED visit. The parent is best able to judge improvement or worsening in the
child’s health condition. Include information about patterns such as sleeping and playing.
PAIN ASSESSMENT: Pain is one of the most common reasons for seeking emergency care. What makes
assessment of pain particularly difficult is that pain is a subjective experience that is unique for each
individual. Despite these aspects of subjectivity, the triage health professional (nurse, physician) must pursue
any complaint of pain. Acknowledging the child's pain through assessment is an initial building block in the
development of trust between the sick patient and ED staff. And remember that the patient (rather than
the caregiver) determines severity of pain. A systematic approach to pain is the "PQRST" system, a rapid,
effective technique to determine pain level (see Table 2-3). Patients with neuropathy or altered mental
status may have increased tolerance for pain or decreased pain perception (Table 2 – 4). Children have an
altogether different language when it comes to pain. Findings of pain assessment contribute enormously to
the triage decision. Use the Pain Scale (0 to 10) for adults and the Faces Scale for children (ENA, 2001)
(Table 2 – 5).
Table 2-3. PQRST System of Pain Assessment

Parameter Assessment
p Provokes/palliates What precipitated the pain?

What makes it better or worse?
What were you doing when it started?
Q Quality & quantity of Describe the quality of the pain.
pain What does it feel like?
R Region or radiation Where is the pain?
How large an area is involved?
Does the pain go anywhere? Where?
S Severity (Utilizing How severe is the pain?
suitable pain rating Rate the pain from 0 to 10 with 0 indicating
scales – FLACC or no pain and 10 indicating the worst pain
CRIES/associated possible.
symptoms Do you have other problems or symptoms?
T Timing or temporal When did the pain or symptoms start?
relations Is the pain constant? Does it come and go?
(Emergency Nurses Association (2001))
28
(Wong-Baker FACES Pain Rating Scale)
CRIES Scale Tool for Pain Assessment
29
Table 2 – 4: FLACC SCALE : Non-Verbal Pain Assessment Tool

0 1 2
Face No particular Occasional grimace Frequent to
expression or smile or frown, withdrawn, constant frown,
disinterested clenched jaw,
quivering chin.
Legs Normal position or Uneasy, restless, Kicking or legs
relaxed tense. drawn up.
Activities Lying quietly, Squirming, shifting Arched, rigid or
normal position back and forth, jerking.
and move easily. tense.
Cry No crying (a wake Moans or whimpers Crying steadily,
or a sleep) occasional, screaming or
complaints. sobbing frequent
complaints.
Consol ability Content, relaxed Reassured by Difficult to console
occasional touching, or comfort.
hugging or talking to,
distractible.
Table 2 – 5 : Pain Assessment Tool For Different Age Groups

Pediatrics’ Age Tools
Neonate – 3 M CRIES
3M–3Y FLACC
Developmentally delayed Child FLACC
Child 3 Y – 14 Y Wong - Baker 0 – 10 Numeric
Verbal Adult Wong - Baker 0 – 10 Numeric
Non Verbal Adult FLACC
EVENTS SURROUNDING THE ILNESS OR INJURY: For illness, obtain information about the onset (rapid or
protracted), duration, and involvement of other family members. Determine whether recent travel to
another state or a foreign country occurred. For injury, obtain information about the time of the injury, the
mechanism of injury, and witness to the event.
DIET: Determine the child’s normal eating patterns and how they are different with the onset of the illness or
injury. Elicit the time of the child’s oral intake in the event that surgery or a procedure is needed.
DIAPERS: Determine the child’s normal urine and bowel elimination patterns. Elicit the time of the child’s has
urination and bowel movement and change from the normal patterns. (Urine out put 0.5 – 2 ml/Kg/hour).
Key Concept
Never assume the accident caused the presenting condition. The presenting condition may have caused the accident.
For example, syncope can lead to a fall that causes a laceration or fracture.
ASSOCIATED SYMPTOMS: Once the triage health professional (nurse, physician) obtains information about
the present illness and pain assessment, the child is assessed for associated symptoms. Determining specific
positive or negative information is necessary for making the triage decision. For example, the sick child with
lower abdominal pain who also has rectal bleeding is more severe than another child with lower abdominal
pain who complains of constipation. Open-ended questions are again used to obtain this type of
information.
The foundation of the present is in the past. With the exception of injury, the child's problem usually
develops over time. An accurate, thorough history and physical assessment assist in making the triage
decision and provide essential information for subsequent caregivers. This information helps organize the
patient's care as well as ensures placement in the appropriate treatment area. For example, a child with
rectal bleeding can be placed in a room equipped with an exam table.
HEALTH HISTORY PREPARATION GOALS:
30
Obtaining health history provides 85% of the information leading to a diagnosis (Gundy,1997). There
are three general goals of and interventions for preparation and completion of the pediatric health history
(Conedrera, 1993):
 Gain the parents’ trust. Address the parent by name to demonstrate the concern for the parent as
an individual. Children sense the parent’s distrust and fear and exhibit these qualities themselves.
Engagement of the parent is an important key to a successful assessment.
 Elicit a meaningful health history. Allow time for the parent to reveal the child’s health problem;
rushing into a history without listening to the parent may cause the parent to withhold important
information.
 Maintain the parent’s child privacy. Elicit the health history in a private area because crowded
waiting area or busy hallways may create a feeling of vulnerability.
TIPS FOR THE TRIAGE INTERVIEW
 Open ended questions help elicit feelings and perceptions along with information. Closed questions
(with yes or no answers) are useful for obtaining facts. In general, initial questions should be open-
ended (subjective assessment), whereas closed questions (objective assessment) can be used to
validate information. Triage providers develop interview techniques that suit their communication
style, the clientele, and the environment. Many factors influence effective communication at triage:
language barriers, age, pain level, hearing disability, mental competency. Non-verbal information is
also an important source of information (CJEM 2004).
 Physical assessment accompanies the triage interview, chiefly through observation. Assessment may
begin with the observation that the patient can speak and therefore has a patent airway. Physical
assessment must be rapid, concise, and focused. In some patients objective measures such as vital
signs and/ or O2 saturation may be reasonable while in others it would be a description of physical
signs (CJEM 2004).
 Effective triage requires the use of sight, hearing, smell and touch. There are many non-verbal clues:
facial grimaces, cyanosis, fear... Listen to what the parent’s child is saying and pay attention to
questions they are reluctant or unable to answer. Listen for a cough, hoarseness, labored
respiration... Touch the patient; assess heart rate and skin temperature and moisture. Notice odors
such as the smell of ketones, alcohol, or infection (CJEM 2004).
 Remember that the purpose of the triage interview is to gather enough information to make a
clinical judgment for priority of care, not a final medical diagnosis. Often, the most time consuming
task of triage is to allay patient and family anxiety (CJEM 2004).
 Attitude and empathy are important aspects of the triage nurse’s demeanor. Remaining consistent
and non-judgmental toward all patients is important. Difficult patients such as those who are
intoxicated and combative require special care. Any element of prejudice, leading to a moral
judgment of patients, can increase patient risk due to incorrect assignment of triage levels, to low
care needs priority. Do not to prejudge patients based on appearance or attitude (CJEM 2004).
3. TRIAGE PHYSICAL ASSESSMENT (Objective Assessment)
The triage health professional (nurse, physician) must assess and prioritize pediatric patients within a
limited time frame. Always consider that the child's condition can be serious or even life-threatening. Do not
guess or make assumptions about the nature of the problem. Physical evaluation provides objective data
about the child's condition to assist in the triage decision. Observations such as appearance, measured
data such as vital signs, and discerned data from localized examination are all part of the objective patient
assessment. In order to accomplish this quickly and effectively, the triage nurse should follow a few simple
steps:
31
 Visualize the area of complaint whenever possible. Unwrap dressings applied prior to arrival. Have
the child point with one finger to the area that is most painful if possible.
 Compare assessment findings with the child's baseline. Do a bilateral comparison when
appropriate.
 When in doubt, check it out. Ask the child’s parents if what you see is normal.
 Move from the least invasive or painful assessment to the most invasive or painful assessment.
Collect objective data from the body system related to the patient's chief complaint and then
move to other systems as appropriate. Remember that body systems do not function independently. A
problem in one system can affect other systems, just as pain from one organ may be referred to other areas
of the body. Consider the child who presents with tachycardia secondary to fever. Knowledge of normal
vital signs and other physical assessment parameters is essential if the triage health professional (physician,
nurse) is to identify potentially serious deviations. These findings vary with age and conditions, so the triage
health professional should have access to reference guides.
A systematic approach to physical assessment using the ABCs is a simple yet effective way to assess
any child. These parameters are the same as those obtained during the across-the-room assessment;
however, the depth of assessment is expanded. The initial across-the-room assessment primarily involves
visualizing and listening from a distance. The focused physical assessment involves inspection, auscultation,
and palpation. Percussion is rarely used in triage. Background noise and limited ability to expose various
areas of the body make it difficult to obtain valid information through percussion. Table 2-6 summarizes the
ABCs of focused physical assessment (ENA, 2000).
Table 2-6 ABCs of the Physical Assessment

Subject Emergent or Urgent Findings
Airway  Abnormal airway sounds (e.g., stridor, wheezing, grunting)

 Abnormal preferred posture (e.g., tripod or sniffing position)
 Inability to speak Drooling or inability to handle secretions
 Dysphagia
 Abnormal breathing pattern
Breathing  Cool, diaphoretic, cyanotic, or dusky skin

 Tachypnea, bradypnea, or apneic periods
 Retractions
 Accessory muscle use
 Nasal flaring
 Expiratory grunting
 Prolonged expiration with pursed lips
 Diminished or absent breath sounds
 Adventitious breath sounds (e.g,, crackles, wheezes, rubs)
Circulation  Tachycardia, bradycardia, irregular pulse, pulselessness

 Cool or hot, diaphoretic, pale, mottled, or flushed skin
 Pale mucous membranes or cyanotic nailbeds
 Delayed capillary refill
 Diminished pulse quality
 Hypotension
 Muffled, distant, variable, or adventitious heart sounds
 Obvious bleeding
32
Table 2-6 ABCs of the Physical Assessment…Con’t..

Subject Emergent or Urgent Findings
Disability  Altered level of consciousness

 Decreased Glasgow Coma Scale (See figure 2.2)
 Decreased interaction with the environment
 Inability to recognize familiar people
 Unusual irritability
 Decreased response to pain
 Flaccid or hyperactive muscle tone
 Unequal, nonreactive, or misshapen pupils
 Seizure activity
Expose  Asymmetry of chest or abdomen
 Extremity deformities
 Unusual or severe bruising
 Petechiae or purpura
 Uncontrolled bleeding
Vital Signs  Temperature, pulse rate, respiratory rate, and blood pressure
Decreased oxygen saturation
 Decreased BP or increased pulse with orthostatic vital sign
assessment Asymmetrical BP and/or pulse
G  Give comfort measures— reassurance, touch, pain control

Head-to-toe 
 Additional injuries, abnormalities, or areas of tenderness,
history discoloration, or bruising
Adapted from Emergency Nurses Association (ENA). (2000), Trauma nursing core curriculum
[Provider Manual] (5th ed.).Des Plaines, IL Author, p 313-314.
The Pediatric Glasgow Coma Scale (Table 2 – 7) is used for baseline neurologic assessment and
monitoring trends over time. The score provides limited information, but has been used as a predictor of
outcome in trauma patients.
Figure 2-7. Paediatric Glasgow Coma Scale
Points
Parameters > 2 Years < 2 Years
Eye Opening 4 Spontaneously 4 Spontaneously
3 To verbal stimuli 3 To speech
2 To pain 2 To pain
1 No response 1 No response
Best Verbal Response 5 Oriented/uses appropriate words and phrases 5 Coos, babbles
4 Confused 4 Irritable, cries
3 Inappropriate words/screams/cries 3 Cries to pain
2 Nonspecific sounds 2 Moans to pain
Best Motor Response 6 Obeys to command 6 Normal spontaneous movement
5 Localized pain 5 Withdraws to touch
4 Withdraws to pain 4 withdraws to pain
3 Flexion response to pain 3 Abnormal flexion
2 extension response 2 abnormal extension to pain
Total Possible Points 3-15
Severe Head Injury <8
Moderate Head Injury 9-12
Minor Head Injury 13-15
Merck Manual. "Modified Glasgow Coma Scale for Infants and Children". Retrieved 2008-05-03
Adequate assessment requires visual and tactile assessment; therefore, areas of concern should be
exposed and examined. Maintain patient privacy during these examinations and use universal precautions.
If an area cannot be exposed in the triage area, elicit as much information as possible from the patient
regarding the problem. Once the patient is placed in a treatment area, the area can be exposed and
assessment completed. The area of concern may be left uncovered to facilitate continued assessment. This
is particularly effective for extremities. Touch the patient to determine skin temperature and presence of
moisture. A simple touch can provide a wealth of information and help to reassure the patient. Be sure to
33
maintain the patient's body heat, particularly for pediatric and geriatric patients. Infants are often bundled
in numerous clothes and blankets - even those with fevers. Remove clothes to allow the heat to dissipate.
Vital signs provide essential information about the child’s condition. For example Noninvasive Blood
pressure (NIBP) monitors are sometimes used in triage areas. Manual readings should be obtained when
monitor readings are suspicious or numbers do not correlate to clinical exam. These machines do not
detect pulse irregularities, so the triage nurse should palpate the pulse when a dysrhythmia is suspected.
Obtaining vital signs in children requires patience and skill. Machines can frighten children and make the
process more difficult. Begin with the least invasive test and move to the most invasive. For example,
observe respirations first, and then heart rate, and, finally, temperature.
Key Concept
Touch the child to ascertain skin temperature, presence of moisture, and presence of an irregular pulse.
4. TRIAGE DECISION & RATIONALE
The triage decision is made at the completion of the triage process. The triage decision determines
the priority for care based on the results of the child’s assessment and the chief complaint.
Internationally, national standardized five level systems (Canadian Triage acuity Scale – CTAS) with
proven reliability are being institute. There is a growing interest in the united state to create such a
standardized system, which would be more accurate and would allow comparison between hospitals and
better care and standardized teaching (Thomas, 2002).
Rationalization of the acuity level depends on the first order modifiers (Vital Signs, Pain Severity and
Mechanism of Injury) which physiologically explain the acuity level of the patient when triaging process
taking place. Table 2-6 reviews processes used to reach the triage decision. These steps may be done
consecutively or simultaneously for one or many patients; however, the importance of each step should not
be minimized. The triage decision is not set in stone; in fact, it changes when patient acuity changes. Once
the triage decision is made and acuity is determined, any qualifiers should be identified so the patient can
be placed in the appropriate treatment area. For example, the patient with severe migraine pain benefits
from a quiet, dimly lit room, whereas a patient with ocular burns may be placed in a special "eye" room. As
the triage nurse gains experience, his or her assessment style and critical thinking skills improve and the
process becomes streamlined.
Key Concept
Discontinue assessment and transport the patient immediately to the treatment area if immediate care is needed. Do not
delay treatment to finish the assessment.
Table 2-8 Systematic Triage Decision Process

Step 1 Observe the patient. Perform visual survey.
Step 2 Determine chief complaint and perform primary survey.
Step 3 Perform assessment of chief complaint, obtain subjective assessment related to present
condition, and complete objective assessment.
Step 4 Consider "worst-case scenarios," pose hypotheses, and collect data to narrow the range of
possibilities. Consider current condition, potential for deterioration, speed of flow within the
department, and resource availability.
Step 5 Determine acuity category (i.e., make the triage decision).
Step 6 Reassess and reassign acuity as necessary.
(ENA, 2001
34
PEDIATRIC PATIENT DISPOSITION
On completion of triage process, pediatrics are transferred to an assigned area within the
emergency department based on the data collected and the acuity of the child’s problems, the child is
assigned an area within the department. If the child’s problem nonurgent and if the room is not available,
the child may be sent to a specific place to wait. The triage nurse or another designated health
professional should perform periodic reassessment of the child’s condition to determine if the condition has
changed from initial assessment.
Key Concepts
The clinical priorities and the principles of urgency for infants, children and adolescents are the same as those for adults.
Determining urgency will require recognition of serious illness, some features of which may be different in infants and
children. The value of parents and their capacity to identify deviations from normal in their child’s level of function should
not be underestimated. (Australian Government Department of Health and Ageing – Emergency Triage Educational Kit, 2007)
REASSESSMENT
When treatment space is not immediately available, patients with lower acuity remain in the waiting
area. These patients are reassessed at periodic intervals to ensure that no change in acuity has occurred.
Reassessment is based on the patient's initial assessment and acuity determination. Specifics of
reassessment include, but are not limited to, repeat vital signs and focused assessment. Significant
symptoms are reassessed to determine if the condition has improved or worsened. Patients may also be
visually assessed each time the triage nurse observes the waiting area. The triage nurse should advise the
patient to return to the triage area if symptoms worsen or if any change occurs that concerns the patient
(CJEM 2004).
Key Concept
If the patient's condition is changes, reassess to determine if the patient requires more immediate attention.
Objectives for time to nursing reassessment is related to triage level
 There should be a nursing reassessment on all patients at the time intervals recommended for
physician assessment. That is: Level I patients should have continuous nursing care, Level II Within 15
minutes, Level III Within 30 minutes, Level IV Within 60 minutes and Level V Within 120 minutes. This is
to ensure that patients are reassessed to confirm that their status has not worsened.
 When patients have a medical diagnosis or are considered “stabilized”, the frequency of nursing
assessment and care will depend on the existing care protocols or physician orders.
 When patients have exceeded the time objective for MD assessment for their triage level they
should be reassessed if they have deteriorated, they have to be re-triaged; otherwise they have to
be in the same level of triage.
APPLYING THE CTAS
The evidenced-based guidelines presented in Table revisions to the Canadian Emergency

Department Triage and Acuity Scale implementation guidelines - Pediatrics.
Key Concepts
The usual primary-survey approach to assessing all incoming patients should be complete prior to commencing mental
health assessment. Mental health triage is based on assessment of appearance, behavior and conversation. The
allocation of a triage code must be based on clinical criteria that are consistent with the CTAS descriptors for acute
behavioral disturbances and risk of harm to self or others.
35
PITFALLS OF ED TRIAGE
 Failure to recognize and attend to a patient who complains of severe pain: Patients with severe pain
should be categorized in the highest level and should immediately be seen in the ED by a physician.
Many instances of catastrophic chest or abdominal pain have had poor outcomes because
patients were assessed and then were sent to a waiting room. The person performing triage should
not judge whether the person might be exaggerating his or her pain (CJEM 2004).
 Failure to recognize or acknowledge high-risk chief complaints: Patients with chest pain, abdominal
pain, or severe headache should be seen immediately to prevent obvious and potentially
catastrophic problems (CJEM 2004).
 Failure to take adequate vital signs: Each patient's temperature must be taken and repeated if it
does not match the clinical condition, for example, as in the case of a patient who feels warm but
has a normal temperature. Respiratory rates must be carefully counted. High respiratory rates are
one of the most sensitive indicators of severely ill or injured patients (CJEM 2004).
 Failure to adequately document the triage: Appropriate documentation is an important part of the
medical record. These records must be available for review by the physician who later sees the
patient (CJEM 2004).
 Failure to re-triage patients initially assigned to the waiting room: Patients assigned to a waiting
room should have vital signs retaken every 2 hours, on the most urgent categories of triage. Failure
to do so may result in patients who progress to critical illness while sitting in the ED waiting room
(CJEM 2004).
 Failure to apply the appropriate acuity scale, either over triaging which means assigning a higher
acuity than needed for a patient, under triaging, assigning a lower acuity than needed for a
patient.
Key Concept
Acuity level may change at any time.
MISTRIAGE AND IMPORTANCE OF RE-TRIAGE
Mistriage refers to assignment of an acuity level that is higher or lower than necessary for a specific
patient. Over-triage (or assignment of a higher acuity level than necessary) taxes resources that could be
used for patients with more serious illness or injury. Length of stay may also be prolonged by over-triage.
Under-triage is potentially more serious, because the patient receives an acuity level that is lower than
appropriate. Delayed treatment because of under-triage can lead to increased morbidity or mortality. The
triage nurse can consult a more experienced triage nurse or physician to facilitate identification of the
appropriate acuity level; however, this may delay care (CJEM 2004).
Patients with minor problems may not need such frequent reassessments. In our triage, the float
nurse in adult care area or the float in the triage area that did that contentiously (CJEM 2004).
In the case of high-risk patients, cardinal signs of severe illness may develop during prolonged waits.
Patients who appear intoxicated or have alternations in mental status could actually have a life-
threatening problem, such as a subdural hematoma or diabetic ketoacidosis, and should not be permitted
to sleep in the waiting room (CJEM 2004).
Also the outcomes of some cases may not have changed had the patients been seen directly in
the ED and immediately evaluated by a physician, these cases do illustrate that patients' medical
conditions are constantly changing, and that triage is an active and dynamic process. If there are long
lines to see a physician in the ED, continually reassess patients (CJEM 2004).
36
Key Concept
When in doubt about acuity level, asking further information regarding to the condition or asking more expert senior triage
health professional for the acuity level decision.
PEDIATRIC TRAUMA
Pediatric trauma patients require a systematic, rapid, and thorough assessment. Anatomical,
developmental, and physiologic differences make the management of these patients a challenge (ATCN,
2008).
Goals:
The goals of resuscitation of the pediatric trauma patient are as follows:
 Recognize common injury patterns based on mechanism of injury.

