The nursing triage
Definition
The word triage derives from the French trier (sorting) and represents one of the multiple skills of the nurse who works in the emergency room, consisting of a rapid assessment of the clinical condition of patients and their evolutionary risk through the use of a scale of color or numerical codes, aimed at defining the priority of treatment
The nursing triage
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Triage purposes and criteria
Triage is practiced in situations where access prioritization choices need to be made since it is not possible to immediately provide the necessary treatment to all patients simultaneously, given the available resources
Utility
The nursing triage
Validity
Reliability
Safety
CONSOLIDATED TRIAGE
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The triad of triage requirements •
Human resources
•
Structural requirements
•
Technological requirements
It is necessary that the nursing staff, belonging to the Emergency Department staff: ✓ has carried out activities in the PS for at least 6 months, following the probationary period ✓ is adequately trained according to national and regional standards ✓ meets the specific requirements ✓ has performed a period of support in triage For the triage function, a dedicated environment must be provided, located in a strategic position near the pedestrian entrances or with vehicles/ambulances of the emergency room, suitable for ReceptionTriage, signposted and clearly identifiable, always accessible and without architectural or functional barriers limit their usability Technological resources are necessary for the maintenance of appropriate quality standards (AED, multi-parameter monitor, blood gas analyzer, Poct, etc.)
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Triage organizational models
Global triage
Counter triage
Non-nursing system
The nursing triage
Spot-check triage
The doublestep triage
EXITY L P M CO CARE
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Main triage scales in the world
ATS
CTAS
Australasian Triage Scale
Canadian Triage and Acuity Scale
ESI
MTS
Emergency Severity Index
The nursing triage
Manchester Triage System
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Evolution of the national and regional reference legislation (Lazio) • • • • • • • • • • •
Presidential Decree No.76 of 27 March 1992: levels of emergency health care The D.G.R. No. 1004 of 1994 of the Lazio Region: standard of the Emergency Department and the DEA Ministerial Decree No. 739 of 1994: professional profile of the nurse Act of Understanding State and Regions (April 1996 – Official Gazette 17/05/1996): introduction of the triage Agreement between the Minister of Health and the Regions of 25 October 2001 (Official Gazette No. 285 of 07/12/2001): organizational and structural aspects of the triage Agreement between the Minister of Health and the Regions, of 22 May 2003: permanent training of personnel operating in the emergency/urgency system (with particular reference to the triage) Code of ethics for nurses (2009) DCA 8/2011 of the Lazio Region: mandatory Triage function in PSs with over 25,000 accesses July 2012, AGENAS document: abandonment of the color code system replacing them with numerical ones Recommendation No. 15 on clinical risk (February 2013) National Guidelines on the Intra-hospital Triage (August 2019)
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Situation in Italy up to 2019 Code
Meaning
Red
Patient with alterations of vital functions Immediate entry
Yellow
Patient at risk of impaired vital functions
Limited waiting in a protected area
Green
Non-at-risk patient with high degree of distress
Waiting in general with limited times
White
Non-at-risk patient with low degree of distress
Variable wait and determined by accesses
%red
%yellow
Waiting time
%green
%white
n. accesses
Year The nursing triage
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New coding system Code 1 2 3
4 5
Name
Red
Definition
EMERGENCY
Maximum waiting time for access to treatment areas
Interruption or impairment of one or Immediate access more vital functions
Orange
URGENCY
Risk of impairment of vital functions. Condition with evolutionary risk or severe pain
Access within 15 minutes
Blue
DEFERABLE URGENCY
Stable condition with no apparent evolutionary risk that usually requires complex performances
Access within 60 minutes
MINOR URGENCY
Stable condition with no apparent evolutionary risk that usually requires simple mono-specialist diagnostic-therapeutic services
Access within 120 minutes
NOT URGENCY
Non-urgent problem or of minimal clinical relevance
Access within 240 minutes
Green White
Fast–Track and See & Treat The nursing triage
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Fast–Track and See & Treat Both are born to facilitate the treatment and the path of low-intensity care accesses
The nursing triage
•
Fast-Track Rapid pathways that are already started in the triage phase to speed up patient care by the competent specialist
•
See & Treat Resolution of minor problems by experienced and trained nurses (350-hour training course) according to validated protocols and shared with emergency medical personnel
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The importance of a global assessment… TABLE OF VITAL PARAMETERS FOR ALLOCATION OF THE PRIORITY CODE ASSESSMENT
1
2
3
4
5
A
airways
obstructed
pervious
pervious
pervious
pervious
B
SpO2
≤ 86%
86-90%
>90-95%
>95%
>95%
FR acts/min
< 10
> 30
22-30
17-21
12-16
C
FC
≥ 160
> 40 - ≤ 50 ≥ 110 - < 160 ≥ 90 < 110 + arrhythmia
> 50 - < 60 ≥ 60 - < 90 ≥ 90 < 110 not arrhythmia 60-90 + arrhythmia
PAS mmHg
≤ 75 or absent peripheral pulses ≥ 250
≤ 90 Shock index ≥1 > 200 - < 250
> 90 ≤ 105 Shock Index <1 > 170
≤ 170
< 140
PAD mmHg
≥ 130
≥ 120 - < 130
≥ 100 - < 120
< 100
< 90
GCS
≤ 11
12-13
14
15
15
< 35
35 - 35.5 > 39.5
38 - 39.5
< 38
reported fever
8-10
4-7
1-3
pain not present
40-60
60-80
> 80
> 80
High or > 300 + symptoms
> 300 not symptoms
< 300
D E Pain
TC
b/m
°C
Scale
Glycemia HGT
mg/dl
Age
The nursing triage
≤ 40
years
< 40
≥ 60 - < 90 not arrhythmia
> 75
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Experimenting with 5-code TML in 2017 No. of triage forms in at least 5 internal survey days (M/P/N)
WHO?
