Major Incident Planning and Support (MIP+S) Level 2

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What is Triage

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So, Mark, let us have a look at actually, what is triage? I have had 20 odd years as a paramedic, so triage, for me, comes in different... In levels, really. You have got your triage when you get to scene, which you do on every scene, but then you have got major incident triage. So we have got different levels of it for different scenarios and situations. But as far as we are concerned, triage is looking at who is the worst patient, tends to be the quiet ones die and the noisy ones tend to just be injured. So we do a triage very quickly on RTCs or incidents with more than one casualty as to who is the worst, who is the best, do we need more resources, do we need more ambulances, do we need Helimed, all this sort of stuff. So our triage is very much a dynamic assessment, very, very quickly done on an initial patient. How does that differ and what is the importance of triage for yourself as a nurse in this department?

Okay, so... Well, triage is... It is a French word and it just means to sort. So really, triage in an A&E setting is a single patient usually and it is to sort out patients according to their level of severity, and that is really the initial assessment. There is another way of looking at it or an additional way of looking at it when you are a nurse in triage, and how soon would this person recover with or without treatment? That is kind of abstract really, but you kind of do that without thinking about it. You are assessing how severe this patient is, but you are also thinking, "Well, what treatment are they going to need and how quickly are they going to need it?"

So what you are saying is, once your patient comes into the this room, where I am talking about multi-casualties and looking at who needs to be in hospital fastest and have I got the resources to do it, when that patient arrives to the door for yourself, in your situation, you are looking and making decisions as to which pathway now that patient needs to travel down, so as they get the correct treatment for their condition and we do not then block up A&E department with patients that do not need to be in A&E departments when we could have sent them directly to departments that fit their criteria, is that correct?

That is right, that is right. And where I work at the moment, we have an urgent care center nearby and really. If a patient does not need to be in accident and emergency, it is not an emergency, it is not an emergent condition, they can be sent to an urgent care center and dealt with quite effectively and they won't have to wait in A&E hours and hours and hours while more severe cases are being brought in, because that is effectively what will happen.

So as far as you are concerned, this is the future, this is the way it should be done, this is basically getting the right treatment to the right patient at the right time?

Correct. A&E is for accidents and emergencies.

And there is a big difference in what an accident and emergency actually is compared to somebody that has just got a cough or a cold. Would you agree?

Right. And that is what triage is about, that quick assessment.

So we have talked already about time span, as you say, that it should take around about 10 minutes to complete. But if the patient shows severe signs and needs to be speeded up, then we can shorten it, we can lengthen it, but it should take an average of around 10 minutes and that should be enough time just to decide which pathway that this patient needs to go down.

Yeah, that is right. And usually triage... Manchester Triage is the common... Is the most well known and it is colour-coded. Red is immediate, orange is 10 minutes, yellow is half an hour, green is 120 minutes and blue is 240 minutes. And you are... Depending on your initial assessment of the patient, that is how long you think, according to your assessment, how long this patient can wait before they have an intervention or their next assessment.

So basically, it speeds up the whole process and again, we go back to it should get the patient the right treatment first time, instead of having to go through and wait and go through all the different hoops. They are automatically being sent down the right channel for their condition and we have got a timestamp on it and that is why it is critically important to follow the rules and regulations and make sure that your data, your assessment is done correctly, because that will then give you the right colour, the right time and the right place.

Yeah. The sickest people get seen quicker than the not-so-sick people, but that does not mean that the not-so-sick people have to wait. They just go down a different pathway.

So, Mark, when you get the person actually from the waiting room into the assessment room with you, is there anything else you are particularly looking for with that patient now they are actually in front of you?

Okay, that is really where the A to E assessment comes in. Airway, breathing, circulation, neurological disability and exposure. So if somebody is in front of you and they are clearly choking, coughing, that is a big problem. So they would go for immediate help. Breathing. Are they breathing fast? Is the chest rising and falling in symmetry? Circulation. Are they agitated? Are they... Do you have good eye contact? We are thinking about disability, neurological disability? Good eye contact. Do they understand? Do they understand why they are here? Are they agitated? And exposure, you are just looking at the condition of their skin, really. Are they pale, clammy? Are they sweating? Are they bright red? Yeah, so that A to E process really is quick. Are they speaking in sentences?

So how long should this process take? If you were doing a proper triage, what is the time span involved to do that triage properly?

Well, typically, it is usually 10 minutes. It should be no longer than 10 minutes. Some triage, particularly mental health triage, can take a little bit longer. Some triage can be really quick, it can take just two or three minutes. But usually, by 60 seconds, you need to know really how sick your patient is in front of you and try to get them quickly on the pathway.

So I take it that it is not really a situation where you are having long conversations with somebody. You just want facts. You just want the exact history of what is going on and what they have come in with, that problem, and then that will give you the correct pathway to send that patient down to, as fast as possible, so they get definitive care in the right pathway?

That is right.

Would that be correct?

That is right. Yeah. And in fact, when the patient comes in, I always say that I am the triage nurse, this is triage, it is your quick initial assessment.

Okay. Do you ever get any problems with people? Do they think it is finished too quickly or... How does a patient feel? I presume you are trying to get the patient to feel comfortable, to relax and to understand that they have now started a path to better health, basically. So you have got to be seen to be cool, calm and understanding, but by the same token, you have also got to make things happen quite quickly because that is the whole idea of triage, it is to speed up the process through the system to get the right care to the patient.

That is right and of course, saying that this is an initial quick assessment. It is also good to let the patient know when you have finished your triage assessment and now it is time to move further down the pathway. You have got to close it as well as open it for the patient.