 Modify the assessment and management based on age, anatomical differences, and size of the
patient.
 Use reference guides for calculating appropriate medication doses and equipment size. D.
Communicate with the patient at the appropriate developmental level.
Anatomical Differences and Injury Patterns
 Certain types of injuries are commonly seen in the pediatric patient. The most commonly seen
cause of death in all pediatric populations are motor vehicles-related injuries, whether an
occupant, pedestrian or bicyclist followed by drowning, house fires, homicides and falls (ATCN,
2008)..
 The priorities of assessment and management of injuries in children are the same as in adults
however children have unique anatomical and physiologic differences that render them vulnerable
to injury as well as resulting in predictable patterns of injury. The following should be considered in
the care of the pediatric patient (ATCN, 2008).:
1. Because of the smaller body mass of children energy imparted from contact results in a greater
force applied to the body area. Furthermore, the ration of a child's body surface areas to body
volume is highest at birth and diminishes as the child ages as a result, thermal energy loss is
significant. Hypothermia develops quickly and can lead to acidosis and coagulopathy.
2. The size of the child's head is larger in relationship to body mass. More than 80% of patients with
multiple injuries have injuries that involve the head.
3. Children have proportionately large heads and weak neck muscles. There is potential for flexion-
extension injuries with spinal cord injuries, this may occur without radiographic findings. This is
referred to as Spinal Cord Injury without Radiographic Abnormalities (SCIWORA).
4. The chest wall is thin and flexible and the sternum and ribs are more cartilaginous. There is a high
incidence of pulmonary contusion without associated rib fractures.
5. Weak abdominal muscles in infants and young children allow the abdomen to protrude. The
liver and spleen are not well protected and are commonly injured.
6. Due to the smaller body size of a child, organs are closer together predisposing the child to
multiple organ injury.
7. The child's skeleton is incompletely calcified, contains multiple growth centers and is more
pliable. Fractures occurring at the growth plate will require special attention.
8. Trachea is shorter therefore making it easier to cause a main stem intubation.
9. Larynx is more anterior making it more difficult to visual the glottis opening.
10. Tongue is larger pre-disposing the children to airway obstruction.
37
 Airway with Cervical Spine Control

1. Assessment
a. Assess airway patency
Anatomical differences
The smaller the child the greater the disproportion between the size of the
cranium and the midface.
The occiput is larger causing flexion of the cervical spine and subsequent airway
obstruction.
Diameter of the airway is small and flexible.
The infant's trachea is approximately 5cm long and grows to 7 cm by 18 months.
Unplanned extubation or right mainstem intubation may result unexpectantly.
The soft tissue of the oropharynx are large compared with the oral cavity; the and
the larynx is more anterior making visualization difficult.
The larynx is funnel-shaped, allowing secretions to accumulate in the
retropharyngeal area.
Infants are obligate nasal breathers for the first several months of life.
2. Interventions:
a. Place padding beneath the entire torso infant or young child to achieve neutral
alignment of the spinal column. This prevents potential airway compromise.
b. Apply oxygen.
c. Suction as indicated.
d. Perform chin lift or jaw thrust maneuver with cervical spine precautions to relieve airway
obstruction.
e. Oropharyngeal airway (OPA).
f. Insert gently into the oropharynx, not at a 180 degree rotation, the use of a tongue
depressor may be helpful
g. Only insert if the child is unconscious to eliminate stimulating the gag reflex causing
vomiting.
 Breathing with Recognition and management of immediate life-threatening chest injuries

1. Assessment
a. Assess the adequacy of breathing and look for signs that indicate respiratory
insufficiency such as:
i. Noisy or decreased breath sounds
ii. Retractions and use of accessory muscles
iii. Nasal flaring and labored respiratory effort
iv. Pallor or cyanosis of the skin is a late finding
v. Use of abdominal muscles particularly during exhalation
vi. Evidence of chest wall injury
vii. Hypoxia is the most common cause of cardiac arrest in the child. Before
cardiac arrest occurs, hypoventilation causes respirator acidosis, which is
the most common acid/base abnormality encountered during the
resuscitation of the injured children. With adequate ventilation and
perfusion, a child should be able to maintain a relatively normal pH.
Attempting to correct an acidosis with sodium bicarbonate can result in
increase carbon dioxide and worsening acidosis.
38
2. Anatomical differences
i. Normal, spontaneous tidal volumes for infants and children vary from 6 to
8 cc (ml)/kg. Intercostal muscles are poorly developed and the chest wall
is compliant, making it difficult for young children to increase tidal volume.
ii. Children use the muscles of the abdomen for respiratory efforts.
 Circulation with Bleeding control and Shock Recognition and management

Assessment
Evaluate the child for deficits in perfusion status as evidenced by the following signs and
symptoms:
Early Signs:
Elevated heart rate for patient age (assess brachial or femoral pulse)
Poor skin perfusion
Later Signs:
Altered mental status
Weak or absent peripheral pulses
Skin mottling/clammy skin
Very Late Signs:
Decreased blood pressure (hypotension is an ominous sign. Children maintain
their blood pressure consistently until very late in the shock cycle).
Urine output less than 1-2 cc (ml)/kg/hr.
A method for estimation of blood pressure specific to the age of the child is follows:
 70 + double the child's age in years = an estimate of the systolic blood pressure
at the 5th percentile.
 2/3 of this number is an estimation of the diastolic blood pressure.
 A blood pressure that is 10 mm Hg less than the estimated blood pressure is
considered hypotension with other signs of poor perfusion.
Anatomical and Physiologic Differences
1. Children have only one method to increase cardiac output. Increased heart rate is their
only compensatory mechanism.
2. Because of compensatory mechanisms, the child can lose 30% of their blood volume
before blood pressure decreases.
3. What appear to be small amounts of blood loss can result in shock.
4. Urine is dilute due to lack of concentration ability by immature kidneys. This limits their
ability to respond to blood loss.
 Disability with recognition and initial management of altered mental status and intracranial mass
lesions
1. Assessment
a. Assess the level of consciousness using a modified Glasgow Coma Scale.
b. Evaluate the pupils for equality, reactivity, and size.
c. Assess for bulging fontanelle in non-comatose infants.
 Exposure with maintenance of body heat

1. The high ratio of body surface area to body mass in children increases heat exchange with the
environment and directly affects the body's ability to regulate core temperature. Because of the
larger head size in young children and infants they lose additional heat there.
2. Overhead radiant warmers, heaters or thermal blankets may be needed to preserve body
temperature.
3. Warm fluids and blood products during resuscitation.
4. Oxygen should be warmed and humidified.
39
 Special Considerations
a. Pseudosublaxation frequently complicates the radiographic evaluation of the child's cervical
spine. Approximately 40% of children < 7 years of age show anterior displacement of C2 on
C3 and 20% of children up to 16 years exhibit this phenomenon. This finding is seen less
commonly at C3 to C4.
b. Pain Management
 Attention must be placed on age specific assessment of the child's pain with
appropriate management, evaluation, and re-evaluation. The child's developmental
phase will greatly influence their response and coping skills. Pain management may
take on a variety of interventions. Children challenge us to use our creative skills in
managing not only their pain but anxiety and fears as well.
 Avoid IM injections whenever possible in children, using the intravenous or oral route
first.
c. Emotional Needs
 Allow the family to be with the child whenever possible. Try to normalize an unfamiliar
environment.
 Involve support personnel such as social service, clergy, and a patient or family
advocate, if available.
 Involve the parents with the care and treatment of their child as soon as possible.
d. The Battered and Abused Child

 Any child who sustains an intentional injury as the result of acts by parent, guardians,
or acquaintances is considered to be a battered and abused child.
 In the United States and many other countries it is mandatory for all health care
Professionals to report suspected cases of maltreatment. All nurses should familiarize
themselves with the reporting laws of their country and/or state.
 All nurses should be able to obtain a detailed history of the incident, identify the injury
patterns associated with child abuse and describe the elements that lead to the
suspicion of child abuse.
 A thorough physical assessment including the child's general appearance and
nutritional state, along with a comprehensive history is essential when potential
maltreatment is identified.
e. Death of a Child
 Sometimes, despite optimal care, the child dies from the injuries or complications. It is
a difficult time for both the family and the staff. Nursing staff needs to be prepared to
support the family and offer comfort measures.
 Families grieve in very different ways. Each situation needs to be assessed in an
attempt to identify the needs of a particular family. Provide the best method for
comforting and assisting in the grieving process.
Summary
Care of the pediatric patient is challenging. Evidence of deterioration may be subtle in a child and decompensation can
occur rapidly. Therefore, the trauma nurse should have a heightened awareness and be prepared to intervene as
warranted. Long term follow up of functional outcome indicates that while victims of major trauma during childhood may
retain functional disabilities, quality of life remains very high ( ATCN,2008).
40
SECTION THREE: CANADIAN ED TRIAGE & ACUITY

SCALE
PURPOSE:
 To develop the ability of the systematic triage assessment in Emergency Department.
OBJECTIVES:
o Formulate the triage & acuity scale category definition according to small group activities.
o Develop the ability to determining acuity and establishing standards of triage practice.
(Case Scenarios / Presentation).
o Explain the Trauma Filed Triage steps.
o Develop an appropriate decision making related to the Multiple Simultaneous presentation
according to small group activities.
41
CANADIAN ED TRIAGE & ACUITY SCALE – REVISED 2008
INTRODUCTION & BACKGROUND
Efficient management of an ED requires a team of providers capable of correctly identifying

patients needs, setting priorities and implementing appropriate treatment, investigation and disposition. As
needs or expectations for rapid access to care change, EDs are frequently challenged to do more for the
“system” than they have either been structurally designed for or have been staffed or equipped to
accomplish.
The Canadian ED triage and acuity instrument attempts to more accurately define patients needs
for timely care and to allow ED’s to evaluate their acuity level, resource needs and performance against
certain operating “objectives”. Three important concepts are included in the design of this scale: 1) Utility;
2) Relevance and 3) Validity (CJEM 2004).
The Canadian Emergency Department Triage and Acuity Scale (CTAS) has been widely adopted in
emergency departments (EDs) across Canada and abroad since its initial publication in 1999 (Beveridge R,
Clark B, Janes L, et al,1999). CTAS continues to be revised and updated on a continuing basis. In 2001, a
paediatric version of the CTAS implementation guidelines was developed and published (Warren D. Jarvis
A, Leblanc L,2001). With the ongoing improvements in computer technology, the increasing demands for
clinical and administrative data and the wider application of information technology in EDs, the Canadian
Emergency Department Information Systems (CEDIS) committee published a standardized presenting
complaint list in 2003 (Grafstein E, Unger B, Bullard M, et al,2003). In 2004, a revision of the adult CTAS
guidelines that incorporated the CEDIS complaint list and introduced the concept of modifiers to assist
nurses in the assignment of the appropriate acuity level was published (Murray M, Bullard M, Grafstein E,
2004).
Modifiers were divided to two types: (Murray M, Bullard M, Grafstein E, 2008)
1. First Order Modifiers: (Broadly applicable to a wide number of different complaints)

a. Vital Signs(Respiratory distress, Haemodynamic instability, altered Level Of consciousness,
and fever)
b. Pain Severity(Acute or chronic, Peripheral or systematic)
c. Mechanism Of Injury
2. Second Order Modifiers: (Specific or limited number of complaints)
a. Example: Low blood sugar level in blood less than 3 mmol/L
(“BS < 3 mmol/L and/or symptomatic” is a modifier for 3 complaints, including altered level of
consciousness, confusion and hypoglycemia; while “BS < 3 mmol/L and asymptomatic”
modifies only 1 complaint: hypoglycemia).
A CTAS revisions supplement that displayed the entire CEDIS complaint list and the relevant first and
second order modifiers was published in Complaint Oriented Triage (COT) as a form of a more
sophisticated Microsoft Excel application in 2007. A new combined adult and pediatric CTAS educational
package was published in December 2006(Murray M, Bullard M, Grafstein E, 2008).
The CTAS National Working Group (NWG) meets annually and responds to the feedback and
comments from the members of the five represented organizations. Following the 2004 revision, there have
been further requests that have been vetted and prioritized through the NWG(Murray M, Bullard M,
Grafstein E, 2008).
42
CHANGING TRIAGE
To prevent unfair or unsafe waiting of patients with lower triage categories, it is reasonable to
reassess the triage level if the time response objective has not been met within the category. For example, if
a level V patient has waited 2 hours or more and being behind presenting category four’s, they may then
be advanced to level IV after consultations with triage physician. This is important because patient’s status
can change while in the ED and the rules will not always accurately separate levels III, IV and V. Electronic
tracking systems are especially suited to this type of operational change to the triage scale. For data
reporting patient acuity can be determined using a combination of triage level, final diagnosis, information
about procedures and length of stay (LOS) (ENA, 2001).
GOALS OF TRIAGE
1. Provide prompt and efficient care to a high influx of emergency care patients.
2. To establish priority of care.
3. To improve patient flow.
4. To expedite Emergency Care.
5. To rapidly identify patients with urgent, life threatening conditions.
6. Ensures assessment and case of patients with less urgent problems.
7. To determine the most appropriate treatment area for patients presenting to the ED.
8. To decrease congestion in emergency treatment areas.
9. To provide ongoing assessment of patients.
10. To provide information to patients and families regarding services, expected care and waiting times.
11. To contribute information that help to define departmental acuity.
(KAMC – R, 2006)
Rapid access to assessment by a health care provider increases patient satisfaction and enhances
public relations. An efficient triage system should reduce client anxiety and increase satisfaction by
reducing length of stay and waiting times in the emergency department.
Factors, which influence triage design and operation, include :( ENA, 2001)
 Number of patient visits

 Number of patients requiring rapid intervention
 Availability of health care providers in the ED treatment area
 Availability of specialty services
 Environmental, legal and administrative issues
 Availability of community care resources
 Computer system used for ADT (admit /discharge/transfer) and patient care.
Each Emergency Department needs a clear understanding of the population being served, all the
system capabilities and specific policies and procedures describing their triage system. Many time
objectives may not be met unless some type of triage assessment (rapid triage) is done before registration.
This is a system design/operational policy issue that must be considered.
GENERALTRIAGE GUIDELINES
Accurate assignment of triage levels is based on:
o Practical knowledge gained through experience and training.

o Correct identification of signs or symptoms.
o Use of guidelines and triage protocols.
 A triage level must be recorded on all patients, during all shifts. This includes all ambulance patients.
 When the triage nurse has categorized more than 3 urgent patients, it is his/her responsibility to
prioritize these patients for the treatment nurse/ emergency physician.
43
 Triage is a dynamic process: A patient’s condition may improve OR deteriorate during the wait for
entry to the treatment area.
 “Primary nursing assessment” is more detailed and more accurately determines the patients need
for care.
 All patients should be assessed (at least visually) within 10 minutes of arrival.
 Full patient assessments should not be done in the triage area unless there are no patients waiting to
be seen. Only information required to assign a triage level should be recorded.
 A primary survey (rapid assessment) should be used when there are 2 or more patients waiting to be
triaged. After all patients have had some assessment done, level IV and V patients that have been
sent to the waiting area should have a more complete assessment done by the triage personnel or
treatment nurse.
 The priority for care may change following a more complete assessment or as patient’s signs and
symptoms change. There should be documentation of the initial triage as well as any changes. The
initial triage level is still used for administrative purposes.
 Level I, II, patients should be in a treatment area and have the complete primary nursing assessment
done immediately.
TRIAGE IS NOT A STATIC PROCESS
It is important to remember that triage is a dynamic process and patients may move up or down on the
urgency continuum while waiting for access to treatment areas, physician assessment, results of
investigation or response to treatment. Triage systems should be accompanied by protocols on:
o How quickly a patient is to be seen by the health care provider for specific complaint types?
o How often patients in each triage category will be reassessed and where that information
should be documented?
o How patients with defined signs and symptoms are categorized i.e., chief complaint.
o What types of interventions are expected to be initiated in triage?
o What types of reassessments should be done? The options vary from a quick overview of the
waiting room patients, to a repeat primary survey and repeat vital signs.
o Designating time frames and methods of reassessment in your guidelines provides a
framework for evaluating quality / outcomes and preventing patient deterioration.
o
TRIAGE & ACUITY SCALE CATEGORY DEFINITIONS (Update)
This update focuses on revisions in 5 key areas: (Murray M, Bullard M, Grafstein E, 2008)
1. General issues including CTAS colors and rural protocol for CTAS Level V.
2. Presenting complaint list changes.
3. First order modifiers related to sepsis and bleeding disorders.
4. Second order modifiers related to chest pain, extremity injury and dehydration.
5. Mental health complaints and related second order modifiers.
1. General issues
a. Alignment of adult and pediatric color palettes

