Emergency Triage and Rapid Assessment

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Emergency Triage and Rapid Assessment

Introduction

This chapter introduces the concept and process of triage. Triage involves the sorting of patients in emergency care settings according to their level of acuity; it aims to ensure that all patients receive access to care in an organised, equitable and timely manner based on the urgency of their clinical need/s. As the demand on emergency care settings in the United Kingdom (UK) increases, it is imperative that nurses working in these settings are able to effectively triage patients in a manner consistent with their organisation’s policies and procedures.(Emergency Triage and Rapid Assessment)

This chapter begins by defining the concept and purpose of triage in emergency care settings. It then considers the system of triage, including the strategies used to determine a patient’s level of acuity. It goes on to explain in detail how a nurse in the emergency care setting may undertake the triage of a patient, describing the practical techniques involved in rapid assessment – including observation, the collection of a health history, and physical assessment using primary and secondary surveys. Finally, this chapter discusses the care provided to a patient once triage is complete, and the variety of challenges involved in triage in emergency care settings in the UK.(Emergency Triage and Rapid Assessment)

What is triage?

As you saw in the previous chapter of this module, there is an ever-increasing demand for emergency care in the UK. Indeed, 22.3 million people attended A&E Departments in the UK in 2014/15, an increase of 35% from the previous year. In some months in the summer of 2015, nearly 56 500 patients attended A&E Departments in the UK each day. Triage is one key strategy used to ensure that all patients who present to an emergency care setting receive access to care in an organised, equitable and timely manner.(Emergency Triage and Rapid Assessment)

Triage is the process of sorting patients as they present to the emergency care setting. Patients are generally sorted into one of three categories: (1) those requiring immediate care, (2) those requiring some type of urgent care, but who are able to wait a short time (e.g. minutes) to receive this care, and (3) those requiring some type of standard care, and who are able to wait considerable time (e.g. hours) to receive this care. Triage involves performing a rapid assessment of a patient; as will be described in some detail in a later section of this chapter, rapid assessment is a two- to five-minute process undertaken by a nurse to identify a patient’s presenting problem, collect the patient’s basic history and ascertain the patient’s current physical / psychological condition. Based on this rapid assessment, the nurse is able to make a decision about the level of acuity assigned to the patient – that is, the type of care they require, and how soon they require it.(Emergency Triage and Rapid Assessment)

As with many nursing techniques, the triage process was progressively developed by allied militaries – particularly, during World War II, the Korean War and the Vietnam War – to improve the provision of care to large numbers of critically wounded soldiers. As the practice of emergency medicine in civilian settings evolved, staff with a military background introduced the concept of triage to these settings. Today, both in the UK and internationally, triage is a fundamental aspect of the role of nurses working in emergency care settings. Read the following from a Registered Nurse working at an A&E Department in Wales, which highlights the importance of triage in the emergency nurse’s role:(Emergency Triage and Rapid Assessment)

“I absolutely love my job as we are with the patient throughout their time at the unit. There is a great satisfaction in providing the whole package of care, from assessment to discharge. When we first meet the patient we take a full history to find out how the injury [or illness] occurred and how it is affecting them. This is important as we need to make sure the injuries [or illnesses] match the cause. To provide the best course of treatment we need to know exactly what happened to prevent causing further injury [or illness]”.

Wales NHS, ND

Triage systems

There are three types of settings in the UK where emergency care is provided:

  • Type 1 A&E Departments – also known as ‘major’ A&E Departments, these departments provide a 24-hour service and are led by consultant doctor/s. They include full resuscitation and critical care facilities, and can handle patients with the most serious injuries and / or illnesses. Nearly two-thirds of patients attending an A&E Department in the UK will present to a Type 1 A&E Department.(Emergency Triage and Rapid Assessment)
  • Type 2 A&E Departments – these are single-specialty A&E Departments, providing targeted speciality services (e.g. for dentistry, ophthalmology, orthopaedics, stroke care, cardiac care, etc.). Type 2 A&E Departments make up approximately 15% of all emergency care services in the UK.
  • Type 3 A&E Departments – these include other services treating minor injuries and illnesses, including minor injury units and out-of-hours walk-in centres. Type 3 A&E Departments are often nurse-led. Unlike general practices (GPs), they can be accessed without an appointment. Just under one-third of patients attending an A&E Department in the UK will present to a Type 3 A&E Department.(Emergency Triage and Rapid Assessment)

