CHAPTER 4

Triage and priority setting

LISA WOLFF

“I have six patients to report on,” say the off-going nurse. “Mr. Jonas is post-op
and withdrawing from alcohol, Mr. Smith’s BP is dropping and there are no CCU
beds, Mr. Brown’s wife is standing in the hallway demanding to know when he’s
going home so she can schedule the cleaners, Ms. Green is a patient with asthma
who was extubated yesterday, and I Just got a transfer from the telemetry unit,
but I haven’t gotten to see her yet, although the report from the unit said she’s
fine”

Holy cow! What’s the priority? Who do you need to see first? How can you keep
you patients safe when where’s no instructor around? You can use the principles
of assessment and triage to order you care, keep you patients safe, and not lose
your mind.

WHAT IS TRIAGE?
Triage is a way to describe how that nurses decide what gets done first. It’s a term
derived from the French word trier. Meaning “to sort, sift or select” and is
usually used in the context of disaster or emergency nursing. Triage is based on
assessment – yours and that of other nurses.

WHEN DO YOU PERFORM TRIAGE?

The answer to this question is “all the time”. Every minute of every shift you are
making decisions about what to do next. For example, you pick up your patients at
7 p.m. After taking report from the off-going nurse, you need to make some
important decisions. What patient needs to be assessed first? What task should
take precedence: medicating patient A for her in 10 pain or finishing the discharge
paperwork for patient B to free up the bed for a waiting patient from the
emergency department (ED)?
This is a very conscious process in the beginning, and so it may seem mysterious
to you to watch an experienced nurse go about her shift almost without obviously
considering her options. This is a great time, while you’re on orientation, to ask
your preceptor to verbalize her process, or “ think out loud.” Why are you doing
that first ? Why are you seeing this patient rather than that patient ? Why are you
choosing to do paperwork before more patient care ? If you start off by letting
your preceptor know you are trying to “ pick her brains “ rather than questioning
her judgment, you will probably get more thoughtful, complete answers to your
questions.
WHAT ARE SOME TRIAGE SYSTEMS?
Quite a few triage systems are in use in EDs: The Emergency Severity Index
(ESI), the Canadian Triage and Acuity Scale (CTAS), and the Australian Triage
Scale (ATS) are a few of the most commonly used. What they share is a five-level
system that guides the nurse in deciding who needs to be seen first and who can
wait. The scale go from “i,” a patient who needs to be seen immediately, be
resuscitated, or is in critical condition, to “5,” a patient who can wait a long time,
has a minor injury or illness, and is classified as nonurgent. Most of the time,
patients who are “1’s or “5’s” are fairly easy to identify. It is the patients in the
middle who are the most difficult to sort out. Similarly, you may have a very sick
patient, an about-to-be-discharged patient, and three “middle” patients in your
section or district.
Another way to set priorities is to use Maslow’s hierarchy, which you may
remember from your mental health nursing or human development coursework.
The hierarchical model, usually drawn as a pyramid, starts with the base:
physiologic needs like food, air, and water. These correspond to the ABCs of
nursing : airway, breathing, and circulation. You can not progress to higher needs
until these basic needs are met. The pyramid then moves upward to safety, love
and belonging, esteem, and self-actualization, needs that are important but ones
that come after the patient has an airway, is breathing, and is perfusing well.
The Take-Home Message
When you are thinking about what the patient needs, or which patient needs to be
seen first, focus on the ABCs or physiologic needs before considering anything
else. For example, you can’t worry about your patient’s self-esteem or spiritual
distress needs until you’ve made sure she has a patient airway, effective breathing
pattern, and good circulation. Similarly, the patient who needs case management
gets in line behind the patient with no BP, no matter who is yelling louder.
HOW DO YOU SET PRIORITIES USING TRIAGE SYSTEMS ?
Compare Maslow versus ESI, for example:
Step 1 : Consider acuity : Who among your patients is a potential high-
acuity patient (a “2”)? That person gets checked first.
