Emergency Triage Workbook PDF

EMERGENCY TRIAGE EDUCATION KIT TRIAGE WORKBOOK www.health.gov.au  EMERGENCY TRIAGE EDUCATION KIT TRIAGE WORKBOOK ISBN: 1 74186 229 9 Publications Number: P3-5240...

EMERGENCY TRIAGE EDUCATION KIT TRIAGE WORKBOOK www.health.gov.au  EMERGENCY TRIAGE EDUCATION KIT TRIAGE WORKBOOK ISBN: 1 74186 229 9 Publications Number: P3-5240 Copyright Statement: (c) Commonwealth of Australia 2009 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Commonwealth. Requests and inquiries concerning reproduction and rights should be addressed to the Commonwealth Copyright Administration, Attorney-General’s Department, Robert Garran Offices, National Circuit, Barton ACT 2600 or posted at http://www.ag.gov.au/cca PO Box 9848, CANBERRA CITY ACT 2601 Website: www.health.gov.au/publicat.html October 2007 Department of Health and Ageing – Emergency Triage Education Kit CONTENTS FOREWORD V ACKNOWLEDGEMENTS VI INTRODUCTION VII CHAPTER 1: INTRODUCTION I Statement of purpose 1 Learning outcomes 1 Learning objectives 1 Content 2 Teaching resources 8 Teaching strategies 9 CHAPTER 2:THE AUSTRALASIAN TRIAGE SCALE 10 Statement of purpose 10 Learning outcomes 10 Learning objectives 10 Content 11 Teaching resources 14 Teaching strategies 14 CHAPTER 3: COMMUNICATION ISSUES 16 Statement of purpose 16 Learning outcomes 16 Learning objectives 16 Content 17 Teaching resources 21 III Teaching strategies 22 CHAPTER 4:TRIAGE BASICS 27 Statement of purpose 27 Learning outcomes 27 Learning objectives 27 Content 28 Teaching resources 34 Teaching strategies 34 CHAPTER 5: MENTAL HEALTH TRIAGE 37 Statement of purpose 37 Learning outcomes 37 Learning objectives 37 Content 38 Teaching resources 46 Teaching strategies 46 CHAPTER 6: RURAL AND REMOTE TRIAGING 49 Statement of purpose 49 Learning outcomes 49 Learning objectives 49 Content 50 Teaching resources 53 Teaching strategies 54 Department of Health and Ageing – Emergency Triage Education Kit  CHAPTER 7: PAIN ASSESSMENT AT TRIAGE 57 Statement of purpose 57 Learning outcomes 57 Learning objectives 57 Content 58 Teaching resources 61 Teaching strategies 62 CHAPTER 8: PAEDIATRIC TRIAGE 63 Statement of purpose 63 Learning outcomes 63 Learning objectives 63 Content 64 Teaching resources 70 Teaching strategies 71 CHAPTER 9: PREGNANCY AND TRIAGE 72 Statement of purpose 72 Learning outcomes 72 Learning objectives 72 Content 73 Teaching resources 77 Teaching strategies 77 CHAPTER 10: MEDICO–LEGAL ISSUES 79 Statement of purpose 79 Learning outcomes 79 Learning objectives 79 IV Content 80 Teaching resources 84 Teaching strategies 85 CHAPTER 11: CONSOLIDATION 87 Statement of purpose 87 Learning outcomes 87 Learning objectives 87 Teaching resources 87 Teaching strategies 87 CHAPTER 12: SELF-TEST 106 Statement of purpose 106 Learning outcomes 106 Learning objectives 106 Teaching resources 106 Teaching strategies 106 APPENDIX A: ACEM POLICY DOCUMENT 132 APPENDIX B: AUSTRALASIAN TRIAGE SCALE DESCRIPTORS FOR CATEGORIES 136 APPENDIX C: CENA TRIAGE NURSE POSITION STATEMENT 139 APPENDIC D: METHODOLOGY 142 APPENDIX E: ANSWERS TO CHAPTERS 11 AND 12 QUESTIONS 149 Answers Chapter 11: Triage Scenarios 149 Answers Chapter 12: Triage Scenarios 168 APPENDIX F: ABBREVIATIONS 192 APPENDIX G: GLOSSARY 193 REFERENCES 194 INDEX 201 Department of Health and Ageing – Emergency Triage Education Kit FOREWORD In 2005–06, nearly 4.8 million people presented to emergency departments in larger Australian hospitals. Only 12 per cent were non-urgent cases. Sixty nine per cent of people were seen within the time recommended for their triage category, with half of this number seen in less than 24 minutes. Despite the pressure on triage staff working, the figures show that they mostly get it right. Providing accurate and timely assessments of seriously ill patients, based on urgency, is what makes the triage system work. A clinically based system of triaging ensures that patients needing priority medical care get it. The Emergency Triage Education Kit aims to provide further support to Triage Nurses. This revised edition includes more than 150 scenarios designed to strengthen Triage Nurses’ assessment skills. It also covers complex areas such as mental health, paediatrics, obstetrics and rural/remote triage. It aims to help nurses provide better assistance to people presenting to emergency departments. The kit was funded by the Commonwealth Government and developed in collaboration with the Australasian College of Emergency Medicine, the Australian College of Emergency Nursing, the College of Emergency Nursing Australasia and the Council of V Remote Area Nurses of Australia. Tony Abbott MP Minister for Health and Ageing Department of Health and Ageing – Emergency Triage Education Kit  ACKNOWLEDGEMENTS Many people and organisations have been involved in the development of this kit. Their feedback and contribution is gratefully appreciated. The contributing authors were: University of Melbourne, School of Enterprise – Marie Frances Gerdtz – Julie Considine – Natisha Sands – Carmel Josephine Stewart – Diane Crellin – Wendy Elizabeth Pollock. LearnPRN – Robin Tchernomoroff – Kaye Knight. Amanda Charles. The National Education Framework for Emergency Triage Working Party, oversaw production and validation of the education tools detailed in this manual. VI The members were: Dr Matthew Chu, Australasian College for Emergency Medicine (ACEM), Director of Emergency Medicine, Canterbury Hospital Ms Tracey Couttie, Paediatrics Triage Clinical Nurse Consultant, Paediatrics Triage, Emergency Department, Wollongong Hospital Ms Judy Harris, College of Emergency Nursing Australasia (CENA), State Management Committee member of CENA, Redcliffe Hospital Dr Marie Gerdtz, Nurse Education, Lecturer in Nurse Education, School of Post Graduate Nursing, University of Melbourne Mr Audas Grant, Rural Clinical Nurse Consultant, Clinical Nurse Consultant, Albury Base Hospital Dr Didier Palmer, Emergency Medicine, Senior Lecturer and Consultant, Emergency Physician, Royal Darwin Hospital Ms Cecily Pollard, Mental Health Liaison Nurse, Liaison Psychiatry Unit, Royal Hobart Hospital Ms Karen Schnitzerling, Director of Nursing, West Coast District Hospital. Council of Remote Area Nurses of Australia (CRANA) Ms Robin Tchernomoroff, Board Member, Australian College of Emergency Nursing Ltd (ACEN), Director LearnPRN Pty Ltd Associate Professor Jeff Wassertheil, Australasian College for Emergency Medicine (ACEM), Director Emergency Medicine, Peninsula Health Mr Rob Wyber-Hughes, Director, Council of Remote Area Nurses of Australia (CRANA), Mr Gordon Tomes, Project Director, Department of Health and Ageing, Acute Care Division. The Department of Health and Ageing would also like to acknowledge the assistance of the expert panel of Triage Nurses throughout Australia for validating the scenarios provided in this kit. Department of Health and Ageing – Emergency Triage Education Kit INTRODUCTION In November 2001, the then Department of Health and Aged Care funded the development of a resource book for nurse educators to promote the consistent application of the Australasian Triage Scale (ATS). This resource is founded on the original fieldwork of Whitby, Leraci, Johnson and Mohsin (1997) that described the clinical features used by Triage Nurses to assess urgency in relation to patient presentations to emergency departments. The ATS (formerly known as the National Triage Scale) has been shown to be both a reliable and valid instrument for sorting patients according to their care requirements in order to optimise clinical outcomes in emergency departments.17,31 In the past decade, a number of researchers have documented acceptable levels of inter-rater reliability among Triage Nurses using the ATS and confirmed its utility in practice.17, 20,31,33 Throughout Australia, triage standards regarding time-to-treatment and performance thresholds are now uniformly employed to quantify both the quality of emergency care and to measure emergency department casemix.4 Enhancing the consistency of the application of the ATS is a shared goal for emergency nursing, the Australasian College for Emergency Medicine (ACEM) and the Australian VII Government Department of Health and Ageing. The first edition of the Emergency Triage Education Kit (ETEK) was published in April 2002 as the Triage Education Resource Book (TERB). This revised edition is the result of a collaborative effort between the Australasian College for Emergency Medicine, the Australian College of Emergency Nursing, the College of Emergency Nursing Australasia and the Council of Remote Area Nurses of Australia. Emergency care is recognised as a nursing specialty of the National Specialisation Framework for Nursing and Midwifery (2006). Additionally, an outcome of the National Health Workforce Strategic Framework (2004) is to build a suitably trained, competent and sustainable health workforce. To underpin this, a single national accreditation scheme for health education and training is to be put in place by 1 July 2008. The Department believes the content of this revised education kit will provide valuable input to the development of emergency triage training materials to support the national accreditation scheme for the emergency care nursing speciality. Department of Health and Ageing – Emergency Triage Education Kit Department of Health and Ageing – Emergency Triage Education Kit CHAPTER 1: INTRODUCTION Statement of purpose The purposes of this chapter are to: Provide an overview of the triage education program and emphasise its role in optimising triage consistency throughout Australia; and Discuss the purpose of triage systems in the context of acute health care delivery. Learning outcomes After completing this chapter, participants will have a clear understanding of the triage education program’s purpose and structure and how the content may be applied in their work environment. Participants will also develop an appreciation of the national and international developments that form the basis of emergency department (ED) triage in Australia. They will also be able to identify factors influencing consistency of triage in that context. 