Rationale: The posters developed as teaching aids for adult and pediatric CTAS did not use the
same color coding system. Consensus was reached by the CTAS NWG that the CTAS level color
assignment will be as follows: Level I - blue, Level II - red, Level III - yellow, Level IV - green and
Level V - white. (Murray M, Bullard M, Grafstein E, 2008)
44
b. Rural protocol for CTAS Level 5

Rationale: In 2003, the Society of Rural Physicians of Canada (SRPC) Emergency (ER) Committee
published a statement about the implementation of CTAS in the rural setting in CJEM (Stobbe K,
Dewar D, Thornton C, et al,2003). Substantively different from the original CTAS implementation
guidelines was the inclusion of “Protocol for CTAS Level V” patients that would allow a trained
registered nurse, without contacting the on-call physician, to refer patients to a more
appropriate service provider or defer care to a later time. This was intended for those hospitals
without onsite duty emergency physicians in order to optimize the use of limited physician
resources without jeopardizing patient safety. However, some members of the National
Emergency Nurses Affiliation (NENA) expressed concerns that this policy may leave nurses liable
in the event of an adverse patient outcome (Murray M, Bullard M, Grafstein E, 2008). In 2007, the
SRPC ER revised the criteria that needed to be met before the implementation of such a
medical directive, incorporating the following:
a. The patient is 6 months of age or older.
b. Vital signs are deemed satisfactory by the nurse, and temperature is 35°C–38.5°C (38.3°C for
age > 60 yr).
c. The patient is assessed as CTAS Level V.
d. After the nursing assessment, there is no clinical indication that the patient may require
urgent physician attention.
e. In borderline cases, or where the nurse is unsure, telephone consultation between the nurse
and physician has determined that the problem is Nonurgent.
f. Appropriate hospital policy is in place.
g. There is local agreement between medical and nursing staff to accept the process.
2. Presenting complaint list
Rationale: in 2003, the CEDIS presenting complaint list was first published with limited number of
complaints in order to make it practical. The CTAS NWG recognized that the list would need to be
revised after feedback from users and updated in order to address the needs of the pediatric triage
nurses. (Murray M, Bullard M, Grafstein E, 2008)
3. First Order Modifiers - Pediatric (Murray M, Bullard M, Grafstein E, 2008)
Level I
VS: Severe Respiratory distress (Sat. <90%, Fatiguing from excessive

work of breathing, cyanosis, single-word speech, unable to speak,
upper respiratory obstruction, lethargic or confused), shock or
severe dehydration (evidence of severe end-organ hypoperfusion:
marked pallor, cool skin, diaphoresis, weak or thready pulse,
hypotension, postural syncope, significant tachycardia, or
bradycardia, flushed, febrile toxic as in septic shock), Unconscious
Level II
VS: Moderate Respiratory distress (Sat. <92%, Increased work

breathing, speaking phrases or clipped sentences, significant or
worsening Stridor but airway protected) , Haemodynamic
Compromise or moderate dehydration (Evidence of borderline
perfusion, pale, history of diaphoresis, unexplained tachycardia,
postural hypotension, suspected hypotension) , alter Level Of
Conscious (GCS 10 – 13), Immunocompromised (neutropenia,
transplant, steroids, etc.) or looks septic, Temperature (<3months,
T< 36C or > 38C, 3 – 36 months T < 32C or >38.5C, appearing
unwell or toxic.
45
MOI: High risk MOI (General Trauma - autoaccidenet as rollover, ejected

from the vehicle, long extraction >20minutes, high speed accident >
60 Km/h, death in the same passenger, MCA impact with car speed
> 30 km/h, fall of 2 meters, , penetrating injuries to the head, torso
and neck and upper extremities, Head trauma as above and
unrestrained passenger, fall from > 3 feet or 5 stairs or assaulted
with a blunt object other than fist or feet, Neck Trauma such as
above and axial load to the head)
Pain Scale (PS): Sever pain (8 – 10).
Level III
VS: Mild Respiratory distress (Sat. 92% - 94%, dyspnea, tachypnea,

SOB on exertion, no obvious work of breathing, able to speak in
sentences, Stridor without any obvious airway obstruction),
Haemodynamic stable, Mild dehydration, Abnormal body
temperature (3 – 36 months, T 32 – 35Cor,>38.5C appearing well
non toxic, >36 months, T >38.5C, appearing unwell(toxic).
PS: Moderate pain (4 – 7) or inconsolable infant.
Level IV
VS: Elevated temperature (> 36 months, T > 38.5 C but appears well,
Normal vital signs.
PS: Mild pain (< 4), consolable infant.
46
47
REVISIONS TO THE CANADIAN EMERGENCY DEPARTMENT TRIAGE AND ACUITY SCALE IMPLEMENTATION GUIDELINES - PEDIATRICS
CTAS Modifiers First Order Other Modifiers /
CTAS Levels CEDIS Chief Complaints VS PS MOI Chronicity Second Order Notes
Feeding difficulties in newborns
1 Feeding difficulties in newborns VS Appearance Pediatrics CTAS
2 Feeding difficulties in newborn , VS PS Appearance Pediatrics CTAS
infant 7 days
Neonatal jaundice
1 Neonatal jaundice VS Appearance Pediatrics CTAS
2 Infant < 7days of age with VS PS Appearance Pediatrics CTAS
jaundice
2 Neonatal jaundice VS Appearance Pediatrics CTAS
Inconsolable crying
1 Inconsolable crying VS Appearance Pediatrics CTAS
2 Inconsolable crying VS PS Appearance Pediatrics CTAS
3 Inconsolable crying VS PS Appearance Pediatrics CTAS
Respiratory
1 2 3 4 SOB – shortness of Breath VS
2 SOB – shortness of Breath Known asthmatic with
FEV1 or PEFR < 40%
predicted sever
FEV1 or PEFR < 40-60%
predicted moderate
FEV1 or PEFR > 60%
predicted mild
1 Respiratory Arrest
2 3 4 Cough VS
5 Cough Chronicity Chronic, normal VS
1 2 3 Hyperventilation VS
4 Resolved
1 2 3 4 Hemptysis VS
1 2 3 4 Respiratory – Foreign body VS
2 3 4 Respiratory – Foreign body PSC
2 Respiratory – Foreign body Drooling or stride,
hoarseness and
dysphasia
48
Respiratory (Cont’d)
3 Respiratory – Foreign body No distress but with
difficulty swallowing
1 2 3 4 Allergic reaction VS
3 4 Allergic reaction PSP
2 Allergic reaction Previous sever reaction
5 Allergic reaction Hay fever causing by
nasal congestion
Skin
1 2 3 4 Bite VS
3 4 5 Bite PSP
2 Bite Previous sever reaction
5 Bite Minor bites
1 2 3 4 Sting VS
3 4 5 Sting PSP Previous sever reaction
2 Sting
3 4 5 Abrasion PSP
5 Abrasion Minor abrasion
1 2 3 4 Laceration, puncture VS
3 4 5 Laceration, puncture PSP
2 Laceration, puncture Neuro-vascular
compromised
3 Laceration, puncture Active bleeding
4 Laceration, puncture Bleeding resolved /
controlled, suture required
5 Laceration, puncture No suture required
1 2 3 4 Burn VS
3 4 5 Burn PSP
2 Burn Split/full thickness to
hands, feet, face,
perineum, or > 25% BSA
3 Burn 5 – 25% BSA
4 Burn < 5% BSA split/full; <10
split thickness
2 Blood and body fluid exposure High risk exposure Defined as needle stick,
hollow bore needle,
known or suspected HIV
or hepatitis +ve source
49
Skin (Cont’d)
3 Blood and body fluid exposure Low risk exposure Defined as non hollow
bore needle or fluid
splash from low risk
source
3 4 5 Pruritis PSP
1 2 3 4 Rash VS
3 4 5 Rash PSP
2 Rash Facial cellulites,
particularly priorbital area,
purpuric or orbital rash;
appears ill
4 Rash Localized cellulites
5 Rash Localized rash
1 2 3 4 Localized swelling - redness VS
3 4 5 Localized swelling - redness PSP
2 Localized swelling - redness Facial cellulites,
particularly priorbital area,
purpuric or orbital rash;
appears ill
4 Localized swelling - redness Localized cellulites
5 Localized swelling - redness Localized rash
3 4 Other skin conditions VS
3 4 5 Other skin conditions PSP
2 3 4 Lumps, bumps and calluses VS
3 4 5 Lumps, bumps and calluses PSP
2 3 4 Redness, tenderness breast VS
3 4 5 Redness, tenderness breast PSP
3 4 5 Rule out infections PSP
1 2 3 Cyanosis VS
1 2 3 Bruising/history of bleeding VS
disorder
2 Bruising/history of bleeding MOI
disorder
2 3 4 Foreign body in the skin VS
3 4 5 Foreign body in the skin PSP
Substance miscuse
1 2 3 4 Substance misuse/intoxication VS
50
Substance miscues (Cont’d)
2 High risk substance /
unknown substance,
altered mental state
requiring close
observation
4 Substance misuse/intoxication Known low risk substance
1 2 3 4 OD - ingestion VS
2 High risk substance /
unknown substance,
attempted suicide, clear
plan, altered mental state
requiring close
observation.
3 OD - ingestion Suicidal ideation, no plan
1 2 3 4 Substance withdrawal VS
1 Substance withdrawal Active seizuring
2 Substance withdrawal Recent seizures, post
ictal, agitated, altered
mental state requiring
close observation, sever
anxiety/agitation
3 Substance withdrawal Moderate anxiety/agitation
4 Substance withdrawal Mild anxiety/agitation
Trauma
1 2 3 Major trauma - penetrating VS
2 3 Major trauma - penetrating PSC
2 MOI Penetrating head, chest,
abdomen, neurovascular
compromise of extremity
1 2 3 4 Major trauma - blunt VS
2 3 4 Major trauma - blunt PS
2 Major trauma - blunt MOI Neurovascular
compromise of extremity
3 Major trauma - blunt Prolonged spinal
immobilization
1 2 Isolated chest trauma – VS
penetrating
51
Trauma (Cont’d)
2 Isolated chest trauma - PSC For intrathoracic pain
penetrating
1 2 3 4 Isolated chest trauma - blunt VS
2 3 4 Isolated chest trauma - blunt PSC
3 4 Isolated chest trauma - blunt PSP For chest wall pain
2 Isolated chest trauma - blunt MOI
1 2 Isolated abdomen trauma - VS
penetrating
1 2 3 4 Isolated abdomen trauma - blunt VS
2 3 4 Isolated abdomen trauma - blunt PSC
2 Isolated abdomen trauma - blunt MOI
General and Minor
5 Exposure to communicable
disease
1 2 3 4 Fever unspecified VS
2 Fever unspecified Petechial rash
1 2 3 Hyperglycemia VS
2 Hyperglycemia > 18 mmol/l symptomatic
3 Hyperglycemia > 18 mmol/l non
symptomatic
1 2 3 Hypoglycemia VS
2 Hypoglycemia < 3 mmol/l and or
symptomatic
3 Hypoglycemia < 3 mmol/l not
symptomatic
1 2 3 4 Direct referral for consultation VS
2 3 4 5 Direct referral for consultation PSC
or P
3 4 5 Direct referral for consultation PSC Chronicity
or P
3 4 Dressing change VS Ensure no other issues Ensure no other issues
exists exists
3 4 5 Dressing change PSP
3 4 Removal staples and sutures VS Ensure no other issues Ensure no other issues
exists exists
3 4 5 Removal staples and sutures PSP
52
General and Minor (Cont’d)
3 4 5 Cast check PSP Ensure no other issues
exists
2 Cast check Tight cast with neuro –
vascular compromise
4 Cast check Tight cast with no neuro –
vascular compromise
5 Imaging test Ensure no other issues
exists
1 2 3 4 Medical device problem VS
2 3 4 Medical device problem PSC
3 4 Medical device problem PSP
4 Medical device problem Medical device problem;
asymptomatic or no
distress
5 Medication request Ensure no other issues
exists
3 4 5 Ring removal PSP
2 Ring removal Neuro-vascular
compromise
2 3 4 Abdominal lab values VS
3 Abdominal lab values Normal VS, critical value
5 Abdominal lab values Normal VS, non critical
value
2 3 4 Post – op complications VS
2 3 4 Post – op complications PSC
3 4 5 Post – op complications PSP
5 Post – op complications Normal VS, no pain,
routine check
1 2 3 4 Pallor/anemia VS
2 3 4 Minor complaints unspecified VS
3 4 5 Minor complaints unspecified PSP
4 5 Minor complaints unspecified PSP Chronicity
53