All of these emergency settings use some form of triage system; however, it is important to be aware that there is no single triage system in use in the UK. Regardless of the specific type of triage system used, though, all triage systems involve assigning a patient a level of acuity. This identifies how serious the patient’s condition is and, subsequently, how urgently the patient requires care. In the UK, a patient’s level of acuity may be identified using a word, a number and / or a colour. Consider the following example:(Emergency Triage and Rapid Assessment)

Example

This table presents the system used to assign patients a level of acuity in emergency care settings in Manchester, UK:

Patient’s level of acuityCare to be provided…
1RedImmediateImmediately
2OrangeVery urgentWithin 10 minutes
3YellowUrgentWithin 1 hour
4GreenStandardWithin 2 hours
5BlueNon-urgentWithin 4 hours

Newell & Smith, 2008.

Examples of clinical presentations which may be categorised into each acuity level are provided following:

  1. Cardiac and / or respiratory arrest, intubated trauma patient, severe overdose.
  2. Ischaemic chest pain, child with fever and lethargy, disruptive psychiatric patient.
  3. Moderate abdominal pain, gynaecological disorders, closed-extremity trauma.
  4. Simple lacerations, cystitis, typical migraine, sprains and strains.(Emergency Triage and Rapid Assessment)
  5. Mild influenza-like symptoms, minor burn, re-checks (e.g. of casts, wounds, etc.).

It is important to note that patients may present to emergency care settings in a variety of different ways, and this will affect how they are triaged. Approximately 24% of patients arrive in UK A&E Departments by ambulance or helicopter; in these situations, the patient will have already been triaged, usually (though not always) as a patient requiring immediate care. In most cases, however, patients self-present by walking themselves into the emergency care setting; in these situations, the nurse will be required to undertake a process of triage. The triage process is described in greater detail in the following section of this chapter.

The triage process

Triage progresses through a series of clearly-defined steps, which focus on the rapid assessment of a patient. As described earlier in this chapter, rapid assessment is a two- to five-minute process undertaken by a nurse to identify a patient’s presenting problem, collect the patient’s basic history and ascertain the patient’s current physical / psychological condition. Rapid assessment includes three tasks: (1) the observation of the patient, (2) the collection of a health history, and (3) the physical and / or psychological assessment of the patient – including a primary survey, and perhaps a secondary survey. The information gathered at each of these steps is used by the nurse to make a decision about the level of acuity assigned to the patient. This section of the chapter will consider each of these three rapid assessment tasks in greater detail.(Emergency Triage and Rapid Assessment)

Rapid assessment – observation: The first step in rapid assessment is the observation of the patient. This is done in the first few seconds in which you engage with a patient. Observation involves visually examining the patient to gather information about how they appear (physically) and behave (psychologically). For example, you may observe:(Emergency Triage and Rapid Assessment)

  • Any issues which immediately threaten the life or wellbeing of the patient.
  • Any obvious physical or psychological problems (e.g. deformity, bleeding, psychosis).
  • The client’s level of consciousness, and their behaviour or manner. (Emergency Triage and Rapid Assessment)
  • The client’s rate and depth of breathing, and the ease of air entry.
  • The client’s current state (e.g. position, stature, colour, tone, mood, distress).
  • The client’s ability to engage and communicate appropriately with others.(Emergency Triage and Rapid Assessment)
  • The level of support the client has, including whether they present with others.
  • Other general information about the client (e.g. their weight, hygiene, dress).

Although observation is a crucial aspect of rapid assessment, it is important that you do not jump to conclusions based on the results of your observation alone. Consider the following example:(Emergency Triage and Rapid Assessment)

Example

Lucy is a graduate nurse working in the A&E Department of a large metropolitan hospital. One shift, Lucy is assigned to assist with patient triage. The first patient she sees is a middle aged man; on observing the man as he approaches, Lucy immediately notices that he is dyspnoeic, breathing deeply and rapidly. (Emergency Triage and Rapid Assessment)

“Sir, are you finding it difficult to breathe?” she asks.

