3. Role of Triage Personnel

Canadian Paediatric Triage and Acuity Scale:
Implementation Guidelines for Emergency Departments

 A. GENERAL TRIAGE PRINCIPLES

1. The triage nurse should have rapid access to or be in view of the registration and waiting area at all times. Triage duties include

   • greeting patients and families in a warm, empathetic manner;
   • performing brief visual assessments;
   • documenting the assessments;
   • triaging patients into priority groups using appropriate guidelines;
   • transporting patients to treatment areas when necessary;
   • giving reports to the treatment nurse or emergency physician, documenting who received the reports, and returning to the triage area;
   • measuring the relevant vital signs for appropriate determination of triage level and for reassessment of patients directed to the waiting room;
   • notifying patients and families of delays;
   • reassessing waiting patients as necessary; and
   • instructing patients and families to notify triage staff of any change in their condition.

2. Accurate assignment of triage levels is based on

   • practical knowledge gained through experience and training;
   • correct identification of signs or symptoms;
   • acknowledgement of key information from the presenting complaint and relevant history; and
   • use of guidelines and triage protocols.

3. A triage level must be recorded on all patients (including all ambulance patients) during all shifts.

   When the triage nurse has categorized more than 3 urgent patients, it is his or her responsibility to prioritize these patients for the treatment nurse and emergency physician.

4. Triage is a dynamic process: A patient's condition may improve or deteriorate during the wait for entry to the treatment area.

5. The triage process: primary survey vs. primary nursing assessment

   There can be confusion about the amount of detail required to assign a triage level. In some circumstances, to ensure patient flow and reduce delays to first health provider contact, it may be necessary to limit the triage assessment to a short primary survey. Conversely, in many rural emergency health care facilities (REHCFs) and, at certain times in larger EDs, the initial triage assessment may be a more detailed "primary nursing assessment." Detailed assessments will more accurately determine the patients' need for care, but to achieve time objectives for triage assignment within 10 minutes of arrival, triage staff will often be limited to very brief (i.e., 2 minutes) assessments, unless there are other operational policies to bring in more triage personnel during busy periods.

6. Triage guidelines

   • All patients should be assessed (at least visually) within 10 minutes of arrival.
   • Full patient assessments should not be routinely completed in the triage area when other patients are waiting to be triaged.
   • All information obtained should be recorded.
   • A primary survey (rapid assessment) should be performed when there are 2 or more patients waiting to be triaged. After all patients have had some form of triage assessment done, Levels IV and V patients who have been sent to the waiting area following rapid assessment should have more complete evaluations done by the triage personnel or treatment nurses.
   • The priority for care may change following a more complete assessment or as a patient's signs and symptoms evolve. The initial triage category and all subsequent changes should be documented. The initial triage level is used for administrative purposes.
   • Levels I and II patients should be placed in a treatment area and have a complete primary nursing assessments done immediately.
   • Vital signs should be completed on all paediatric patients at some time during their emergency visit. The timing of vital sign measurement may vary depending on patient presentation. For Levels I and II patients, this will most often be completed in the resuscitation area. When the ED is busy, Levels IV and V patients may have their vital signs delayed until re-evaluation in the waiting area or treatment area. Level III patients need full vital sign assessment to document that it is safe for them to wait for treatment.
   • Relevant vital signs must be completed prior to initiating medical directives.

7. The paediatric triage assessment

   • First impression: paramedic assessment in the field or "quick look" initial impression of the triage personnel.
   • Chief complaint: the patient's or family's statement of the problem.
   • Validation and physiologic assessment of the chief complaint:
     

     1. Subjective evaluation: onset, course and duration
        The ability of young children to accurately describe symptoms, feelings and events should never be underestimated. Age- and developmentally-appropriate approaches, language, interactions and evaluation tools (e.g., pain scales) must be used. In potential medicolegal cases, it is important to avoid leading questions, which may contaminate evidence. It is also important to recognize that information provided by the parent or caregiver may be altered by their perception of the child's condition. This may further be complicated by the use of an interpreter.

        • When did the symptom start? (Be exact with the time.)
        • What were you doing when it started?
        • How long did it last?
        • Does it come and go?
        • Is it still present?
        • Where is the problem? Describe the character and severity. If painful, use a pain scale.
        • Is there radiation?
        • Aggravating or alleviating factors?
        • If pain is or was present, the character and intensity should be documented (pain scale).
        • Has the presenting complaint affected appetite?
        • Has the presenting complaint impaired usual activities?
        • Is the child consolable by a parent or caregiver?
        • Is there a previous history of the same condition? If so, what was the diagnosis?
        • What does the parent or caregiver think is causing the problem or exacerbation?