Step 2 : If all patients are of roughly equal acuity, who’s being
discharged ? To where ? Does someone need that bed ? He or she gets
attended to first.
Step 3 : If all patients are of equal acuity, the one whose needs are lower
(closest to the base) on Maslow’s hierarchy gets seen first.
Use the alphabet (ABCDs) to gauge acuity :
Airway : Is your most important assessment and therefore the assessment
you do first. If your patient is not breathing, stay with your patient and call
for help. If your patient is cold and not breathing, call for help anyway.
Vital signs are important is looking at the patient. I see nurses all the time “
getting the story “ from the ambulance service and not really looking at their
patient. You have to look at your patient. –Lisa, ED nurse.
Breathing : Is your second assessment.
 Is your patient working hard to breathe ?
 Is his color normal ?
 Does he seem anxious ? A restless patient needs to be evaluated not
restrained!
 Is your patient using any accessory muscles ?
 Can he speak in complete sentences ?
 What is the breathing rate and rhythm ? I it normal ?
 What do his lungs sounds like ? Are there any adventitious sounds ?
 Where ? Where do you think is causing them ?
Circulation : The best measures of cardiac status are level of consciousness
(LOC) and urine output. These two measures indicate how well the brain and
kidneys, respectively, are being perfused. Because these two organs receive about
25% of blood flow each, constant assessment of these two systems is crucial to
stay on top of your patient’s perfusion status.
Cardiac output = stroke volume x heart rate : To keep cardiac output stable,
the body will respond to a drop in blood volume or pressure (stroke volume [SV])
by increasing the heart rate (HR). therefore, one of the first signs that a patient is
hypovolemic is tachycardia, not a drop in BP !
Ask yourself the following :
 What does this patient look like overall (LOC, color, anxiety level, urine
output) ?
 What is his HR ?
 What does his pulse feel like (strong, weak, regular, irregular) ?
 What is his BP ? I s he within his trend ?
 Does he have any complaints of dizziness or weakness ? Fatigue ?
 How does his skin look ? Are there areas of mottling ? Is it warm ? Cold ?
 Does this patient have peripheral (pedal and radial) pulses ?
If this patient is tachycardic :
 Does he have a fever ?
 Is he anxious or restless ? If so, what is his arterial oxygen saturation (Sao2) ?
 Does he feel short of breath ?
 What is his heart rhythm ?
Disability (Neurologic) : LOC is the most important part of the neuro status
check. In essence, every time you go into the room and interact with your patient,
you are doing a neuro check.
Ask yourself the following :
 Is my patient awake ? Alert ? Responding to my questions ?
 Is my patient able to have a conversation without wandering ? Is my patient
speaking clearly, using the correct words for things ?
 Is my patient moving all extremities ? If I ask him to squeeze my hands, is his
grip equal bilaterally ?
 If I ask him to push down on my hands with his feet, is his strength equal
bilaterally ?
 F my patient is allowed out of bed, is his gait normal ? Is he wobbly ? Is he
walking into things ?
 Most importantly : Is there a change since the last time I interacted with this
patient ?
I set my priorities by the sickest patient first, then prioritize what care I’ll give
that patient based on their ABCs, and that’s not always easy. For example, I had
a patient who had both CHF and sepsis. His BP was really low, and I had to get it
up with fluid, but too much fluid would have killed him. I give the liter bolus of
normal saline the doctor orders, then I listen to the lungs – crackles rising !
Aack ! I’m drowning this guy ! I thought to myself, OK, now what ? The patient
had a good airway, an O 2 saturation of 98% on 2 liters of oxygen, but rising
crackles, although no respiratory distress. I went to my change burse, who
pointed out that the patient was maintaining respiratory function but wouldn’t
last much longer without a BP. I spoke with the doctor, placed a Foley, titrated
the fluids to maintain an appropriate MAP, and started some antibiotics and
vasopressors. –Liz, ED nurse
Whether you do assessment by body system or “head to toe,” the most important,
yet most difficult part of being a new grad is developing your own system os
assessment. Personally, I do my assessments by body system. I do this based on
ABCs being in the emergency room. –Liz, ED nurse