Cardiovascular System
1 Cardiac Arrest – Non Traumatic
1 Cardiac Arrest - Traumatic
1 2 Chest Pain cardiac features VS PSC
1 2 3 4 5 Chest Pain non cardiac features
1 2 3 4 Chest Pain non cardiac features VS
2 3 4 Chest Pain non cardiac features PSC
3 4 5 Chest Pain non cardiac features PSC Chronicity
3 4 5 Chest Pain non cardiac features PSP note for chest wall pain
the score is peripheral
3 Chest Pain non cardiac features other significant chest pain
(ripping/tearing or pleuritic)
1 2 3 4 Palpitations/Irregular heart beats here the level 1, 2 and 3
is determined by VS
1 2 3 Palpitations/Irregular heart beats VS
4 Palpitations/Irregular heart beats Chronicity
2 Palpitations/Irregular heart beats History or documented
lethal dysrhythmia, or with
chest pain cardiac
features
3 Palpitations/Irregular heart beats Acute onset ongoing
1 2 3 4 Hypertension
1 2 3 Hypertension VS
2 Hypertension SBP>220 or DBP>130
with symptoms
3 Hypertension SBP>220 or DBP>130 No
symptoms, SBP 220 – 200
or DBP 130 – 110 with
symptoms
4 Hypertension SBP220 – 200 or DBP
130 – 110 No symptoms
2 3 4 General Weakness
2 3 4 General Weakness VS
54
Cardiovascular System – Cont’d
3 General Weakness Chronicity Acute inability to ambulate
4 General Weakness Chronicity Chronic weakness
1 2 3 Syncope/Presyncope VS
2 Syncope/Presyncope History of or new onset 2 equal syncope pulse
dysrhythmia irregular any of these
pulse, and/or
known/suspected change
in rate, No prodromal
symptoms, or occurring
during exercise.
3 Syncope/Presyncope With prodromal symptoms 3 equals syncope with
or sudden position change this or ongoing
Presyncope
4 Syncope/Presyncope Chronicity Symptoms resolved 4 equals a level 3
syncope or Presyncope
with symptoms now
resolved
1 2 3 4 Oedema Generalized VS
2 3 4 5 Bilateral leg
swelling/edema(limb)
2 3 4 Bilateral leg VS
3 4 Bilateral leg PSP
3 4 5 Bilateral leg PSP +
swelling/edema(limb) Chronicity
1 2 Cool pulseless limb VS
2 3 4 Cool pulseless limb VS
3 4 Cool pulseless limb PSP
3 Cool pulseless limb Extensive inflammation
4 Cool pulseless limb Localized inflammation
ENT - Ears
3 4 earache VS
3 4 5 earache PSP
3 4 5 Foreign body ear PSP
3 Loss of hearing Chronicity Acute loss
5 Loss of hearing Chronicity Gradual loss
55
ENT – Eras(Cont’d)
2 4 Tinnitus/dysacusis Suspected Aspirin
ingestion
3 4 Discharge VS
2 3 4 Ear injury VS
3 4 5 Ear injury PSP
2 Ear injury Amputation
3 Ear injury Cold injury sever with
Blanching, cyanosis
4 Ear injury Cold injury, minor with no
discoloration, laceration
required sutures
5 Ear injury Laceration/abrasion not
required sutures
ENT – mouth throat neck
3 4 5 Dental/ gum problem PSP
2 Dental/ gum problem Dental avulsion
1 2 3 4 Facial trauma VS
3 4 5 Facial trauma PSP
2 Facial trauma MOI Hoarseness & dysphasia,
paresthesias, neurologic
signs
1 2 3 Difficulty swallowing/Dysphagia VS
2 3 Difficulty swallowing/Dysphagia PSC
3 Difficulty swallowing/Dysphagia Possible foreign body
2 3 4 Facial pain(non-traumatic, non- VS
dental)
3 4 5 Facial pain(non-traumatic, non- PSP
dental)
4 5 Facial pain(non-traumatic, non- PSP Chronocity
dental)
ENT – nose
1 2 3 4 Epistaxis VS
2 Epistaxis Uncontrolled epistaxis
despite appropriate
pressure
56
ENT – nose (Cont’d)
3 Epistaxis Bleeding controlled with
pressure, clotting
disorders(anticoagulants
and blood dyscrasia)
4 Epistaxis Chronicity Acute epistaxis, no active
bleeding
5 Epistaxis Chronicity Periodic/recurrent, no
active bleeding
5 Nasal congestion/hay fever Nasal congestion with
known hay fever
2 3 4 Foreign body, nose VS The only appropriate
level 2 modifier is
"moderate respiratory
distress
3 4 5 Foreign body, nose PSP
2 3 URI complaints VS The only appropriate
level 2 modifier is
"moderate respiratory
distress
3 4 5 URI complaints PSP
5 URI complaints Well, no fever
2 3 4 Nasal trauma VS
3 4 5 Nasal trauma PSP
2 Nasal trauma Uncontrolled epistaxis
despite appropriate
pressure
3 Nasal trauma Clotting disorder
(anticoagulants and blood
dyscrasia)
Environmental
3 4 5 Frostbite/cold injury PSP
4 5 Frostbite/cold injury PSP Chronicity
2 Frostbite/cold injury Cold pulseless limb
3 Frostbite/cold injury Blanching of skin
1 2 3 Noxious inhalation VS Don't include fever VS
modifiers for this
complaint
57
Environmental(Cont’d)
3 Noxious inhalation Smoke inhalation, or
other, no distress
4 Noxious inhalation Chronicity Remote exposure, no
symptoms
1 2 3 Electrical injury VS Don't include fever VS
modifiers for this
complaint
2 Electrical injury Obvious cutaneous injury
3 Electrical injury No obvious cutaneous
injury
1 2 Chemical exposure VS The minimum level is 2
to ensure early
documentation and
identification of the
substance as toxic or
not
1 Chemical exposure Major burn >25% BSA
2 Chemical exposure Major burn hand, feet,
groin, or face,
symptomatic eye "splash"
1 2 3 4 Hypothermia VS
2 Hypothermia Core temperature <32C
3 Hypothermia Core temperature 32 –
35C
4 Hypothermia No frostbite, normal VS
Gastrointestinal
1 2 3 4 Abdominal pain VS
2 3 4 Abdominal pain PSC
3 4 5 Abdominal pain PSC Chronicity
2 3 4 Anorexia VS
3 Anorexia Significant weight loss
2 3 4 Constipation VS
2 3 4 Constipation PSC
3 4 5 Constipation PSC Chronicity
1 2 3 4 Diarrhea VS
3 Diarrhea Uncontrolled bloody
diarrhea
58
Gastrointestinal (Cont’d)
5 Diarrhea Mild, no dehydration
1 2 3 4 Foreign body in rectum VS Patients in shock from
rectal trauma should be
documented under
"major trauma –
penetrating"
3 4 5 Foreign body in rectum PSP
2 3 4 Groin pain/mass VS
2 3 4 Groin pain/mass PSC
3 4 5 Groin pain/mass PSC Chronicity Chronic
1 2 3 4 Nausea and/or vomiting VS
2 Nausea and/or vomiting Active significant
hematemesis
3 Nausea and/or vomiting Coffee ground emesis/
melena, Age < 2 no
dehydration(PEDIATRICS)
5 Nausea and/or vomiting Chronicity Chronic, normal VS
2 3 4 Rectal/perineal pain VS
3 4 5 Rectal/perineal pain PSP
4 5 Rectal/perineal pain PSP Chronicity
1 2 3 Vomiting blood VS
2 Vomiting blood Active or significant
hematemesis
3 Vomiting blood Coffee ground emesis/
melena, small amount with
normal VS
1 2 3 4 Blood in stool/melena VS
2 Blood in stool/melena Large amount melena or
rectal bleeding
3 Blood in stool/melena Moderate amount melena
or rectal bleeding
4 Blood in stool/melena Rectal bleeding small
amount
2 3 4 Jaundice VS
2 3 4 Jaundice PSC
3 4 5 Jaundice PSC Chronicity
3 4 Hiccoughs VS Fever
59
Gastrointestinal (Cont’d)
3 4 5 Hiccoughs PSP
4 5 Hiccoughs PSP Chronicity
1 2 3 4 Abdominal mass/distention VS
2 3 4 Abdominal mass/distention PSC
3 4 5 Abdominal mass/distention PSC Chronicity Chronic
3 Abdominal mass/distention Persist vomiting
1 2 3 4 Anal/rectal trauma VS Patients in shock from
rectal trauma should be
documented under
"major trauma –
penetrating"
2 3 4 Anal/rectal trauma PSC
Genitourinary
1 2 3 4 Flank pain VS
2 3 4 Flank pain PSC
3 4 5 Flank pain PSC Chronicity
1 2 3 Hematuria VS
2 3 4 Hematuria PSC If pain is suspected to
be bladder or higher
then use "central" pain
3 4 5 Hematuria PSC Chronicity
3 4 5 Hematuria PSP Chronicity If pain is suspected to
then use "peripheral"
pain
3 4 Genital discharge /lesion VS
3 4 5 Genital discharge /lesion PSP Chronicity
2 3 4 Penile swelling VS
3 4 5 Penile swelling PSP
3 4 5 Penile swelling PSP Chronicity
2 Penile swelling Priapsim, paraphimosis Foreskin retracted and
unable to return normal
2 3 4 Testicular/scrotal pain VS
2 3 4 Testicular/scrotal pain PSC
3 4 5 Testicular/scrotal pain PSC Chronicity
60
Genitourinary (Cont’d)
3 4 Urine retention VS The only VS modifiers
for urinary retention are
the fever modifiers. If
patient is unable choose
another complaints
2 3 4 Urine retention PSC
3 4 Urine retention PSC Chronicity
2 3 4 UTI complaints/symptoms VS
2 3 4 UTI complaints/symptoms PSC If pain is suspected to
be from bladder or
above then use "central"
pain
3 4 5 UTI complaints/symptoms PSC Chronicity
3 4 5 UTI complaints/symptoms PSP If pain is suspected to
then use "peripheral"
pain
1 2 3 4 Oliguria VS
2 3 4 Oliguria PSC
1 2 3 4 Polyuria VS
2 3 4 Polyuria PSC
1 2 3 4 Genital trauma VS
2 3 4 Genital trauma PSC
3 Genital trauma Sexual assault, stable
Mental Health
2 Depression/Suicide Attempt suicide as clear
plan, active thoughts,
requiring close
observation
3 Depression/Suicide Suicidal ideation, no plan
4 Depression/Suicide Depression +/- passive
thoughts
2 Anxiety/situational crisis Sever anxiety/agitation
3 Anxiety/situational crisis Moderate anxiety/agitation
4 Anxiety/situational crisis Mild anxiety/agitation
2 3 4 Hallucinations VS
61
Mental Health (Cont’d)
2 Hallucinations Acute psychosis, sever
agitation
3 Hallucinations Moderate agitation or with
paranoia
4 Hallucinations Mild agitation, stable
5 Hallucinations Chronicity Mild agitation, chronic
hallucination
4 Insomnia Acute
5 Insomnia Chronicity Chronic
1 Violent behavior Imminent harm to self or
others
2 Violent behavior Unsettled, altered mental
state requiring close
observation
3 Violent behavior Resolved, settled
3 Social problem Risk of eloping, abuse
physical, mental, high
emotional stress
4 Social problem Unable to cope
5 Social problem Lack of support
1 Homicidal Imminent harm to others,
specific plans +/- access
2 Homicidal Active thoughts, unsettled,
requiring close
observation
3 Homicidal Passive thoughts
2 3 4 Bizarre/paranoid behavior VS
1 Uncontrolled
2 Altered mental state
requiring close
observation
3 Controlled
Neurologic
1 2 3 Altered level of consciousness VS
62
Neurologic (Cont’d)
2 Altered level of consciousness MOI High risk mechanism,
BS<3 mmol: &/or
symptomatic
2 3 4 Confusion VS
2 Confusion High risk mechanism,
BS<3 mmol: &/or
symptomatic, acute, with
headache or altered LOC
3 Confusion acute without headache or
altered LOC
4 Confusion Chronicity Chronic, no change from
usual state
2 Vertigo Not positional +/- other
neurological findings
3 Vertigo Positional, no other neuro
symptoms
4 Vertigo Chronicity Chronic
1 2 3 4 Headache VS
2 3 4 Headache PSC
3 4 5 Headache PSC Chronicity Chronic or recurring
2 Headache Sudden, sever, worst ever,
visual acuity disturbance
+/- eye pain
1 2 3 Seizures VS
2 3 Seizures PSC
1 Seizures Actively seizing
2 Seizures Post ictal
3 Seizures Resolved, normal level of
alertness
1 2 3 Gait disturbance/ataxia VS
4 Gait disturbance/ataxia Chronicity
2 Gait disturbance/ataxia Time of onset symptoms < Possible CVA
3 hours
1 2 3 4 Head injury VS
2 3 4 Head injury PSC
2 Head injury MOI New focal neurologic
findings
63
Neurologic (Cont’d)
3 Head injury History of LOC
4 Head injury No history of LOC
2 3 4 Tremor VS
4 Tremor Chronicity Chronic
1 2 3 Extremity weakness/symptoms VS
of CVA
2 3 Extremity weakness/symptoms PSC May use pain scales if
of CVA headache present
2 Extremity weakness/symptoms Time of onset symptoms <
of CVA 3 hours
3 Extremity weakness/symptoms > 3 hours or resolved
of CVA
3 Sensory loss/paresthesias New onset
4 Sensory loss/paresthesias Chronicity Chronic
OB-GYN
2 3 4 Menstrual problems PSC
1 2 3 4 Foreign body, vagina VS
3 4 5 Foreign body, vagina PSP
2 3 4 Vaginal discharge VS
3 4 5 Vaginal discharge PSP
5 Vaginal discharge Mild symptoms
1 2 3 4 Sexual assault VS
2 3 4 Sexual assault PSC
2 Sexual assault < 2 hours
3 Sexual assault > 2 hours; <12 hours
4 Sexual assault > 12 hours, no injury
1 2 3 4 Vaginal bleed VS
2 3 4 Vaginal bleed PSC
2 3 4 Labial swelling VS
3 4 5 Labial swelling PSP
Ophthalmology
3 4 5 Discharge eye PSP
4 5 Discharge eye PCP Chronicity
4 Discharge eye Chronicity Acute discharge
5 Discharge eye Chronicity Chronic
2 Chemical exposure, eye
2 Foreign body eye Penetrating foreign body
64
Ophthalmology(Cont’d)
3 4 5 Foreign body eye PSP This includes corneal
abrasion and corneal
foreign body
2 Foreign body eye Acute or abrupt change in
vision
2 Visual disturbances Acute or abrupt change in
vision
4 Visual disturbances Chronicity Chronic/ gradual change
in vision
2 4 5 Eye pain PSC
3 4 5 Eye pain PSC Chronicity
2 Eye pain Acute or abrupt change in
vision
3 4 5 Itchy red eye PSP
2 3 4 Photophobia PSC
3 Diplopia Acute onset
4 Diplopia Chronicity Chronic
2 3 4 Periorbital swelling & fever VS
3 4 Periorbital swelling & fever PSP
2 3 4 Eye trauma PSC
2 Eye trauma MOI Penetrating injury,
chemical or direct thermal
burn, or an inability of the
nurse to be able to access
the eye, blunt with visual
loss, Acute or abrupt
change in vision
3 4 5 Recheck eye PSP
2 Recheck eye Acute or abrupt change in
vision
Orthopedic
1 2 3 4 Back pain VS
2 3 4 Back pain PSC
3 4 5 Back pain PSC Chronicity
2 Back pain Neuro-deficit +/- bowel
bladder problems
1 2 3 4 Traumatic back /spinal injury VS
65
Orthopedic (Cont’d)
2 3 4 Traumatic back /spinal injury PSC
2 Traumatic back /spinal injury MOI Traumatic amputation of a
digit
1 Traumatic back /spinal injury Traumatic amputation of
an extremity
1 2 3 Amputation VS
3 Amputation PSP
2 Amputation MOI Traumatic amputation of a
digit
1 Amputation Traumatic amputation of
an extremity
1 2 3 4 Upper extremity injury VS
3 4 5 Upper extremity injury PSP
4 5 Upper extremity injury PSP Chronicity
2 Upper extremity injury MOI Neuro-deficit compromise,
open fracture
4 Upper extremity injury Tight cast with no neuro-
vascular compromise
1 2 3 4 Lower extremity injury VS
3 4 5 Lower extremity injury PSP
4 5 Lower extremity injury PSP Chronicity
2 Lower extremity injury MOI Open fracture
3 Lower extremity injury Tight cast with neuro-
vascular compromise
4 Lower extremity injury Tight cast with no neuro-
vascular compromise
1 2 3 4 Upper extremity pain VS
3 4 5 Upper extremity pain PSP
4 5 Upper extremity pain PSP Chronicity
2 Upper extremity pain Neuro-vascular
compromise
3 Upper extremity pain Tight cast with neuro-
vascular compromise
4 Upper extremity pain Tight cast with no neuro-
vascular compromise
1 2 3 4 Lower extremity pain VS
3 4 5 Lower extremity pain PSP
66
Orthopedic (Cont’d)
4 5 Lower extremity pain PSP Chronicity
3 Lower extremity pain Tight cast with neuro-
vascular compromise
4 Lower extremity pain Tight cast with no neuro-
vascular compromise
2 3 4 Joint swelling VS
3 4 5 Joint swelling PSP
4 5 Joint swelling PSP Chronicity
67
68
SECTION FOUR: TRIAGE DOCUMENTATION
PURPOSE:
OBJECTIVES:
o Describe three primary goals of triage documentation.

o Identify five essential components of triage documentation.
o Discuss two elements of essential documentation elements for patients who leave before
receiving definitive care.
RESOURCES
 Blank copy of the ED chart, nursing documentation forms, and other related documentation tools.
 Policies related to ED charting, triage documentation, protocols, and patient disposition.
 Examples of quality monitoring tools related to triage
69
TRIAGE DOCUMENTATION
INTRODUCTION
Triage documentation should support the triage decision, communicate essential information to other
caregivers, and comply with regulatory and legal mandates. Your institution may require additional data. Format
used by a given institution is affected by staffing patterns, patient acuity, current technology, and departmental
culture. Documentation may be a handwritten narrative or a check-off format. Increased availability of
computerized documentation programs has increased the number of EDs that use computers for nursing
documentation. (ENA, 2001)
Regardless of format, requirements for triage documentation are the same. Table 3-1 lists essential
components for triage documentation. In addition to these components, the Joint Commission on Accreditation of
Health Care Organizations (JCAHO) requires assessment of learning needs and cultural, religious, and spiritual
needs related to care (JCAHO, 1998). The chart should also reflect assessment of developmental issues for
pediatric patients.
Table 3-1 Essential Components of Triage Documentation

Time seen by the triage nurse Chief complaint
Allergies Current medications
Vital signs Subjective and objective assessment
Patient acuity rating Diagnostic tests and triage actions
Disposition – not always detection Reassessment (If waiting)
by triage – Float Nurse
Immunization Diaper / Diet
(ENA, 2001)
Triage documentation should follow the same basic principles as other nursing documentation, including
legibility, appropriate signatures, correction of errors, and use of accepted medical abbreviations (Newberry,
1998). Do not chart assumptions or things you do not know. For example, the patient may smell of alcohol, but
you should not chart that the patient is intoxicated if you do not know the serum ethanol level. Describe the
patient's behavior without judgmental commentary (ENA, 2001). Also document that you smell alcohol on breath
or clothes.
Key Concept
Document as if the next time you see the chart it will be in court. (ENA, 2001)
INITIAL DOCUMENTATION
Triage documentation may be done as a single step by one person, or it may be done in stages by one
triage nurse or two different triage nurses. When several patients arrive at the triage area simultaneously, the
triage nurse screens patients to identify those who require immediate care. This type of screening is limited to
visual and verbal assessment. Tactile examination may be done on select patients; however, vital signs are
usually not taken in this situation. Documentation for this type of screening includes name, chief complaint, and a
brief description of appearance and patient acuity. The need for an interpreter is usually identified during the first
contact with the patient. This documentation provides a "snapshot" of the patient at that point in time (Newberry,
1998). If the patient leaves before further assessment and suffers an adverse outcome, this documentation may
offer the hospital some legal protection.
TIME SEEN BY TRIAGE NURSE
Document the time you begin evaluation of the patient in the triage area. Use of military time may be
required by some institutions. Time of subsequent evaluations and interactions should also be documented. This
documentation can provide information for caregivers and serve as a time line for the patient's visit to the ED.
(KAMC – R, 2006)
70
CHIEF COMPLAINT
The chief complaint is written in the patient's own words using quotes as appropriate. It is also acceptable
to write the complaint as a sentence fragment without quotes. For example, "I have a sprained ankle" may be
written as c/o sprain ankle. The advantage of using direct quotes is that the patient's impression is clearly doc-
umented. If the patient provides specific expectations, such as "I need a shot," "I need to be admitted," or "I need
an x-ray," these should also be documented. Record obstacles for communicating with the patient must be
considered as language barriers, hearing limitations, mental disability. (Newberry,L., 2001)
ALLERGIES
Medication allergies should be identified and specific reactions documented. Description of the allergic
response helps clarify true allergies from, expected side effects such as nausea. Allergies to latex and tape
should also be documented (JCAHO stresses the importance of including food allergies ,1998).
MEDICATIONS
All medications the patient takes on a regular basis should be listed, including over-the-counter
medications, prescription medications, and home remedies. Be sure to question the patient about medicines
taken recently, such as a single dose of pain medication. Your institution may only require documentation of the
drug, whereas another institution may require the triage nurse to document drug, dosage, and frequency. Patients
taking multiple medications may keep a list with them that can be copied and attached to the patient chart.
(Newberry,L., 2001)
VITAL SIGNS
Temperature, pulse, and respiratory rate are documented on all patients. Identify how the temperature
was obtained and any irregularity of pulse or respiratory pattern. Blood pressure (BP) documentation is required
for adults and children with certain complaints or clinical presentations. The age when BP is routinely obtained
varies by institution, usually beginning with adolescents. Orthostatic vital signs should be documented for patients
with potential volume deficits and complaints of dizziness when standing. Document BP in both arms for patients
with suspected aortic disease. Other requirements may be specified by your institution. (Newberry,L., 2001)
SUBJECTIVE AND OBJECTIVE ASSESSMENT
The triage nurse must rapidly assess the patient and determine acuity. Documentation should facilitate
and support this process without delaying care. A patient who is ashen, diaphoretic, and complains of chest pain
requires minimal documentation by the triage nurse. Documentation of the patient's life history is not appropriate.
Key Concept
Document sufficient information is essential to justify the triage decision.
Historical documentation varies by patient, but basic information includes current medical conditions,
pertinent surgical procedures, obstetrical history, and immunization status. Date of last menstrual period and
method of contraception are documented for women of reproductive age.
Other objective data that may be documented include oxygen saturation level, weight, height, and
immunization status. Requirements for these vary by institution (ENA, 2001).
Subjective data should be documented carefully. Document patient denials if they conflict with objective
findings or add significant information for subsequent care-givers. For example, denial of neck pain by a patient
who dove into shallow water and has a laceration on the top of the head is cogent information. Another example
is "multiple wrist lacerations - denies trying to kill self." In addition to documentation that a patient may be a
danger to self or others, steps taken to protect the patient and others should be documented.
ACUITY CATEGORY
Most ED charts have a designated area to document acuity level. Change in acuity must be documented
and include when the change occurred and the new acuity level assigned to the patient. The new acuity level may
be documented in the same area as the original acuity or in another designated area and time of change should
be documented. Additional information in narrative or checklist format should support any documented change in
acuity.
71
DIAGNOSTIC TESTS AND TRIAGE ACTIONS
Document any diagnostic tests ordered at triage (e.g., lab tests, x-rays). Triage actions such as
application of splints, administration of medications, and finger stick glucose testing are also documented. The
patient's response to these actions must be noted. First aid interventions should be included in documentation.
DISPOSITION
Most EDs do not require documentation when the patient is taken from triage to the treatment area
because the record of the room or bed where the patient is placed indirectly documents this. Tiered systems with
different triage stations may require documentation of treatment area. The procedure must be carefully docu-
mented and include who made the decision and how the patient will get to the intended destination. This process
of "triaging out" should be guided by carefully crafted written protocols with defined sources for alternative care
(Newberry, 1998).
REASSESSMENT
Reassessment is done when there is a change in the patients condition or acuity level. Urgent patients
should be reassessed every 30 minutes, whereas nonurgent patients may be reassessed every 1 to 2 hours and
this depend on the category level. Your facility may have established more stringent time parameters. Carefully
document changes in the patient's condition and adjust acuity level accordingly. Record actions taken when the
patient's condition changes (Zimmermann,P. & et.al.,2006).
TRIAGE DOCUMENTATION (DOCUMENTATION STANDARDS)
Triage classification will be validated in the documentation of:
 Date and time of triage assessment.