“No,” the man says, “I’m short of breath because I ran from the carpark to avoid getting wet in the rain. It’s my finger I’m here about!” He holds up his hand, which is wrapped in a bloody towel.(Emergency Triage and Rapid Assessment)

It is important to note that, in some cases, patient assessment may not progress past the nurse’s initial observation of a patient. This is particularly true if in their initial assessment the nurse identifies an issue which presents an immediate threat to the life or wellbeing of the patient; in this situation, the patient is provided with immediate care. However, if no acute needs are identified during patient observation, the nurse’s assessment can progress to the collection of a health history.(Emergency Triage and Rapid Assessment)

Rapid assessment – health history: Collecting a health history involves speaking with a patient and / or their family (as appropriate), to find out about: (1) their presenting complaint, and (2) their relevant past medical history. During this stage of the rapid assessment, you may collect information about:(Emergency Triage and Rapid Assessment)

  • The client’s presenting complaint: “Why have you come to A&E today?” (This question is important even if you know why the client has presented, because it helps to establish the client’s own understanding of their presenting problem).
  • The history of the client’s complaint: “When did this start / happen? How? What symptoms do you experience? What causes / relieves these symptoms?”(Emergency Triage and Rapid Assessment)
  • The client’s medical history: “Do you have any pre-existing medical conditions? Have you been admitted to hospital or had any surgical procedures in the past?”
  • The client’s medications: “Do you take any drugs, vitamins or supplements?”
  • The client’s allergies: “Are you allergic to anything you know of? How do you react?”
  • The client’s pre-existing treatment plans: “Do you have a health care or treatment plan? Is this plan current? How is it used to manage our condition/s?”(Emergency Triage and Rapid Assessment)
  • The client’s last consumption: “When did you last have something to eat or drink?” (This question is vital for patients who may require rapid surgical intervention).

Most organisations will have a template which nurses working in emergency care settings can use to guide them in collecting a health history from a patient.

It is important to note that, in emergency care settings, the process of collecting a health history from a patient may be brief; this is particularly true if a patient requires immediate care. In these situations, a nurse should focus on collecting only the information which is necessary for the patient’s immediate care. A more comprehensive health history, which will involve the collection of data to inform the patient’s longer-term care and management, can be completed when the patient is more stable.(Emergency Triage and Rapid Assessment)

Rapid assessment – primary survey: Once the health history has been completed, the nurse can progress to the primary survey. This involves physically assessing the patient’s life-sustaining body systems to identify issues which may immediately threaten their life or wellbeing. It involves five stages, which may be remembered using the ‘ABCD’ mnemonic:(Emergency Triage and Rapid Assessment)

AAirwayThis step involves assessing the patency of the airway. A patient whose airway is compromised may be dyspnoeic and unable to vocalise; furthermore, the nurse may be able to visualise secretions, a foreign body or trauma affecting the airway. The airway may be opened using a jaw-thrust manoeuver, by suctioning (including to remove secretions or a foreign body), or by the insertion of an artificial airway and ventilation. (Emergency Triage and Rapid Assessment)
BBreathingThis step involves assessing the adequacy of the patient’s breathing and gas exchange. Patients who are having difficulty breathing may be dyspnoeic, have paradoxic or asymmetrical movements of the chest wall, use accessory muscles, have increased or decreased breath sounds, or be cyanotic, tachycardic and / or hypertensive. The administration of high-flow oxygen via a non-rebreather mask or an artificial airway is the key treatment. Depending on the cause of the breathing difficulties, thoracostomy and chest tube insertion may also be required.(Emergency Triage and Rapid Assessment)
CCirculationThis step involves assessing the functioning of the cardiovascular system – specifically, the quality and rate of the pulse and capillary refill time – and determining whether the patient has adequate blood volume. The nurse may also assess the patient’s skin colour and temperature, particularly centrally versus at the peripheries. Depending on the nature of the circulatory issue a nurse identifies, there are a variety of potential treatments – including fluid resuscitation, chest compression, defibrillation and medications to control cardiac function, in addition to direct pressure to control haemorrhage, etc. It is standard care in emergency settings for vascular access to be established during the primary survey for patients with urgent or immediate care needs.(Emergency Triage and Rapid Assessment)
DDisabilityThis step involves briefly assessing the patient’s neurological system, including their level of consciousness. Another simple mnemonic – ‘AVPU’ – is used to prompt nurses during this step:AThe patient is alert. VThe patient responds to voice (e.g. “Open your eyes!”).PThe patient responds to pain (e.g. a shoulder pinch or sternal rub).UThe patient is unresponsive.During this brief neurological examination, the patient’s pupils should also be assessed for their size, shape, equality and response to light.It is important to note that there are a variety of reasons why a patient’s level of consciousness may be altered – including use of substances, physical conditions (e.g. epilepsy, infection, trauma, etc.), and / or psychological conditions (e.g. psychosis, etc.). The only real treatment for neurological problems identified during the primary survey is to identify and correct the cause of the problem.During this step of the primary survey, other disabilities – for example, obvious physical or psychological problems – may also be identified. These are explored further in the secondary survey. Some organisations recommend that nurses complete a brief pain assessment at this stage; however, pain is also assessed comprehensively in the secondary survey.(Emergency Triage and Rapid Assessment)

