EMS Triage Systems (Nursing)

© All copyrights reserved
Introduction to
Pre-Hospital Care
The Emergency Medical Services (EMS) system

BASIC AMBULANCE CARE (BAC) COURSE 2
Development of towns and

cities
 In newly developing towns and cities, the first
hospitals were established. Patients must be
brought in to these hospitals.
 Patients brought to medical care
 Ambulance services still
did not exist yet
Patients brought
to Medical Care
Medical Care
brought to
patients
INTRODUCTION TO PRE-HOSPITAL CARE SYSTEMS Monday, December 24, 2007
Baron Dominique-Jean Larrey

1766 – 1842
‘The worthiest man I have ever met’ – Napoleon
Bonaparte
 1797 – Napoleon’s Army Italian Campaign

 Ambulance Volante “Flying ambulances”
 Casualties reached within 15 minutes,
treated on site and transported
back to base hospital.

Baron Dominique-Jean Larrey

1766 – 1842
Introduced the concepts of triage that are still used today
The best plan that can be adopted in such emergencies, to prevent the
evil consequences of leaving soldiers who are severely wounded
without assistance, is to place the ambulances as near as possible
to the line of the battle, and to establish headquarters, to which all
the wounded, who require delicate operations, shall be collected to be
operated upon by the surgeon-general. Those who are dangerously
wounded should receive the first attention, without regard to
rank or distinction. They who are injured in a less degree may wait
until their brethren-in-arms, who are badly mutilated, have been

operated and dressed, otherwise the latter would not survive many
hours; rarely until the succeesing day. Besides with a slight wound, it is
easy to repair to the hospital of the first or second line, especially for
the officers who generally have means of transportation. Finally, life is
Ambulances bringing patients
Typical horse-drawn
ambulances
Horse-drawn ambulances had to contain a defined

set of equipment, including ample brandy.

Developments in ambulance
The Electric Ambulance

Rolls-Royce ambulances
Today’s
Still serving the same function of

bringing the patient to medical care
Is this correct?
Are we just transports??

The importance of TIME

 1960’s and 1970’s
 Emergency Medicine emphasized the
importance of medical care to be given as
early as possible
 Heart attacks and road traffic accidents were
major killers
 Outcomes could be improved if treatment
started in time
 A few minutes makes a lot of difference in
survival
 Role of ambulances changed

 Patients often cannot wait until reaching
hospital to start receiving emergency care
INTRODUCTION TO PRE-HOSPITAL CARE Care had to be brought to the patient
SYSTEMS Monday, December 24, 2007
Role of the modern ambulance

service
 Transportation
 Respond quickly
 Reach early
 Transport rapidly
 Refer accurately
 Emergency Care
 Start medical care
 Time-related
interventions
 Assessment of
patients
 Documentation

The Pre-Hospital Environment

 Pre-hospital environment poses difficult
circumstances
– Difficult to find
– Unaccustomed personnel
– Unusual environment
– Limitations with equipment
– Dangerous scenes and people
– No support from others
– Transportation difficulties
– Time pressures


Scene Safety Precautions

 Some scenes are DANGEROUS
 Violence / Crime / Mob
 Environment and Terrain
 Persisting dangers
 Hazardous Materials
 Scene Safety is most important

 Assess scene safety from FAR (rule-of-thumb)
 Approach only when deemed safe
 Park the ambulance safely
 Look around for persisting dangers
 Get information
 Ask for help / advice

Techniques to reduce traffic

hazards
 Let the experts guide you
 Position “fend-off” position
 Establish staging area and
ambulance loading area
 Use equipment to slow traffic and divert
away from safe zone
 Use only essential warning lights;
position them properly so as not to
blind incoming traffic
 Wear high-visibility clothing

Hazardous Materials (HazMat)

 Call for assistance / Call for help
 Suspicion and Identification of
Products
 Identification of Zones
– Red (Hot) Contaminated
– Yellow (Warm) Control
– Green (Cold) Safe
Wind
Direction

Hazardous Materials (HazMat)

 Personal Protective equipment
(PPE)
– Don’t be a dead hero!!
– Do not enter a contaminated site
without adequate Hazmat PPE
– Levels A, B, C, D
A
 Decontamination
– Dry powder
– Liquid
– Gaseous B
D C
EMT well-being
 Basic physical fitness
 Exercise and nutrition
 Habits and Addictions
 Body Substance Isolation (BSI)
 Back Safety
 Vaccination
 Decontamination of Equipment
 Post-Exposure Prophylaxis