 Chief complaint as presenting concern.
 Past medical / history of presenting concern.
 Subjective history; asset of injury / symptoms.
 Objective observation.
 Vital signs.
 Triage category.
 Designated location in department.
 Triage nurse signature.
 Give report to treatment nurse and documents appropriately.
 Known allergies.
 Medication.
 May diagnostic tests: e.g.: gluco - check, urine dipstick, and pregnancy test, and just aid measures,
therapeutic intervention should be documented.
 Reassessment of patient according to triage guidelines to provide ongoing support.
 Left without being seen status.
(Zimmermann,P. & et.al.,2006)
72
SECTION FIVE: LEGAL ISSUES

PURPOSE:
OBJECTIVES:
o Discuss three legal concerns related to triage.

o Identify two resources available to the triage nurse when legal questions arise.
o Define the triage nurse's responsibility regarding patients with hearing impairments.
RESOURCES
 Policies related to Emergency Medical Treatment and Active Labor Act (EMTALA), release of
medical records, consent for treatment, holding patients against their will, confidentiality, telephone
advice, leaving against medical advice (AMA), refusing treatment, restraints, American Disabilities
Act (ADA)
 Policies related to reportable patient situations, legal blood and urine collection, evidence
collection, and chain of custody
 Policies related to advance directives, living wills, and durable powers of attorney
73
PEDIATRIC LEGAL ISSUES
INTRODUCTION
Numerous legal considerations confront emergency health professionals in triage area, as they care for
children and families. Theses legal issues range from appropriate screening and assessment to end - of - life
decisions. This section outlines the basic legal care ramifications faced by triage health professionals as they care
for the children and families.
MEDICAL EXAMINATION SCREEN:
Hospitals must state in their individual bylaws that a medical screening examination will be conducted on
all patients presenting to the ED for treatment. These bylaws specify:
 Those healthcare providers who can conduct the screening, such as a nurse or physician. It is important
to determine who can provides the screening examinations, because such a formal determination
assures that the hospital's governing body recognizes the hospital's capability and assumes proper
accountability for this function (Hospital Association of Pennsylvania, 1996).
 The components of the screening, such as a cursory or comprehensive approach. Medical screening
examination is defined by the institution as it deems appropriate. One recommendation for the medical
screening examination is (Frew Consulting Group, 1996):
 Log entry with disposition

o Triage record
o Recorded ongoing vital signs
o Oral patient history.
o Physical assessment of the affected body systems
o Physical assessment of potential affected body systems and known chronic health conditions,.
o Any testing necessary to rule out the presence of legally defined emergency health conditions.
o Use of on-call personnel to complete the above assessment.
o Use of on-call physicians to diagnosis and stabilize patients.
o Discharge / transfer of vital signs.
 Adequate documentation of these points

 Patient disposition following the screening, examples of common dispositions are:
o Remain in the ED for treatment.
o Transfer to another area of the hospital.
o Transfer to a different healthcare facility.
 Emergency Medical Treatment and Active Labor Act(EMTALA) requiring the hospitals :
o Provide appropriate medical screening examinations to determine if an emergency
health decision exists (42 USC, 1395(dd)(b)(l)).
o Stabilize the patient's health condition and / or transfer the patient to another healthcare facility.
Moreover, Multiple, complex legal issues affect triage. Changes in the kingdom laws and regulations from
new case law interpretation challenge the triage nurse to remain current in applicable legal issues.
CONSENT
Written informed consent for treatment is required unless the patient is physically or mentally unable to
provide it. The age at which a patient can give consent varies from hospital to hospital. The children considered
within the age groups from newborn to 14 years. The patient's spouse, parent, or adult child can give involuntary
consent when the patient cannot. Consent for treatment covers assessment, evaluation, diagnostic tests such as
lab and x-ray, and other treatments. It does not cover surgical procedures and invasive diagnostic procedures.
Implied consent allows treatment in emergency situations under the premise that the patient would give consent if
able to do so (ENA, 1999; Kitt, Selfridge-Thomas, Proehl, & Kaiser, 1995; Newberry, 1998).
Consent for other minors must come from a legal guardian unless the physician determines the patient
requires emergency treatment to prevent significant morbidity or loss of life. However, in most of Arabian Gulf
countries, a 12 years old considered and adult and is able to give consent in behave of this mother or sister.
74
Key Concept
Consent for treatment must be obtained for any minor that is not emancipated. If a parent or guardian cannot be reached, the
physician should examine the patient to rule out an emergent condition.
MEDICAL RECORD
The medical record is a legal document that describes the patient's care. The record reflects the
sequence of events that occurred during the time the patient spent in the facility. Lab results and x-rays are
considered part of the medical record. A paper record is most common, but more and more facilities are moving
toward computerized documentation. The triage note provides information about presenting complaint and a
description of patient status on arrival (ENA, 2001).
CONFIDENTIALITY
The patient has a right to privacy and confidentiality. Personal information is shared only with those
involved in care. This applies to written, verbal, and computerized data. The triage area is usually an open area,
so privacy and confidentiality can be a challenge. Be sensitive—the patient may not wish to explain his or her
problem in this open, exposed area. Whenever possible, provide visual and verbal privacy. Monitor the volume of
your voice during interviews to ensure that others in the waiting area cannot hear (ENA, 2001).
Busy EDs often receive inquiries about accident victims or shooting victims. Each country has laws
regarding release of information about these and other patient situations. Many facilities designate certain
patients as "no information" (e.g., mental health admissions, celebrities, patients in protective custody). Check the
computer or facility log to determine if information can be released about a specific patient. When you are not
sure, err on the side of confidentiality (ENA, 2001).
The ED by its very nature attracts the media. Events such as shootings, car accidents, and outbreaks of
meningitis are a source of news for the press. Your facility may have media representatives who provide
interviews, answer questions, and run interference. When media support is not available, problems with release of
information and crowd control may develop. Anyone charged with interacting with the media should be familiar
with the facility's policies regarding release of information as well as definitions for critical, serious, fair, and stable
conditions. Policies usually discuss filming in parking lots, waiting rooms, and treatment areas. Become familiar
with these policies and know whom to call when reporters do not comply with written expectations (ENA, 2001).
According to country law requires mandatory reporting of certain crimes and situations (e.g., gunshot
wounds, child abuse, and neglect). Other situations may not be so clear cut. For example, should you report the
child abuse at home? These situations may be addressed by state law or department policy. Check with your
facility's risk management department for additional information (ENA, 2001).
EMERGENT MEDICAL CONDITION
The definition of what constitutes an emergency varies. The patient may have an entirely different
definition than the health care provider. For legal purposes, EMTALA specifically defines an emergent medical
condition as "Acute symptoms of sufficient severity including pain that the absence of immediate medical attention
could be reasonably expected to result in placing the individual's health in serious jeopardy, serious impairment to
bodily functions, or serious dysfunction of any bodily organ or part." (ENA, 2001).
LEAVING AGAINST MEDICAL ADVICE
A competent patient cannot be held against his or her will. When a patient has been seen by the physician and
decides to leave before treatment is complete, the patient is leaving against medical advice (AMA). Risks associated with
leaving before treatment is complete should be carefully explained and evidence of the patient's competence documented.
Ask the patient to sign an AMA form that explains risks and confirms the patient's decision to leave. Regardless of why the
patient is leaving, make sure that the patient knows that he or she can return at any time. If there are any questions
regarding the patient's competence, the physician should evaluate the patient to determine competence. Notify
appropriate services if an incompetent patient leaves (ENA, 2001).
75
Institutions may use a separate term and release form for patients who leave before they are seen by the
physician (e.g., left before being seen, left without being seen, left without seeing the physician). These patients
are distinguished from patients who leave AMA, because a physician has not seen the patient (ENA, 2001).
Key Concept
Treatment of a patient refusing treatment must be considered in patients such as those unable to make a logical decision.
REPORTING SITUATIONS
Most states require hospitals to report certain patient situations to law enforcement. These include, but
are not limited to, sexual assault, child abuse, gunshot wounds, knife wounds, and animal bites. Some states
require reports on elder abuse, domestic violence, and suicide attempts. If state law dictates, these reports are
made regardless of the patient's wishes (ENA, 2001).
LEGAL SPECIMEN AND EVIDENCE COLLECTION
The triage nurse may be the first person to identify evidence of crime. For example, the patient with a
stab wound or gunshot wound may appear at the triage area seeking treatment or the victim of sexual assault
may arrive without benefit of a police escort. The triage nurse must be sensitive to the patient's needs while
preserving essential evidence. Without attention to details, valuable evidence may be lost and the case dismissed
(ENA, 2001).
In addition to preserving evidence, the triage nurse may be required to collect certain legal specimens.
Individuals charged with driving under the influence maA be asked to provide blood and urine. Blood, urine,
saliva, and semen may be obtained from those charged with rape. Evidence kits with instructions for sexual
assault cases and kits for collecting blood and urine for legal analysis are available. Evidence collection must
follow specific guidelines to ensure integrity of the evidence and preserve the chain of custody (ENA, 2001).
PATIENT RESTRAINTS
Patient injury and even death have occurred with use of restraints (JCAHO, 1998). JCAHO has
implemented stringent requirements for applying restraints and monitoring patients in restraints in an effort to
decrease use of restraints and to protect patients. Today's violent society makes it unlikely that restraints will ever
be eliminated from the ED; however, use of alternatives may decrease use of restraint (ENA, 2001).
ADVANCE DIRECTIVES
America has a Patient Self-Determination Act (1991) provides patients with a formal mechanism for
establishing their beliefs and desires regarding life support measures. The patient can complete an advance
directive or living will document that explains the patient's wishes and identifies an individual responsible for
making decisions about health care if the patient is unable to do so. Each patient admitted to the hospital should
be asked about advance directives (JCAHO, 1998). A copy of the document is placed in the medical record. The
triage nurse may ask patients about advance directives in your institution; however, this is not the normal practice
of most Eds(ENA,2001).
76
SECTION SIX: CUSTOMER SERVICES

PURPOSE:
OBJECTIVES:
o Define the term “ Customer”

o Describe two types of customers.
o Describe the conflict resolutions.
o Identify the basic skills of customer services.
o Articulate the primary purpose of customer service in triage.
RESOURCES
 Hospital and department philosophy, mission statement, and code of conduct

 Formal customer service programs, if applicable
 Letters from satisfied and dissatisfied customers
 Fliers and registration forms for customer service classes
77
Customer Service
INTRODUCTION
The advent of managed care has had a tremendous effect on how health care organizations do business.
Corporations contract with hospitals and health systems to provide care for thousands of employees. Quality
clinical care and quality customer service are expected. When a health care organization does not meet the
customer's expectations, it can lose not just one dissatisfied customer but thousands if an entire contract is lost. In
today's competitive health care market, lost contracts mean lost jobs. Consider customer service skills in the
same light as clinical skills. Your job is in jeopardy if you do not have both (ENA, 2001).
Key Concept
Customer service is just as important as clinical skill to the triage nurse and the organization.
A customer is a "person with whom one must deal" ("Webster's II New Riverside University Dictionary,"
1984). The customer may be within your organization or company or he or she may originate from the outside.
External customers are individuals who originate from outside the work area. Patients, family, and visitors are
external customers. Insurance companies, and ambulance, fire, and police personnel are also external
customers. Internal customers are based in the organization or the work area. These are individuals essential to
work completion. Registration clerks, nurses in other areas of the hospital, radiology staff, lab personnel, and
physicians are the ED's internal customers (ENA, 2001).
BASIC SKILLS
Customer service is an inherent part of patient care and human interactions. Politeness, courtesy, and
respect are just as important for the triage nurse as for the cashier at the grocery store or receptionist at the gas
company. The triage nurse encounters more individuals in crisis; however, other aspects of these three jobs are
similar. All three individuals deal with the public and may face angry, hostile, or intoxicated customers. These
individuals are also the frontline for their organizations. A poor impression during this first crucial encounter can
affect how the customer perceives the entire organization. The golden rule for customer service is to treat others
as you would like to be treated. The ability to do this involves verbal skill, body language, and acceptance of the
customer. Table 5-1 highlights basic customer service skills (ENA, 2001).
Key Concept
Treat each and every patient as you wish to be treated.
Table 5-1 Basics of Customer Service

 Treat the person with respect.
 Be polite.
 Listen.Give the person your full attention.
 Speak slowly and clearly. Do not speak loudly unless you identify that the person has a hearing problem.
 Apologize if you are interrupted.
 Ask questions to clarify understanding. Paraphrase the complaint to confirm understanding.
 Be sensitive to nonverbal cues.
 Maintain privacy and confidentiality.
(ENA, 2001)
Chaos in the triage area and the ED does not mean customer service should suffer. High volume and high
acuity are no excuse for rudeness. How then do you keep customer service and clinical skill on the same
plane? Building a foundation of effective customer service skills and practicing these skills routinely make it
easier to maintain these skills during times of stress and tension. As you develop your own customer service
technique, remember the following rules for customer relations. The customer
(Gerson, 1992):
 Is the most important person in any business?

 Is not dependent on you—you are dependent on the customer.
 Is not an interruption of your work—he or she is the purpose for it.
 Does you a favor when he or she calls—you are not doing the customer a favor by serving him or her
 Is a part of your business—not an outsider.
78
 Is not a cold statistic—he or she is a flesh-and-blood human being with feelings and emotions like your
own.
 Is someone who brings you his or her wants—it is your job to fill those wants.
 Deserves the most courteous and attentive treatment you can give him or her.
 Is the life blood of this and every business?
CUSTOMERS
Today's society is not conditioned for waiting. Fast food, take-out service, fast copy services, drive-
through banking, and short checkout lines at the grocery store were all developed to meet the desire for instant
service. These same services have decreased the public's tolerance for waiting regardless of the reason. Long
wait times in the ED are even more frustrating for the patient who is ill or injured. Waiting increases anxiety and
can lead to frank hostility in some situations. Lack of information about the wait only worsens the situation. The
triage nurse should provide as much information as possible to make the wait more tolerable. Be truthful. Don't
promise that the wait is only a "few minutes" if you know it is already 2 hours. It is better to overestimate than
underestimate wait time (ENA, 2001).
In an ideal world, patients understand that those with more serious problems come first. Realistically, this
may not be the case. To the patient, his or her problem is an emergency and requires immediate attention. The
patient with a laceration may not understand why he is waiting while staff care for victims of a car crash. Accept
this, apologize for the wait, and assure the patient that he or she will be seen as soon as possible (ENA, 2001).
Key Concept
Overestimate how long the patient will wait.
Patients are also exposed to unusual sights, sounds, and smells during the wait. Be sensitive to
interactions in the waiting area. Intervene when possible by moving certain individuals to other waiting areas.
Place patients with offensive odors or soiled clothing in separate waiting areas whenever possible. Moving
intoxicated patients out of the main waiting area is also helpful (ENA, 2001).
Establishing rapport with the patient as he or she enters can make it easier to interact during the wait.
Acknowledge the patient and the problem during the first conversation. Present a welcoming, helpful demeanor.
Greet the patient by his or her appropriate title and name. If you do not know the patient's name, use Sir or
Ma'am. Do not call patients by their first name unless asked to do so. Remember the importance of body
language. Establish eye contact and welcome the patient with a smile. If you are sitting behind a desk, lean
forward in a welcoming manner or stand to greet the patient. If you are standing, step toward the patient. Do not
cross your arms or put your hands on your hips. These positions convey an attitude of judgment or confrontation
and do not offer a sense of welcome. Chewing gum or blowing bubbles is inappropriate at any time. Touching the
patient to assess skin temperature and moisture is indicated for most patients, but it should be done in the right
context. Establish rapport first, and then touch the patient's hand (ENA, 2001).
Key Concept
Body language is an important part of customer service. Make sure your stance and facial expressions are as welcoming as your
words.
As you interact with patients who are waiting, offer information in a positive way. Negative comments
make the situation worse. Telling the patient the wait is because of a slow doctor does not serve you, the facility,
or the doctor. Blaming other departments (e.g., lab, x-ray, ICU) is also inappropriate. These comments do not
make patients feel secure about the care they are receiving. Offer comments in a positive context. "The
department is full so there is a wait. I am right here if you have any questions. Please let me know if there is
anything I can do while you wait." Other ways to make the wait more tolerable include providing magazines and
television. Keep the television set on a channel with broad appeal (ENA, 2001).
79
CONFLICT RESOLUTION
Violence is a real threat for the triage nurse. Do not place yourself or your patients at risk. Be sensitive to
situations that lead to conflict and gracefully resolve problems as they arise. If a patient becomes angry and
verbally attacks you, do not take it personally. Speak in a normal volume and tone. Shouting at the patient makes
the situation worse. Do not defend yourself or the institution. Focus on the customer's feelings and concerns.
Logic takes second place to emotions in these situations. Do what you can within the limits of your job as the
triage nurse. If you cannot resolve the situation, you should then involve the charge nurse or department
manager. Summon help if the patient becomes violent. Do not attempt to subdue the patient without assistance
(ENA, 2001).
Key Concept
Do not take the patient's anger personally. Focus on the patient's concerns and feelings.
80
SECTION SEVEN: CULTURE AND RELIGIOUS

CONSIDERATIONS
PURPOSE:
OBJECTIVES:
o Explain the significance of understanding cultural diversity in triage.

o Describe techniques for gaining information about the patient's culture and health belief
practices.
RESOURCES
 Cultural references
 Language references
 Lists of interpreters
 Policies related to interpreters and language lines
81
Cultural and Religious Considerations
INTRODUCTION
No matter where you live and work, you are more likely today than ever before to encounter individuals
who do not share your cultural origins and beliefs. This is particularly true in the ED. Understanding and accepting
another person's cultural beliefs are essential for providing care in the ED or in any health care facility. The ability
to elicit essential information about the patient in triage requires sensitivity to the person's culture. Culture does
not refer to where a person lives, the color of his or her skin, or where his or her grandparents were born.
Leininger (1985) defined culture as "values, beliefs, norms, and practices of a particular group that are learned
and shared and that guide thinking, decisions, and actions in a patterned way (ENA, 2001)." An individual's
culture is characterized by variations in communication, time, space, biology, social organization, and
environment (Newberry, 1998).
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (1998) requires

assessment of cultural, religious, and spiritual needs for every patient. The purpose of this assessment is to
identify specific needs in these areas and to use this information to plan the patient's care. Recognition of primary
cultural groups seen in the ED can facilitate this assessment. Prior study of cultural practices for the dominant
groups makes it easier to assess cultural needs (ENA, 2001).
CULTURAL PRACTICES
Cultural practices play a significant role in perception of health care and the health care provider. One
cultural group may see the "good nurse" as the one that hovers over the patient or is constantly in attendance,
whereas another cultural group may view this as invasive behavior (Leininger, 1985). Comprehensive discussion
of specific cultural practices for various groups is beyond the scope of this text; however, a brief discussion is
provided. Table 6-1 outlines select cultural beliefs related to health care. You are encouraged to expand your
study of these and other cultural groups encountered in your practice area.
82
Table 6-1 Cultural Beliefs Regarding Health Care

Cultural Group Belief Common Health
Problems
African-American  Using the patient's first name without Hypertension, coronary
permission is considered disrespectful. artery disease, diabetes
 Considerable variations exist in health attitudes mellitus, sickle cell anemia
and behaviors.
 The family is oriented around women.
 Illness occurs because of disharmony in life.
 Some may believe in folk medicine, voodoo,
witchcraft, and magic.
Appalachian  Illness is the will of God. Tuberculosis, diabetes
 Folk medicine is very important. mellitus, coronary artery
 Eye contact is considered very rude. disease
 The focus is on the state of the Wood—thick or
thin, high or low, good or bad.
 There is an inherent distrust of hospitals
Arabic  Disease is caused by evil eye. Urinary infections,
 Illness and/or injury are the will of God. cardiovascular disease,
 Little information about self or family is given to diabetes mellitus,
strangers. thalassemia, Renal and
 Health caregivers are seen as personal liver
employees.
 Any display of flesh is considered pornographic.
Cambodian  Imbalance causes "wind illness." Coin rubbing, Chloroquine resistant

cupping, or other dermal abrasive techniques malaria
are used to release the bad winds.
 Only dose relatives should touch the head.
 Pain may be severe before relief is requested.
Chinese  Physical contact with strangers is Hypertension, liver cancer,

uncomfortable. stomach cancer, lactose
 Accepting something when first offered is rude. intolerance, diabetes
 Hospitals are a place to die. lactose
intolerance,
 Illness is an imbalance between yin and yang.
diabetes
 Do not accept pain medicine when first offered.
Cuban  Hand gestures are important for Diabetes mellitus, lactose
communication. intolerance
 Illness is caused by supernatural powers such
lactose intolerance as evil eye. Magic spells are
the only treatment.
 Verbal expression of pain acceptable.
Eastern Indian  Illness is an imbalance between body, fire, Anemia in women, vitamin
earth, wind, space, and water. A deficiency
 Quiet acceptance of pain.
83
Table 6-1 Cultural Beliefs Regarding Health Care cont.