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Emergency Triage and Rapid Assessment
Emergency Triage and Rapid Assessment

Note that emergency treatments to manage the airway, breathing and circulation of a patient in an emergency care setting will be described in detail in the following chapter of this module.(Emergency Triage and Rapid Assessment)

Once the primary survey has been completed, and if no issues which may immediately threaten their life or wellbeing have been identified, the nurse may progress to the secondary survey.(Emergency Triage and Rapid Assessment)

Rapid assessment – secondary survey: Following on from the primary survey, the secondary survey is a more comprehensive assessment of the functioning of a patient’s body systems. It is the first step in identifying exactly what type of care and management a patient may require. It involves four stages, which may again be remembered using a mnemonic – in this case, ‘EFGH’:(Emergency Triage and Rapid Assessment)

EExposureThis step is usually only completed for patients with traumatic injury/ies (suspected or actual). It involves completely removing the patient’s clothing, with the aim of identifying subtle issues which were not obvious during the primary survey. Ensuring the patient’s clothes are removed, they should be re-covered with warm blankets to prevent excessive heat loss, and also to preserve their dignity to the greatest extent possible.(Emergency Triage and Rapid Assessment)
FFull Vital SignsThis step involves taking a complete set of vital signs. Vital sign data provides important objective information about the patient’s current physiological state. In particular, the nurse should measure:TThe patient’s body temperature may be affected by certain disease processes, environmental factors, inflammation, infection and / or injury. Temperature is measured using a thermometer at the oral, axillary, temporal or tympanic sites or, less commonly, via a rectal or intravascular probe.HRA patient’s heart rate, or pulse, is measured for its rate (in beats per second), its rhythm (regularity), and its quality (e.g. bounding, weak, thready, absent, etc.). It is generally recommended that nurses in emergency settings palpate a patient’s pulse, rather than using electronic monitoring equipment to simply count the rate.RRA patient’s rate of respiration should be measured over one full minute, and the rhythm, depth and work of their breathing assessed. Signs of airway and breathing issues, as described in the primary survey section, should be evaluated in greater detail.O2 satsA patient’s oxygen saturation should be measured using a pulse oximeter. This measurement provides important information on the amount of oxygen present in a person’s blood and, therefore, the effectiveness of the gas exchange process.BPIdeally, a patient’s blood pressure should be measured using a manual sphygmanometer. The blood pressure reading may provide information about the efficiency of a patient’s cardiac function, as well as their circulating blood volume. Orthostatic blood pressure – that is blood pressure measured in two or three different positions (e.g. lying, sitting and standing) – may be recommended by some organisations.Depending on the reason/s for the patient’s presentation to the emergency care setting, a variety of other assessments may be undertaken at this stage. These assessments may include:Electrocardiogram (ECG) monitoring.Other diagnostic imaging studies (e.g. X-rays, CAT scans, MRI scans, etc.). Urinalysis (e.g. for blood, glucose, protein, specific gravity, etc.).Blood laboratory studies (e.g. typing and crossmatching, coagulation profiling, haemoglobin, blood urea nitrogen, creatinine, toxicology screening, arterial blood gasses, electrolytes, liver / cardiac enzymes, etc.).Blood glucose levels.Comprehensive neurological evaluation (e.g. using the Glasgow Coma Scale, or a similar standardised assessment tool).Neurovascular function (e.g. colour, temperature, pulses, sensation and motor function in the limbs).Height, weight and Body Mass Index (BMI).Sensory perception (e.g. vision, hearing, touch, etc.).Skin assessment (e.g. colour, integrity, turgor, diaphoresis, etc.).Mental health assessment.Pain assessment – this can be completed using the ‘OPQRST’ mnemonic:OOnset: “When did the pain begin?”PProvocation and palliation: “What makes the pain worse? What helps the pain?”QQuality: “Describe the pain.” (E.g. sharp, dull, stabbing, etc.).RRegion and radiation: “Where do you feel the pain? Does the pain spread to other areas of your body?”SSeverity: “On a scale of 1 to 10, where 1 is no pain and 10 is the most severe pain you have experienced, how would you rate the pain?” (Note that there are a range of other pain scales – including visual scales for paediatric and non-verbal patients – which may be used in emergency settings).TTime: “How long has the pain been present?”(Emergency Triage and Rapid Assessment)
GGive Comfort MeasuresMost patients presenting to emergency care settings will experience some degree of pain. Providing comfort measures – that is, pain management – early in the patient’s care is therefore an important consideration. Comfort measures may include a combination of:Pharmacologic interventions (e.g. non-steroidal anti-inflammatory drugs, intravenous opioids, etc.).Non-pharmacologic interventions (e.g. imagery, distraction, repositioning, breathing techniques, heat packs, etc.).There are a variety of other ways nurses may provide comfort measures to patients in emergency care settings. Verbal reassurance, taking the time to listen to the patient’s concerns, reducing stimuli (e.g. noise, light), and developing a trusting relationship with the patient are all crucial. Facilitating the presence of the patient’s family and / or significant others is also an important consideration.(Emergency Triage and Rapid Assessment)
HHead-to-Toe AssessmentIn this step, a more comprehensive head-to-toe assessment is undertaken. This involves sequentially assessing:The head, neck and face.The chest.The abdomen and flanks.The pelvis, and the perineal area (if appropriate).The extremities.The posterior surfaces.(Emergency Triage and Rapid Assessment)

