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May 1, 2019

By: Lynn Sayre Visser MSN, RN, CEN, CPEN

What’s a rapid triage assessment?

Five patients arrive simultaneously into the emergency department (ED) waiting room. Who will you see first? Who will go straight to an ED bed? Who can wait for care? The rapid triage assessment in the emergency nursing environment is a quick assessment that helps the triage nurse identify those patients requiring immediate care from those who can safely wait.

In Fast Facts for the Triage Nurse, 2nd Ed., Anna Sivo Montejano DNP, RN, PHN, CEN shares insight into performing the rapid triage assessment.

RAPID TRIAGE ASSESSMENT

A rapid triage assessment begins with an across-the-room survey. Visualizing the patient’s appearance as he or she enters the facility is the beginning of the rapid triage assessment. A great deal of information can be gathered by visualizing the patient as he or she steps into the waiting room (WR):

  • Does the person use a device to assist with ambulation (e.g., cane, walker)?
  • Does the facial expression or body language indicate pain?
  • What is the skin tone and color?
  • Is the gait slow, rapid, absent, or demonstrating signs of weakness?
  • Is he or she unresponsive or altered?
  • Is there limited eye contact? Does the person express fear, anxiety, or agitation?
  • Do the clothes give clues to his or her profession (e.g., paint on clothing)?

Gathering information on every patient who enters the ED is important to assess for a potential or actual life-threatening condition and enable care to be rendered if needed. A few examples of objective information obtained during the rapid triage assessment include:

  • Airway: Patent or impaired (e.g., stridor, hoarseness, drooling, facial, or oropharyngeal edema)
  • Breathing: Unlabored or labored (e.g., accessory muscle use, retractions, nasal flaring)
  • Circulation: Skin color (e.g., pallor, cyanosis) and moisture (e.g., dry, moist, diaphoretic); pulse rate (e.g., fast or slow) and rhythm (e.g., regular or irregular); obvious bleeding
  • Disability (neurological status): Level of consciousness including Glasgow Coma Scale (GCS) or alert, verbal, pain, unresponsive (AVPU) scale; muscle strength in upper extremities (e.g., pronator drift, grips) and lower extremities (e.g., ability to lift both legs?)
  • Exposure/environment: Hyperthermic, hypothermic, or normothermic; presence of objects or forensic evidence requiring preservation

The importance of performing a rapid triage assessment cannot be overemphasized. Imagine a scenario in which 10 patients arrive simultaneously to the ED. If the triage nurse initially performs a lengthy assessment on each individual, the last patient in line may be the sickest. By rapidly assessing each patient for no more than 60 to 90 seconds, the nurse can best prioritize patients, ensuring that higher acuity level patients are seen first.

Reproduced with permission from Springer Publishing Company from Fast Facts for the Triage Nurse (2ndEd.). New York, NY: Springer Publishing.

 

Each patient only requires 60 to 90 seconds of your time to make an initial determination about his or her level of urgency. That’s it. Only 60 to 90 seconds. Your actions in that timeframe just may give you the opportunity to save a life.

 

Lynn Sayre Visser is the author of Fast Facts for the Triage Nurse (2ndEd.) and Rapid Access Guide for Triage and Emergency Nurses. She has devoted her career to emergency nursing, triage education, and mentoring others.

*This blog is the third in a series.

 

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