Body substance isolation (BSI)

 Assume that all body fluids and blood is
INFECTIOUS
 Always use PPE whenever you are treating any
patient
 Protective gloves (wearing and removing technique)
 Masks and Eye protections
 N-95 masks, if needed
 Disposable water-proof gowns
 Safety boots
 Resuscitation barriers

Back Safety
 Good back posture
 Proper body weight
 Avoid ego; ask for help
 Position load as close to body as possible
 Keeps palms upward
 Bend your knees; keep your chin up
 “Lock in” spine and abdo muscles
 Don’t twist or turn
 Use leg muscles, not back muscles
 Exhale during lift; don’t hold your breath

 Push, not pull

Scheme of Pre-Hospital Care

How we do our work
General scheme of Pre-hospital

care
Scene Size-Up
Initial Assessment
Trauma Medical
Focused History and Focused History and

Physical Examination Physical Examination
Detailed Physical
Examination
On-going Assessment

Scene size-up
 Scene Safety
 Determine need for assistance


Determine need to report in
Determine mechanisms of
LOO

Injury
Determine nature of Illness
K
SAFE?
 Determine number of patients
 Request additional assistance HOW?
when

Multiple casualties
Expanding scene / scope HELP?
 Hazmat or Rescue situation
 Dangerous (violent, weapon, mass
General scheme of Pre-hospital care

Scene Size-Up
Initial Assessment
Trauma Medical

Detailed Physical
Examination
On-going Assessment

Initial Assessment - Check the

ABCs
 Mental status
 Airway
 Breathing
 Circulation
 Identify the Priority Patients
 Manage the Priority Patient first

Form a general impression of the

patient
 Does the patient appear to have a life-threatening
condition?
 Was it trauma? Does he need spinal
immobilization?
 Is it a medical problem?
 Is the patient conscious and coherent? Can he
answer questions and obey commands?
Is this a priority patient? Will this patient need to


be transported urgently?

Paramedic
Eyes Ears Touch Monitors
SKILL
Symptoms Signs
Patient
TRAUMA
Scene Size-Up
Initial Assessment
Trauma Medical

Detailed Physical
Examination
On-going Assessment

Trauma patients
Focused History and Physical examination
 Reconsider the Mechanism of Injury

– Decide if significant mechanism of injury exists, or
not
– Significant Mechanism of Injury

 Golden Hour Concept extremely important
 Rapid trauma assessment and tranport
– No Significant Mechanism of Injury

 More time for assessment
 More time for interventions

 More time for transport

Significant Mechanisms of Injury

 Ejection from vehicle
 Death in same passenger compartment
 Significant intrusion into patient compartment
 Intrusion more than 12 inches in lateral impact
 Fall greater than 15 feet
 Vehicle roll-over mechanisms
 Vehicle – pedestrian collision
 Motorcycle crash
 Unresponsive patient or altered mental status
 Penetrating injury to head, chest or abdomen

Significant Mechanisms of Injury – what to do
 Rapid Trauma Assessment (complete within 5 mins)

– Continue Spinal Immobilization
– Assess for DCAP-BTLS in head, neck, chest, abdomen,
pelvis, extremities, back (log-roll)
– Full spinal immobilization
– Baseline vital signs and SAMPLE history
 Packaging and Rapid transport (complete within 10
mins)
 Followed by Detailed Physical Examination on the way
to the receiving hospital
Deformity,
INTRODUCTION Contusions,
TO PRE-HOSPITAL Abrasions,
CARE SYSTEMS Penetrating, Burns, Tenderness, Lacerations,
Monday, Swelling
December 24, 2007
No significant mechanisms of injury
 Focused assessment (based on chief

complaint)
 Full physical examination
 Baseline vital signs and SAMPLE history
 Transport
 Documentation

MEDICAL
Scene Size-Up
Initial Assessment
Trauma Medical

Detailed Physical
Examination
On-going Assessment

Medical Patients
 Evaluate responsiveness again
 Unresponsive
– Rapid Medical Assessment
– Baseline Vital signs and SAMPLE History
– Transport
 Responsive
– History of Illness with SAMPLE History
– Focused Physical Examination based on chief complaint
– Baseline vital signs
– Transport decision to re-evaluate

Actions for Medical Patients
 Depends on history and clinical findings

 Provide Oxygen
 Monitor breathing (and oxygen saturation)
 Monitor pulse (and vital signs)
 Monitor conscious levels (talk to the patient)
 Reassurance and Comfort