Note that comfort measures suitable for use in the emergency care setting, including emergency pain management, will be described in detail in a later chapter of this module.

In many A&E Departments in the UK, the triage process is supported by a Clinical Decisions Unit (CDU) or similar service. The purpose of CDUs is to help improve the efficiency of the triage process. CDUs use specialist teams of medical, nursing and allied health staff to assess, investigate and diagnose patients – and, subsequently, plan their care. CDUs are particularly useful for supporting the triage of patients with multiple and / or complex conditions.(Emergency Triage and Rapid Assessment)

Related Content: Triage Assessment Form

Management of a patient post-triage

Once the process of triage, as described throughout this chapter, is complete, a patient will be provided care – specifically, investigations and / or interventions to manage the clinical complaint for which they presented. Remember: the type of care a patient requires, and the time-frame in which they require it, will be determined (at least in part) during the triage process, and the level of acuity assigned to patient. The type of care provided to patients with a variety of injuries and illnesses in the emergency care setting will be explored in detail in later chapters of this module.(Emergency Triage and Rapid Assessment)

Once care has been provided within the emergency care setting and the patient is stable, or the care options which can be provided in this setting have been exhausted, a patient will be discharged from emergency care. In the UK, patients are typically discharged to one of three different settings:(Emergency Triage and Rapid Assessment)

  • To the community; this decision is made if the patient is sufficiently stable, and if any further investigation and / or intervention they may require can be delivered on an outpatient basis at a later time.
  • To an inpatient setting, such as a hospital, where they will be admitted for further investigation and / or intervention. Approximately 75% of emergency admissions to hospitals in the UK are made via A&E Departments, primarily Type 1 Departments.(Emergency Triage and Rapid Assessment)
  • To a short stay unit (or similar setting), if their condition is less serious but would still benefit from further investigation or intervention. These units, usually attached to Type 1 A&E Departments, allow patients to be monitored in a low-acuity setting for up to 72 hours. A decision is then made to admit the patient, or discharge them to the community.(Emergency Triage and Rapid Assessment)

It is also important to note that, although uncommon, it is possible for a patient to die in an emergency care. In this situation, the patient’s body may be discharged to a mortuary or similar location.

