ENK LIFE      Erasmus and Kinkajou What you need to know about LIFE -
what they don't teach you at school.

 

 

 

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MEDICAL TRIAGE

Erasmus Erasmus : Everyone at some stage of their life, runs the risk of being at the focal point of a disaster.
It’s about giving you the tools to help as many people as possible. I think it’s the opposite of being a survivalist in a post-apocalyptic world- helping the many not just yourself. Be an asset to humanity. Part of the EnKie creed.

 

Erasmus Erasmus : From the French word, "trier"
"To Sort"
Triage is simply a sorting PROCESS that when applied
Creates a situation that allows for "doing the greatest good for the greatest number"

Rapid Triage Triage Hierarchy

 

Triage
Kinkajou FaceKinkajou : What are the OBJECTIVES of doing Triage?
Dr Xxxxx Dr Xxxxx : Rapid sorting of the more serious patients from those less serious to facilitate the rapid care of the more serious patients. When problems exceed resources, triage should facilitate "doing the greatest good for the greatest number"

Triage: Getting it Right - It’s Crucial
In the health industry, triage literally means the sorting of patients, based on their illness and other factors, into categories that determine the urgency and extent of medical care required.
People are required to ask a series of questions to assess a patient’s health status and to determine the urgency of their situation.

 

Dr Xxxxx Dr Xxxxx : Common questions and subsequent actions include;
Record the patients name and phone number;
What is the patient’s age?
Nature of their problem;
Duration of their symptoms;
Severity of their problem;
and has the patient had any previous major health problems.

Remember, that often the most seriously ill , make the least noise.

 

Dr Xxxxx Dr Xxxxx : Triage Process:
*    ??Assess the patient
*    ??Make a judgment
*    ??Prioritise medical need
*    ??Implement ‘accepted’ protocols
*    ??Document / report

Suggested Categories:
??Emergency - Immediate

??Urgent - 5-20 minutes
??Interrupt Doctor / GP – ASAP 1-4 hours

??Today - Same Day
??Within 24 Hours

GPs in Australia doing Triage

 

Kinkajou FaceKinkajou : WHAT ARE THE ISSUES  for Triage


Dr Xxxxx Dr Xxxxx :

1. GP/ Doctor  Shortage/ Medical staff access difficulties- long waits for appointments. There is a balancing act between patient safety and workforce pressures
2. Clinical risk- Undifferentiated problems exist ( You are not the doctor. You have limited knowledge. The situation needs your best judgment but if you are not skilled ,
the world does not expect perfection  , 
personalities of people are difficult, 
dumb people exist- you need to make decisions for them, 
Believe a worried mum


3. Legal considerations-increasing pressure to identify presentations which may
constitute urgent or emergency situations
4.  Time pressures exist

 

Dr Xxxxx Dr Xxxxx : PATIENT CONFIDENTIALITY
In order for us to determine how to best assist you,  staff may need to ask you a few questions about your problem.

Talking with the patient (professional considerations)

. Volume of your voice – keep things personal , not loud enough to be public.
. Privacy issues exist

 
Dr Xxxxx Dr Xxxxx : THE AUSTRALASIAN TRIAGE SCALE
Each presentation must be assessed as a unique episode of illness/injury that is independent of chronicity and frequency of presentation.

• Chief complaint
• General appearance


• Airway• Breathing• Circulation• Disability• Environment• Limited history•

The most obvious observations are the most important.
If they look or sound really bad, they probably are really bad.

 

Airways Symptoms: Bad if
Can’t walk, has to sit up, can’t lie down, can’t sleep, trouble talking
Has Trouble breathing can’t breathe

Causes: Airway Obstructed:
Swelling: infections: epiglottitis,
Foreign body has gone into airway
Noisy breathing: stridor, salivation: can’t swallow own saliva

Causes Trouble Breathing: 
Asthma: wheeze, cough a lot, tight, using lots of Ventolin / Asmol / Puffers, been to hospital
Pneumothorax: injury or fall, really sore ribs
Rib Fractures: really sore chest: can’t breathe, can’t cough, can’t get out of bed
Coughs: croup, whoop
Blockage: foreign or other body in airways

 

 

Heart or Chest Symptoms:
Heart Attack: Crushing dull central chest pain may go up into Left arm or into Left neck,
Associated with Shortness of breath, often sweating, may have a funny heart beat, or feel as if an elephant were standing on their chest
Needs to last more than 3 minutes, often over half an hour to be serious and if this happens, these patients with these symptoms, need to go to hospital immediately
Not always typical


Heart rhythm disturbances occur within the first hour and cause 50% mortality. With medical care, these odds change a lot for the better.