General scheme of Pre-hospital care
Scene Size-Up
Initial Assessment
Trauma Medical

Detailed Physical
Examination
On-going Assessment

On-going assessment
 Continued assessment of the patient
 To detect any changes / deterioration in patient’s
condition
 To detect any new findings / injuries
 Adjust care provided if needed
A Assess
I Intervene
R Re-assess
What can we assess on the
M
 Mental Status
 Responsiveness
 Irritability, agitation
 Airway patency and Breathing
effort


Listen for abnormal sounds
Look for effort of breathing
A
 Pulse and Skin


Rate and volume
Peripheries warmth, capillary refill
P
 Signs of Shock

Tarik
Nafas
!!

Remember TRIAGE ??
38
Today………….
 Widely used
 Concept unchanged
 To serve objectives
 Use of available resources
 Objectives DIFFERENT
 Save lives
 Reduce further morbidity
Achieving the Triage Objectives
 Ensure that unstable or potentially unstable
patients are seen and treated urgently
 Ensure those who are not likely to
deteriorate could wait safely for care
 Concept of
 prioritizing patients
 provide immediate critical care when needed
 do the most for the most with available
resources
Triage in different scenarios
 Trauma Triage
 Sequence of transfer
 Mode and speed of transport
 Proper destination
 Disaster Triage
 In mass casualties / disasters, the objectives include
doing the most for the most with available resources
 Hospital Triage
 Determines time and sequence of treatment
 Enables proper functioning of Emergency Department
TRAUMA TRIAGE?
 Sorting of patients based on

injury severity and
resource availability and
time management
HOW DOES IT WORK?
Deliver the RIGHT patient

to the RIGHT place
at the RIGHT time.
GUIDELINES for TRAUMA TRIAGE
 Patient assessment to look for immediate
life threatening injuries
 Abnormal physiologic sign
 Anatomic location of injuries
 Mechanism of injury
 Pre or co-morbid conditions
Measure vital signs & level of consciousness
STEP 1 GCS < 13

Systolic BP< 90mmHg
Resp rate <10 or >29
yes No
Assess anatomic location

To trauma center of injury (Step 2)
Penetrating injury to chest, abdomen, head, neck/groin
Flail chest
Two or more proximal long bone #
Step Burns >15%, face/airway burns
2 Pelvic #
Limb paralysis
Amputation proximal to wrist/ ankle
No
Yes
Evaluate for evidence of
Mechanism of injury
To trauma center Or high energy impact
(Step 3)
•Ejection from automobile
•Death in same passenger compartment
•Extrication time > 20 min
Step •Falls > 20 feet
3 •Roll over accident
•High speed auto crash
•Auto-pedestrian injury with significant impact
•Pedestrian thrown or run over
•Motorcycle crash > 20 mph with separation of
rider and motorcycle
yes no
To trauma center Step 4

Age < 5 or > 55 years
Known cardiac or respiratory disease
Step
Diabetic taking insulin, cirrhosis, malignancy
4
Obesity, coagulopathy
Psychotics taking medication
yes no
Contact medical control and Re-evaluate with

Consider transport to trauma center Medical control
Hospital Triage
 Different objectives
 Ensuring that unstable patients get immediate
medical attention
 Ensuring that potentially unstable patients receive
prompt medical attention
 Identifying patients who require time-related
interventions (eg pain, poisoning)
 Ensuring that those who are not likely to deteriorate
can wait safely for care (with regular reassessment)
Hospital Triage
Essential for effective and efficient
functioning of the Emergency Department
Provision of emergency medical care cannot