     2. Objective evaluation
        Note that this part of the triage assessment may be deferred to the treatment area if the patient requires rapid access to care and intervention (e.g., Levels I or II patients).

        • Physical appearance: colour, skin, activity.
        • Degree of distress: severe distress, moderate distress, no acute distress.
        • Emotional response: anxious, indifferent.
        • Complete vital signs are necessary for triage level determination (Levels III, IV, V).
        • Are behaviour and social interactions appropriate for age and developmental level?
        • Are family dynamics appropriate?
        • Are there any indications of child abuse or neglect?
        • Are there any signs or suggestions of spousal abuse?
        • General physical assessment.

     3. Additional information
        Note: level of detail will vary with presentation.

        • Allergies?
        • Medications: list by name if possible, or by category (e.g., antibiotic, asthma, stomach, or seizure medicine) if the name is unavailable.
        • Family history of similar illness?
        • Travel or infectious contacts, including attendance at day care.
        • Immunization history?
        • Past health and development?

8. 8. Triage is a dynamic process

   Patients may move up or down the urgency continuum as they await access to treatment areas, physician assessment, results of investigation or response to treatment. Triage systems should include protocols that define

   • how quickly health care providers should see patients with specific complaint types;
   • how often patients in each triage category will be reassessed and where that information should be documented;
   • how patients with defined signs and symptoms are categorized (i.e. chief complaint);
   • what types of interventions will be initiated at triage; and
   • what types of reassessments should be done (options range from a quick overview of waiting room patients to repeated primary surveys and physiologic assessments).

9. 9. Reassessment after initial triage

   Time objectives for nursing reassessment are related to the patient's initial triage level. To ensure that patient status is not deteriorating after initial triage, reassessments should occur at the time intervals recommended for medical care assessment (see Table 2). Therefore, Level I patients should have continuous nursing care; Level II patients should be reassessed every 15 minutes; Level III patients, every 30 minutes; Level IV patients, every 60 minutes; and Level V patients, every 120 minutes. When patients have had a diagnosis made or are considered "stabilized," the frequency of nursing assessments and care will depend on existing care protocols or physician orders. When patients have exceeded the time objective for physician assessment for their triage level, to prevent unfair or unsafe "bumping" of patients with lower triage scores, it is reasonable to see these patients ahead of more recent arrivals with higher triage score (if these patients are stable).

   

B. 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. Nonverbal information is also important.

Physical assessment accompanies the triage interview, chiefly through observation. All paediatric patients must have an evaluation of their general appearance (activity level and level of consciousness), respiratory rate and effort, heart rate and perfusion. Physical assessment must be rapid, concise and focused. In some patients, objective measures such as pain scales, blood pressure or oxygen saturation may be determinants of triage level, while in others a treatment decision is made during the rapid evaluation of appearance, respiratory status and perfusion.

Effective triage requires the use of sight, hearing, smell and touch. There are many non-verbal clues, including facial expressions, cyanosis and fear. Listen to what the patient is saying and pay attention to questions they are reluctant or unable to answer. Listen for a cough, hoarseness and laboured respirations. Touch the patient to assess heart rate, skin temperature and moisture. Notice odours such as the smell of ketones, alcohol, or infection. Remember that the purpose of the triage assessment is to determine priority of care, not to establish a final medical diagnosis.

Often, the most time-consuming task of triage is to allay patient and family anxiety. Attitude and empathy are, therefore, important aspects of the triage nurse's demeanor. Remaining consistent and non-judgemental toward all patients is important. Difficult patients and families, such as those who are intoxicated and combative, require special care. Any element of prejudice leading to a moral judgement of patients can increase patient risk due to incorrect assignment of triage levels.

Do not prejudge patients based on their appearance or attitude.

C. NURSING PROCESS

A rapid and accurate triage process is critical because paediatric patients have the potential for rapid deterioration. The child's diagnosis is not as important as recognition of the potential for rapid deterioration based on the history and physical findings. It is important to gather enough information to determine patient acuity and any immediate care needs. Essentials of the triage evaluation include

• a 2- to 5-minute interview;
• quick assessment, using the PAT (Paediatric Assessment Triangle) (Fig. 1): appearance, respiratory effort and perfusion;
• the triage history; and
• the triage physical assessment.

Fig. 1. Paediatric Assessment Triangle (PAT).