Cultural Group Belief Common Health
Problems
Ethiopia  Magico-religious. Yellow fever,
 Amulets may be worn for protection against chloroquine-resistant
disease. malaria, AIDS.
 May use bloodletting to treat malaria. May refuse
pain medications.
Greece  Bio-medical, magico-religious. p-Thalassemia,
 Protective beads or stone charms may be worn. Mediterranean-type
 Passive reactions to pain are practiced. G6PD deficiency,
familial Mediterranean
fever.
Japanese  Illness is an imbalance between the person and Hypertension, liver
the universe. cancer, stomach
 Isoniazid may be inactive in Japanese patients. cancer, lactose
 The effects of succinylcholine are prolonged. intolerance
Laotian  Illness is caused by bad winds. Winds are released Tuberculosis •Iodine
by scratching or pinching until red lines or marks deficiency
appear.
 There is a strong belief in herbal medicine.
 Parents are the only ones allowed to touch the top
of a child's head.
 Pain must be severe before relief is requested.
Mexican-  Health is harmony between the social and spiritual Diabetes mellitus,
American world. Disease occurs because of an imbalance lactose intolerance,
between hot and cold. tuberculosis
 There is a strong belief in evil eye and hexes.
 A child's head may be shaved to treat a respiratory
illness.
Native  Each tribe or nation has its own language, religion, Lactose intolerance,
American and beliefs. alcoholism, cirrhosis,
 Health is a balance between the social and diabetes mellitus, heart
spiritual world. disease
 Children are very independent. Parents may not be
aware of a child's recent behaviors.
 Patients may metabolize ethanol differently.
Vietnamese  Illness is caused by bad winds. Skin is rubbed with Tuberculosis, hepatitis,
coins or other abrasives to release winds. cholera, typhoid
 Touching the top of a child's head is not
acceptable.
(Geissler, 1998)
84
LANGUAGE BARRIERS
Language is often the first and most obvious source of cultural conflict between the triage nurse and the
patient (ENA, 1997). The triage nurse may recognize obvious problems such as broken bones or lacerations
without the benefit of words; however, verbal communication is essential to fully assess the patient and determine
important historical information. Many EDs have full-time interpreters available, whereas others use on-call
interpreters. Language lines which provide access to more than 100 language interpreters, but cost may be a
concern. Using family members as interpreters is not without problems.
The ability to speak a given language does not necessarily include a familiarity with jargon and
professional terms. Ideally, the interpreter is familiar with these and other aspects of the languages of both the
triage nurse and the patient. The interpreter needs to translate information from the triage nurse's educational or
intellectual level to the patient's level. Jargon and professional terms must be decoded and expressed in terms
the patient can understand. This decoding and translation may be difficult if words do not have the same context
when translated. This is true even for English words. For example, a word that means dance or dancing in one
country may be an obscenity in another.
Social level, personal characteristics, gender, and other unrecognized factors may skew communication
despite the interpreter's level of expertise. There are no easy answers to this challenge. The best action for the
triage nurse is to utilize all available resources and remain sensitive to cultural variations within the area.
RELIGIOUS PRACTICES
Religious beliefs may be determined by culture; however, this is not always the case. Table 6-2 briefly
outlines various religious groups and their beliefs. Again, this should not be viewed as a comprehensive guide. If
you are not sure of the person's beliefs, ask the patient.
85
Table 6-2 Religious Considerations

Religion Health Practices
Baptist  Some believe in lying on of hands."

Black Muslim  Alcohol and pork are prohibited. •Faith healing is not acceptable.
Buddhist  Some sects are strict vegetarians. •Alcohol and drug use is discouraged.
 The body should be left as it is at death and covered with a sheet. No one should
touch the hand or close the mouth and eyes.
Catholic  No meat is consumed on Friday.

 Contraception and abortion are unacceptable.
 Religious articles are important
 Amputated body parts should be buried.
 The Sacrament of Anointing of the Sick is given to those with serious illness and at
time of death.
Christian  Medications or blood transfusions are not accepted.
Scientist  Immunizations are limited to those required by law.
Church of God  Members observe beliefs surrounding clean and unclean meat as described in the
Bible.
Church of Jesus  Members do not smoke, or drink alcohol, tea, or coffee. They eat meat sparingly.
Christ of Latter-  Members believe in anointments or laying on of hands.
Day Saints  Members may wear special garments.
Eastern  Restrictions depend on the specific sect.
Orthodox
Episcopal  Some believe in faith healing. •Religious icons are very important.
Greek Orthodox  A health crisis is handled by an ordained priest.
 Autopsies are discouraged.
Hare Krishna  Members do not eat meat, fish, or eggs and do not drink alcohol.
Hinduism  Believers eat no beef, pork, or veal and may be strict vegetarians.
 Believers prefer to die at home. •Autopsies are not encouraged.
Islam  Members do not eat pork or pork byproducts.
 Members do not drink or take any intoxicants.
 After death, the patient's arms and legs should be straightened,eyes should be
closed, and mouth shut with a bandage.
Jehovah's  Blood transfusions are not allowed.
Witness  Members will eat nothing to which blood has been added.
 Organ donation is not supported.
Judaism  There are numerous dietary kosher laws. Believers usually do not eat pork
 Amputated body parts must be buried.
 Burial must take place within 24 hours of death. The body is attended until burial.
Lutheran  Anointments are important.
Methodist  Communion is important. •Donation of body parts is encouraged.
86
Table 6-2 Religious Considerations cont.

Religion Health Practices
Pentecostal  Some abstain from alcohol and do not eat pork.

Orthodox Presbyterian  Pastor or elder is called for ill person.
Russian Orthodox  Members believe in divine healing.
 The cross necklace is very important.
 Autopsy, embalming, or cremation is discouraged.
Salvation Army  Members abstain from alcohol, tobacco, and
nonprescription drugs.
Seventh Day Adventist  Members abstain from alcohol, tobacco, and drugs
found in cola, tea, and coffee.
Unitarian Universalist  Members believe that God helps those who help
themselves.
 Some clergy do not make hospital visits.
(Miller, 1995; Newberry, 1998; Ontario Multifaith Council on Spiritual and Religious Care, 1995; Wong, 1993 ;)
87
SECTION EIGHT: VIOLENCE

PURPOSE:
OBJECTIVES:
o Formulate the appropriate definition for the violent acts according to role play
discussion.
o Identify the main group at risk for violence.
o Identify two interventions to minimize the language barrier.
o Identify two patient populations at high-risk for violent behavior.
o Describe three behaviors used to predict violence.
o Discuss two approaches to prevent violent behavior.
RESOURCES
 Policies related to restraint and seclusion

 Procedures to call security and law enforcement
 Lockdown procedures and other security measures
88
Violence
INTRODUCTION
Violence is a reality in the world at large and in the hospital. Homicide is the second leading cause of all
work-related deaths in this country, and it is the leading cause of work-related deaths in women (US Department
of Labor, 1996). Williams and Robertson (1997) described two general forms of violence that frequently occur in
hospitals. Physical violence is any physical act that causes injury to another person or property. Acts of
aggression are verbal or physical actions used to cause fear.
Health care workers are 16 times more likely to be injured in the workplace than other types of workers
(Elliott, 1997). Unique features that make hospital personnel vulnerable to attack are described in Table 7-1.
The reality is that staff in the ED are at greater risk for violence than other hospital employees. Fifty
percent of all hospital assaults are reported in the ED (Stultz, 1994). More than 90% of emergency nurses have
reported verbal abuse, and 87% have reported physical abuse (ENA, 1994). With increasing violence in schools,
the workplace, and other previously "safe" areas, it is imperative that emergency nurses remain alert to the
potential for violence and intervene appropriately.
Key Concept
The threat of violence is a reality for the emergency nurse. Protect yourself and your patients by remaining alert to the potential for
violence.
The ENA position statement "Violence in the Emergency Setting" notes six primary factors leading to ED
violence (ENA, 1991). Long waits, staff shortages, ED overcrowding, availability of drugs and potential hostages,
easy access, and presence of patients with alcohol and drug problems were factors 15 years ago and are just as
critical today. The magnitude of these issues has increased significantly in the past decade. Lack of a pre-existing
relationship with the patient as well as the inherent chaos and stress of the ED increases the potential for
violence.
Table 7-1 Factors That Increase the Risk for Violence In Hospitals
Origin Factor Description
Patients, Unrestricted setting  A 24-hour open door policy allows individuals easy access and
families, movement from one place to another within the hospital (Elliott, 1997).
visitors Patient population  Patients may abuse drugs or alcohol, may be gang members, or may
have a history of violence or mental illness.
Inability to cope  Trauma or a sudden, catastrophic illness may increase stress beyond
the patient or family's ability to cope.
Societal changes  There is easy access to drugs, alcohol, and guns. •Patients with acute
and chronic mental health conditions can refuse medication or
treatment in certain circumstances.
Robbery  Drugs and money available in the hospital are prime targets for
desperate thieves (Williams & Robertson, 1997).
Illness and drugs  Systemic disorders, toxic levels of certain drugs, and various neuro-
logic disorders can result in violent behavior.
Revenge  An individual who feels there has been a lack of attention or improper
treatment can become violent, particularly in the ED. (Simonowftz,
1996).
Fellow Downsizing  Disgruntled employees may become violent (Williams & Robertson,
employees 1997).
Unhappy employees  Those who feel no control over the environment or job assignment
may become violent (Williams & Robertson, 1997).
The advent of technology to monitor turnaround times and identify bottlenecks has done little to decrease
ED wait times. Other factors such as an increasing volume of patients, staff shortages in supporting departments
(e.g., lab, x-ray) and increasing patient acuity have made the wait even longer. This can lead to havoc in the
89
waiting area and presents a challenge for the triage nurse. Patients and families are already under stress
because of the problem that brought them to the ED. A long wait in a crowded, noisy waiting room just increases
the stress. Appropriate and timely interventions by the triage nurse can defuse a violent response and prevent
catastrophe (ENA, 2001).
HIGH-RISK PATIENT POPULATIONS
Violent behavior is associated with low tolerance for frustration, problems with authority, limited
resources, and poor coping skills. Many patients who come to the ED have a significant potential for violence.
Patients with psychiatric or organic disorders resulting in acute confusion are two populations most likely to
behave violently (ENA, 2001).
The most common psychiatric diagnoses related to violent behavior are bipolar disorder (manic phase
with psychotic symptoms) and paranoid schizophrenia. A patient with delusions, particularly paranoid delusions, is
also at risk. The patient may believe that violence is justified as a defense against those he or she believes are
plotting against him or her (ENA, 2001).
Organic causes of violent behavior include head injury, hypoglycemia, hypoxia, postic-tal state, dementia,
and—the most common cause of violent behavior—alcohol or drug toxicity and withdrawal. Any organic disorder
that alters metabolic or neurologic equilibrium and impedes the ability to think logically can lead to violence.
Confusion and poor impulse control found in patients with dementia and organic brain disorders increase the risk
for violence. Alcohol intoxication is associated with uninhibited behavior, increased emotional liability, and
impaired judgment. Cocaine, amphetamines, and other stimulants are associated with increased irritability,
psychomotor agitation, and suspicion. Stimulants are also noted for causing "superhuman strength", which makes
the violence even more destructive (ENA, 2001).
PREDICTORS OF VIOLENT BEHAVIOR
Violence does not happen in isolation; it occurs in incremental phases. Two phases of prevalent behavior
precede the violent outburst. Previolent phase I is characterized by subtle verbal and nonverbal clues to violence.
Verbal interventions are usually effective during this phase (Drury, 1999). Violence is imminent during previolent
phase II. Individuals in this phase do not generally respond to verbal interventions. Table 7-2 summarizes
indicators for violent behavior.
As the triage nurse, you must remain alert. Do not ignore your gut instinct or inner voices. If you feel
uncomfortable or frightened during the interview, you may be responding to subtle clues from the patient. Some
patients may purposefully try to provoke defensive statements by insulting you or making obnoxious statements.
Key Concept
Do not ignore your gut instinct. If you feel unsafe, stop the interview and get help.
90
Table7-2 Indicators of Impending Violence
Patient Characteristic
Appearance  Piercing stare
 Narrow, glaring eyes
 Red face—veins may be "popping out"
 Fearful or angry expression
 Perspiring heavily
Demeanor  Talking rapidly
 Repeating the same thing over and over
 Chanting or singing
 Interacting in a euphoric or grandiose manner indicative
of a manic state
 Making delusional, paranoid statements
 Admitting to hearing voices
 Using a loud, angry, screaming voice
 Using profanity
 Making aggressive or threatening statements
 Pacing, fidgeting, unable to sit still
 Clenching and unclenching hands
 Pounding fists
 Making exaggerated movements
 Tensing muscles
 Frequently changing position
 Rocking upper body while sitting
 Carrying a weapon
(Drury, 1999, POV, 1998; Williams & Robertson, 1997)
Behavior  Hostile, threatening, belligerent, confused, suspicious,

throwing things, hitting, pushing, kicking
 Soiled clothes, disheveled appearance
 Bizarre behavior
(Williams & Robertson, 1997)
PATIENT INTERACTIONS
When you identify patients at risk for violence, you must exercise caution to safeguard yourself and other
patients. Approach the patient and introduce yourself from a distance. Remain calm and speak in a self-assured
voice. Agitated patients may react strongly to fear in health care providers. Interview the patient in an open area
when possible. Or, keep the door open and position yourself between the patient and the door. Notify colleagues
so they can keep an eye on the situation. Ask the patient "How can I help you?" Do not use medical jargon while
speaking to the patient. Intoxicated or verbally abusive patients often respond better to a very low voice, even a
whisper in some cases (ENA, 2001).
Key Concept
Never let the patient get between you and the door.
Maintain a nonthreatening posture. Hold your arms at your side rather than crossing them in front. Avoid
a square-on stance. Maintain distance of at least an arm's length so you do not invade the patient's personal
space. This position requires the patient to step toward you to attack. Stop the interview and get help if you ever
feel unsafe.
Violent episodes occur when the patient feels provoked or threatened. Avoid startling or scaring the
patient.
Use a low tone of voice and a neutral expression— cheerfulness or excessive concern may be misinterpreted.
Violence can be associated with care activities that violate the patient's personal space. Exercise extreme caution
when assessment involves removing clothing or when checking pockets or other belongings for identification. Do
91
not touch the patient who appears to be sleeping, distracted, confused, or listening to voices. Avoid reaching or
leaning over the patient. Calmly call the patient's name to get his or her attention (ENA, 2001).
Key Concept
Never crowd an upset patient or visitor - give the person space.
(Hoag-Apel, 1999)
Anxious Patients
Extreme anxiety can progress to agitation or even frank violence in certain situations. When you identify a
patient with severe anxiety, listen carefully to what the patient is saying. Ask questions in a simple, direct manner.
Encourage the patient to express his or her concerns. Provide support and understanding. If the patient becomes
agitated, use a more direct approach.
Agitated Patients
When dealing with an agitated person, avoid actions that may increase frustration or confusion. Do not
criticize or make unnecessary requests. Reassure the patient that you are here to help. Acknowledge the person's
emotions without being judgmental. Place the person in a less stimulating environment and establish simple,
realistic limits on his or her behavior. Build esteem and confidence by recognizing how much strength it takes to
remain calm and cooperative; however, do not negotiate on the patient's terms. For example, do not bargain
when the patient offers to shut up in return for a cigarette. Do not argue with the patient or defend yourself against
accusations. Use a more direct approach when anxiety and fear escalate to hostility and aggression.
PATIENT MANAGEMENT
When anxiety or agitation escalate to violence, the goal is to safeguard the patient and the staff. A team
approach is required for patient restraint. Never attempt to subdue the patient alone. Use security, police, or other
able-bodied personnel. A show of force may be all it takes, because it tells the patient that his violence is being
taken seriously. When a show of force and other alternatives to restraint fail, the patient must be physically
restrained to prevent injury to everyone concerned. Restraints may be applied without an order in an emergent
situation, but a physician's order must be obtained, usually within one hour (JCAHO, 1998). Restraint orders must
be time limited; as-needed restraint orders are not acceptable. The reason for the restraint and failed
interventions must be documented.
The violent patient should be restrained on a stretcher with the minimum amount of restraint required to
safeguard the patient and others. Usually four or five individuals are required for this procedure. One person
controls the patient's head while other team members secure the limbs (Glasson, 1993). Staff should use care to
avoid being bitten or spit on during the restraint procedure. Hold the upper extremities at the wrist and shoulder
and secure the lower extremities above the knee and at the ankle. Leather restraints or other safety devices may
be used to limit movement. After restraints have been applied, the patient should be carefully searched to remove
potential weapons. Exercise great caution during the search process, because needles or other sharp objects
may be in the patient's pockets(ENA, 2001).
Violence in the triage area or waiting area is a threat to the triage nurse but other patients, family
members, and visitors. These individuals should be guided to a safe place to make sure they are not hurt or that
they do not become part of the violence. Backup personnel may be required if the violence involves guns or
several people. Brawls have occurred in ED waiting rooms (ENA, 2001).
Weapons
More and more patients come to the hospital with weapons such as knives and guns (Drury, 1999). Some
EDs have installed metal detectors at all entrances to identify individuals with weapons so that weapons can be
removed before they can be used. Shootings and stabbings in hospitals and EDs have been reported across the
country (Elliott, 1997; Fiesta, 1996; Hoag-Apel, 1998, 1999; Point of View [POV], 1998). When you suspect a
patient has a gun or other weapon, notify security or designated personnel immediately. Do not confront the
individual. Never argue with or attempt to take weapons from a threatening individual. Security and law
enforcement are trained to manage these situations. Remove individuals at risk immediately. Your first priority in
this situation is to protect yourself and others in the area (ENA, 2001).
92
SECTION NINE: CHILD ABUSE & NEGLECT
PURPOSE:
OBJECTIVES:
o Define the child abuse.