Challenges in the triage process

As highlighted earlier in this chapter, triage aims to ensure that all patients who present to an emergency care setting receive access to care in an organised, equitable and timely manner. However, as the number of presentations to emergency care settings in the UK increases, and as the complexity of the clinical conditions for which these patients present also increases, the triage system is being placed under increasing demand.

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Emergency Triage and Rapid Assessment
Emergency Triage and Rapid Assessment

Statistics compiled by the National Health Service (NHS) suggest that time to initial assessment – both for patients arriving by ambulance / helicopter, and for self-referred patients – in A&E Departments in the UK is steadily increasing. Subsequently, time to treatment and total time in the emergency care setting are also increasing; indeed, the vast majority of A&E Departments in the UK continually fail to meet the Four-Hour Standard, which states that all patients seen in NHS A&E Departments must be seen, treated and admitted or discharged in under four hours. It is essential that nurses practicing in emergency care settings in the UK are well-equipped with the skills and knowledge necessary to meet these challenges, and to contribute to the delivery of effective, high-quality emergency services.(Emergency Triage and Rapid Assessment)

Conclusion

Triage involves the sorting of patients in emergency care settings according to their level of acuity, with the aim of ensuring that all patients receive access to care in an organised, equitable and timely manner based on the urgency of their clinical need/s. As the demand on emergency care settings and patient complexity in the UK increases, it is imperative that nurses working in these settings are able to effectively triage patients. This chapter has provided a broad overview of triage in emergency care settings. (Emergency Triage and Rapid Assessment)

It has considered the system of triage, including the strategies used to determine a patient’s level of acuity. It has explained in detail how a nurse in the emergency care setting may undertake the triage of a patient, describing the practical techniques involved in rapid assessment – including observation, the collection of a health history, and physical assessment using primary and secondary surveys. Finally, this chapter has discussed the care provided to a patient once triage is complete, and the variety of challenges involved in triage in emergency care settings in the UK. You will draw on the skills and knowledge you have developed in this chapter in the next chapter of this module, which describes how to effectively manage patients with immediate care needs.(Emergency Triage and Rapid Assessment)

Reflection

Now we have reached the end of this chapter, you should be able:

  • To define the concept and purpose of triage in emergency care settings.
  • To explain the system of triage in terms of a patient’s level of acuity.
  • To understand how to effectively triage a patient in an emergency care setting, including (1) observation, (2) collection of a health history, and (3) physical assessment. 
  • To describe the care provided in an emergency care setting once triage is complete. 
  • To discuss the challenges involved in triage in emergency care settings in the UK.

‘Hands on’ scenario

Triage and rapid assessment of a patient arriving in an emergency care setting with multiple critical injuries

Dan is a graduate nurse working in a Type 1 A&E Department in London. He is preparing to receive a patient arriving via the helicopter emergency medical service (HEMS). The only information Dan has about this patient is that he is a forty-nine-year-old male who has been involved in a road traffic accident. (Emergency Triage and Rapid Assessment)

As he is arriving via HEMS, the patient has already been triaged as a ‘Level 1’ patient – that is, a patient who requires care immediately on arriving in the A&E Department. Dan’s role, therefore, will be focused on rapidly assessing the patient to identify: (1) his specific injuries and / or illnesses, including any which may immediately threaten his life or wellbeing, and (2) the type of care which may be required to address these issues. Dan will need to use the rapid assessment process described in this chapter: (1) observing the patient, (2) collecting a health history, and (3) assessing the patient – including a primary survey, and perhaps a secondary survey.