HOW DO YOU GET ENOUGH INFORMATION TO PRIORITIZE

ADEQUATELY?
To prioritize your care, you need to have some sense of what’s going on with your
patients : what they’ve been like over the last shift, are they trending up or down,
what specific issue needs to be addressed, and what the plan of care is. For
example, this is areport you may get at the end of a busy day :
Mr. smith is an 80-year-old man admitted for pneumonia. He has a history of
atrial fibrillation and diabetes. He hasn’t gotten out of bed today because I was
too busy with my other patients, and anyway he’s going back to his nursing home
tomorrow. I think he still has some oxygen on, and he’s fine.
So what’s the problem with that report ? You really don’t know enough about the
patient to decide whether he really is “fine” or not, do you ?

THINGS TO ASK FOR IN A REPORT

 Name, age, diagnosis, MD (the one you’re going to call, not the one who
hasn’t seen him in a week ), activity level, diet.
 Presenting complaint.
 Tests done and tests pending.
 Meds given in ED (if recently arrived) and meds that need to be given before
the end of the shift.
 Orders
 Admitting/discharge paperwork done.
 Vital signs throughout the shift, and important changes (improvements or
decompensation) and what’s been done about it.

THINGS TO CLARIFY IF POSSIBLE

Those things the nurse tells you “ need to get done,” like paperwork, a bath, a
treatment, or dressing change, does he or she mean before the patient goes home ?
Before the nurse goes home ? Before the patient’s family arrives for visiting
hours? Try to clarify timelines as best you can.
Discharges: When is the patient supposed to go? When? By ambulance? Who
needs to be called?
New admissions: has anyone actually seen the patient? Sometimes. If a patient
come to the floor at change of shift, the off going nurse doesn’t see the patient,
and the oncoming nurse won’t get the them for hours, based on the ED report, not
what the most recent assessment on the floor has been. This very dangerous.
Always clarify when a patient has lat been assessed!
Meds for 8 a.m. or 8 p.m.: sometimes the off-going shift is responsible for 8
o’clock medications; sometimes it’s the oncoming shift. Ask about them so you
know they’re there. Otherwise you may find out about them at 10 or 12.
When You Don’t Have Any Information At All
It’s always crucial that you see the patient you don’t know anything about first.
Murphy’s law dictates that that’s the patient who will be much sicker that you
thought! This can be the patient who’s about to be transferred as well. I remember
a night in the intensive care unit (ICU) when the report I got on a patient was that
“she’s all packaged an ready to go to the floor. Everything ‘s fine—they’ll be up
to get her in 10 minutes.” That of course didn’t happen, and after assessing my
first patient I thought I’d check in on my “stable, ready-for-transfer” patient. She
was pale, with crackles up to her shoulders, Sao 2 of 85%--the patient had gone
into pulmonary edema—who knew when? She ended up staying awhile longer in
the ICU. I never accept a report like that again, unless the transferring nurse plans
on staying until the patient goes.
How to make sure your information is correct
 Assess the patient
 Verify orders and check for new orders
 Check the medication administration records for accuracy
Don’t live in the chart! The answer is in the room! I have a friend who calls
nursing a “contact sport” – you have to interact early and often with the patients,
not the charts. Check you patient first. Make sure your assessment matches what
you’ve heard in the report. However, patients change fast. Just because the off-
going nurse didn’t hear crackles in the lungs at 6 a.m. doesn’t mean they won’t be
there at 7:30 a.m.
How to Decide Whom to See First
Consider these potential problems:
Airway
 Known dysphagia
Cerebrovascular accident (CVA)
Altered anatomy (tach[tracheotomy], gastrostomy [G] tube,
nasogastric tube [NGT])
Altered mental status
Craniofacial trauma
Intubated
Breathing
Pneumonia
Asthma
Thoracic trauma
Pulmonary edema / CHF
Broken ribs/surgical site plan
Large abdomen/ascites/hepatomegaly/advanced pregnancy
Head Injury; brainstem
Patient-Controlled anesthesia (PCA) narcotics