1 Learning objectives State the aims and purpose of ED triage systems. Differentiate the purpose of military and disaster triage systems from ED triage systems. Define ‘urgency’. Make a distinction between the concepts of urgency, severity and complexity of illness and injury. Compare and contrast the basic categories of the Australasian Triage Scale (ATS) with the Canadian Triage and Acuity Scale (CTAS), the Manchester Triage Scale (MTS), and the Emergency Severity Index (ESI). Identify the four essential features of a robust triage scale and discuss these with respect to the ATS. Key points A triage system is the essential structure by which all incoming emergency patients are prioritised using a standard rating scale. The purpose of a triage system is to ensure that the level of emergency care provided is commensurate with clinical criteria. ‘Urgency’ is determined according to the patient’s condition on arrival at the ED. A five-tier triage scale is a valid and reliable method for categorising ED patients. This program forms part of a national strategy aimed at optimising consistency of triage using the ATS. Department of Health and Ageing – Emergency Triage Education Kit  Content The program aims to provide a nationally consistent approach to the educational preparation of nurses for the triage role, particularly the consistent application of the Australasian Triage Scale (ATS).1,2 The program’s educational strategy integrates available evidence into a valid set of training tools. These tools are used by clinicians* performing triage in hospital EDs and those working in rural and remote area health services who make triage decisions as part of their role. The program provides teaching strategies to assist educators in the delivery of specific triage training to suitably qualified and experienced emergency nurses. In the context of rural and remote environments, the program can be used as a self-directed learning package because the core principles for consistent application of the ATS still apply. Program structure The course content has been designed to allow for the inclusion of locally based 2 policies and protocols to optimise consistency of triage or reduce ED transit time. The program comprises the following 10 individual learning units. Chapter 1: Introduction Chapter 2: The Australasian Triage Scale Chapter 3: Communication issues at triage Chapter 4: Triage basics Chapter 5: Mental health triage Chapter 6: Rural and remote triage Chapter 7: Pain assessment at triage Chapter 8: Paediatric triage Chapter 9: Obstetric triage Chapter 10: Medico–legal issues at triage. Each chapter comprises a summary of the key points related to the topic, lesson plans, learning activities and resource materials, including web-based materials, evidence-based reviews, research articles and opinion papers. A summary of each available resource is also provided, stating how the information can be used for training and/or practice. * A clinician is defined as a registered nurse or medical practitioner who is performing triage. Department of Health and Ageing – Emergency Triage Education Kit Program implementation The process for implementing the program involves the following steps: 1. Selection of appropriate participants. The selection of participants to undertake the program will be informed by local policy. Individual organisations will be responsible for setting criteria with respect to the level of emergency experience and qualifications required for entry into the program. Importantly, there is no minimum number of participants required; however it is desirable for participants to have opportunities for group discussions with their peers during the program. 2. Implementation of the lesson plans. The implementation of the lesson plans involves the completion of a series of structured learning activities. Each of the 10 lesson plans comprises learning objectives, a synopsis of the literature relevant to the topics discussed, teaching strategies including learning activities, multiple-choice questions, discussion points and/or patient scenarios, and a list of additional resources for use by participants. The final two chapters consolidate and test the participant’s knowledge. Successful completion of the program is at the discretion of the instructor*. In settings where there is no infrastructure for triage training, the program can be used as a self-paced learning resource, with participants working through the readings and 3 learning activities in a structured way. Definitions Triage system: The process by which a clinician assesses a patient’s clinical urgency. Triage: A triage system is the basic structure in which all incoming patients are categorised into groups using a standard urgency rating scale or structure.3 Re-triage: Clinical status is a dynamic state for all patients. If clinical status changes in a way that will impact upon the triage category, or if additional information becomes available that will influence urgency (see below), then re-triage must occur. When a patient is re-triaged, the initial triage code and any subsequent triage code must be documented. The reason for re-triaging must also be documented.2, 6 Urgency: Urgency is determined according to the patient’s clinical condition and is used to ‘determine the speed of intervention that is necessary to achieve an optimal outcome’.4 Urgency is independent of the severity or complexity of an illness or injury.5 For example, patients may be triaged to a lower urgency rating because it is safe for them to wait for an emergency assessment, even though they may still eventually require a hospital admission for their condition or have significant morbidity and attendant mortality.2 * The instructor will be the nominated person within the organisation who is responsible for clinical development of nurses providing emergency care. Department of Health and Ageing – Emergency Triage Education Kit  A brief history of triage The term ‘triage’ is derived from the French work trier, meaning to pick or to sort.7 Triage systems were first used to prioritise medical care during the Napoleonic wars of the late 18th century. 8 Subsequent wars have led to the refinement of systems for the rapid removal of the injured from the battlefield to places providing definitive care. Mass Casualty Incident (MCI) triaging has also been developed and continues to evolve. The underlying principle of MCI triage is to achieve the greatest good for the greatest number of casualties in a setting where clinical demand overwhelms the available resources. In civilian medicine, triage systems have been refined and adapted for use within a range of settings. In all health care environments, the triage process is underpinned by the premise that a reduction in the time taken to access definitive medical care will improve patient outcomes. Emergency department triage Australia is experiencing increased public demand for emergency medical care. Current trends indicate a growth in the number of ED presentations in many locations; the reasons for this growth are varied and complex.9 4 Standardised triage scales are useful in developing strategies to manage ED demand. In this context they can also be used to inform clinical service development, clinical risk management and patient safety.10 Purpose of a triage system The purpose of a triage system is to ensure that the level and quality of care that is delivered to the community is commensurate with objective clinical criteria, rather than administrative or organisational need. In this way, standardised triage systems aim to optimise the safety and the efficiency of hospital-based emergency services and to ensure equity of access to health services across the population. The use of a standard triage system facilitates quality improvement in EDs, because it allows for comparisons of key performance indicators (i.e. time-to-treatment by triage category) both within and between EDs. Since the early 1990s the use of computerised information systems in Australian EDs has permitted the precise calculation of time-to-treatment against a variety of patient outcomes, including triage code, chief complaint, diagnosis and discharge destination. Department of Health and Ageing – Emergency Triage Education Kit Function of triage Triage is an essential function underpinning the delivery of care in all EDs, where any number of people with a range of conditions may present at the same time. Although triage systems may function in slightly different ways according to a number of local factors, effective triage systems share the following important features: 5 A single entry point for all incoming patients (ambulant and non-ambulant), so that all patients are subjected to the same assessment process. A physical environment that is suitable for undertaking a brief assessment. It needs to include easy access to patients which balances clinical, security and administrative requirements, and the availability of first aid equipment and hand-washing facilities. An organised patient processing system that enables easy flow of patient information from point of triage through to ED assessment, treatment and disposition. Timely data on ED activity levels, including systems for notifying the department of incoming patients from ambulance and other emergency services. Emergency triage scales Internationally, five-tier triage scales have been shown to be a valid and reliable method for categorising people who are seeking assessment and treatment in hospital EDs.11-22 These scales show a greater degree of precision and reliability when compared with either three-tier23 or four-tier triage systems.3 5 The features of a robust triage system can be evaluated according to the following four criteria: Utility: The scale must be relatively easy to understand and simple to apply by emergency nurses and physicians. Validity: The scale should measure what it is designed to measure; that is, it should measure clinical urgency as opposed to severity or complexity of illness or some other aspect of the presentation or of the emergency environment. Reliability: The application of the scale must be independent of the nurse or physician performing the role, that is, it should be consistent. ‘Inter-rater reliability’ is the term used for the statistical measure of agreement that is achieved by two or more raters using the same scale.24 Safety: Triage decisions