Triage Nurse Calls Shots in ED

ED nurses Mika Miriani (left) and Missy Smith assist a patient.

Emergency departments are organized to care for the most critical patients first. That’s why if you come to an ER and your problem is not life-threatening, you may not be seen immediately. The order in which you are assessed by an emergency department practitioner, in a full emergency department, is determined by the triage nurse.

“Triage” is a French term used for the quick assessment and assignment of level of care for patients according to the resources needed to care for that patient. “An experienced triage nurse can assess a patient in less than two minutes,” says Erica Taylor, R.N., an ED nurse at NorthBay VacaValley Hospital. “You’re acting as an investigator, trying to gather as much information as you can to navigate the patient to the correct resources.”

Pulse, respiration, mental status and skin signs are the four keys used to assess a patient’s condition. Mental state is determined by asking if the patient knows their name, the date, and where they are. By touching the patient’s wrist, pulse rate and quality are assessed, while at the same time the nurse is observing the patient’s rate of breathing. Skin signs, including whether the skin is cool, clammy or hot, or if bleeding is present, help provide valuable clues to the patient’s stability and help to determine the patient’s route to care.

“I also ask questions I call the five ‘Ws,’ Taylor says. “Who, what, when, where, why. Who are you, what happened, when did it happen, where did it happen and why or what brings you in today?”

Who are you, what happened, when did it happen, where did it happen and why or what brings you in?

Both NorthBay Medical Center and NorthBay VacaValley Hospital have a triage nurse available 24 hours a day to monitor the ED waiting rooms.

It is the hospitals’ goal to triage every patient within 15 minutes of their arrival and get them to see an ED practitioner as soon as possible.

NorthBay uses five official triage levels, ranked from Level 1 to Level 5.

Level 1 is the highest priority. The patient needs immediate physician evaluation and intervention. Level 1 case includes cardiac arrest, respiratory arrest, stroke, heart attack, critically injured trauma patients and patients having an anaphylactic reaction (a reaction that causes swelling in the airways, usually an allergic reaction).

Level 2 recognizes the patient in a high-risk situation. It could be active chest pain, an overdose, an asthma attack, trauma from a motor vehicle accident or a patient who is confused, lethargic or disoriented.

Level 3 is for the patient who needs two or more resources (lab work, x-rays, IV fluids, etc.) but who can safely wait awhile to be seen by the ED practitioner.

Levels 4 and 5 are reserved for the patient who needs one or no resources. They made need a wound evaluated, sutures, simple cough and/or runny nose, and a possible prescription refill. Patients with minor complaints usually fall into this category and when the ED is busy, they have the longest wait times for treatment.