Circulation
Recent surgery
Gastrointestinal bleed
Recently postpartum/postmiscarriange
Trauma
Postcathetterization
Increased/decreased BP (trend)
Increased/decreased HR
Decreased urinary output
Disability
Diabetic (hypo/hyperglycemia)
Substance abuse
CVA
Hypoxia
 Sepsis
THE IMPORTANCE OF ACCURATE TIMELY VITAL SIGNS
In my research with rapid response teams, the most striking thing I find when I
do a chart review is the huge amount of empty space where vital signs should be.
As nurse, we make triage and treatment decisions (what this whole chapter is
about) based on clinical data. That data is its purest form come from physical
assessment, patient subjective information, and vital signs. If you’re not taking
them frequently enough, you may not spot signs of deterioration until it’s too late.
If you are not talking them accurately, it’s the same problem. Accurate vitals signs
may require you to match the presentation if the patient against the numbers
you’re getting.
For example, when I was a night educator, more than once I was called to evaluate
a patient who was tachycardic (in the 120s or so) and tachypeic (30s) I’d get to the
room and listen to the patient’s lungs. In putting my hands on the patient, it was
clear that the patient was febrile. Very febrile. I’d ask what the last temperature
was, and inevitably be told It was 98.6 o F. how has is a taken? Orally. The patient
was mouth breathing in the 30s so an oral temperature was not going to be
accurate. But the nurse didn’t put the hot, flushed skin together with the
tachycardia and tachypnea because the temperature was “normal”. Rectally, the
patient had a temperature of 105o F. Suddenly, everything started to make sense.
The lesson here is to always ask yourself, “Does this make? Does these vital signs
reflect what the patient look like?” especially if someone else has taken those vital
signs, like a tech or an aide, this is crucial.

The importance of trends versus Absolute numbers, or when is a

systolic BP of 80 good? When is a systolic of 110 bad?
It’s really important to get a sense of your patient’s history, and their likely
compensatory mechanisms or lack of them. For example, you’d think that a
systolic BP of 110 is pretty good, right? After all, everyone should have a BP of
110/70 if they’re in good shape.
However, let’s look at the following scenario:
Mr. Jones is a 78-year-old man admitted for a unary tract infection. He has a
history of coronary artery disease and diabetes, as well as hypertension. He takes
aspirin, metoprolol, metformin daily. You see is most recent vitals are as follows:
BP 110/60, HR 70, RR 24, Sao2 95%.
Do these numbers actually tell you anything? Not really. As emphasized in the
preceding section, you need to put together the vital signs with the patient
presentation. But you want to keep in mind a few things.
Like 75% of people older than 75 years, you patient has hypertension, so his BP
probably runs on the high side, even with medication. For this patient 110 is
probably quite low. Another this is his medication. Metoprolol is a β-blocker,
which will not be evident given the β-blocker. Not so easy now, right?
The crucial piece is to put together what you know about the patient, with their
history and medications, and then think about what you expect to see. If you don’t
see what you’re expecting, start looking for why you’re not seeing it. Thinking
this way will help you pick up in issues early, before the patient starts
decompensating.
So when is a systolic BP of 80 good? When you’ve started at 50 and the patient is
getting better. Look at the past 24 hours of vital signs. Look at where the vitals are
going, and intervene or support accordingly.
Similarly, the patient who needs your immediate attention is usually the patient
who is trending dangerously or in a direction you don’t like. If vital signs are
changing, think, is this a good direction? Is there a reason for this change (e.g.,
you given medication, oxygen, fluids, or changed activity level?) is your patient in
pain?
PAIN AND WHERE IT FIGURES IN
In most emergency triage system, a pain scale rating of 7 or above out of 10 puts
the patient in a more acute category. The patient with pain that is:
New; wherever it is, but especially if it is head, chest, or belly pain refractory to
the medication they are receiving