o Identify the red flags regarding to indications child neglect.
o Decide the red flags regarding to indications child physical abuse.
o Explain the red flags regarding to indications child sexual abuse.
o Differentiate between the sexual child abuse and other form of buses in related to
psychological issues.
o Identify the specific data on child victim of sexual abuse.
o Evaluate the main signs that indicate a child could be a victim of abuse.
o Analyze the main elements in triage documentation that assist in validating the concerns
in child abuse.
o Decide the common errors made in triage documentation.
o Assess the main common demonstrated behaviors by the parents who are mistreating
the child.
o Decide the main red flags regarding to the person presenting with the chills may be the
perpetrator.
o Identify the main motivates that make the person want to harm or neglect the child.
o Explain the role of the Department of Children/Human Services.
93
CHILD ABUSE AND NEGLECT
How is child abuse defined, and who defines it? State definitions vary but all have a common theme in
that maltreatment of children is against the law. The categories of abuse with their frequency are (Triage
Nursing Secrets, 2006):
 Neglect 63%
 Physical abuse 19%
 Sexual abuse 10%
 Emotional (including verbal) abuse 8%
Some red flags that indicate a child could be a victim of neglect are but limited (Triage Nursing Secrets, 2006):
 Sudden change in behavior or ability to perform schoolwork
 Inappropriate growth and development for age
 Dehydration without presence of illness
 Stealing or hiding food
 Overt lack of dental or other medical care
 Not dressed appropriate for weather
 Left alone unsupervised at home
Children 5 years and younger is the most common age group is the victim of fatality related to abuse or
neglect because of their size and inability to independently provide self-care explain why they are the most
vulnerable (Triage Nursing Secrets, 2006).
The red flags that indicate a child could be a victim of physical abuse are(Triage Nursing Secrets, 2006):
 Unexplained wounds or bruises
 Bruises in various stages of healing
 Wounds that appear to be the shape of objects such as a curling iron, a belt, or a cigarette butt
 The story from the caregiver of the injury does not match the capability of the child's age and growth and
development
 The child appears frightened in the presence of adults who are their caregiver
The majority of children with head injuries from abuse have no outward sings of the abuse. Many perpetrators
inflict physical abuse in areas that they think a health care worker will not look, such as cigarette burns to the
soles of 1 feet which makes the physical abuse really bad.
The red flags that could indicate a child could be a victim sexual abuse (Triage Nursing Secrets, 2006):
 The child does not want to sit or walk or it appears painful to do so.
 Bedwetting as a new behavior
 Pregnancy at an inappropriate age
 Presence of sexually transmitted disease (especially in children younger 12 years because they are
usually not sexually active)
 History of running away
 Anorexia
 Overtly sexually aggressive toward adults or other children
Some of the psychologic issues related to child victims of sex abuse different than the other forms of
abuse which include (Triage Nursing Secrets, 2006):
 They blame themselves.
 They have different levels of anger toward both parents. They are angry at the one abusing them and
angry with the other parent for not stopping the abuse.
 They may believe this behavior between an adult and child is normal expected in everyone's household.
 They feel trapped if they have tried to tell someone and were not
94
Is there more specific data on child victims of sexual abuse?

The National Incident Base Reporting System gathers information fro enforcement agencies and their data
from 1991 to 2002 reveals (Triage Nursing Secrets, 2006):
 Sixty-seven percent of sexual assault victims were under the age of 18.
 Thirty-four percent were under the age of 12.
 One out of every 7 victims were under the age of 6.
 Forty percent of the offenders who victimized children in this manner were juveniles (under 18). In the
majority of the cases, the offender was known by the child.
What might be signs that indicate a child could be a victim of emotional abuse?
 Suicide attempts
 Developmentally delayed
 Cares for the other siblings as an adult would
 Flat affect
 Demonstrates extreme attempts to please caregiver
 Regressive child-like behaviors (rocking) in an older child
Be Alert:
An estimated 3 to 10 million children witness domestic violence in their home and between 65% and 75% of those children are also
abused. Often abused women do not leave their batterers until their children are endangered. Ask an adult victim of domestic
violence about the children. (Triage Nursing Secrets, 2006)
The elements in the triage documentation that can assist in validating the concern are (Triage Nursing Secrets,
2006):
 Document what you see, hear, smell.
 Use the actual quotes of both the patient and caregiver.
 Identify specific behaviors of child (e.g., makes no eye contact with father)
 Consider statements of other siblings present ("We didn't eat yet today")
In one case I triaged, both the parent and child claimed he had fractured his femur when he fell off the swing
in their back yard. The young sister at the bedside stated, "We am t got no swing." The police photographed
the backyard without the swing and we had a validated need for children's services.
So it is not recommended that you document your assessment of the age of a wound, because:
A nurse cannot know a wound's age for a fact because the nurse was not there. Put anything stated by the
caregiver or child in quotes. The goal is for documentation to be objective, accurate, and be able to support the
victim, not the perpetrator. For instance: Mother states, "She fell a week ago at school." Purplish-blue circular
bruise, 3-inch diameter noted in mid-lower abdomen (Triage Nursing Secrets, 2006).
Common errors made in triage documentation

Documentation about the patient or caregiver that are either not within the nurse's expertise to document,
imply something that may not be true, and/or would be difficult to defend in court. Examples of these could
include:
 "Father is angry." (How do you know another person's emotion?) A better way to state this would be:
Father states, "I'm angry that this child is such a brat."
 "Poor social interaction between mother and child." (What is your training and expertise to make this
judgment?) Again, a better way to state this would be: "Mother does not reach out to comfort crying child."
Some commonly demonstrated behaviors by the parent who is mistreating the child are (Triage Nursing Secrets,
2006):
 Minimal physical contact (no hugging or hand holding)
 Unrealistic expectations for a child of that age
 Encourages others to use severe punishment in their absence
 Does not address the child by their given/legal name
 Speaks of the child in a negative way and does this in the presence of the child
 Blames and berates the child for issues out of the control of the victim
 Overtly treats the child in a way that suggests they prefer not to recognize them at all
95
In 1999 statistics gathered from twenty-one state child protective service systems reveal the following
(Triage Nursing Secrets, 2006):
 Women: 61.8% (almost half of them under the age of 30)
 Men: 38.2%
 Mother: 44.7 %
 Both parents: 17.7%
 Father: 15.9%
For specific types of maltreatment, the data collected reveals (Triage Nursing Secrets, 2006):
 The mother is the perpetrator and acted alone in 51% in cases of child neglect.
 The mother acted alone in 35.6% of cases involving physical abuse.
 The father acted alone in 20.8% of sexual abuse cases.
Red flags regarding the person presenting with the child may be the perpetrator (Triage Nursing Secrets, 2006):
 They are overly protective of child or the extreme opposite and have no concern.
 They will not allow the child to speak to anyone unless they are present.
 Their story changes in detail as different members of the health care team interact with them.
So, how do you separate the parent from the child so you can screen them alone?
Triage may not be the most appropriate place to do the screening/assessment. You have to look for
opportunities during their emergency department (ED) visit. Examples could include walking the child to the
bathroom for a specimen collection, offering to sit with the child so the parent can smoke a cigarette outside, or
staying with the child while the doctor reviews the radiology results with the parent (Triage Nursing Secrets, 2006).
The strong motivators for kids that prompts them not to tell us what is really happening to them are (Triage
Nursing Secrets, 2006):
These motivators vary with age, but include threats for separation from someone they trust or love
(grandparent), loss of access to food or privileges, and physical beating.
Are there any particular questions that can help prompt a child to tell you their story?
The nature of the questions will vary with the developmental capability of each child. Some examples that
help eliminate the sense that the child is "telling" on a parent include "We had spaghetti at our house last night,
what did you have to eat at yours?" and "Does anyone wake you up at night and crawl into your bed?"
The following are motivates a person to want to harm or neglect a child (Triage Nursing Secrets, 2006):
 Substance abuse on the part of one or both parents plays a role in almost one-half of the cases of child
neglect and abuse categories.
 Lack of tools or skills to cope and deal with life stressors appropriately. The child becomes the target of
the person suffering the stress.
 Victims of unhappy or unsuccessful relationships or an unwanted pregnancy.
 Mental illness.
 A history of the perpetrator being abused as a child.
Key Concept:
In most cases it is the role of all health care workers, teachers, police officers, and many others to report the suspicion. Assessment
for any abuse begins at triage. (Triage Nursing Secrets, 2006)
Also, there are some questions will be asked regarding to the child abuse suspicious, such as (Triage Nursing
Secrets, 2006):
 If I am not sure if there is an abuse issue or not. What should I do? Always go with your gut. It is in
the better interest of the child to file the reports than to not. Your phone call on file may be the one that
gives the caseworker enough validation to remove a child from the home or to require that another person
in the home move out.
 What if the physician disagrees with the assessment of the triage nurse and feels there is no
validation for concern? Should the nurse still file a report? The nurse has a duty to follow state and
facility requirements regardless of whether the physician agrees.
96
 What if I am wrong and no abuse is found? Can I be sued by the family? No, not if the report was
made with legitimate intentions (vs. revenge, etc.).
 How can I find out the statutes for the state in which I practice? You can access this information from
several sources:
o Via the internet by searching with the name of your state and the words child abuse
o Police department
The role of the Department of Children/Human Services:

Some aspects of the role may vary by state, however the primary responsibility is to respond to reports of
concerns related to child maltreatment, investigate complaints, and identify living situations that are unsafe for the
child. The staff may present to the ED or request to take a telephone report only (Triage Nursing Secrets, 2006).
Is child abuse an issue that the media has exaggerated?

The National Child Abuse and Neglect System reported 1,300 children fatalities in 2001. The U.S.
Department of Health and Human Services data from 2002 reveals that more than three children die each day as
a result of child abuse in the home. Altogether, 14 million kids a year are suffering abuse or neglect, or sometimes
both (Triage Nursing Secrets, 2006).
Discuss abandoned baby laws.

Since 1999, at least 35 states instituted some form of "abandoned baby" or "dumpster baby" laws after a
government report revealed a 62% increase in the number of discarded newborns left to die in public places.
These state laws permit an unwanted newborn infant (the range of allowed ages varies from 3 days to 1 month) to
be "dropped off" at an ED without question or legal consequence (Triage Nursing Secrets, 2006).
Most EDs want any nursing staff that has contact with the individual dropping off the infant to ask about health
information. However, the person should be allowed to leave immediately if the infant has no obvious signs of
trauma or abuse. Organizations with literature and additional information include Project Cuddle
(www.projectcuddle.org), Garden of Angels and Safe Arms (www.gardenotangels.org), and A Secret Safe Place
for Newborns (http://secretsateplace.org) (Triage Nursing Secrets, 2006).
Key Concepts:
 Never assume that because the caregiver has a professional occupation and is well known in the community that they
cannot be the offender.
 Absence of wounds or bruises does not indicate absence of abuse.
 Use quotations to document comments made by both the patient and the adult.
 Listen to the child's story and believe them, it is someone else's job to disprove it.
 Become familiar with red flag alerts for neglect because this is the most common form of child abuse.
97
SECTION TEN: EXPECTATION OF ALL HEALTH

WORKERS IN TRIAGE AREA
EXPECTATION OF ALL HEALTH WORKERS IN TRIAGE AREA
Standard of Practice
 To work within the Standard of Practice for the Registered Nurses OR Licensed Emergency Medicine
Physicians. (Zimmermann,P. & et.al.,2006)
Triage Guidelines
 Adhere to the triage guidelines at all times (KAMC –R, 2006).
 To initially assess and reassess the patients in waiting area (KAMC –R, 2006).
Documentation
 Timely, accurate. Legible documentation of patient assessments, treatments, procedures, and any other
relevant information. REMEMBER IF IT IS NOT WRITTEN IT HAS NOT BEEN DONE (KAMC –R, 2006).
 Adhere to the existing guidelines of triage documentation place in the triage communication book (KAMC
–R, 2006).
Languages
 Speak either English or Arabic ONLY in patient care areas at all times (KAMC –R, 2006).
Take a Pride In Surrounding
 Keep your area clean.
 Tidy up your cubicles after yourself
 Restock the work areas for the next shift.
Communication Book
 Read the currant communication clipboard (KAMC –R, 2006).
 All specific-communication will be in the reception desk (KAMC –R, 2006).
 Familiarize yourself with specific assignment (KAMC –R, 2006).
Scope of Practice
 Familiarize yourself with the policy and procedures both departmental and hospital (KAMC –R, 2006).
Dress Code
 Adhere to the hospital dress code(KAMC –R, 2006).
 Jewelry at the minimum.
 Minimal piercing especially in your face.
Equipment management
 Treat equipment with respect and do not let it lie around.
 If broken, record what is wrong with it and report to the Charge Nurse or the Senior Staff physician in
Triage area immediately.
 Please clean after use. We are responsible for cleaning our own equipment.
Answer telephones
 This is not just the job of the Unit Assistant (KAMC –R, 2006).
Noise level
 Work to keep the noise level down. Avoid shouting (KAMC –R, 2006).
 Cell phones should be off and never be used while working (KAMC –R, 2006).
 Be nice. Speak-calmly to patients and colleagues. High-pitched sounds are not accepted (KAMC –R,
2006).
98
Professional Development
The Joint Commission for Accreditation of Healthcare Organizations (JCAHO) requires documentation of
clinical competence but does not specifically define how to do that. One study found that only 43% of surveyed
hospitals had a special education program designated for nurses in triage. (Zimmermann,P. & et.al.,2006)
Ideally, the triage personnel with pediatric emergency experience should be responsible for the triage of
pediatric patients. It is best such that triage health personnel (Holleran.R.S, ENA.2003):
 Attend a formal triage course that addresses pediatric specific concerns.

 Have 6 months - 1 year's experience as an emergency department.
 Possess knowledge of growth and development principles.
 Recognize variety of pediatric-related patient's problems.
 Have ACLS, PALS and Emergency Nursing Pediatric Course (ENPC) verification
 Demonstrate competence in the process of pediatric triage; have the ability to perform the four
components of pediatric triage.
Grossman's (2003) list also includes more nebulous, but just as important, factors involving nursing style,
nursing skills, and local resource knowledge factors. They include:
 Working knowledge of intradepartmental policies

 Understanding of local emergency services
 Possessing precision assessment skills
 Having well-developed skills in handling patients with special needs or barriers
 Demonstrating interpersonal and communication skills in the areas of interpersonal relationships,
conflict resolution, supervision/delegation, telephone communication, and decision-making
 Serving as a role model
 Exhibiting flexibility, adaptability, the ability to anticipate and plan to potential occurrences, and
common sense Murphy's (1997) list of qualifications also includes:
 Rapid critical thinking skills
 Excellent prioritization skills
 Ability to adapt to stress
 Effective communication skills for all categories of people (e.g., patients, families, health care
clinicians, community)
 Others include tact, discretion, patience, organizational skills, and the key ability to recognize "sick"
versus "not sick."
Cultural Awareness
 Please be very aware of the culture and tradition of the Kingdom (KAMC –R, 2006).
Professional conduct and punctuality
99
REFERENCES
1. Beveridge R, Clark B, Janes L, et al. Canadian Emergency Department Triage and Acuity Scale:
implementation guidelines. CJEM 1999;1(suppl):S2-28.
2. Warren D. Jarvis A, Leblanc L; the National Triage Task Force members. Canadian Paediatric
Triage and Acuity Scale: implementation guidelines for emergency departments. CJEM
2001;3(suppl):S1-27.
3. Grafstein E, Unger B, Bullard M, et al. Canadian Emergency Department Information System
(CEDIS) Presenting Complaint List (Version 1.0). CJEM 2003;5:27-34.
4. Murray M, Bullard M, Grafstein E. Revisions to the Canadian Emergency Department Triage and
Acuity Scale implementation guidelines. CJEM 2004;6:421-7.
5. Stobbe K, Dewar D, Thornton C, et al. Canadian Emergency Department Triage and Acuity Scale
(CTAS): rural implementation statement. CJEM 2003;5:104-7.
6. Boufous, S. & et.al. (2003),” Impact of a chest-pain guideline on clinical decision-making”,
MJA,Vol.178,21.April.2003,375 – 380.
7. “The Risk Management Reporter”,(2005),The Newsletter of Healthcare Risk Control
System,Vol.24,No.3,June.2005.
8. Surina J. et .Al.,(2004),Aqualitative tool for critical thinking skill development, Nursing Educator,
Vol.29,number4,147 – 151.
9. Luckowski A.,(2003),Concept Mapping as a Critical Thinking Tool for Nurse Educator”, Journal for
nurses in staff - development,Vol.19,number 5, 288 – 233.
10. Kawashima/Petrini (2004), Study of Critical Thinking Skills in Nursing Students and Nurses in
Japan”,Nurse Education today,24, 286 – 292.
11. “Triage Orientation Manual in KAMC – R”, (2006), ECC – CRN.
12. Bracken, J.E. (1998) Triage, in Newberry, L. Sheehy’s Emergency Nursing – Principles and Practice
(4th Ed). Mosby: St Louis.
13. Derlet, J. (2003) Triage. Source -www.emedicine.com/emerg/topic670.htm. Accessed 11/09/04
14. Travers, D.A. (2002). Five level Triage System More Effective Than Three Level in Tertiary
Emergency Department. Journal of Emergency Nursing, 28:5, 395-400.
15. Murphy, K.A. (1997) Pediatric Triage Guidelines. Mosby: St Louis.
16. Chick, S. & et.al.,(2003),”Pairing Emergency Severity Index- 5 Level Triage Data with Computer
aided System Design To Improve ED Access and Throughput”, Emergency Department York
Hospital.
17. Jurishica,C., (2005),”Emergency Department Simulations: Medicine for Building Effective Models",
Beaver Street, USA.
18. Beveridge, R. & et.al.,(1998),” Implementation Guidelines for The Canadian Emergency
Department Triage & Acuity Scale (CTAS)”, Version: CTAS16.DOC December 16, 1998.27
19. ACEM POLICY DOCUMENT, “GUIDELINES FOR IMPLEMENTATION OF THE AUSTRALASIAN TRIAGE
SCALE IN EMERGENCY DEPARTMENTS”,(Nov.2000)
20. Commonwealth Department of Health and Family Services, Coopers and Lybrand Consultants.
Development of Agreed Set of National Access Performance Indicators for: Elective Surgery,
Emergency Departments and Outpatient Services. Canberra, (July 1997), p106.
21. Emergency Nurses Association (2001). Making the Right Decision: A triage curriculum (2nd ed).
ENA.
22. Beveridge, R., Clark, B., Janes, L., Savage, N., Thompson, J., Dodd, G., Murray, M., Nijssen
Jordan, C., Warren, D., Vadeconcoeur, A. (19980 Implementation Guidelines for the Canadian
Emergency Department Triage & Acuity Scale (CTAS).
23. Canadian Association of Emergency Physicians (2001). Canadian Pediatric Triage and Acuity
Scale: Implementation guidelines for Emergency Departments. Accessed on 2/21/2003 from
www. caep.ca/oo4.cjem-jcmu/004-00.cjem/vol-3.2001/cptas-egtp/pff/cptas-epf.htm
24. www.ag.gov.au/cca
25. www.emsresource.net
26. www.health.gov.au/publicat.html
100
27. “Violence Occupational Hazards in Hospitals”,(2002),Department of Health & Human Services,