10 facilities hospital
S. Maria Goretti di Latina – DEA II
850
S. Scolastica di Cassino – DEA I
525
Ospedale Civile di Tarquinia – PS
230
S. Filippo Neri – DEA I
420
S. Andrea – DEA I
650
S. G. Calibita FBF – DEA II
470
Bambino Gesù Children’s Hospital – DEA II
1100
S. Camillo Forlanini – PS pediatrico – DEA II
230
Policlinico Umberto I – PS generale – DEA II
860
Policlinico Umberto I – PS pediatrico – DEA II
360
S. Spirito – DEA I
520
TOTAL
AS?
Minimum 6215 patients equal to 8% of accesses in 2 months for the 10 structures
(1100 OPBG cases)
6215
WHEN? 2 months August-September 2017 The nursing triage
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Methods of experimentation
Arrival of the patient
Evaluation and attribution of the 4-color triage code
Consultation of the TML files
Attribution of triage code to 5 codes in the chosen field of the master data (3rd telephone ref)
Insertion of the case in the statistical database
At the end of the trial period, the various CEDs send the collected data to the Region for statistical analysis together with feedback from the operators.
Patients transferred from other facilities are excluded from the trial
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Pediatric aggregate tables and OPBG Aggregate Data Nuova Codifica Current Coding RED YELLOW GREEN WHITE TOTAL %
1
2
3
4
5
TOTAL
%
13 1 90 3,0% 296 380 68 6 752 24,9% 19 504 1065 112 1700 56,3% 2 20 216 242 480 15,9% 78 330 905 1349 360 3022 2,6% 10,9% 29,9% 44,6% 11,9%
AGGREGATE DATA OLD CODING
AGGREGATE DATA NEW CODING
56.30%
76 2
44.60% 29.90%
24.90% 15.90% 3.00%
ROSSO RED
GIALLO GREEN VERDE BIANCO YELLOW WHITE
11.90%
10.90% 2.60% 1
2
3
4
5
OPBG data Nuova Codifica Current Coding RED YELLOW GREEN WHITE TOTAL %
1 3 2
2
4
5
46 23 7 210 328 75 16 121 188 5 81 272 472 270 0,5% 7,4% 24,7% 42,9% 24,5%
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3
TOTAL
%
OPBG DATA OLD CODING
3 0,3% 147 13,4% 625 56,8% 325 29,5% 1100
OPBG DATA NEW CODING
56.8%
42.9% 29.5%
24.7%
13.4% 0.3% ROSSO RED
GIALLO GREEN VERDE BIANCO YELLOW WHITE
0.5% 1
24.5%
7.4% 2
3
4
5
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Stages of triage
Immediate evaluation (on the door)
The nursing triage
Subjective and objective evaluation
Triage decision
Revaluation
MEDICALLEGAL ASPECTS
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Privacy, GDPR and professional secrecy Health data is defined as “personal data relating to the physical or mental health of a natural person, including the provision of health care services, which reveal information relating to his state of health”. It is no longer mandatory to receive the consent from the interested party (patient) for the processing of his personal data, but it is essential that he is correctly "informed" on the ways in which his data is used through written or verbal information.
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Privacy, GDPR and professional secrecy The privacy policy The information on the processing of personal data must report what is required by the privacy code and the European regulation, i.e: • who is the data controller • who is the data protection officer (DPO - Data Protection Oficer) • the purpose of the data processing • the legal basis on which the processing is based and the legitimate interest in the event that this constitutes the legal basis of the processing • any recipients or any categories of recipients of the personal data • the possible transfer of personal data to third countries and, if so, through which instruments When? • at triage (administrative or nurses) during the collection of personal data for deferrable access priority codes • ED doctors (in case of yellow/red codes after having provided clinical stabilization treatment)
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