1. Vital signs

Triage personnel must know the normal ranges of paediatric vital signs and the implications of high or low measurements. Whenever possible vital signs should be done when the child is quiet. Vital signs should be assessed on patients as required for categorization of triage levels and reassessment of waiting patients. In most children designated as Level I or Level II, the performance and documentation of vital signs will generally be the responsibility of the primary nurse.

2. Fever

Febrile illness is a common reason for presentation to an ED, but the degree of temperature elevation does not necessarily reflect illness severity. A history of temperature elevation prior to arrival may indicate significant illness in infants and immunocompromised children, even if they have a normal temperature at the time of triage. There is considerable controversy over the accuracy and clinical relevance of temperatures measured by ear thermometry and the axillary route. Precise technique must be applied to all temperature measurement procedures to maximize accuracy. The Canadian Paediatric Society issued a position statement in the Summer of 2000 to clarify the preferred routes of temperature measurement in children based on age. Table 3 summarizes the preferred routes of measurement and lists the normal temperature ranges.

Emergency departments may elect to use a screening method (a less preferred route for age) for temperature measurement at triage and in the waiting area. At some time during the ED visit the most preferred route for age should be used to record an accurate temperature, as appropriately indicated by the clinical presentation. Note: immunocompromised children must not have rectal temperature measurements because this may result in proctitis and sepsis.

3. Pain scale

An age- and developmentally-appropriate pain scale should be attempted on all children with pain. This evaluation is used in conjunction with the presenting complaint, to assign patients with similar complaints to different triage levels. Pain scales are not absolute, but do allow patients to communicate the intensity of a problem from their perspective. The more intense the pain (8­10/10) the more the care provider should be concerned about the need to identify or exclude serious illnesses and attempt to offer empathy or interventions that will diminish unnecessary pain and suffering. Pain perception is subjective. Individual variability is influenced by age, past experience and cultural differences. It is unwise to assume that mild pain rules out serious problems, and most children are so terrified of "needles" that they deny significant pain. Tachycardia, pallor, sweating and other physiological signs are useful in the evaluation of pain. It is also true that severe pain can be associated with benign processes (e.g., otitis media). Pain scales are less helpful and less reliable at the extremes of age.

The consistent use of pain scales is an important component of CTAS. This also allows for confirmation of improvement that both provider and patient can understand. Continued severe pain should lead to a reconsideration of the diagnosis and treatment. Pain scales are dependent on previous painful experiences. The first pain someone has may be by definition 10 out of 10, if the question is asked as "the worse pain you have ever had" (as opposed to "the worse pain imaginable").

Providers should never assume that a patient's pain is mild. Sometimes patients with minor conditions are assigned a triage leve of III or IV, despite reporting high pain levels (>7/10). For such cases, the department should develop standing orders for analgesic administration, or arrange rapid verbal review with a physician for analgesic orders while waiting for formal physician assessment.

Paediatric pain management should always involve a spectrum of interventions. These may include non-pharmacological interventions such as comfort and physical measures, distraction and imagery, along with adequate pharmacological interventions.

4. Planning

The triage system requires planning for nursing interventions, medical procedures and diagnostic protocols (e.g., use of ice, immobilization and electrocardiography).

5. Implementation

Effective triage includes responsibility for placing patient in appropriate treatment areas and providing critical information to the receiving health provider (physician or nurse).

6. Evaluation

All waiting patients require reassessment, as previously described, according to assigned triage level and nature of problem.

7. Documentation

As a minimum, documented patient assessment information should include

• the Paediatric Assessment Triangle (PAT) and triage history;
• triage level assignment;
• vital signs where appropriate, as well as allergy status and medications; and
• all reassessments, interventions, teaching, and medical directives or patient care plans implemented.

D. DOCUMENTATION STANDARDS

Important documentation includes

1. date and time of triage assessment
2. identification of adults accompanying children to the hospital
3. mode of transport
4. nurse's name
5. chief complaint or presenting concerns
6. a limited subjective history as described above
7. objective observation
8. assigned triage level
9. location in the department
10. report given to treatment nurse
11. allergies
12. medications
13. immunization
14. involvement of Social Services
15. diagnostic, first aid measures and therapeutic interventions applied
16. reassessment(s) performed.

E. TRIAGE NURSE QUALIFICATIONS

1. Communication skills are crucial. Providers must interact with patients, families, police, EMS personnel and visitors.
2. Triage staff must have tact, patience, understanding and discretion.
3. Triage staff require organizational skills to deal with patient line-ups, inquiries and unexpected problems. Triage staff are constantly under patient scrutiny.
4. Triage staff must be able to perform under stressful conditions.
5. Triage staff must have the experience, skill and expert clinical judgement to recognize patients who are sick.