Heart Rhythms
Fast Heart rhythms: ECG: may be very serious
Slow heart rhythms: ECG, probably less likely to be serious

Chest wall pains: sharp short jabs in the chest, lasting seconds to minutes, intermittent
Most chest symptoms end up remaining undiagnosed

Circulation absent: pale, blue, white, unconscious
Hemorrhage: how much and how fast

 

Dr Xxxxx Dr Xxxxx : People Not Able to Intereact or Respond

Disabled
GCS: Unconscious People
Dumb people
People with Psychiatric Issues
People with bad memories
Drugs causing mind wipe

Hospital Emergency Emergency Theatres: Hospital

 

Dementia
Dementia is a common problem. It is not a diagnosis rather a cluster of progressive
Symptoms, the most common being:
•    memory loss and confusion
•    intellectual decline
•    Personality changes.

 

Kinkajou FaceKinkajou : Other issues in Triage assessments ?

Environment
# Extremes of age (very young or very old) are associated with  physiological differences that increase risk of poor medical outcomes
# High-risk features including chronic illness, cognitive impairment( brain not right), communication deficit, multiple co-morbidities (lots of things wrong with them),  poisoning or severe pain may warrant allocation to a high ATS (Acute Trauma State) category.
# Patients with high risk alerts, such as a history of violence. 
# Trauma patients

Dr Xxxxx Dr Xxxxx : Glasgow Coma Scale used to assess degree of head injury.
Reaction are expected to questions and then physical touch and pressure


Eye opening

Spontaneous
To speech
To pain
No response


Motor response

Follows commands
Localizes pain
Movement or withdrawal to pain
Decorticate
Decerebrate extension
No response
Verbal response


Alert and oriented

Disoriented conversation
Speaking but nonsensical
Moans or unintelligible sounds
No response

Musculoskeletal

Fractures
Bad Backs
Ankle Sprains
Note Neck Injuries can be dangerous to move

Strokes:

Painless: loss of function
Altered behaviour or function
If pain, may be a bleed
Beware if violence involved head or neck trauma

    
People’s Personalities are Important:
Enneagram 4s
Enneagram 8s

People are very different but usually in quite predictable ways. Some extreme bad
behaviours or illness behaviours are fairly typical of the personality type. People use
particular words: and often have a characteristic appearance. 
Some people are not “fast” – so being slow  can be normal.

 

Dr Xxxxx Dr Xxxxx : Eye Problems
• Penetrating eye injury
• Sudden loss of vision with or without injury
•Sudden onset severe eye pain
• Sudden abnormal vision with or without injury
– Flash burns
– Foreign body

Chemical injury: burns
Eyes exposed
Lungs exposed

 

Dr Xxxxx Dr Xxxxx : Envenomations and Bites:
Snakes
Spiders
Cardiovascular and renal problems are most serious

 

Dr Xxxxx Dr Xxxxx : Fractures: Symptoms are
Pain, loss of function, deformity, swelling, bruising is rare early

 

Fractures: Typical Locations:
Hands: scaphoid, long little hand bones
Ribs
Shoulders
Ankles: sprains
Toes

 

Stomach Problems
Pain Usually, Sometimes Nausea


Gallstone and infection
Kidney Stone
Diverticulitis
Gynaecological Problems in women : infection, Bleeding
Problems peeing: pain, frequency

 

Infections :

Let’s worry about us first: Flu, Weird bad stuff: Pneumonia

Meningitis : headache, vomiting , looks sick, sleepy, Really sick with a rash
Can’t breathe : pneumonia
Eyes: Not going to kill you but consequences of delay are serious
Smell: old grungy people with bad legs, Unhappy looking women

The Queensland Ambulance Service Ambulance Vehicle : Brisbane Qld

 

MENTAL HEALTH

Psychotic illness, depressive illness, attempted suicide, suicidal thoughts, anxiety, acute situational crisis, substance-induced disorders, and physical symptoms in the absence of illness is the most common mental health presentations at triage.

•    Are they displaying bizarre, odd or unpredictable actions?
•    Are they orientated?
•    How is the patient reacting?

•    Are they angry, hostile, uncooperative, over-familiar, suspicious, guarded, withdrawn, inappropriate or fearful?

