Triage and Telephone Triage resources

1. Pediatric Assessment Triangle.  PAT is a visual assessment tool to quickly determine if a child is sick.   It gives nurses a systematic approach to assessment.

   1. Appearance: the mnemonic TICLS. It stands for tone, interactivity, consolability, look (gaze), and speech (cry). When it comes to assessing the appearance of the child, it becomes important to observe their tone. We will ask ourselves, “are they limp or are they stiff?” We will also be observing their interaction with their caregivers. Do they make eye contact? Are they tracking? Are they consolable? Lastly, for appearance, we are listening for the pitch of their cry and, if they are old enough to speak, we are observing their speech patterns.

   2. Work of breathing: Breathing:  The second side of the Pediatric Assessment Triangle is work of breathing. Again, most of this part of the assessment can be performed without physically touching the child. Work of breathing includes listening for audible breath sounds and observing for signs of increased work of breathing. For this part of the assessment, since we are trying to limit any physical interaction with the child, we are not going to use a stethoscope, but are only listening for stridor, grunting, audible wheezing, as these can be heard without one. Signs that indicate increased work of breathing include nasal flaring, abdominal retractions, suprasternal retractions, and scalene muscle use.  Look at positioning – are they tripoding?

   3. Circulation: The last side of the Pediatric Assessment Triangle is circulation. Again, trying to minimize physical interaction with the child during this initial assessment, look at skin color: pale, mottling, cyanotic?  Flushed? Petechiae? Bruising?  Obvious bleeding? Mucous membranes: pale? Yellow? Moist? Delayed cap refill?

   4. Positive findings on the PAT indicate a child who should require prompt evaluation by a provider.

CSM.073 Triage of Walk-in Patients

RN Triage of a Febrile Infant

1. PSR will register the WI pt.  If there is provider availability (e.g. no-show, cancellation) they can move the patient to that appointment slot without RN triage.  Some providers may ask you to triage patient even if an appointment is found as your triage can expedite the visit.

2. Patients shouldn’t be added to RN WI schedule 30 minutes prior to lunch or close of business unless it is a life-threatening emergency.

3. Sites that see multiple walk-ins daily (Elm, Peds) should follow clinic workflows for adding patients to RN triage

4. Triage workflow.  RN will do:

   1. HPI, vital signs, brief medication reconciliation, focused assessment, point-of-care testing if applicable.

   2. Document in eCW – use template if there is one for the complaint.

   3. Determine disposition:

      1. Advice only

      2. Future appointment

      3. Same day appointment (e.g. no-show, provider willing to see pt as EMV or WI)

      4. Urgent Care/ED

5. Provider consultation

   1. Use SBAR (Situation, Background, Assessment, Recommendation) when communicating with providers.

   2. Keep communication brief and succinct.

   3. Whenever you are calling EMS for a patient or have an urgent patient need, notify a provider of the situation.