emergency care and triage

NRS 400

Where does emergency care occur?

Emergency care occurs in emergency departments/trauma bays, during rapid response/medical emergencies, and during patient deterioration situations.

What are key nursing priorities in emergency care?

ABCs, early recognition, escalation of care, and communication.

Why does triage matter in critical care?

Critical care environments manage limited resources, patient conditions can change rapidly, and nurses are often the first clinical decision-makers.

What does triage determine?

Priority, placement, speed of intervention, and patient outcomes.

What are the learning objectives for emergency care and triage?

Define emergency care and triage in hospital settings; describe ED triage categories and implications; compare hospital and disaster triage; explain the nurse's role; and apply triage principles to ED and disaster scenarios.

What is triage?

Sorting patients based on urgency and available resources.

What are the goals of triage?

Do the greatest good for the greatest number; prioritize care based on severity of illness/injury rather than arrival time; and constantly reassess.

Why is triage considered a dynamic process?

Patient conditions and available resources can change, so patients must be continually reassessed and priorities may change.

What does hospital-based triage focus on?

Individual patient needs, diagnostic prioritization, resource matching, and patient flow and safety.

What triage system do U.S. emergency departments use?

The Emergency Severity Index (ESI).

What is the Emergency Severity Index (ESI)?

A 5-level, rapid triage algorithm that classifies patients by acuity/severity and resource needs.

What patient information matters in ESI triage?

Vital signs, mental status, and the mechanism of illness/injury.

What is ESI-1?

Resuscitation.

What type of patient is ESI-1?

A patient who is dying and requires immediate, life-saving intervention.

What are examples of ESI-1 patients?

Airway obstruction, apnea, cardiac arrest, severe shock, and uncontrolled hemorrhage.

What is the nursing focus for ESI-1?

Immediate intervention, team-based care, and high-stakes communication.

What is ESI-2?

Emergent.

What type of patient is ESI-2?

A patient in a high-risk situation, who is confused/lethargic/disoriented, or who has severe pain/distress.

What are examples of ESI-2 patients?

Chest pain concerning for MI, stroke symptoms, sepsis, OB emergencies such as cord prolapse, and severe respiratory distress.

How stable are ESI-2 patients?

They are stable for minutes, not hours, so they require immediate intervention and team-based care.

What is ESI-3?

Urgent.

What does an ESI-3 patient need?

Labs, imaging, and medications.

How is an ESI-3 patient generally described?

Stable but requiring monitoring.

What is an example of ESI-3?

Abdominal pain requiring labs and a CT scan.

What is ESI-4?

Less urgent.

What does an ESI-4 patient need?

One resource, such as an X-ray or sutures.

How is an ESI-4 patient generally described?

Stable and requiring little monitoring.

What is an example of ESI-4?

A simple laceration needing sutures.

What is ESI-5?

Non-urgent.

What does an ESI-5 patient need?

No resources are needed, such as for a medication refill.

How is an ESI-5 patient generally described?

Stable and requiring minimal to no monitoring.

What are examples of ESI-5?

Sore throat and prescription refill.

What does the lecture emphasize about being stable?

Stable does not mean not sick.

What is the purpose of the primary survey?

To identify life-threatening problems quickly and allow appropriate interventions to be initiated.

What happens first when performing the primary survey?

Life-threatening problems are rapidly identified and addressed so lifesaving interventions can begin.

When is the usual ABC assessment reprioritized?

When there is uncontrolled external hemorrhage.

What does CABC mean in the context of uncontrolled hemorrhage?

Catastrophic hemorrhage is addressed before the usual ABC sequence.

What does the C in CABC represent?

Catastrophic hemorrhage.

What is the purpose of the secondary survey?

To identify all other possible injuries after the primary survey has been addressed and needed lifesaving interventions have started.

When does the secondary survey begin?

After addressing each step of the primary survey and starting needed lifesaving interventions.

What type of process is the secondary survey?

A brief, systematic process aimed at identifying other possible injuries.

What areas can involve triage beyond the ED?

ICU admission decisions, rapid response calls, OB triage units, mass casualty events, and disaster response.

What is the key idea about triage beyond the ED?

The principles are similar, but the context changes.

When does disaster triage occur?

When patient volume exceeds resources and normal systems are overwhelmed.

What is a Mass Casualty Incident (MCI)?

An incident in which the number of people injured or killed is large enough to strain or overwhelm a community's ability to respond with existing resources.

What are examples of disaster situations?

Natural disasters, mass shootings/mass casualties, pandemics, large-scale accidents, and community emergencies.

How does the goal of triage change during a disaster?

The goal shifts from individual optimization to population survival.

What is the focus of hospital ED triage?

Individual patients.

What is the focus of disaster triage?

The population.

What is the resource assumption in hospital ED triage?

Adequate resources are assumed.

What is the resource situation in disaster triage?

Access to resources is limited.

How do diagnostics differ between hospital and disaster triage?

Diagnostics are available in hospital ED triage, while disaster triage uses minimal diagnostics.

What is the goal of hospital ED triage?