The patient is transferred off the helipad and into a critical care bay in the A&E Department. Dan immediately begins observing the patient. He firstly looks for any issues which may immediately threaten the life or wellbeing of the patient. He notices a large, bloody contusion on the patient’s forehead; this suggests to Dan that the patient has sustained an impact to their head, and may therefore be at risk of neurological injury.(Emergency Triage and Rapid Assessment)

Dan also notices that the patient has C-spine immobilisation in-situ (i.e. a ‘cervical collar’); this indicates the possibility of spine and / or spinal cord injury, though Dan also knows C-spine immobilisation is routinely applied by HEMS paramedics as a precautionary intervention. (Emergency Triage and Rapid Assessment)

As well as C-spine immobilisation, Dan notices the patient has a box splint on his left leg, implying a fracture or break of bone/s in this leg. The patient is receiving high-flow oxygen via a non-rebreather mask. During his observation, Dan notices that the patient appears alert but not distressed; indeed, the patient makes eye contact with Dan when Dan introduces himself. Although Dan has obtained a significant amount of information about the patient during his observation, this observation took little more than 5 seconds.

Related Content: What is the purpose of triage? How do you make it effective?

Dan progresses to the next stage of the rapid assessment process – the collection of a health history. In this case, the health history is provided by the HEMS paramedic who attended to the patient at the scene of the accident. Because of the acuity of the situation, the HEMS paramedic provides only the information which is necessary for the patient’s immediate care. The HEMS paramedic tells the A&E team:(Emergency Triage and Rapid Assessment)

“This is John Brown. He is a forty-nine-year-old male. Approximately forty-five minutes ago, John was involved in a high-speed road traffic accident in Croydon. He was the front seat passenger in a stationary vehicle which was hit by a lorry. John states he struck his head against the side window of the vehicle. He has an obvious contusion on his forehead, and has complained of pain in the C4 / C5 region. On site he was assessed to have a GCS of 15. John also has a compound fracture of his left ankle. John has had 15 milligrams of intravenous morphine and states his pain is ‘under control’. John’s wife has been notified, and is on her way to A&E.”

As Dan is listening to this health history, he progresses to the next stage of the rapid assessment process – the physical assessment of the patient. This continues on from Dan’s observation of John, where he determined there were no obvious injuries, illnesses or other issues which may immediately threaten John’s life or wellbeing. Prior to commencing his assessment, Dan provides John with a brief explanation of what he plans to do and why, and obtains John’s consent. Dan then commences the primary survey. Remembering the ‘ABCD’ mnemonic, Dan assesses John’s:

AAirwayDan assesses John’s airway to be patent. He is breathing and vocalising normally. The C-spine immobilisation helps to maintain airway patency.(Emergency Triage and Rapid Assessment)
BBreathingDan assesses John’s breathing to be normal. He does not appear dyspnoeic. He has symmetrical chest movements with no accessory muscle use. His breath sounds are normal.
CCirculationDan assesses John’s circulation to be normal. He does not appear hypoxic or hypothermic. He has not lost significant blood from the head wound.
DDisabilityDan assesses John’s neurological condition to be normal. He is alert, and is reported to have a GCS of 15. He does, however, have two significant physical disabilities: (1) a contusion to the forehead, and (2) a suspected compound fracture of the left ankle.

Once the primary survey has been completed, Dan progresses to the next stage of the rapid assessment process – the secondary survey. Remembering the ‘EFGH’ mnemonic, Dan works with John to complete the following assessments

EExposureWith John’s consent, Dan exposes John and examines him. No issues, other than those obvious during the primary survey, are identified.(Emergency Triage and Rapid Assessment)
FFull Vital SignsDan takes a full set of vital signs. He finds that John’s HR is 102 (slightly elevated), his RR is 17 (slightly elevated), his BP is 130/85 (slightly elevated), his O2 Sats are 99% (normal), and his T is 36.8 Celsius (normal). Dan determines that John’s mildly elevated HR, RR and BP are likely due to the stress of the situation, rather than any physiological cause; however, he recognises the importance of ongoing monitoring.  
At this stage, Dan also completes a number of other assessments on John, including:Blood laboratory studies – specifically, typing and crossmatching; according to department policy, this is a requirement for all major trauma patients.

Diagnostic imaging studies (e.g. an MRI scan), with the aim of identifying other internal soft tissue or orthopaedic injuries. No spinal injuries are identified; therefore, John’s C-spine immobilisation is removed. It is confirmed that John has a compound fracture of his left ankle. No additional injuries, including none related to the head contusion, are identified.A comprehensive neurological evaluation (e.g. using the Glasgow Coma Scale [GCS]).

