Emergency Department and Triage Score

Emergency Nursing and Triage

• Emergency Nursing Overview

  • Involves a wide range of clinical presentations.
  • Care for patients who are usually not diagnosed but are acute.
  • Requires broad foundational knowledge for assessing and prioritizing care needs.

• Triage

  • Clinical skill unique to emergency nursing.
  • Means to 'sieve or sort'; first step in patient management in the Emergency Department (ED).
  • All patients are triaged on arrival by a trained registered nurse.
  • Establishes initial care and assessment.

• Australasian Triage Scale (ATS) Categories

  1. Category 1:
  • Critically ill patients needing immediate transfer.
  • Common conditions: multi-trauma, shock, unconsciousness, cardiorespiratory arrest.
  1. Category 2:
  • Imminently life-threatening conditions.
  • Requires treatment within 10 minutes (e.g., chest pain, severe dyspnoea, severe abdominal pain).
  1. Category 3:
  • Potentially life-threatening; treatment within 30 minutes.
  • Examples: moderately severe pain, significant infections, injuries.
  1. Category 4:
  • Potentially serious; requires treatment within 1 hour.
  • Examples: minor trauma, mild hemorrhage, mild pain.
  1. Category 5:
  • Less urgent; can delay treatment up to 2 hours.
  • Conditions: chronic pain, minor wounds, skin conditions, non-urgent administrative needs.