Center Disease Control a& Prevention, National Institute for Occupational Safety and Health
(NIOSH), DHHS (NIOSH) Publication No. 2002–101, Cincinnati, OH 45226–1998.
28. www.cdc.gov/niosh
29. “TRAUMA FIELD TRIAGE CRITERIA”, EMS MEDICAL ADVISORY BOARD, CLARK COUNTY HEALTH
DISTRICT,IMPLEMENTATION DATE 2/9/05.
30. “Trauma Field Triage and Point of Entry Plan for Adult and Pediatric Patients”, (2002), Department
Of Public Health, Commonwealth of Massachusetts.
31. Hotz,H. & et.al.(2003),”Advanced Trauma Care for Nurses”,Chapter1,P.P 1-22.
32. MacLachlan, S. MD(2003),” Blunt Pediatric Trauma”, Power Point presentation, Emergency
Medicine Round.
33. “Submission Packet For Regional Variation to State Trauma Triage Protocols”, State Board of
Emergency Medical Services, Revised in 10/01/2003.
34. Hotz,H. & et.al,(2003),”Advanced Trauma Care for Nurses”, Instructor Manual,Edition 2003,
Paediatric Trauma, P.P 90 – 106.
35. Blanda, M. “Geriatric Trauma: Current Problems, Future Directions”, Summa Health System/
Northeastern Ohio Universities College of Medicine.
36. Rutschmanna, O. & et.al,(2005),” Pitfalls in the emergency department triage of frail elderly
patients without specific complaints”, Swiss Med Weekly ,Vol.135,P.P145–150.
37. www.smw.ch
38. EAST Practice Management Guidelines Work Group. Practice management guidelines for
geriatric trauma. Allentown (PA): Eastern Association for the Surgery of Trauma (EAST); 2001. 55 p.
[29 references]
39. Newberry, L (Ed.) 2003. Sheehy’s Emergency Nursing. Principles and Practice. Fifth Edition. St.
Louis. Mosby
40. American College of Surgeons (Ed.) 1997. Advanced Trauma Life Support for Doctors. Student
Course Manual. Sixth Edition. Chicago. American College of Surgeons
41. Nettina, S (Ed.) 2001. The Lippincott Manual of Nursing Practice. Seventh Edition. Philadelphia.
Lippincott Williams & Wilkins
42. Hotz,H. & et.al,(2003),”Advanced Trauma Care for Nurses”, Instructor Manual,Edition 2003.
43. Newberry,L.(2001),”Making the Right Decision A Triage Curriculum”, Second Edition, Ch.3, P.P 39
– 44.
44. Mackway-Jones,K. & et al.,(2006),”Emergency triage – Manchester Triage Group”, Second
Edition, BlackWell Publishing, BMJ Books.
45. Zimmermann,P. & et.al.,(2006), “ Triage Nursing Secrets”, Ch.10, P.P 97 – 104, Mosby Company.
46. Eckle,N.,Haley,K., & Baker,P. (1998),Emergency Nursing Pediatric Course Provider Manual (2nd
Edition, pp. 82 - 85), Park Ridge, IhEmergency Nursing Association.
47. Emergency Nursing Association.(1992). Triage: Meeting the Challenge. Park Ridge, I: Author.
48. Engel. (1993). Pediatric assessment. St. Louise: Mosby- Year book.
49. FredricksonJ. (1994), Triage In S. Kelly(Ed), Pediatric Emergency Nursing (pp. 11-16), Norwalk, CT:
Appleton & Lange.
50. Grossman, V.(1999). Quick references to triage (p.5), Philadelphia: Lippincott.
51. Murphy, K. (1997), Pediatric Triage Guidelines (pp316 - 323), St. Louise: Mosby, Year book Int.
52. Ramler, C.L. & Mohammed, N(1665), Triage. In S. Kitt, J. Selfridge-Thomas, J.Prochi, and
J.Kaiser(Eds), Emergency Nursing: A Physiology and Clinical Prospective (pp. 19 - 27),
Philadelphia: Saunders.
53. SeidelJ., & Henderson, D. (1997), Approach to the Pediatric Patient in emergency department. In
R. Barkin (Ed), Pediatric Emergency Medicine: Concepts and Clinical Practice (2nd ed, pp.1 - 7),
St. Louise Mosby - Year Book.
54. American College of Surgeons, Committee on Trauma. Pediatric Trauma. In: Advanced Trauma
Life Support® for Doctors. 8th ed. Chicago, II: Author; 2008.
55. American Heart Association Subcommittee on Emergency Cardiac Care and American
Academy of Pediatrics Working Group on Pediatric Resuscitation: Textbook ofpediatric
advanced life support. Author.
101
56. Cox S. Pediatric trauma: Special patients / special needs. Critical Care Quarterly. 1994; 17 (2):51-
61.
57. Emergency Nursing Pediatric Course (ENPC) Manual: Emergency Nurses Association. 4th ed.
Park Ridge, II. Author.
58. Fleisher GR, Ludwig S. Textbook of Pediatric Emergency Medicine. Baltimore, Md: Williams &
Wilkins, 1993.
59. Inababb AS, Seward PN. An Approach to pediatric trauma - unique anatomic and physiologic
aspects of the pediatric patient. EmergMed Clin NA. 1991; 9 (3): 523.
60. Jerby B, Altorri R, Morton D. Blunt intestinal injury in children: The role of the physical examination.
J Fed Surgery. 1997; 32(4): 580-84.
61. !yer M, Burd R. The top 10 things to evaluate in children with suspected blunt abdominal injuries. J
Trauma Nursing. 2001; 7 (4): 98-101.
62. Moloney-Harmon P. Pediatric Trauma. In: Trauma Nursing Resuscitation through Rehabilitation,
3rd ed. McQuillan K, VonRueden K, Hartsock R, Flynn M, Whalen E. (eds). Philadelphia,Pa:
W.B.Saunders, 2001.
63. Moulton, SL. Early Management of the Child with Multiple Injuries. Clinical Orthopaedics and
related Research. 2000, 376.
64. Pang D, Pollack I. Spinal Cord Injury Without Radiographic Abnormality in Children - The
SCIWORA Syndrome. J Trauma. 1989; 29(5):654-664.
65. Subcommittee on Advanced Trauma Life Support of the American College of Surgeons
Committee on Trauma: Advanced Trauma Life Support Overview of Changes for 8th Edition.
Chicago, 111: American College of Surgeons; July 2008.
66. Tepas J. Resuscitation of the injured child. Current therapy of Trauma. 4th ed. Tntnkey D, Lewis F.
(eds). St. Louis, Mo; C V Mosby Co: 1999; 81-87.
67. US Advisory Board on Child Abuse and Neglect. A Nation's Shame: Fatal Child Abuse and
Neglect in the United States. Washington, DC, US Department of Health and Human Services,
1995.
68. Werner, H.: Practical tips for airway management in the injured child. International J Trauma
Nursing. 1998 4(3) 94-97.
69. Whitten, C. Anyone Can Intubate. 2nd Edition, San Diego,Ca: K-W Publishing Services, 1990.
70. Administration for Children and Families—Child Abuse and Neglect
(http://nccanch.acf.hhs.gov/)
71. Childhelp USA—National Child Abuse Statistics (www.childhelpusa.com.)
72. Faulkner, Nancy, PhD, Pandora's Box—Sexual Abuse Statistics (www.prevent-abuse-now.coni.)
73. Child Welfare League of America: Making managed health care work for kids in foster care,
Washington, DC,1996, CWLA Press.
74. Mulryna K, Gathers P, Fagin A: How to recognize and respond to child abuse, Nwrsmg34(10):52-
56, 2004.
75. Rosen P: The 5-minute emergency medicine consult, Philadelphia, 1999, Lippincott, Williams &
Wilkins.
102
PEDIATRIC TRIAGE ORAL TEST FORMAT

PEDIATRIC TRIAGE ORAL TEST FORMAT
Name: …………………………………… Participant’s No.:----------Case No.:-------Date: ------------------

Performance Grade Assessor Date
A. Knowledge Base
Discuss triage categories (Canadian system) and

1
different tiers to respective areas of the ECC
department, with rationale.
Explain the four main components of the triage
2
process.
Describes the terms ‘objective’ and ‘subjective’
3
data in relation to patient assessment in triage.
Identify the three first order modifiers.
4
Discusses the role of the triage nursing during a
5
disaster phase and the similarities and differences
with the role of the triage nurse in non-disaster
triage.
B. Clinical Practice
TRIAGE PATIENT SCENARIO
Routinely performs across the room assessment on

1
all patients entering the triage area and responds
appropriately to identified problems and
abnormalities.
Performs primary assessment of the adult and
2
pediatric triage patient, and provides appropriate
and immediate nursing interventions associated
with abnormal ABCD findings.
Accurately identifies the patient’s presenting

3
complaint(s) including history of presenting
complaint, and collection of objective and
subjective data that validate the presenting
complaint (s).
4 Is able to identify the index of suspicion
associated with patient presentation and data
collection.
5 Performs collection of additional triage information

relevant to different adult triage presentations.
6 Performs triage nursing assessment appropriate to

the triage vital signs area, including collection of
further objective and subjective assessment data.
103
TRIAGE CATEGORIZATION AND PLACEMENT
7 Demonstrates effective triage categorization with

rational and appropriate reassessment time.
RE-ASSESSMENT AND RE-TRIAGE
8 Performs effective and timely triage re-assessment

consistent with the patients triage categorization
and placement when required.
Final Grade:
Assessors comments:
Final Result:
 Pass  Instructor Potential
 Remediation  Incomplete
104
COURSE EVALUATION TOOLS
COURSE EVALUATION
Course evaluation is an important part of any course process, and it is necessary to review and
revise all material to be current with latest evidence and the needs of the participants. Your constructive
feedback is valuable to us and each day’s evaluation will be collated and presented to the group and then
after the course is completed, all information is relayed to the Educational Centre for review.
The 10 Principle Roles of Evaluation
1. Achievement
2. Measuring Progress
3. Improving Monitoring
4. Identifying strengthen & weakness
5. Effort Effectiveness
6. Coast benefit
7. Collecting information (data)
8. Sharing experiences
9. Improving collectiveness
10. Allow for better planning
105
Emergency Pediatric Triage Program

Participants' Reaction Form
Site: ----------------------------------- Date: --/--/2010 Course # :( )
You suggestions and criticism are valuable to us in preparing for future courses. Please assist us by evaluating each
course items at its completion. Your overall rating for each course item should include the faculty member's performance as
well as the core content (see the rating key). Written comments are encouraged and welcomed. It is important that you also
respond to the strengths and weakness for the course items in the second page.
Thank You
NOTE: Receipt of this completed and signed form is necessary for receiving CME credit.
Rating Key:
Very Good = 3 Good = 2 Fair = 1 Poor = 0
The instructor and session were
Program Items Rating Comments

(3) (2) (1) (0)
Overall Presentations & Lectures as:
 Overview of core content
 Triage Scenarios
 Initial Assessment and Management Skills
General
 Program content was consistent with printed
objectives.
 Content was relevant to and met my educational

needs.
 Discussion time was adequate and enhanced my

understanding of the learning outcomes.
 The interactive format of the program enhanced my

learning of the content.
 Acquired knowledge and skills will be applied to my

practice field.
 Room, facilities, presentation methods was

appropriate.
 Overall Program was fair, learning outcomes and

unbiased toward any institution or by individual.
 Added Comments:-------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------- -----------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------
 The strengths of the program is/are: --------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------------------
 The weakness of the program is/are: --------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------------------
106
EMERGENCY PEDIATRIC TRIAGE PROGRAM

TRAINING PROGRAM EVALUATION
The objectives of Initial Triage Training are to introduce professional health workers (Physicians,
RN, EMT, PCT) to Provide reflective, proactive, accountable, independent, and safe practitioner in
triage area, to Make available practice focused professional relationship, to Maintain and improved
the standards of care in triage, to Maintain and improve the flow of patient and confident care givers,
to Develop problem solving and critical thinking skills, to Improve competency, confidence, efficiency
and ethical practice, and to Increase professional expertise in triage area. Also training will allow them
to practice their triage skills on disaster or non disaster conditions using the guidelines, pathways and
protocols of the triage.
Date: ____________________ Lead Instructor: _______________________________
Location: ____________________ Other Instructor(s): ______________________________
1. Using the scale to the right, please rate the following aspects of the program:
Items Excellent Good Fair Poor Comments
(4) (3) (2) (1)
Helpfulness of the Additional knowledge
Quality of Lead Instructor’s skills
Usefulness of the Handouts (assessment
exercises & review questions)
Usefulness of Triage Exercise
2. After today’s training, how comfortable or confident do you feel if you had to perform triage
at a multiple patient incident?
Very Confident

 Confident

Somewhat Unsure of Myself Very

 Unsure of Myself
3. Would you be interested in participating in a Triage Nurse Program Training in the next time

Yes
 
Maybe
No
4. Additional Comments (What did you like the MOST about the program)?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
THANK YOU!
107
EXAMPLES OF PEDIATRIC TRIAGE GUIDELINES &

PROTOCOLS
108
Emergency Care Center – Triage Area Patient’s Flow
Patient arrived to TRIAGE RECEPTION

(Walking, Wheelchair or Stretcher)
Initial Assessment of triage components within

3 minutes - Triage Reception
All stretcher patients will be attended & categorized immediately by triage nurse in front desk
& to be send to appropriate treatment areas directly.
National Guard CTAS First Order Modifiers

Eligible Normal (V/S, Pain Severity
& Mechanism of Injury)
NO YES
Abnormal
Triage Level I OR
Triage Triage Triage Triage Level II
Level Level Level (Life, Limb or
V IV III Sight Threatening)
Eligible & Non
eligible Patients)
Triage Triage Triage Appropriate

Triage
Assessment Assessment Assessment Treatment
Reception
Room Room Room Area Immediately to
(Triage
(Triage (Triage (Triage (Directly Resuscitative
Nurse
Physician Physician Physician trough Triage
Decision) Area
Decision) Decision) Decision) Nurse Decision)
ID Band
issued CC / PC
and affixed
AC / PC / UCC AC/ PC Notify

UCC Registration
and Affixed
Armband
Definitive Definitive
Management Management
in Treatment Area in Treatment Area
Triage Away / PHU

Discharge Admission
Prepared By: CRN – Saleem Diknash (2009)
109
Pediatric Physiologic Discriminator - Example

(Australian Government Department of Health and Ageing – Emergency Triage Educational Kit, 2007)
110
Pediatric Physiologic Discriminator – Example.. Cont'd

(Australian Government Department of Health and Ageing – Emergency Triage Educational Kit, 2007)
111

01 Emergency Pediatric Triage Program Manual PDF

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

01 Emergency Pediatric Triage Program Manual PDF

Diunggah oleh

Hak Cipta:

Format Tersedia

Emergency Pediatric Triage Program Manual (2013)

Created & Complied By:

And finally, I am grateful to following colleagues for their support:

Saleem Diknash, 2013

02 Pediatric Triage Assessment

03 Canadian triage ED & Acuity Scale – Revised 2011

05 Pediatric Legal issues

07 Cultural and religious considerations

09 Child abuse & neglect

10 Expectations of all health workers in pediatric triage area

 Triage Oral Test Format

 Course Evaluation Tools

 Examples of Pediatric Triage Guidelines and Protocols

PEDIATRIC TRIAGE CONCEPTS

SECTION ONE: TRIAGE OVERVIEW

 Determine the essential facts related to the conceptual foundation of triage.

o Define the term" Triage “

 Patient flow diagram showing the process from arrival to disposition

EMERGENCY DEPARTMENT TRIAGE SYSTEMS

Table 1-1 ED Triage Systems

II. Spot-Check RN or MD Three: Emergent, urgent, delayed

Type II: Spot-Check Triage

Type III: Comprehensive Triage

Table 1-2. Primary Objectives for ED Triage Systems

ACUITY CATEGORIES AND REASSESSMENT

 Emergent: Involves an immediate threat to life, vision, or limb

Table (1 – 4) CTAS Categories

(Emergency Nurses Association (2001))

HISTORY OF TRIAGE IN THE EMERGENCY DEPARTMENT

THE TRIAGE RECEPTION DESK RESPONSIBILITIES

THE NURSES OF TRIAGE ASSESSMENT ROOM ROLES AND RESPONSIBILITIES

12. Check for lacerations, abrasions, bruises, deformities etc.

REGISTRATION DESK - PROCEDURE

EMERGENCY MEDICAL SYSTEM (EMS) AREA ROLES

TRIAGE NURSE CHARACTERISTICS IN ED

 Be able to work in stressful situations.

TRIAGE NURSE DUTIES IN ED

 To work collaboratively in a multi - displinary team.

TRIAGE PHYSICIANS ROLES AND RESPONSIBILITIES

1. Greet all patients

The ED- triage physicians must assess the following:

 Chief complaint - High acuity, high risk, true emergency

SECTION TWO: PEDIATRIC TRIAGE ASSESSMENT

o Explain the term “Triage process”.

PAEDIATRIC TRIAGE ASSESSMENT

Table 2-1. Anatomic and Physiologic Considerations in Pediatric Assessment

Parameter Description of Variations

Airway Infants are obligate nose breathers.

Get vital Vital signs vary significantly with age.

 Assume a position eye-level with the child.

SPECIAL CONSIDERATIONS FOR PEDIARTIC TRIAGE:

 Use plain language.

Pediatric Physiological approach to triage assessment and decision-making

PEDIATRIC TRIAGE PROCESS

1. Across the Room Assessment & initial Assessment

1. ACROSS THE ROOM ASSESSMENT & INITIAL ASSESSMENT

The pediatric assessment triangles is an across The Room assessment or an As-You-Approach-The-

Paediatrics: Critical Look

(Figure 1: Complaint Oriented Triage (2008), ppt. Slid # 206)

Table 2-2. Across- the -Room Findings That

Parameters Assessment Critical Findings

2. PEDIATRIC TRIAGE HISTORY (Eckle, Haley, and Baker, 1998):

Table 2-3. PQRST System of Pain Assessment