must be commensurate with objective clinical criteria and must optimise time to medical intervention. In addition, triage scales must be sensitive enough to capture novel presentations of high acuity.3 The Australasian Triage Scale (ATS), formerly the National Triage Scale (NTS) The National Triage Scale (NTS) was implemented in 1993, becoming the first triage system to be used in all publicly funded EDs throughout Australia. In the late 1990s, the NTS underwent refinement and was subsequently renamed the Australasian Triage Scale (ATS). Department of Health and Ageing – Emergency Triage Education Kit  The ATS has five levels of acuity2: Immediately life-threatening (category 1) Imminently life-threatening (category 2) Potentially life-threatening or important time-critical treatment or severe pain (category 3) Potentially life-serious or situational urgency or significant complexity (category 4) Less urgent (category 5). The ATS has been endorsed by the Australasian College for Emergency Medicine1 and adopted in performance indicators by the Australian Council on Healthcare Standards.25 Canadian Triage and Acuity Scale (CTAS) The Canadian Triage and Acuity Scale (CTAS) was officially included in policy throughout Canada in 1997. The CTAS has been endorsed by the Canadian Association of Emergency Physicians and the National Emergency Nurses Affiliation of Canada. This scale is very similar to the ATS in terms of time-to-treatment objectives, with the exception of category 2, which is 30 minutes) immuno-compromised sexual assault Parental concern temperature. death same car occupant congenital disease neglect. explosion. complex medical Hx. 69  Teaching resources Further reading Triage Observation Tool Browne GJ, Gaudry PL, Lam LA. Triage observation scale improves the reliability of the National Triage Scale. Emergency Medicine Australia 1997; 9:283–8.91 The Triage Observation Tool is a more extensive tool than the ATS and focuses on approximately 15 assessment parameters. It addresses history of presenting problem (activity, feeding, output, etc.) and prompts a brief examination (breathing, crying, signs of dehydration, circulation, etc.) and collection of vital signs (heart rate, RR, SpO2, temperature and blood pressure). Yale Observation Scale McCarthy P, Sharpe M, Spiesel S, Dolan T, Forsyth B, DeWitt T, et al. Observation scales to identify serious illness in febrile children. Paediatrics 1982; 705: 802–9.93 McCarthy P, Sharpe M, Spiesel S, Dolan T, Forsyth B, DeWitt T, et al.Yale Observation 70 Scale. In: Family Practice Note Book [Online] 1982 [cited March 24 2007]. Available from: URL: http://www.fpnotebook.com/ID468.htm94 The Yale Observation Scale is a six-point instrument that predicts serious infection and toxic appearance in children from 3 to 36 months of age.Variables include quality of cry, reaction to parents, state variation (arousal), colour, hydration and social response. A total score of 30 is possible, with scores 16 with a 92.3 per cent incidence of serious illness. Additional reading Bromfield L, Higgins D. National comparison of child protection systems. Child Abuse Prevention Issues 2005 Autumn;22. Gorelick MH, Shaw KN, Murphy KO.Validity and reliability of clinical signs in the diagnosis of dehydration in children. Paediatrics 1997; 99(5): e6. Hewson, P, Poulakis, Z, Jarman, F, Kerr, J, McMaster, D, Goodge, J, et al. Clinical markers of serious illness in young infants: a multimeter follow-up study. Journal of Paediatrics & Child Health; 2000, 36(3):221–5.116 Department of Health and Ageing – Emergency Triage Education Kit Teaching strategies Multiple-choice questions Select one answer only. 1. The primary aim of paediatric triage decision-making is to ensure that: (a) ED care is delivered according to clinical need (b) children do not wait in the waiting room (c) children are seen more urgently than adults (d) children do not deteriorate. 2. A physiological approach to triage assessment can be used to evaluate children presenting to the ED because: (a) the priorities of assessment and care are the same regardless of age (b) this approach does not rely on the evaluation of vital signs which differ vastly with age (c) the differences between adults and children can be accounted for in assessment and interpretation of findings using this approach (d) both (a) and (d). 3. A mother presents to the ED with a three-month-old baby with fever and poor feeding.Your first priority of assessment is: (a) evaluation of the infant’s hydration status 71 (b) assessment of airway patency (c) establishing the colour of the child’s skin (d) measuring the child’s temperature. 4. The following sign is negatively predictive for serious illness: (a) feeding within normal limits (b) smiling (c) fever (d) alterations in activity or conscious state. 5. A two-year-old child with a soft stridor, mild increase in work of breathing, pink and warm skin who is playful during assessment should be allocated the following urgency category: (a) ATS 1 (b) ATS 2 (c) ATS 3 (d) ATS 4. Critical discussion After completing the lesson and the prescribed reading, discuss the following: 1. What (national or local) policies exist to influence paediatric triage practice, and why have they been implemented? 2. How do these policies impact on other patients presenting to the ED and on the effectiveness of the triage system? Department of Health and Ageing – Emergency Triage Education Kit Department of Health and Ageing – Emergency Triage Education Kit CHAPTER 9: PREGNANCY AND TRIAGE Statement of purpose The purposes of this chapter are to: Provide an outline of the physiological adaptations that occur in pregnancy; and Discuss the factors that influence the triage code allocation for pregnant women. Learning outcomes After completing this chapter, participants will be able to state the main physiological changes that occur in pregnancy and explain how these adaptations will influence the allocation of a triage code. Participants will also be able to identify common and life-threatening complications that present to triage and discuss how urgency is determined for these conditions. Learning objectives 72 Outline the physiological changes in pregnancy that may modify triage decision-making. Describe the relevant questions to ask about a woman’s obstetric history. Discuss common non-obstetric conditions that may adversely impact on a pregnant woman and the unborn child. Explain the maternal factors that may alert the Triage Nurse that urgent foetal assessment is required. Discuss significant obstetric complications of pregnancy that impact on the pregnant woman and the unborn child. Key points All women of child-bearing age should be considered to be pregnant until proven otherwise. An assessment of urgency must be made on the basis of both the woman and the foetus. An elevated BP is an ominous sign: the higher the BP the more urgent the review. Pregnant women are at an increased risk of a number of conditions, including cerebral haemorrhage, cerebral thrombosis, severe pneumonia, atrial arrhythmias, venous thrombosis and embolus, spontaneous arterial dissection, cholelithiasis and pyelonephritis, than non-pregnant women of child-bearing age. Presentations may include concerns about normal manifestations or progression of pregnancy. Department of Health and Ageing – Emergency Triage Education Kit  Content Triage and the pregnant patient A pregnant woman presenting to an ED raises a number of unique challenges to the Triage Nurse. The Triage Nurse needs to be aware of the normal physiological and anatomical adaptations of pregnancy because these will influence assessment. Triaging should consider the wellbeing of both the mother and the foetus and potential threats to either. The pregnant woman may present with any disease. The presentation of some diseases is modified by pregnancy and some diseases only occur in pregnancy. Pregnancy and the primary survey Airway Any pregnant women presenting to the ED with a potentially compromised airway needs urgent medical attention. Pregnant women are often difficult intubations due 73 to patient size, patient positioning and different induction agent requirements due to cardiovascular physiological changes. Breathing Progesterone is thought to be responsible for altering the sensitivity of the respiratory centre and increasing the drive to breathe.119 Pregnant women commonly experience increased nasal and airway vascularisation and mucosal oedema. This presents as an increase in complaints about nasal congestion. About one-third of women with asthma suffer a deterioration of their illness during pregnancy.120 Circulation Pregnancy is described as a hyperdynamic state and physiological changes occur as early as 6–8 weeks gestation. Progesterone causes widespread vasodilatation and oestrogen is thought to contribute to a 40–50 per cent increase of blood volume. The diastolic blood pressure falls on average 6–17 mmHg, with BP lowest during the second trimester. Cardiac output (CO) increases by 30–50 per cent. At 20 weeks gestation, the weight of the uterus compresses the inferior vena cava if the woman is lying on her back. The subsequent reduction in placental flow is enough to compromise foetal wellbeing and the drop in venous return reduces maternal CO and BP. Unspecified changes occur to blood vessels that predispose pregnant women to spontaneous arterial dissections.121 Department of Health and Ageing – Emergency Triage Education Kit The splenic artery, subclavian artery and aorta, for example, have an increased tendency to spontaneous dissection, even in women with no previous medical history. Domestic violence is more common during pregnancy and is associated with an increase in obstetric complications for the mother and adverse neonatal outcomes.123 Important points to note: Pregnant women often describe palpitations during pregnancy, which is usually due to the hyperdynamic flow. The high volume and dynamic blood flow is thought to contribute to the increased likelihood of cerebral haemorrhage (especially sub-arachnoid haemorrhage (SAH)) in pregnancy. It is not uncommon for pregnant women to experience a sudden and serious deterioration of their condition therefore pregnant women showing signs of haemodynamic de-compensation require urgent