Triage is inherently chaotic, It’s a balancing act really…
The nurse must be ready for anything to walk through the door. The more patient care experience the nurse has the more prepared they will be to recognize and act quickly. A great triage nurse will add value to the team and earn credibility among co-workers.
Take a deep breath and keep your cool, remember this is the patient’s emergency, not yours.
Read on to learn more about the triage process…
True Emergencies
Start with an across-the-room impression and assess the patient for life-threatening injuries, altered mental status, and the condition of their skin. Any sign that the patient is going to die in the next few minutes without treatment must be treated as a true emergently. This may include bypassing the triage room and going straight to a treatment area. The nurse must initiate life-saving interventions.
Determine an Acuity Level
Once the nurse has determined there is time to formulate a working diagnosis in the triage room it’s time to draw on their experience. Continue to evaluate if the patient is high risk by asking open-ended questions and performing a focused hands-on exam. Consider the patient’s medical history and how that may be contributing to the patient’s current condition. Look for small clues such as; do they appear disheveled and unable to care for themselves? What is the patient’s baseline mental status? Do they appear in significant pain or distress? Reference your department’s triage code system, the most commonly used is the Emergency Severity Index (ESI) which offers the nurse a framework to determine acuity level.
Apply Advanced Nursing Interventions
Not all patients are run back to a room, there are times when the ED is at capacity and it’s determined a patient is stable enough to wait. The nurse should consider placing orders called advanced nursing interventions (ANIs) which are predetermined protocols based on the nurses working diagnosis. This allows the triage nurse and provider to have a better understanding of what is going on with the patient.
Re-evaluate
Sending patients to the waiting room can create a very risky situation. The triage nurse only gets a snapshot of what’s going on with the patient. They may feel pressured to downplay the patient’s condition due to the lack of available rooms. This is why it is extremely important to round and re-evaluate patients that are sent to the waiting area. Re-evaluation should be done at predetermined intervals based on the patient’s condition and ESI Level. This is also a great time to review ANI results, consult a provider, or “up triage” a patient that is declining.
Triaging will get easier with practice and consistency. Remember great triage nurses will add value and earn credibility among co-workers.
