Goals of Triage
Triage is a French word that means what?
To sort
What are the three parts of the Pediatric Assessment Triangle?
Appearance, Work of Breathing and Circulation
Mrs. Smith has been to the ED, determined there was not an emergency and discharged back to her nursing home. What disposition code would be utilized?
Home
The ED triage area will be staffed by how many triage trained nurses?
At least 1 triage trained nurse at all times
For any medical condition, individuals will receive __________, regardless of the fact that the reason for examination clearly does not indicate an emergency
Medical Screening Exam
How often are reassessments performed in triage?
1 hour
If a psychiatric patient comes in with paranoia, hallucinations and suicidal ideations, what ESI Level is given?
ESI Level 2
Left Without Being Seen
Obstetrical patients greater than 20 weeks with water broken should be taken down to birthing center by which mode of transportation?
Wheelchair or gurney
According to policy, who can perform a medical screening exam?
Physician
Physician Assistant
Nurse Practitioner
Certified Midwife
What is the time frame for EKG to be completed on a patient complaining of chest pain?
10 minutes
Name the two types of pain scales that can be utilized when triaging pediatric patients?
FLACC scale, Wong Baker faces
Mr. Compton has been medically cleared and will be transferred to Stephen's Unit. What disposition code would be utilized?
Admit in
All OB patients presenting to the Emergency Department with medical complaints unrelated to their pregnancy are evaluated where?
In the emergency department
What form must be filled out PRIOR to all patients transfer from FHS and who is responsible to review it?
Interfacility Transfer Form
Charge Nurse
What is the time frame for patient's to receive an initial triage?
Within 10-15 minutes of arrival
What mnemonic is utilized when obtaining pediatric history?
C- Chief Complaint determine the cause for the visit and duration of complaint
I – Immunization – completion of immunizations should be evaluated
A – Allergies – medications, foods, latex, and environmental
M – Medications – child's current medications, over the counter and medicinal
Dose administered, time of last dose
P – Past health history – illnesses, injuries, hospitalizations, surgeries
Evaluate use of tobacco, alcohol, drugs
Medical hx of neonate should include prenatal and birth history maternal complications,
Parent’s or caregiver's impression of the child’s condition. Consider cultural differences that may affect impressions
E – Events preceding problem – Illness – length of illness, onset of symptoms, etc.
Injury – MIVT – mechanism, injuries, vitals, treatment
D – Diet – assess the child’s recent oral intake and changes in eating patterns
time of last meal and last fluid intake
usual diet
5-year-old trauma patient is being transferred to Children's Mercy. What disposition code would be utilized?
Transfer to Specialized Care Facility
If the patient's clinical status changes while in triage and determined to be less than optimal for the comfort or safety of the patient, who needs to be notified?
Charge Nurse
How many yards away from the buildings, sidewalks, and driveways are we responsible for?
250 yards
Name 2 additional tasks that are the responsibility of triage RN when an ESI level 2 is present in triage and can not be placed immediately?
Contact charge nurse
Make a nurses note
What age and above does the suicide screening need to be completed?
Age 9 and greater
Pt was sent to the ED from Stephen's Unit. The patient was medically cleared and sent back to Stephen's Unit. What disposition code would be utilized?
Still an inpatient
What is the difference between Left Without Being Seen and Against Medical Advice?
LWBS - patient leaves before seeing the ERP or qualified personnel
AMA - Patient checks out of the ED against the advise of the doctor, prior to completion of tests, diagnosis, treatment and/or discharge instructions
What does EMTALA stand for?
Emergency Medical Treatment and Active Labor Act