medical assessment.124 All pregnant women >20 weeks gestation should have a left lateral tilt (wedge under their right hip, or whole bed tilted if wedge is contraindicated) if they are lying down. Pulmonary embolus is relatively common during pregnancy due to the changes in the coagulation system associated with pregnancy. In the setting of trauma, all usual trauma criteria should be considered. Additional considerations include trauma to the uterus, placenta or foetus, particularly in the third trimester when the foetus is viable. The maternal vital signs may remain stable even when loss of one-third of blood volume may have occurred.125 74 ‘The best initial treatment for the foetus is the optimum resuscitation of the mother.’125 Common conditions that present to ED according to gestational age Problems occurring prior to 20 weeks Pregnant women frequently present to the ED with vaginal bleeding. Common causes include the various types of miscarriage (i.e. threatened, inevitable, complete, incomplete and septic). Knowledge of the volume and colour of per vaginal (PV) loss will assist the Triage Nurse with categorising the urgency of the case. Bright red blood loss is usually indicative of active bleeding, while brownish red blood loss is usually old. Many women may also complain of associated abdominal pain that may be likened to severe period pain. Shoulder tip pain can be indicative of a bleeding ectopic pregnancy. The first and foremost diagnosis to exclude in the female of child-bearing age, including those who have undergone sterilisation procedures presenting with vaginal bleeding, is an ectopic pregnancy.126 Department of Health and Ageing – Emergency Triage Education Kit  Abdominal pain is the most common symptom in ruptured ectopic pregnancy.127 Non-ruptured ectopic pregnancies generally present with bleeding (brown being the most common) due to low progesterone and consequent shedding of the decidua. Regardless of the diagnosis, vital signs that deviate from normal and severe pain (such as torsion or ruptured cysts) warrant prompt medical assessment. Problems occurring from 20 weeks onwards Pregnant women from 20 weeks gestation may present with the following obstetric conditions: Antepartum haemorrhage Preeclampsia (including eclampsia) Pre-term rupture of the membranes and labour. Hypertension (>140/90) is a particularly important sign to alert the Triage Nurse to a more serious problem. The presence of the associated symptoms of severe preeclampsia warrants urgent medical assessment. These include: Headache Visual disturbances Epigastric pain Right upper quadrant (RUQ) pain 75 Non-dependent oedema. These women are at risk of fitting and placental abruption, and the foetus has a higher risk of placental insufficiency. There is a correlation between the degree of hypertension and complications such as cerebral haemorrhage. Antepartum haemorrhage is defined as >15 mL of blood loss from the vagina from 20 weeks gestation. Common causes include placenta praevia and placental abruption. In placenta praevia, blood loss is usually visible PV and is not usually accompanied by pain. In placental abruption, the primary symptom is abdominal pain. The associated blood loss may be concealed between the placenta and uterus. Haemodynamic changes are only seen with big bleeds, smaller bleeds may be difficult to detect or more easily detected with an abnormal cardiotocograph (CTG).The main signs and symptoms are haemodynamic changes associated with hypovolaemic shock and abdominal pain. Department of Health and Ageing – Emergency Triage Education Kit Postnatal women may present with the following: Secondary postpartum haemorrhage ± puerperal sepsis Mastitis Wound infection Eclampsia Postpartum cardiomyopathy Postnatal depression. Urgent threats to foetal wellbeing Changes in oxygen saturations in the mother are of direct relevance to foetal wellbeing. A small reduction in maternal oxygenation can severely impact on foetal oxygenation because of the left shift in the oxyhaemoglobin dissociation curve associated with foetal haemoglobin.129 Consider oxygen saturation at triage on all pregnant women. Major alterations in blood pressure (whether high or low) are not well tolerated by the foetus. Active vaginal bleeding at any gestation presents a risk to the foetus. Abdominal pain during pregnancy may represent a pathological process threatening the foetus. Pregnant women normally feel foetal movement from 18–20 weeks gestation. A regular pattern of foetal movement is a reassuring sign of foetal wellbeing. Absent or diminished foetal movements require prompt assessment. 76 Department of Health and Ageing – Emergency Triage Education Kit  Teaching resources Further reading Angelini DJ. Obstetric triage revisited: Update on non-obstetric surgical conditions in pregnancy. Journal of Midwifery & Womens Health 2003;48(2):111–18. Beischer NA, MacKay EV, Colditz PB. Obstetrics and the Newborn: An Illustrated Textbook. 3rd ed. London: Bailliere Tindall; 1997 Coppola M, Della-Giustina D. Emergency Gynaecological Presentations. Emergency Medicine Clinics of North America 2003; Aug: 21.3 DeLashaw MR,Vizioli TL, et al. Headache and seizure in a young woman postpartum. Journal of Emergency Medicine 2005;29(3):289–93. Fuschino W. Physiologic changes of pregnancy: impact on critical care. Critical Care Clinics of North America 1992;4(4):691–701. Murray H, Baakdah H. et al. Diagnosis and treatment of ectopic pregnancy. Canadian Medical Association Journal 2005;173(8):905–12. 77 Teaching strategies Multiple-choice questions Select the correct response by circling one answer only. 1. The normal blood pressure changes that occur during pregnancy, develop: (a) at about 20 weeks gestation (b) from about 6–8 weeks gestation (c) during the third trimester (d) during the second trimester. 2. A 26-year-old woman in her third trimester presents to the ED with a severe headache. What are the primary pieces of information you need to make a triage decision? (a) past medical history, presenting history (b) conscious state and blood pressure (c) what medications the woman has taken (d) her gestation and presence of foetal movements Department of Health and Ageing – Emergency Triage Education Kit Short-answer questions 1. A 42-year-old woman presents with no foetal movements. Discuss the information you need to determine a triage category. 2. A 32-year-old woman presents with PV bleeding. She says that it is possible that she is pregnant, though she’s not sure. Describe how you would assess this woman. 3. A 39-year-old woman who is 27 weeks pregnant presents to the ED with chest pain. What are the potential causes of this symptom, and how may they be distinguished? Discussion points After completing the prescribed reading consider the following questions. Discuss your answers with a peer or your educator. 1. What are the key questions you would ask about the pregnancy, when a pregnant woman presented to triage? 2. Acutely unwell pregnant women may remain haemodynamically stable until a sudden deterioration in condition takes place. Why may there be a delay in changes to vital signs in pregnant women? 78 Department of Health and Ageing – Emergency Triage Education Kit Department of Health and Ageing – Emergency Triage Education Kit CHAPTER 10: MEDICO–LEGAL ISSUES Statement of purpose The purpose of this chapter is to outline the legal responsibilities associated with the professional practice of triage. Learning outcomes After completing this chapter, participants will be able to apply medico–legal concepts to triage practice. Learning objectives Discuss the role of education and supervised practice in relation to triaging; and Describe the medico–legal responsibilities of the nurse performing the triage role including: – Informed consent 79 – Duty of care – Negligence – Documentation – Confidentiality – Preservation of forensic evidence. Key points Nurses performing the role of triage must have appropriate education and supervised practice prior to practicing independent triage. Documentation must be accurate and contemporaneous. There should be clear understanding of duty of care. Nurses must appreciate the importance of re-triaging. Policies and protocols should be readily accessible for the nurse performing the triage role. Department of Health and Ageing – Emergency Triage Education Kit  Content Role of the Triage Nurse A nurse performing triage must have an appropriate level of knowledge and skills to perform the role. Nurses have a legal and professional duty to perform the role of Triage Nurse utilising a systematic approach. Emergency Nurses, as professionals, are accountable for their practice. The accountability comes from the utilisation of available protocols, the completion of the correct documentation, and adherence to standards and quality guidelines. Protocols ideally help in the maintenance of a consistently high standard of care at the institution and can be utilised if necessary to provide evidence of the clinical practice encouraged at the health care facility. The physiological discriminators and Australasian Triage Scale (ATS) are examples of the guidelines that are available for the nurse to utilise. It is not assumed that following protocols blindly will protect the nurse from any legal liability. With this in mind, consideration should also be given to the autonomy of the role, with use made of the Triage Nurses’ independent judgement for each triage episode, and the ability to utilise his or her expertise to individualise the assessment of the patient. 80 Protocols should be viewed as the minimum standard of care required to be delivered. Position statements that describe the roles and responsibilities of the Triage Nurse including the minimum practice standard have been produced by the professional bodies. All nurses should know some basic legal principles, which include consent, the elements of negligence, definition and sources of the standards of care, and how policies and guidelines can influence practice. There is an expectation that the nurse performing the role of the Triage Nurse will have had adequate experience, training and supervision to perform the role. The employing institution also has a responsibility to ensure that the staff are adequately prepared to perform the role. Consent The five elements of consent are as follows: 1. Consent must be given voluntarily. 