Assessment techniques for safe triage
Assessment of environmental hazards
This is the first step to safe practice at triage. The Triage Nurse must be aware of internal security response protocols. In addition, the Triage Nurse should observe standard precautions whenever there is potential for exposure to blood or other body fluids. The Triage Nurse should be aware of the risks associated with leaving the triage area to retrieve patients from vehicles or reception areas of the hospital. Local policy will determine practice in this regard, but a general principle is that the triage desk should never be left unattended and that staff members should never place themselves in a situation in which additional help cannot be mobilised.
As part of maintaining a safe environment, the Triage Nurse must ensure that equipment for basic life support( bag-valve mask and oxygen supply) is available at triage. Likewise, equipment which complies with standard precautions is required. At the beginning of each shift, the Triage Nurse should conduct a basic safety and environment check of the work area to optimise environmental and patient safety.
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General appearance
This is an essential component of the triage assessment. Observation of the patient’ s appearance and behaviour when they arrive tells us much about the patient’ s physiological and psychological status. Take particular notice of the following:
• Observe the patient’ s mobility as they approach the reception area. Is it normal or restricted? If it is restricted, in what way?
• Ask yourself the question‘ Does this patient look sick?’
• Observe how the patient is behaving.
The primary survey underpins safe practice in the ED. When an assessment of the environment and general appearance is complete( this should take seconds), the primary survey should begin.
Airway
Always check the airway for patency, and consider cervical spine precautions where indicated.
An occluded airway or an immediate risk to airway must be allocated ATS category 1( this includes unresponsiveness with GCS of < 9 and ongoing or prolonged seizure).
In adults, stridor occurs when in excess of 75 per cent of the airway lumen has been obstructed: these patients have failed their primary survey and require definitive airway management, so warrant allocation to a high triage category( ATS 1).
Department of Health and Ageing – Emergency Triage Education Kit