Chapter 2: 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.

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.

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.

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.

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:

"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.
• 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.

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:

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.
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.

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:

• 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. 
• 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.
• 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:

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.

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:

• 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?"
• 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?"
• 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.

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:

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.

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.

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':

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.

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.

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:

• 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.
• 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.

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. 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.

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. 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.

'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. 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. 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. 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.

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:

"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:

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

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.