2. A person must have the legal capacity to give consent. 3. Consent should be informed. 4. Consent must be specific. 5. Consent must cover what is actually done. Department of Health and Ageing – Emergency Triage Education Kit The absence of any one element renders the consent invalid. Consent may be given in several ways: Implied consent: Implied consent is the most straightforward. With implied consent, by virtue of the patient presenting at the triage area to be assessed does not necessarily imply consent, but consent is often implied by the patient’s behaviour. This implied consent becomes less defined if the patient is confused or unable to communicate for any other reason. Verbal consent: This form of consent is more valid than implied consent. For example, if the Triage Nurse states that he or she is going to ask the patient a couple of questions, and the patient agrees to this, this implies verbal consent. Written consent: This form of consent is not something that is necessarily obtained by the Triage Nurse during his or her assessment, however there should be awareness of the local policies and procedures regarding obtaining of written consent. Duty of care By engaging with a patient as they present to the ED, the Triage Nurse enters into a health professional–patient relationship. The nurse shares the responsibility of the hospital to ensure that patients who present to the ED are offered an appropriate assessment of their treatment needs. A ‘duty’ is an obligation that is recognised by law, and the nurse’s duty to a patient is to 81 provide the same level or degree of care that would be employed by a nurse practising under similar or the same circumstances. The Triage Nurse then has an obligation to try to protect the patient from any foreseeable harm or injury ensuring a reasonable standard of care. This reasonable standard of care may be informed by policies such as the Minimum Standards for Triage and other documents such as the Australian Nursing and Midwifery Council (ANMC) competencies. Scales such as the ATS are also utilised to guide decision-making, remembering that the ATS are guidelines for care. There are certain circumstances when the Triage Nurse may be forced to rapidly detain a patient because, if they leave they pose a risk of harming themselves or others in the community. Such action is covered by legislation (which is different in different jurisdictions) and may be initiated under the principle of necessity under common law. It is important that such circumstances are immediately referred to the senior clinician on duty. The proportion of patients who do not wait for medical treatment in EDs may be up to 20 per cent of presentations. This is regarded as representing a failure to access the health system. Patients may choose to leave the hospital without being seen by the medical staff in the ED, and if the patient is competent the Triage Nurse cannot restrain them. However, the Triage Nurse has a responsibility to warn the patient of the consequences of such a decision, and appropriate documentation recording this decision should be completed by the patient and witnessed. Department of Health and Ageing – Emergency Triage Education Kit  However, patients who have cognitive impairment from drug use, alcohol use or mental illness are at risk from adverse events in such situations. The Triage Nurse must therefore consider their duty of care in such cases. The Triage Nurse must be aware of his or her responsibilities with these patients and abide by any local policies or protocols. Negligence Negligence laws vary between states and have recently undergone significant changes. Nurses have a responsibility to behave in a reasonable manner. If there is any breach from this responsible approach which results in some type of injury to another, this breach constitutes negligence. For negligence to be proven it requires the establishment of all of the following elements: Duty to meet the standard of care Breach of the duty to meet the standard of care Breach of that duty which causes foreseeable harm Causing actual harm and injury Causing loss. 82 Documentation requirements Communication with and by the staff leads to increased information shared and clear advice given. Medical records are a method of communication for health care team members and are a contemporaneous record of events.They must be accurate, clear and succinct. It is also expected that the records will be easily accessible and able to be understood. Documentation of each interaction between the nurse performing triage and the patient and/or significant others are another area of accountability for practice. The Australasian College for Emergency Medicine (ACEM) is clear in its guidelines about the minimum information that is required to be recorded for any triage episode. Documentation standards that are required by ACEM are: Date and time of triage assessment Name of the Triage Nurse Chief complaint/presenting problem Limited relevant history Relevant assessment findings Initial triage category allocated Re-triage category with time and reason Assessment and treatment area allocated Diagnostic, first aid or treatment initiated at triage. Any change in the patient’s condition should be documented clearly. This documentation should include the time of the re-triage, the reason for the re-triage and who was responsible for the performance of the re-triage. (See ‘The Challenge of Triage’ on page 33 of Chapter 4.) Department of Health and Ageing – Emergency Triage Education Kit The Triage Nurse should be aware of the management systems in place at the individual institutions to facilitate this documentation. Similarly, if it is the practice of the institution to transfer the care of patients to other health care providers such as general practitioners, accurate and concise documentation of any treatment administered and any recommended course of action should be made. Some patients choose to leave prior to medical assessment. If such a patient advises the Triage Nurse they are not waiting, the Triage Nurse should document this decision, as well as any advice given to the patient, including possible adverse outcomes. Confidentiality Health professionals must maintain any information that has been provided in-confidence to them. It is also expected that the patient is in receipt of privacy from health professionals. Safeguards are in place to protect patient’s information. These include health legislation at both federal and state level. The Triage Nurse also has a responsibility to ensure the patient’s privacy is respected both during the triage assessment and while the patient waits in the waiting room. The hospital policy regarding patient’s privacy and rights should also be readily accessible to the Triage Nurse. 83 A health care professional is obliged to treat the patient’s medical information as private and confidential. However, in certain circumstances there is a legal requirement to override a patient’s privacy and confidentiality; for example, children at risk. Otherwise, a breach of a patient’s privacy constitutes a breach of the duty of care. Mandatory reporting responsibilities If there is any suspicion that a child or children may be in need of care or may be being maltreated, the nurse has a legal responsibility to report it to the relevant authorities and refer to their jurisdiction. Although this reporting may not occur from the triage desk, the nurse needs to be aware of the legal requirements and of the procedures and documentation requirements of the hospital, in order to fulfil these obligations. Preservation of forensic evidence Nurses performing the triage role must be familiar with the hospital’s procedures for dealing with the preservation of forensic evidence involving a patient who is a possible victim of crime (e.g. rape or assault). These procedures should include liaison with police officers as appropriate, with the patient’s consent. Department of Health and Ageing – Emergency Triage Education Kit  Teaching resources Further reading Australasian College for Emergency Medicine. Guidelines for implementation of the Australasian Triage Scale in Emergency Departments. ACEM [Online] 2005 [cited 2007 Feb 2]. Available from: URL: http://www.acem.org.au/media/policies_and_guidelines/G24_Implementation__ ATS.pdf 2 Australasian College for Emergency Medicine. Policy on the Australasian Triage Scale. ACEM [Online] 2006 [cited 2007 Feb 2]. Available from: URL: http://www.acem.org.au/media/policies_and_guidelines/P06_Aust_Triage_ Scale_-_Nov_2000.pdf1 Australian Nursing and Midwifery Council. National Competency Standards for the Registered Nurse. ANMC [Online] 2005 [cited 2007 Mar 9]. Available from: URL: http://www.anmc.org.au/docs/Competency_standards_RN.pdf Australian Nursing and Midwifery Council. National Competency Standards for the Enrolled Nurse. ANMC [Online] 2005 [cited 2007 Mar 9]. Available from: 84 URL: http://www.anmc.org.au/docs/Publications/Competency%20standards%20EN.pdf Australian Nursing and Midwifery Council. Code of Professional Conduct for Nurses in Australia. ANMC [Online] 2005 [cited 2007 Mar 9]. Available from: URL: http://www.anmc.org.au/docs/Publications/ANMC%20Professional%20Conduct.pdf Bromfield L, Higgins D. National comparison of child protection systems. Child Abuse Prevention Issues 2005 Autumn;22. College of Emergency Nursing Australasia. Availabe from: URL: http://www.cena.org.au Wand T. Duty of care in the emergency department. International Journal of Mental Health Nursing 2004; 13(2): 135–9 This paper explores issues that relate to the management of deliberate self-harm in the ED from a New South Wales perspective. Tim Wand is a nurse practitioner in the ED at the Royal Prince Alfred Hospital. Department of Health and Ageing – Emergency Triage Education Kit Teaching strategies Discussion points 1. Join with a colleague and role-play patient presentations to triage. Attempt to be as varied in your complaints as possible.Your colleague is to perform an accurate and succinct triage assessment, including the documentation of the assessment and the utilisation of the ATS. The documentation should take into consideration the objective assessment. 