In safe hands: how the triage process works
Posted on 15 September 2015
The triage process starts with a question to the patient or their parent/carer: ‘What is the reason for you coming to the Emergency Centre?’ This is followed by gathering info about the patient’s medical and travel history, as these can often influence or lead to the problem presented.
Further questions are about the patient’s health. The triage nurse uses the answers to establish a brief history relating to the case. During this time the patient is assessed for any emergency clinical signs – such as not breathing, current seizures, burns or wounds, and so on. If such clinical signs are noted, the patient is assigned a red level and taken to the resuscitation area immediately.
If no emergency clinical signs are present, the patient is checked for very urgent or urgent clinical signs. Vital signs are then measured, the TEWS (triage early warning score – a composite score of the patient’s physiology) is calculated and a triage priority is assigned and adjusted as necessary.
All nursing staff who work in the Emergency Centre (EC) are trained according to the South African Triage Group’s training programme on the South African Triage Scale (SATS). These are the steps followed:
1. History taking, where key words are identified as clinical indicators or discriminators as a starting point of the triage scale. This is a subjective assessment based on the patient’s answers.
2. Measuring of vital signs, which includes data such as temperature, blood pressure, pulse and alertness of the patient. Although this data, which is represented as a score or TEWS, cannot downgrade the patient, it can push the patient into a higher triage category if not within normal ranges for their age group. This is an objective component of the tool.
3. Additional investigations are the final part of the SATS tool. These include tests such as a finger-prick sugar test and urine test for diabetic patients, and the results can still influence the final outcome of the triage category.
Theresa Geldenhuys, unit manager of Mediclinic Cape Gate’s EC, says it is important to note that triage is not a static tool and the patient can be reassessed at any time should additional information come to light. Once patients have been triaged, they are verbally handed over to a nursing staff member and then to the doctor.
Types of emergency
• Cardiac arrest
• Patient not breathing
• Current seizures
• Burns to the face or inhalation burns
• Level of consciousness reduced
• Sudden shortness of breath
• Chest pain
• Stabbed neck
• Dislocation of a large joint
• Pregnancy and abdominal trauma
• Vomiting fresh blood
The above examples are specific to adults. Emergency signs for paediatric patients are more detailed.
Sometimes patients are prioritised based on something other than their current condition. In an adult, someone who is extremely aggressive can be brought into the unit immediately. Small babies, younger than two months, are also regarded as very urgent, irrespective of their presenting problem.
Every patient who enters the EC will be triaged. According to Dr Theunis Potgieter, head of the EC at Stellenbosch Mediclinic, triage is a dynamic process and can change while patients wait to be seen. ‘It’s important that we keep the waiting patients informed regarding potential waiting times. I also emphasise good communication between admin, nursing staff and the doctor.’
All nurses are governed by the South African Nursing Council (SANC), which is the body entrusted to set and maintain standards of nursing education and practice in South Africa. They adhere to principles guiding the practice of nursing, which is included in the Code of Conduct and Ethics of nursing.