Again, John has a GCS of 15 (normal).A neurovascular assessment on the left limb with the broken bones (e.g. colour, temperature, pulses, sensation, motor function). The neurovascular function appears normal.A pain assessment, focusing on the severity of pain experienced. John rates his pain as ‘moderate’, at 6/10.
GGive Comfort MeasuresFollowing the emergency consultant’s orders, and with John’s consent, Dan provides John with another dose of intravenous morphine. At John’s request, Dan brings John’s wife into the emergency bay to be with him. Dan explains to John and his wife the results of the assessment so far, and explains that the plan of care is being developed.
HHead-to-Toe AssessmentIn this step, Dan completes a more comprehensive head-to-toe assessment of John. He sequentially assesses John’s head, neck and face, chest, abdomen and flanks, pelvis, extremities and posterior surfaces. No issues, aside from those already identified, are noted.

Once Dan has completed his rapid assessment of John, more comprehensive care can now be provided to address John’s specific health needs – most importantly, his badly fractured left ankle. The rapid assessment also provides important baseline data which can be used to inform the evaluation of John’s condition over time, and the impact of the care he is provided.

Reference list

Buckinghamshire Healthcare NHS Trust. (ND). Emergency Nursing. Retrieved from: http://www.buckshealthcare.nhs.uk/Downloads/Emergency%20nursing.pdf

Bucher, L. (2007). Nursing Management: Emergency and Disaster Nursing. In S. Lewis, M.M. Heitkemper, S.R. Dirksen, P.G. O’Brien & L. Bucher (Eds.). Medical-Surgical Nursing: Assessment and Management of Clinical Problems – International Edition. (7th edn.): St Louis: Mosby-Elsevier.

Howard, P.K. & Steinmann, R.A. (Eds.). (2010). Sheehy’s Emergency Nursing: Principles and Practice. Naperville, IL: Mosby Elsevier.

House of Commons Library. (2015). Accident and Emergency Statistics. Retrieved from: http://researchbriefings.parliament.uk/ResearchBriefing/Summary/SN06964

Kings Fund. (2016). What’s Going on in A&E? The Key Questions Answered. Retrieved from: http://www.kingsfund.org.uk/projects/urgent-emergency-care/urgent-and-emergency-care-mythbusters

Newell, J. & Smith, P. (2008). Triage in the Light of Four Hour Targets: Results of a Survey of Current Practice in Emergency Departments in the UK. Retrieved from: https://www2.rcn.org.uk/__data/assets/pdf_file/0014/232700/4.3.1_triage_in_light_of_four_hour_target.pdf

Smith, B. & Burscough, S. (2015). Developing a programme of patient ‘streaming’ in an emergency department. International Journal of Orthopaedic & Trauma Nursing, 19(2), 85-91.

Stephenson, J., Andrews, L. & Moore, F. (2015). Developing and introducing a new triage sieve for UK civilian practice. Trauma, 17(2), 140-141.

Related FAQs

1. What is the rapid triage assessment in the emergency nursing environment?

The rapid triage assessment in the emergency nursing environment is a quick assessment that helps the triage nurse identify those patients requiring immediate care from those who can safely wait. In Fast Facts for the Triage Nurse, 2nd Ed., Anna Sivo Montejano DNP, RN, PHN, CEN shares insight into performing the rapid triage assessment.

2. What is the purpose of a triage?

Triage is the process of rapidly examining sick children when they first arrive in order to place them in one of the following categories: 1 Those with EMERGENCY SIGNS who require immediate emergency treatment. 2 Those with PRIORITY SIGNS who should be given priority in the queue so they can be rapidly assessed… 3 Those who have no emergency.

3. What are the signs of a patient being triaged?

Triage of patients involves looking for signs of serious illness or injury. These emergency signs are connected to the Airway – Breathing – Circulation/Consciousness – Dehydration and are easily remembered as ABCD.

4. What is the best way to prioritize patients in triage?

If the triage nurse initially performs a lengthy assessment on each individual, the last patient in line may be the sickest. By rapidly assessing each patient for no more than 60 to 90 seconds, the nurse can best prioritize patients, ensuring that higher acuity level patients are seen first.

Read More:

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