2. Identify what the requirements are of the health care facility for the documentation of patients who choose not to wait for treatment or who leave at their own risk. 3. Be familiar with the triage area including any extra resources such as protocols that may be available. 4. Observe an experienced nurse performing the triage role, including review of documentation. 5. Identify the policies/protocols for the individual health care facility that demonstrates the standard of care. 85 6. Use the following patient scenarios as a basis for discussion in tutorial groups. Patient scenarios 1. John Oliver was a 25-year-old man who was a regular night clubber and had spent the night before out with friend until the early hours of the morning. Later that day he attended the local ED and was complaining of a headache. He was accompanied by a friend who waited with him in the waiting room. He was assessed as an ATS category 4 and was seated in the waiting room accompanied by his friend. After two hours, the friend spoke to the Triage Nurse about his concerns for his friend, but John made the decision not to wait to be seen by a doctor and went home. The next day he was found to have died at home. Suggested areas for discussion include: The identification of the role/responsibility of the Triage Nurse to stop John from leaving the ED; The documentation of any interactions with the patient or his friend; and The procedure of documentation at the hospital. 2. A five-year-old girl is brought in by ambulance with moderately severe asthma. She is accompanied by her 14-year-old brother who is translating for her. Her mother is at home, being unable to attend as she is 38 weeks pregnant (and is looking after a three and seven year old). What issues does this presentation illustrate? Why? Department of Health and Ageing – Emergency Triage Education Kit  3. A 15-year-old girl presents to triage in the presence of police, smelling of alcohol, stating that she was raped in the toilets of the local club. Outline your responsibilities as a Triage Nurse and describe local practices to manage this case. 4. A six-year-old presents with his mother with a deep laceration to his arm. His mother states that he fell over in the park. The wound is not actively bleeding, and you assign him an ATS category 4. You place him in the waiting room and 30 minutes later they are gone.You phone the mobile number they have given and find that it is disconnected. What do you do next? 5. A woman aged 40 is brought in by ambulance, having called it herself. She reports feeling suicidal, and states that she has the necessary tablets and that she wrote a suicidal note. But she says she changed her mind and wants help. She identifies multiple recent stressors. (a) How would you go about triaging this person? (b) Someone else has triaged the woman as an ATS category 3 and placed her in the waiting room.You go to call the patient but she has left. 6. Information about a patient is requested of the Triage Nurse by: A police officer 86 A child protection worker The media The patient’s employer The driver of the other car involved in the accident A concerned bystander or witness to the accident The patient’s parent A relative of the patient Another member of the hospital staff. (a) What are your responsibilities? (b) How would you deal with this situation? 7. Identify the risks associated with the note ‘DNW’ (did not wait) being the only documentation by a Triage Nurse of a patient who did not wait to be seen for medical treatment. Department of Health and Ageing – Emergency Triage Education Kit CHAPTER 11: CONSOLIDATION Statement of purpose The purposes of this chapter are to: Apply the principles learnt in Chapters 1–10 to a set of 63 triage scenarios; Use the tools contained within the ETEK to assist decision-making; and Assess your own level of decision making consistency by comparing your performance with the expected triage category for this scenario set. Learning outcomes After completing this chapter, participants will have consolidated the principles learnt in Chapters 1–10, and will be familiar with the application of the ATS guidelines to actual occasions of triage. Learning objectives Choose the most appropriate ATS category for each of the 63 triage scenarios. 87 Teaching resources Australasian College for Emergency Medicine. Guidelines for Implementation of the Australasian Triage Scale in EDs. ACEM [Online] 2005 [cited 2007 Feb 2]. Available from: URL: http://www.acem.org.au/media/policies_and_guidelines/G24_Implementation_ATS.pdf Mental Health Triage Tool – Table 5.1, page 43. Paediatric Triage Tool – Table 8.2, page 68. Teaching strategies This activity will take approximately two hours, of which 30 minutes should be spent discussing answers and obtaining feedback on performance for the scenario set. For each triage scenario, select the ATS category you think is most appropriate by ticking the box; chose one option only. Make notes in the comments section to justify your decisions. When you have finished, compare your answers with the answer guide (see Appendix E). Discuss any disagreements with your triage instructor. Department of Health and Ageing – Emergency Triage Education Kit  Triage scenarios 1. Ebony is a four-month-old girl who is brought to the ED by her mother at 4.00 pm. Her mother states that the child has had difficulty breathing for two days and has been worse overnight. The child has been coughing and feeding poorly. Her fluid intake has been approximately half that of a normal day and she has had a decrease in the number of wet nappies. She has a moist-sounding cough and no audible wheeze. She is tachypneic with a respiratory rate of 60 breaths per minute. Examination of her chest shows mild use of accessory muscles. On auscultation she has an expiratory wheeze. Her skin is pink and she has moist mucous membranes. 1 2 3 4 5 Comments: 2. Laura is a 10-year-old girl who presents to the ED at 11.00 pm with her older sibling saying that she has had abdominal pain for the past few hours. She indicates that the pain is across the centre of her stomach and paracetamol has not helped. She complains of nausea and says that she has vomited once since the onset of pain. When asked, she states that she has had normal bowel motions. She is able to give 88 her own history while leaning over onto the desk, holding her stomach. Her skin is 88 89 pink and she is not short of breath. 1 2 3 4 5 Comments: 3. Graham is a 55-year-old male who presents to the ED accompanied by his partner. He states that he has been ‘bleeding from the back passage’ since the previous night. He is very anxious about the bleeding and reports that it was ‘bright red’ in colour and ‘filled the toilet bowl’ on two occasions. His blood pressure is 155/100; his heart rate is 102 beats per minute; his respiratory rate is 20 breaths per minute. 1 2 3 4 5 Comments: Department of Health and Ageing – Emergency Triage Education Kit  4. Louisa is a 24-year-old female who presents to the ED with her friend after ‘fainting’ in the toilet at home. She is complaining of left-sided abdominal pains, which she has had ‘on and off’ for several months. She previously attended the ED two weeks ago for the same problem. An abdominal ultrasound was performed at that time but identified no abnormalities. She rates her pain as ‘six out of ten’. Her heart rate is 82 beats per minute and her respiratory rate is 18 breaths per minute. Her skin is cool and dry. She looks pale and uncomfortable. 1 2 3 4 5 Comments: 5. A mother presents to the ED at 9.20 pm with her nine-week-old son, Christopher, stating that he has had a fever since 4.00 pm that afternoon. She gave him paracetamol at 5.00 pm. She says that he normally vomits after feeds but has vomited once this evening between feeds. Christopher is breast-fed; he has fed less frequently this evening. Christopher’s mother also informs you that he had his first immunisation two days ago. He is in his mother’s arms and is crying. He appears slightly pale. His hands are warm but his feet are cold. Capillary refill is about two seconds and he has moist mucous membranes and normal skin turgor. His anterior 9 fontanelle is not bulging. 89 1 2 3 4 5 Comments: 6. Kimberley is 32 years of age. She was sent to the ED following an accident at work. She was carrying a pot of hot oil and slipped, spilling it on her upper legs. She immediately removed her clothing and stood under a cool shower for 15 minutes. On arrival in the ED she is in considerable pain (‘nine out of ten’).You estimate that she has approximately eight per cent burns to her anterior thighs. Her heart rate is 110 beats per minute and her respiratory rate is 24 breaths per minute. 1 2 3 4 5 Comments: Department of Health and Ageing – Emergency Triage Education Kit  7. Michaela is a three-week-old infant who is brought to the ED at 9.30 pm by her parents. She has been referred by her local doctor. Her parents state that Michaela has been feeding poorly for several days and that her weight gain has been poor. The infant seems lethargic. The parents have not noticed a fever. The infant is sleeping in her mother’s arms and her skin is pale. Her peripheries are cool and her eyes slightly sunken. Painful stimulus is required to wake the child, who then wriggles and cries vigorously. 1 2 3 4 5 Comments: 8. Toby is an 18-month-old boy who presents to triage at 6.00 pm with his parents. They state that he has been ‘unwell’ for two days; he started vomiting 48 hours ago, developed diarrhoea yesterday and has had seven loose stools today. He has had episodes of ‘crying and drawing up his legs’. He is drinking small amounts. He appears lethargic and uninterested in his surroundings. He is pale and his capillary refill is approximately three to four seconds. 