be performed adequately if the system is
overwhelmed by non-emergency cases
Hospital Triage
 Clinical assessment: brief but accurate
 Limited time; not to make specific diagnosis
 Aim: decide whether the patient needs to be seen earlier
 Performed by experienced health care provider with years
of clinical judgment & decision making
Triage System in the Emergency Department
Patient in Initial Encounter
Primary Triage
Resuscitation
Critical
(RED)
Urgent Treatment
Required?
Semi-Critical Intermediate
(YELLOW)
Non-Critical
Under-triaged
Secondary Triage
Waiting Area
Fast-Track
Green Zone
 Primary Triage
 Assessment: What you can see
What you can ask
 Aim: To identify patients that need to be seen
urgently (either yellow or red)
 Secondary Triage
 Assessment: Further History
Vital Signs, ECG, Initial wound care
 Aim: To screen for unstable patients
Under-triaged
Fast-track
To provide initial care and investigations
Primary Triage – Assessment Phase
 See
 General Condition: Airway, Breathing, Unconscious,
Pale, Movement, Sitting up, Walking, Injuries
 Ask
 Chief Complaint, Brief History to assess severity,
duration
 Mechanism of Injury and Circumstances of Injury
Primary Triage – Action Phase
 Do
 Assist in patient transfer from vehicle onto stretcher,
wheel chair if necessary
 Provide further instructions for next phase of care
(for patient and relatives)
 Decide
 Urgent Triage Category
 Critical (Red)
 Semi-Critical (Yellow)
 Non-Urgent Category – proceed to secondary triage
 Normal (Green)
 Fast-track
Secondary Triage
 Aims
 Second Screening to detect unstable patients based
on further history, vital signs monitoring, ECG,
initial wound assessment and clinical reassessment
 Actions
 Review patients after registration
 Ask further history
 Perform vital signs, initial wound dressing, ATT,
ECG if necessary, splinting and bandaging.
 Identify under-triaged patients
 Identify fast-track patients
 Record onto clerking sheet
CURRENT TRIAGE SYSTEM:
 3-tier emergency system
 Red: critical; response time 0 min
 Yellow: semi-critical; response time 10 mins
 Green: non-critical; seen within 60 mins
 Some mention a 4th level “non-emergency” which
ideally should not be seen within the ED (the well
known ‘cold cases’)
Examples Triage RED
 Patients requiring Active Resuscitation
 Unstable Haemodynamics
 Potentially Unstable Haemodynamics eg myocardial
ischaemia, arrhythmias
 Polytrauma
 Acutely Breathless patients
 Patients requiring active monitoring
 Patients requiring aggressive oxygen therapy
 Patients requiring ventilation
 Patients requiring emergency procedures
Examples Triage YELLOW
 Stable haemodynamics
 All patients on stretchers except triaged RED.
 Patients unable to walk or sit upright
 Gross limitation of movement
 Unconscious but with stable haemodynamics
 All acute poisonings even if patient currently stable.
 Asthma patients (although usually separate area
with separate triage code)
Examples Triage GREEN
 Stable Patients
 Able to sit upright unaided
 Fully conscious
 Walking wounded
 Simple upper limb fractures and Minor injuries
Please note that Triaged Green patients are still Emergency cases, although
they are NOT critical;
This should be differentiated from the Non-Emergency cases
ie COLD cases
TRIAGE is a dynamic process
 need to reassess patient from time to time
(triage and re-triage)
 Ideal triage
 Expedite care with accurate initial assessment
 Ensure appropriate prioritization depending
on severity of illness
 Improve patient flow within ED
IDEAL TRIAGE:
 Triage process and rules must be:
 Easily understood & remembered
 Rapidly applicable to different age group,
illness/injury
 Provide a common language for all
emergency health care providers
LIMITATIONS TO TRIAGE:
 Over-triage: burden existing resources
& prevent patients with serious injuries
from appropriate care
 Under-triage: cause delays in treatment
& transfer of patients with life/limb
threatening injuries.
Over-triage and Under-triage concepts
Ideal level
 Over-triage burdens the
system, but under-triage
maybe detrimental to the
patient Under-triage
50% Over-triage
 Over-triage of up to
50% to achieve an
under-triage rate of
10% 10%
Increasing stringency of triage

CONCLUSION:
 Triage requires clinical experience & skill
 The need for a common standardized triage
system within a department
 A standard triage system will optimize clinical
care for patients with different severity of
injuries/illness
 A triage system is meant to meet the need of an
Emergency Department; different departments
therefore will have different needs, and therefore
different triage systems.
Short
Break ?

Disaster Triage and
Field Operations
Medical Services, Pulau Pinang 67

Disaster Management Programme
Why are Resources Important in Triage?
 Disasters is commonly defined as

an incident in which patient care
needs overwhelm local response
resources
 Daily emergency care is not usually

constrained by resource
availability.

START Triage
Simple Triage And Rapid Treatment

START: Step 1
Triage officer announces that all

patients that can walk should get
up and walk to a designated area
for eventual secondary triage.
All ambulatory patients are initially

tagged as Green.