Best care per patient.

What is the goal of disaster triage?

Most lives saved.

What is S.T.A.R.T.?

Simple Triage and Rapid Treatment.

What is the focus of S.T.A.R.T.?

Rapid sorting using simple breathing, circulation, and mental status checks.

Why is S.T.A.R.T. commonly used?

It is faster and more widely recognized.

What is S.A.L.T.?

Sort, Assess, Lifesaving Interventions, Treatment/Transport.

What does S.A.L.T. prioritize?

Sort, Assess, Lifesaving Interventions, and Treatment/Transport.

What advantage does S.A.L.T. provide?

It allows rapid lifesaving interventions, such as hemorrhage control.

What additional category does S.A.L.T. include?

An Expectant category.

Who may be placed in the Expectant category in S.A.L.T.?

Victims who are still clinically alive but have obvious, massive injuries or other conditions that will almost certainly be fatal.

What is the typical disaster triage category Immediate/Red?

Life-threatening but survivable.

What is the typical disaster triage category Delayed/Yellow?

Serious but stable.

What is the typical disaster triage category Minor/Green?

Walking wounded.

What are the Black disaster triage categories?

Dead/Expectant; the lecture describes these as unlikely to survive.

What does the Immediate/Red category mean?

The patient has a life-threatening condition that is survivable and requires priority treatment.

What does the Delayed/Yellow category mean?

The patient has a serious but stable condition.

What does the Minor/Green category mean?

The patient is a walking wounded patient.

What does the Dead/Black category represent?

Patients who are deceased.

What does the Expectant/Black category represent?

Patients who are still clinically alive but have massive injuries or conditions that will almost certainly be fatal.

What ethical issues may occur during disaster triage?

Withholding care, reallocating resources, moral distress, and altered standards of care.

What should nurses do when facing ethical challenges during disaster triage?

Follow protocols, work within teams, practice self-awareness, and participate in debriefing.

Why can disaster triage cause moral distress?

Triage may require withholding care or reallocating limited resources, creating difficult ethical decisions.

What is the nurse's role in emergency and disaster triage?

Perform initial triage, reassess patients continuously, advocate for reassignment, communicate with providers and EMS, support families, and participate in disaster planning.

Why should nurses continuously reassess patients?

Triage is dynamic and patient conditions can change, requiring priorities to be updated.

What does advocating for reassignment mean in triage?

Recognizing when a patient's priority or placement should change and communicating that need.

Why is communication important in emergency and disaster triage?

Rapid, high-stakes communication helps coordinate care, escalation, reassignment, and lifesaving interventions.

Why is team-based care emphasized in ESI-1?

ESI-1 patients require immediate life-saving intervention and coordinated care.

Why is team-based care emphasized in ESI-2?

These patients may be stable for minutes rather than hours and require immediate intervention.

A patient arrives with an airway obstruction and requires immediate life-saving intervention. What ESI level should the nurse assign?

ESI-1, resuscitation.

A patient arrives in cardiac arrest. What ESI level applies?

ESI-1, resuscitation.

A patient arrives with severe shock. What ESI level applies?

ESI-1, resuscitation.

A patient has uncontrolled hemorrhage. What ESI level applies?

ESI-1, resuscitation.

A patient has chest pain concerning for MI but is not currently in cardiac arrest. What ESI category is listed for this example?

ESI-2, emergent.

A patient presents with stroke symptoms. What ESI category is listed?

ESI-2, emergent.

A patient presents with sepsis. What ESI category is listed?

ESI-2, emergent.

A patient presents with an OB emergency such as cord prolapse. What ESI category is listed?

ESI-2, emergent.

A patient presents with severe respiratory distress. What ESI category is listed?

ESI-2, emergent.

A patient has abdominal pain requiring labs and a CT scan. What ESI category is appropriate from the lecture example?

ESI-3, urgent.

A patient has a simple laceration needing sutures. What ESI category is appropriate?

ESI-4, less urgent.

A patient needs a medication refill and no resources. What ESI category is appropriate?

ESI-5, non-urgent.

A patient has a sore throat and requires no resources. What ESI category is appropriate?

ESI-5, non-urgent.

A patient arrives before another patient but has a less severe condition. Who should be prioritized?

The patient with the more severe illness/injury should be prioritized; triage is based on severity, not arrival time.

Why should arrival time not determine triage priority?

Triage prioritizes care according to severity of illness/injury and available resources.

A disaster produces more patients than the healthcare system can manage. What type of triage is required?

Disaster triage.

A hospital has adequate resources and is prioritizing individual patients. What type of triage is being used?

Hospital/ED triage.

A mass casualty event overwhelms community resources. What principle should guide triage?

Shift the goal from individual optimization to population survival.

A nurse must decide between providing extensive diagnostics to one patient and rapidly sorting many patients during a mass casualty event. What principle applies?

Disaster triage prioritizes population survival and most lives saved with limited resources.

A disaster triage patient is walking and able to move independently. What category may this patient fall into?

Minor/Green, walking wounded, depending on the full triage assessment.