1 2 3 4 5 90 90 9 Comments: 9. Edward is a 36-year-old male with a past history of alcoholism. He presents to triage at 5.30 pm. He has a referral letter from the nearby drug and alcohol service and an escort. The referral letter states that the patient has ‘suicidal ideation and homicidal thoughts’. The letter requests a psychiatric assessment and states that the patient is ‘possibly experiencing alcohol withdrawal’. He states that his last drink was at 9.00 am. 1 2 3 4 5 Comments: 10. Rae, a 24-year-old university student, comes to the ED with a friend. She has a four-hour history of generalised abdominal pain now localised to the right iliac fossa. She has vomited twice and had one episode of diarrhoea about two hours ago. Her heart rate is 92 beats per minute and her temperature is 38.2°C. 1 2 3 4 5 Comments: Department of Health and Ageing – Emergency Triage Education Kit  11. A father presents to the ED at 8.00 pm with his three-and-a-half-year-old daughter, Savannah, stating that she has had a sore throat for ‘a day or two’. It started with a runny nose and a fever, and then yesterday she began complaining of a sore throat. She has no cough or stridor, she demonstrates no shortness of breath and her skin is pink and warm. 1 2 3 4 5 Comments: 12. Baz, 34 years old, was installing a ceiling fan with the assistance of a friend in his own home. He received a 240 volt charge to his right hand, and was thrown back against the roof. His friend immediately switched the power off and called an ambulance. Baz had a brief period of loss of consciousness, but was alert when the ambulance crew arrived. His heart rate is 80 beats per minute and irregular; his respirations are 20 breaths per minute. He has a five centimetre blackened area to his right hand. No exit wound is seen. 1 2 3 4 5 91 Comments: 91 13. Hannah is a 41-year-old woman who presents via ambulance with an altered conscious state following collapse. She is 30 weeks pregnant (G3P1) and is normally well. She was out shopping with a friend when she suddenly collapsed. Ambulance officers report a fluctuating conscious state. At the scene she tolerated an oropharyngeal airway but spat it out en route. She is in a lateral position on the ambulance trolley with supplemental oxygen via a mask. Her respiratory rate is 10 breaths per minute. Her SpO2 is 93 per cent; her heart rate is 130 beats per minute. Her skin is pale, cool and moist. Her blood pressure is 190/110. Her Glasgow Coma Score is 10 out of 15. Her temperature is 36.3°C. 1 2 3 4 5 Comments: Department of Health and Ageing – Emergency Triage Education Kit  14. Mr J is a 74-year-old man who is brought to the ED by ambulance at 5.10 am. He has acute shortness of breath and a history of left ventricular failure. His heart rate is 112 beats per minute and irregular, his blood pressure is 180/100 and his respiratory rate is 30 breaths per minute, with accessory muscle use. His SpO2 is 89 per cent, but the pulse oximetry display is giving a poor trace. Oxygen is being administered at 100 per cent via bag-valve-mask. Mr J is trying to remove the mask and is very agitated. 1 2 3 4 5 Comments: 15. Bo is a 16-month-old boy who presents to triage at 11.00 am with his mother. She states that he has had ‘a cold for over a week’ which ‘has not improved’. Since last night he has had a fever and a cough and has seemed ‘more congested’. He was restless over night, is tired today and is drinking less than usual. He is resting against his mother and doesn’t protest when examined. No cough, stridor or grunting is heard. He is tachypneic and demonstrates mildly increased work of breathing. His skin is flushed and warm. His capillary refill is less than two seconds and his mucous membranes are moist. 92 92 9 1 2 3 4 5 Comments: 16. Luka is a nine-year-old boy who presents to triage with his father at 3.00 pm. He has an injured elbow as a result of a fall playing football. He is distressed and is clutching his arm, which is in a sling. He tells you that his pain is ‘ ten out of ten’. His left elbow is markedly swollen and deformed. He has a strong radial pulse, and sensation distal to the injury is intact. He is pale, slightly diaphoretic and tachycardic. 1 2 3 4 5 Comments: Department of Health and Ageing – Emergency Triage Education Kit  17. Albert, 62 years old, often attends your ED. Today he says he is constipated. His bowels have not opened for ‘at least two weeks’. He says he has pain and feels bloated. When you ask him to score his pain he is not sure what to say and just answers ‘it’s really bad’. His vital signs are within normal limits and his skin is warm and dry. 1 2 3 4 5 Comments: 18. Sebastian is a 16-year-old boy who is brought to the ED by a passer-by, who found him crying and banging his head against the footpath in a small laneway. After bringing Sebastian to the triage the accompanying adult leaves the ED. Sebastian has superficial lacerations to both wrists, and is dishevelled and unkempt. He is upset about having being brought to the ED, and is saying, ‘just leave me alone – why don’t you just piss off’. He admits trying to hurt himself, and says that he will do so again as soon as he can. 1 2 3 4 5 93 Comments: 93 19. Anne-Marie is a 22-year-old female who is brought to the ED by her flatmates, who are concerned about her bizarre behaviour. She had been talking to herself for several days, turning the television off and on because it is sending her messages, yelling out at night and not sleeping. Her flat mates are concerned that she will come to some harm without help. 1 2 3 4 5 Comments: 20. Mohammed is a 24-year-old Somali man who is brought to the ED by police. He is crying and lying on the floor, rocking. He smells of alcohol, and police say he is a refugee who has recently been released from a detention centre. He has committed no crime, but was apprehended ‘directing traffic’ in the middle of a busy city highway. 1 2 3 4 5 Comments: Department of Health and Ageing – Emergency Triage Education Kit  21. Damien is a 36-year-old male who is brought to the ED by his friend. He has had a recent marriage break-up, which involved a lengthy custody and property court case. He has had symptoms of depression for several weeks, including low mood, ruminations, poor sleep and appetite, feelings of hopelessness and agitation. Since receiving the outcome of the Family Court hearing three days ago, Damien has been using the amphetamine ‘ice’, and is now ‘obsessed with plotting revenge’ on his former spouse. He has been awake for more than 48 hours, and presents as angry, rambling in speech, volatile and disordered in his thinking. 1 2 3 4 5 Comments: 22. Chloe is a 15-year-old girl who is brought to the ED from a friend’s house after taking an overdose. The circumstances are unclear, however, she admits to having taken 12 paracetamol tablets and ‘some ‘other things’, including alcohol. She is known to the ED, having presented 12 months ago following an episode of self-harm. She is cooperative, coherent and not drowsy. Her breath smells of alcohol. 1 2 3 4 5 94 94 9 Comments: 23. Leonie is a 29-year-old woman who presents to triage with her mother. She has had three days of abdominal pain and vomiting. She tells you she is 32 weeks pregnant (G2P1) and is an insulin-dependent diabetic. Her main reason for coming to the ED is that she couldn’t get an appointment with her obstetrician and the pain is ‘worrying’ her. She appears a little short of breath and her respiratory rate is 28 breaths per minute. Her SpO2 is 98 per cent. Her heart rate is 128 and her skin is pale, warm and dry. She is alert and oriented and her Glasgow Coma Score is 15 out of 15. Her temperature is 37.2°C (tympanic). 1 2 3 4 5 Comments: Department of Health and Ageing – Emergency Triage Education Kit  24. Paul is a 47-year-old male. He has a painful left shoulder, and received treatment in the ED for the same problem two days ago. There is no history of injury, but Paul tells you that his shoulder is stiff and keeps ‘seizing up’. He tells you that he was prescribed some pain killers that worked initially, but that the pain is back and is ‘much worse now’. He is crying in pain. His left hand is pale and cool; a week radial pulse is noted. His right hand is pink and warm. 1 2 3 4 5 Comments: 25. Gillian is a 26-year-old woman who presents via ambulance with palpitations. She is 34 weeks pregnant (G1P0) and is normally well. She tells you that she was out shopping when her palpitations started. She does not have any associated chest pain or shortness of breath. Her respiratory rate is 20 breaths per minute. Her SpO2 is 98 per cent. Her heart rate is 108 beats per minute and her blood pressure is 120/80. Her skin is pale, warm and dry. Her Glasgow Coma Score is 15 out of 15. 1 2 3 4 5 95 Comments: 95 26. Mal is a 28-year-old male who presents to triage saying that he has been bitten by ‘some sort of insect’. He was clearing rubble from a building site about two hours ago when he felt a sudden burning sensation in his right hand. He said ‘I flicked something off but I didn’t see what it was’. Over a period of two hours his right arm has become increasingly painful and he is sweating. He is complaining of a frontal headache. He is alert and oriented to time, place and person. His heart rate is 98 beats per minute and his respiratory rate is 22 breaths per minute. 1 2 3 4 5 Comments: Department of Health and Ageing – Emergency Triage Education Kit  27. Thuy, a 44-year-old woman, presents to the ED with back pain. She has had the problem on and off for many years. This current episode was brought on after lifting a light shopping bag from her car four hours ago. She has taken Nurofen with little improvement. Currently she has no general practitioner so she ‘didn’t know where else to go when the pain happened’. Her vital signs are within normal limits and she is not sure how to rate her pain but says it is ‘very bad’. 1 2 3 4 5 Comments: 28. Patty is a 53-year-old female who presents to triage complaining of right-sided abdominal pain. She states that the pain has been constant for two days now. She has not had any nausea or vomiting. She tells you that the pain is worse when she is sitting still. She states that she has had this pain before and that her doctor thought it might be gall stones. Prior to coming to the ED she took two paracetamol with minimal effect. She rates the pain as ‘five out of ten’. Her blood pressure is 145/84, her heart rate is 96 beats per minute and her respiratory rate is 18 breaths per minute. Her temperature is 36.4°C. 96 1 2 3 4 5 96 9 Comments: 29. Emil is a five-year-old boy with a seven-day history of diarrhoea and vomiting. He presents to the ED with his mother at 9.30 pm. He has been unable to keep food or fluids down today. He is pale, lethargic and drowsy. His heart rate is 124 beats per minute and his respiratory rate is 20 breaths per minute. 