•    Are they responding to unheard voices or sounds, or unseen people or objects?

 

Possible questions:

‘This must be distressing for you. Can you tell me what is happening?’
‘I can see that you are very anxious. Do you feel safe?’
‘I can see that you are angry. Can you tell me why?’
‘Are your thoughts making sense to you?’
‘Are you taking any medication?’
Conversation and mood – does this seem normal to you?
Are you hearing voices?
Do they know what day and time it is and how they got to the ED?

 

Mood
How does the patient describe their mood? Do they say they feel?
Down, worthless, depressed or sad?
Angry or irritable?
Anxious, fearful or scared?
Sad, really happy or high?
Like they cannot stop crying all the time?
What do you think is the risk of suicide/homicide?

 

For example, does the patient tell you that they are thinking about suicide, wanting to hurt others, worrying about what people think about them, worrying that their thoughts don’t make sense, afraid that they are losing control, feeling that something dreadful is going to happen to them, and/or feeling unable to cope with everything that has
happened to them lately in relation to recent stressors?

Possible questions:
‘Do you feel hopeless about everything?’
‘Do you feel that someone or something is making you think these things?’
‘Are you being told to harm yourself and/or others?’
‘Do you feel that life is not worth living?’

Possible questions:
• ‘Do you have access to tablets/a gun?’
Presentations to the ED for self-harm or risk of self-harm are very common and are increasing, in all age groups. Regardless of the motivation or intent, these behaviours are associated with a high risk of death. Consider the use of the Mental Health Act 2000
and risk assessments (such as removal of weapons and close observation).

 

 

 

 

 

Youth

Depression is the most common mental health problem for young people and is a well-recognised risk factor for suicidal behaviour.

Psychostimulants
Psychostimulants are a group of drugs that stimulate the central nervous system, causing feelings of false confidence, euphoria, alertness and energy.
Common Psychostimulants include methamphetamines (meth, crystal meth, ice, base), which are amphetamine (speed) derivatives.

Psychostimulants may produce symptoms similar to paranoid psychosis, including delusions of persecution, ideas of reference, bizarre visual and auditory hallucinations, and violent outbursts. Symptoms are not related to the time of ingestion or the dose taken.

Assessment and rapid and safe management of acute behavioural disturbance and medical complications is the priority.

Threat of harm to others–
Unable to wait safely Supervision
Continuous visual supervision (see definition below)
Use defusing techniques (oral medication, time in quieter area)
Ensure adequate personnel to provide restraint/detention
? Disturbance  likely to others

 

Infants and small children differ from adults physiologically and psychologically.
Children and adolescents are also developmentally different from adults.

 

The principles of paediatric assessment are the same as those for adult assessment; however, age influences the pattern of presentation, assessment and management, as children are prone to rapid deterioration.

Consistency of triage is optimized for this population when age, historical data and clinical presentation are all included in the triage

History-taking in paediatrics relies on information provided by primary carers and sometimes by the child or young person. It is important to develop a rapport with the patient and the carer in order to elicit the maximum amount of information in a relatively short timeframe.

Interpreting the meaning of the information provided by carers is an additional challenge when triaging children, as the information that is given in this context will be influenced by the carer’s own knowledge and experience .

The importance of privacy for parents, children and young people at triage should not be ignored. Simple health problems may be an opportunity for parents to seek assistance regarding more sensitive issues.

Young people have high mental and emotional needs and require greater privacy. They may wish to discuss their health concerns without the presence of their parents.

 

Clinical urgency
A number of clinical features have been found to be significantly predictive of serious illness in infants and young children

 
Decreased feeding (<½ normal intake in preceding 24 hours)
Breathing difficulty
Having fewer than four wet nappies in the preceding 24 hours
Decreased activity
Drowsiness
Being pale and hot
Febrile illness in a child under three months old.

 

Infants and small children Circulation

Hypotension is a very late sign of haemodynamic compromise in infants and children.
Initial assessment should be dependent upon general appearance, pulse and central capillary refill.

Onset of pallor in infants is a significant finding and an indicator of serious illness. Capillary refill time is an indicator of central perfusion and therefore an indirect measure of cardiovascular function.