START: Step 2
 Triage officer assesses patients in the

order in which they are encountered
 Assess for presence or absence of
spontaneous respirations
 If breathing, move to Step 3
 If apneic, open airway
 If patient remains apneic, tag as Black
 If patient starts breathing, tag as Red

START: Step 3
 Assess respiratory rate

 If ≤30, proceed to Step 4
 If > 30, tag patient as
Red

START: Step 4
 Assess capillary refill

 If ≤ 2 seconds, move to Step 5
 If > 2 seconds, tag as Red

START: Step 5
 Assess mental status

 If able to obey commands, tag as
Yellow
 If unable to obey commands, tag as
Red

Mnemonic
R 30
P 2
M
Can do


Summary
 Triage
• Prioritization
• For the good of the patient
• For the good of most patients
• For the good of the system
 Field (Military) Triage

 Trauma Triage
 Hospital Triage
 Disaster Triage

Emergency Medical Systems and
Triage Systems
Thank You

EMS Triage Systems (Nursing)

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© All copyrights reserved

The Emergency Medical Services (EMS) system

Development of towns and

Baron Dominique-Jean Larrey

 1797 – Napoleon’s Army Italian Campaign

INTRODUCTION TO PRE-HOSPITAL CARE SYSTEMS Monday, December 24, 2007

Baron Dominique-Jean Larrey

Introduced the concepts of triage that are still used today

until their brethren-in-arms, who are badly mutilated, have been

Ambulances bringing patients

Horse-drawn ambulances had to contain a defined

INTRODUCTION TO PRE-HOSPITAL CARE SYSTEMS Monday, December 24, 2007

The Electric Ambulance

Still serving the same function of

Are we just transports??

INTRODUCTION TO PRE-HOSPITAL CARE SYSTEMS Monday, December 24, 2007

The importance of TIME

 Role of ambulances changed

Role of the modern ambulance

INTRODUCTION TO PRE-HOSPITAL CARE SYSTEMS Monday, December 24, 2007

The Pre-Hospital Environment

INTRODUCTION TO PRE-HOSPITAL CARE SYSTEMS Monday, December 24, 2007

INTRODUCTION TO PRE-HOSPITAL CARE SYSTEMS Monday, December 24, 2007

Scene Safety Precautions

 Scene Safety is most important

INTRODUCTION TO PRE-HOSPITAL CARE SYSTEMS Monday, December 24, 2007

Techniques to reduce traffic

 Wear high-visibility clothing

INTRODUCTION TO PRE-HOSPITAL CARE SYSTEMS Monday, December 24, 2007

Hazardous Materials (HazMat)

INTRODUCTION TO PRE-HOSPITAL CARE SYSTEMS Monday, December 24, 2007

Hazardous Materials (HazMat)

INTRODUCTION TO PRE-HOSPITAL CARE SYSTEMS Monday, December 24, 2007

Body substance isolation (BSI)

INTRODUCTION TO PRE-HOSPITAL CARE SYSTEMS Monday, December 24, 2007

 Exhale during lift; don’t hold your breath

INTRODUCTION TO PRE-HOSPITAL CARE SYSTEMS Monday, December 24, 2007

Scheme of Pre-Hospital Care

General scheme of Pre-hospital

Focused History and Focused History and

INTRODUCTION TO PRE-HOSPITAL CARE SYSTEMS Monday, December 24, 2007

General scheme of Pre-hospital care

Focused History and Focused History and

INTRODUCTION TO PRE-HOSPITAL CARE SYSTEMS Monday, December 24, 2007

Initial Assessment - Check the

INTRODUCTION TO PRE-HOSPITAL CARE SYSTEMS Monday, December 24, 2007

Form a general impression of the

Is this a priority patient? Will this patient need to

INTRODUCTION TO PRE-HOSPITAL CARE SYSTEMS Monday, December 24, 2007

Focused History and Focused History and

INTRODUCTION TO PRE-HOSPITAL CARE SYSTEMS Monday, December 24, 2007

 Reconsider the Mechanism of Injury

– Significant Mechanism of Injury

– No Significant Mechanism of Injury

 More time for interventions

INTRODUCTION TO PRE-HOSPITAL CARE SYSTEMS Monday, December 24, 2007

Significant Mechanisms of Injury

 Penetrating injury to head, chest or abdomen

INTRODUCTION TO PRE-HOSPITAL CARE SYSTEMS Monday, December 24, 2007

Significant Mechanisms of Injury – what to do

 Rapid Trauma Assessment (complete within 5 mins)

No significant mechanisms of injury

 Focused assessment (based on chief