1 2 3 4 5 Comments: 30. Catherine is a four-year-old girl who is brought to the ED at 4.30 pm with a 12-hour onset of being unwell. In the past four hours she has developed a petechial rash on her abdomen. She also has a runny nose and a fever (her temperature is 37.8°C per axilla). She has been tolerating sips of oral fluid but now seems drowsy. 1 2 3 4 5 Comments: Department of Health and Ageing – Emergency Triage Education Kit  31. Lee is a 20-year-old female who presents to the ED with her mother. Her mother reports that she has had paranoid hallucinations and that since yesterday she has not taken any fluids. She states that her reason for not drinking is that she believes that there are ‘spiders and poison around’. 1 2 3 4 5 Comments: 32. Candy, a three-month-old female, presents to the ED with her mother. She has been referred by the maternal child and health nurse. According to her mother, the infant has been ‘crying a lot’ and has ‘bad colic’. The baby was born prematurely at 36 weeks, and was delivered by emergency caesarean section due to preeclampsia. Since birth, the baby has gained weight and her mother says that apart from the colic she ‘is doing OK’. When you examine the baby you note green/yellow bruising and red welts on her upper arms. 1 2 3 4 5 Comments: 97 97 33. Nathan is a 45-year-old man who presents to the ED with his wife and child. He asks to see a psychiatrist because he has been having problems managing his anxiety about his work situation, and he doesn’t know how to get a referral. He reports that he once saw a psychiatrist, four years ago, and that it helped him sort out his troubles, but that he can not remember the doctor’s name. He is on no medication and has no active thoughts of harming himself; he says that he ‘just needs to sort out his anxiety’. 1 2 3 4 5 Comments: 34. Brian is a 39-year-old male who walks to the triage desk. He says he fell in his driveway and now has left shoulder pain. On examination his shoulder is very swollen and painful on movement. His arm is already in a sling. His left hand is warm and a radial pulse is present. 1 2 3 4 5 Comments: Department of Health and Ageing – Emergency Triage Education Kit  35. Bianca is 24 years old. She has a history of a perianal abscess, which underwent drainage two days ago. She continues to have pain (‘six out of ten’) and was seen by her local doctor today. She has taken Panadeine Forte with no relief and is also on oral antibiotics. 1 2 3 4 5 Comments: 36. Craig is an 18-year-old male patient who presents saying he feels ‘suicidal’ and requesting admission. He makes a verbal threat to ‘cut up’ if he is not admitted. 1 2 3 4 5 Comments: 37. Karen, a 36-year-old female, presents to triage accompanied by a social worker. She has come from the plaster clinic. She has increasing pain in her left foot from a 98 fractured right fibula which she sustained yesterday morning. A lower-leg plaster was 98 9 applied in the ED last evening. The social worker tells you that the patient has a history of depression and has said that she wants to ‘end it all’. 1 2 3 4 5 Comments: 38. Ida is a 66-year-old female who presents to the ED alone. She states that she is on Aropax and is having ‘suicidal’ ideation. She tells you that she has two possible plans to harm herself. She says she is having an anxiety attack and reports poor sleeping and eating patterns for the past two weeks. 1 2 3 4 5 Comments: Department of Health and Ageing – Emergency Triage Education Kit  39. A 52-year-old male presents to triage. He has a history of schizophrenia. He is currently on medication for his condition but can not recall the name of the medication, or the name of his case manager. He says that he has been having suicidal thoughts and that ‘there are voices’ urging him to ‘step in front of a train’. 1 2 3 4 5 Comments: 40. Rohan, a 50-year-old male, has been brought to the ED by the district nurse. The nurse states that he has a history of alcohol abuse and that he is feeling ‘suicidal’. She notes also that over the past week he has been neglecting his general care. The patient has a history of an intracerebral bleed (two years ago) and he is deaf. 1 2 3 4 5 Comments: 99 41. While playing volley ball, Gary, 47, hurt his left wrist. He has a good range of 99 movement but reports pain when asked to rotate his left hand. 1 2 3 4 5 Comments: 42. Janine is a 56-year-old woman who presents to the ED with her partner at 2.30 am. She has pain in the epigastric region which has been increasing since yesterday. The pain radiates to her lower abdomen and she says that she has been vomiting clear fluid tonight. Her bowels last opened two days ago. She is on Oridus and has a history of hypertension. 1 2 3 4 5 Comments: Department of Health and Ageing – Emergency Triage Education Kit  43. Mr D, 84, has a chronic leg ulcer. The district nurse has sent him to the ED because she believes the wound is infected. Mr D has a history of hypertension and ischemic heart disease. He lives with his daughter, who normally helps him out with his daily living, but she has gone to Queensland for a holiday. The wound is covered when you see him, but the bandage is soiled with what appears to be haemo-serous ooze. His temperature is 35.9°C and his vital signs are within normal limits. 1 2 3 4 5 Comments: 44.Nic, a 38-year-old arborist, has cut his left arm with a chain saw. He was brought to the ED by a workmate. He has a deep laceration of about ten centimetres to the inner aspect of his arm. The wound was bleeding ‘quite a bit’, but the blood loss has been controlled with a firm bandage. He tells you that the wound is ‘not that painful’, but he looks pale and is sweating. His heart rate is 84 beats per minute and his respiratory rate is 20 breaths per minute. His workmate reports that the dressing was changed once, half an hour ago, because it was soaked with blood. 1 2 3 4 5 100 100 1 Comments: 45. Liam is a 23-year-old male who presents to triage after being seen by a locum doctor. He is backpacking around Australia and has been staying in a boarding house near the hospital. His partner has brought him to the ED. He has a six-hour history of fever and lethargy. He has been vomiting, and complains of a headache. The doctor gave him intramuscular Maxalon, with some effect. His temperature is 38.4°C, and his partner points out a fine petechial looking rash on his torso. He is drowsy but oriented to time, place and person. 1 2 3 4 5 Comments: 46. Ashley, a 23-year-old university student, fell off her bicycle two days ago and was seen in another ED. She is complaining of stiffness and pain to her left wrist. Her left hand is swollen but she has full range of movement; her left hand is pink and warm. 1 2 3 4 5 Comments: Department of Health and Ageing – Emergency Triage Education Kit  47. Remo is a 43-year-old male who presents with a two-week history of right renal stones. He now has pain, which he describes as ‘colicky’ in nature. He rates the pain as ‘four out of ten’. He has had no pain relief today. 1 2 3 4 5 Comments: 48. Angie is a 27-year-old woman who presents via ambulance following a high-impact motor vehicle accident. She is 38 weeks pregnant (G2P1) and is normally well. She was a passenger in a car that collided head-on with another vehicle in an 80 kph zone. The ambulance officers report significant damage to both vehicles. Angie was wearing a seatbelt and the passenger airbag was deployed. She has good recall of events but complains of a painful chest and abdomen and has visible seatbelt marks. She also has a facial abrasion and lacerations to both her knees. She has a cervical collar on; oxygen is at 10 litres per minute via mask and 500mls crystalloid fluid in progress intravenously. Her respiratory rate is 28 breaths per minute, her SpO2 is 93 per cent and her heart rate is 134 beats per minute. Her skin is pale, cool and dry. Her Glasgow Coma Score is 15 out of 15. Her blood pressure is100/R. Her pain is ‘six out of ten’. She has no PV loss. 101 101 1 2 3 4 5 Comments: 49. Norm is a 60-year-old man who arrives at triage at 9.20 am. He is ambulating using a walking stick. When asked what is wrong he points to his abdomen and chest and says, ‘This is as tight as billy-o. I got stirred up yesterday – I had a barney with a bloke up home, and then the tightness got worse, like a vice’. On examination you find that his heart rate is within normal limits and is regular. His skin is warm and dry. He is not short of breath. His SpO2 is 95 per cent on room air. 1 2 3 4 5 Comments: Department of Health and Ageing – Emergency Triage Education Kit  50. Ann is a 16-year-old female who walks to triage with her mother. She reports that she injured her left wrist while playing volley ball. On examination you note good range of movement but she still has some pain. She says the pain is ‘three out of ten’. 1 2 3 4 5 Comments: 51. Mr A is a 54-year-old man who has been sent to the ED by his local doctor. He is unsteady on his feet and requires the assistance of his son to walk. His referral letter reads: Dear Doctor, Please assess this man who was recently admitted to your hospital with left renal calculi. He has been complaining of dizziness and headache for several days. No focal weakness, visual disturbance or confusion. Seen for same 2/7 ago no improvement with Stemitil. PMx, IHD, NIDDM, renal calculi, hypertension. Blood pressure: 215/130. Please assess. Via translation through his son, Mr A tells you that he is ‘very dizzy’, feels ‘weak all over’, has pain in his back and his abdomen and has vomited twice today. 102 102 1 2 3 4 5 Comments: 52. Jake, 46 years of age, presents to triage with his carer. He is crying because he has abdominal pain and has a recent history of a small bowel obstruction (six months ago). Jake has an intellectual disability, and lives in a community residential unit with three other adults and supervisory staff. His carer says that he is ‘normally able to attend to his activities of daily living under supervision’, and that he ‘usually tolerates a lot of pain before he will let staff know he is unwell’. In fact, his carer says that ‘last time he was hospitalised he had been ill for