 

Estimation of the level of dehydration is important

Signs of Severity

General condition
Thirsty, restless,
Agitated
Irritable
Withdrawn, somnolent or comatose; rapid
Deep breathing
Pulse weak Rapid,
Anterior fontanelle l Sunken
Very sunken Eyes
Tears
Mucous membranes Dry
Skin turgor Decreased, Decreased with tenting
Urine Reduced, concentrated, none for several hours
Weight loss 4–5% 6–9% >10%
Disability

An abnormal conscious level always requires urgent assessment. An alteration in the level of activity can be an indicator of serious illness in infants and children

Decreased conscious level can be a result of serious derangement of oxygenation or circulation.

Ambos Brisbane Ambulance Crew Brisbane

 

 

History of presenting complaint

History can be gathered from a number of sources, including the child and/or the caregiver.

Children suffer different patterns of injury from adults in trauma. Mechanism of injury is an important part of assessment, as it is in adults, and can be used to predict patterns of injury. For example, a greenstick fracture is typical in a young child suffering from a fall.
Child protection issues must be a consideration . It is important to ascertain recent potential contact with infectious diseases, such as chicken pox.

 

Past history

Co-morbid factors should be evaluated for the likely effect on their acute condition and therefore clinical urgency. For example, premature infants or children with congenital heart or lung diseases have a greater propensity to developing significant cardiorespiratory dysfunction from respiratory infections.

Paediatric past history should also consider perinatal and immunisation history.

 
Paediatric physiological discriminators
Risk factors for serious illness or injury
These should be considered in the light of history of events and physiological data.
Multiple risk factors = increased risk of serious injury.
The presence of one or more risk factors may result in allocation of triage category of higher acuity.

Assessment of Mechanism of injury,

Penetrating injury•
Fall>2–height•
MCA>60kph•
MBA/cyclist>30kph•
Pedestrian•
Ejection/rollover•
Prolonged extrication
(>30 minutes)
Death same car occupant•
Explosion.


Co morbidities, e.g.

•    History prematurity•
•    respiratory disease•
•    cardiovascular disease•
•    renal disease•
•    carcinoma•
•    diabetes•
•    substance abuse•
•    immuno-compromised•
•    congenital disease•
•    Complex medical History.
•    Age <3 months and•
•    febrile•
•    acute change to feeding pattern•
•    acute change to sleeping pattern

 


Special Issues:

Victims of violence,

Child at risk•
Sexual assault•
Neglect.

 

Historical variables, e.g.
Events preceding presentation to ED•
Apneic/cyanotic episode•(not breathing and blue)
Seizure activity•
Decreased intake – food or fluids
Decreased output – feces or urine
Red currant jelly stool•
Bile stained vomiting.
Parental concern

 

 

 

 

PREGNANCY AND TRIAGE

All women of child-bearing age should be considered to be pregnant until proven otherwise.

An assessment of urgency must be made on the basis of both the woman and the foetus.

Pregnant women are at an increased risk of a number of conditions, including Cerebral haemorrhage, cerebral thrombosis, severe pneumonia, atrial arrhythmias, Venous thrombosis and embolus, spontaneous arterial dissection, cholelithiasis and pyelonephritis, than non-pregnant women of child-bearing age.

• Presentations may include concerns about normal manifestations or progression of pregnancy.

 

Triage and the pregnant patient
A pregnant woman presenting to an ED raises a number of unique challenges as  normal physiological and anatomical adaptations of pregnancy will influence assessment.

• Wellbeing of both the mother and the foetus and potential

 

Pregnant women commonly
experience increased nasal and airway vascularization and mucosal oedema. This presents as an increase in complaints about nasal congestion.

About one-third of women with asthma suffer a deterioration of their underlying  illness during pregnancy. 

 

 

Circulation
Pregnancy is described as a hyperdynamic state and physiological changes occur as early as 6–8 weeks gestation. Progesterone causes widespread vasodilatation and oestrogen is thought to contribute to a 40–50 per cent increase of blood volume. The diastolic blood pressure falls on average 6–17 mm Hg, with BP lowest during the second
trimester. Cardiac output (CO) increases by 30–50 per cent.

At 20 weeks gestation, the weight of the uterus compresses the inferior vena cava if the woman is lying on her back. The subsequent reduction in placental flow is enough to compromise foetal wellbeing and the drop in venous return reduces maternal CO and BP. In Pregnancy, changes occur to blood vessels that predispose pregnant women to spontaneous arterial dissections.

The splenic artery, subclavian artery and aorta, for example, have an increased
tendency to spontaneous dissection, even in women with no previous medical history.

 

Domestic violence is more common during pregnancy and is associated with an increase in obstetric complications for the mother and adverse neonatal outcomes.

