Triage VS standards

[F.E.R.N., BSN, RN]

I'm doing a little research for some of our new hires who are learning how to triage in ambulance patients. We don't train nurses to triage at the front triage desk until they've been here at least a year, but they will have to class their ambulance patients, and re-class as necessary the patients who have come to them from the front.

We use a 4-tier mixed system: emergent class 1 (e.g. CPR, traumas), emergent class 2 (e.g. CP w/out acute MI), urgent class 3 (stable patients that requires more than one resource, but could sit for several hours before being seen), fast-track class 4 (sore throat, sprained ankle).

I'd like to hear if others have a standard for VS. I know it can be very subjective with experienced staff, but the new nurses could use a few rules to start off with while they're getting their critical thinking skills down.

[back2bRN]

It is subjective with some experienced nurses(which I find frustrating), but per the guidelines I work with when on the unit(brought back from front) it is a minimum of hourly and prn in that time frame.IE: After meds there can be specific intervals, pt condition changes , following procedures ect.

What I find happening is that inexperienced staff begin modeling their habits after the more seasoned nurses, but minus the experience. So there has been some horrible situations and poor outcomes occur.

But what exactly do you mean when you say "re-class"is that the same as reassess?

[mmutk, BSN, RN, EMT-I]

ENA has a course for teaching triage to nurses on thier website

[F.E.R.N., BSN, RN]

But what exactly do you mean when you say "re-class"is that the same as reassess?

By that I mean to change the triage classification of a patient.

[F.E.R.N., BSN, RN]

ENA has a course for teaching triage to nurses on thier website

We send our nurses through a course before they can do front desk triage, but not until they've been working for at least a year. New hires are still expected to triage ambulance patients arriving directly to rooms. I was really just wondering if other facilities had their own short-and-sweet guidelines or algorithms.

[traumakimi]

we use the emergency severity index (ESI) it is a 5 tiered triage classifying system but you might be able to modify it to a 4 tiered to work for you. It takes into account the severity of the illness as well as the number of resources that are expected to be used for the patient.

you can find the algorithm on line at the ahrq website.

Emergency Severity Index Implementation Handbook: Figure 3-1a. ESI Triage Algorithm

it gives guidelines for danger zone vitals.

I hope this helps!

[canoehead, BSN, RN]

why not use an internationally recognized scale? Then you have established standards. Like CTAS (Canadian Triage Assessment Scale). Sounds like yours is pretty close, just add level 5, which is people that could wait for a week...like chronic butt rashes.

[mmutk, BSN, RN, EMT-I]

we use the emergency severity index (ESI) it is a 5 tiered triage classifying system but you might be able to modify it to a 4 tiered to work for you. It takes into account the severity of the illness as well as the number of resources that are expected to be used for the patient.

you can find the algorithm on line at the ahrq website.

Emergency Severity Index Implementation Handbook: Figure 3-1a. ESI Triage Algorithm

it gives guidelines for danger zone vitals.

I hope this helps!

I agree this is good for any type of triage and it's easy to remember.