From the Guidelines
Nursing triage involves a systematic assessment process to prioritize patient care based on medical urgency, with the goal of maximizing patient safety and positive outcomes. The first step is the initial rapid assessment where nurses evaluate airway, breathing, and circulation (ABC) to identify immediately life-threatening conditions. Next, nurses collect vital signs including temperature, pulse, respiratory rate, blood pressure, and oxygen saturation to establish baseline measurements. The third step involves gathering a focused medical history, including chief complaint, current symptoms, allergies, medications, and relevant medical history. Nurses then perform a targeted physical assessment based on the presenting complaint, looking for clinical indicators of distress or deterioration.
After assessment, patients are categorized using standardized triage systems like the Emergency Severity Index (ESI) or Manchester Triage System, typically on a 1-5 scale where level 1 represents immediate life-threatening conditions requiring immediate intervention 1. For example, in the case of stroke patients, the ESI puts them in the level 2 or “needs immediate assessment” category, the same as for an unstable trauma patient or a critical care cardiac patient 1. Throughout this process, nurses must document findings thoroughly, initiate appropriate interventions such as oxygen therapy or IV access for critical patients, continuously reassess patients waiting for treatment to detect deterioration, and communicate effectively with the healthcare team.
Some key considerations in nursing triage include:
- Triage to appropriate environment for safe clinical care
- Objective monitoring for change in signs and symptoms suggestive of response to treatment
- Discharge planning and referral to multidisciplinary disease management programme
- Addressing patient anxiety by promptly answering questions and providing clear information to the patient and family 2. Effective and consistent communication should be maintained with the patient and/or family, and relevant changes in clinical status should be promptly addressed and communicated to the physician. This structured approach ensures that limited healthcare resources are allocated appropriately, with the most urgent medical needs addressed first to maximize patient safety and positive outcomes.
From the FDA Drug Label
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From the Research
Nursing Triage and Tasks
The steps involved in nursing triage and tasks to prioritize patient safety and well-being include:
- Assessing the patient's urgency level and analyzing their health status and expected resource needs 3
- Using clinical judgement and triage tools to determine appropriate acuity categories 4
- Communicating clearly the acuity categories assigned to patients 4
- Taking a structured approach to patient assessment to guide decision-making and identify issues 4
- Using diagnostic tests to facilitate the triage process, while avoiding prolonging the process 4
Factors Contributing to Patient Safety
Factors contributing to patient safety during the triage process include:
- Patient assessment and high workload 3
- Frequent interruptions and staffing 3
- Nurse traits, experience, knowledge, triage fatigue, and work schedule 3
- The emergency department's work environment 3
- Triage nurse characteristics, patient characteristics, and work environment 5
Triage Accuracy
Triage accuracy is essential for prioritizing patient care and providing appropriate treatment 5. Factors associated with triage accuracy include:
- Triage nurse characteristics, such as experience and training 5
- Patient characteristics, such as nontrauma and trauma patients 5
- Work environment, including shift time and patient volume 5
Assessing Patient Needs and Planning Care
Nurses play a crucial role in assessing patient needs and planning effective care 6. This includes:
- Assessing people's needs and planning care 6
- Using evidence-based nursing interventions 6
- Keeping accurate records of patient care 6
Impact of Emergency Triage Practices on Patient Safety
Emergency triage practices can impact patient safety, and quality assurance measures are necessary to detect errors 7. A scoping review of the literature can help identify the impact of triage practice errors on patient outcomes 7.