Important points to note:
Pregnant women often describe palpitations during pregnancy, which is usually due to the hyperdynamic flow.
The high volume and dynamic blood flow is thought to contribute to the increased likelihood of cerebral haemorrhage (especially sub-arachnoid haemorrhage (SAH)) in pregnancy.
It is not uncommon for pregnant women to experience a sudden and serious deterioration of their condition therefore pregnant women showing signs of haemodynamic de-compensation (cardiovascular shock) require urgent medical assessment.

All pregnant women >20 weeks gestation should have a left lateral tilt (wedge under their right hip, or whole bed tilted if wedge is contraindicated) if they are lying down.
Pulmonary embolus is relatively common during pregnancy due to the changes in the coagulation system associated with pregnancy.

 

Trauma
Considerations include trauma to the uterus, placenta or foetus, particularly in the third trimester when the foetus is viable. The maternal vital signs may remain stable even when loss of one-third of blood volume may have occurred•

Pregnant women frequently present to the ED with vaginal bleeding. Common causes include the various types of miscarriage (i.e. threatened, inevitable, complete, incomplete and septic).

Knowledge of the volume and colour of per vaginal (PV) loss will assist the Triage
• Bright red blood loss is usually indicative of active bleeding, while brownish red blood loss is usually old.
• Many women may also complain of associated abdominal pain that may be likened to severe period pain.
• Shoulder tip pain can be indicative of a bleeding ectopic pregnancy. • The first and foremost diagnosis to exclude in the female of child-bearing age, including those who have undergone sterilization procedures presenting with vaginal bleeding, is an ectopic pregnancy. Ectopic pregnancies are  often lethal in otherwise healthy well young
women.

 

Abdominal pain is the most common symptom in ruptured ectopic pregnancy.
Non-ruptured ectopic pregnancies generally present with bleeding (brown being the most common) due to low progesterone and consequent shedding of the decidua.

Regardless of the diagnosis, vital signs that deviate from normal and severe pain (such as torsion or ruptured cysts) warrant prompt medical assessment.
Problems occurring from 20 weeks onwards
Pregnant women from 20 weeks gestation may present with the following obstetric conditions:

Bleeding Related Problems

Antepartum haemorrhage
Preeclampsia (including eclampsia)
Pre-term rupture of the membranes and labour.


Hypertension (>140/90) is a particularly important sign to alert the Triage Nurse to a more serious problem. The presence of the associated symptoms of severe preeclampsia warrant urgent medical assessment.

These include:
Headache
Visual disturbances
Epigastric pain
Right upper quadrant (RUQ) pain
Non-dependent oedema.
These women are at risk of fitting and placental abruption, and the foetus has a higher risk of placental insufficiency.

 

There is a correlation between the degree of hypertension and complications such as cerebral haemorrhage.

• Antepartum haemorrhage is defined as >15 mL of blood loss from the vagina from 20 weeks gestation.

• Common causes of antepartum hemorrhage include placenta praevia and placental abruption. • In placenta praevia, blood loss is usually visible PV and is not usually accompanied by pain.

• In placental abruption, primary symptom is abdominal pain. The associated blood loss may be concealed between the placenta and uterus. Haemodynamic changes are only seen with big bleeds, smaller bleeds may be difficult to detect or more easily detected with an abnormal cardiotocograph (CTG).The main signs and symptoms are
haemodynamic changes associated with hypovolaemic shock and abdominal pain.

 

Postnatal women may present with the following:
Secondary postpartum haemorrhage ± puerperal sepsis
Mastitis
Wound infection
Eclampsia
Postpartum cardiomyopathy
Postnatal depression.

 

 

 

Consent

The five elements of consent are as follows:

1. Consent must be given voluntarily.
2. A person must have the legal capacity to give consent.
3. Consent should be informed.
4. Consent must be specific.
5. Consent must cover what is actually done.

The absence of any one element renders the consent invalid. Consent may be given in several ways:

Implied consent: Implied consent is the most straightforward. With implied consent, by virtue of the patient presenting at the triage area to be assessed does not necessarily imply consent, but consent is often implied by the patient’s behaviour. This implied consent becomes less defined if the patient is confused or unable to communicate for
any other reason.

Verbal consent: This form of consent is more valid than implied consent. For example, if the Triage Person states that he or she is going to ask the patient a couple of questions, and the patient agrees to this, this implies verbal consent.

Written consent: This form of consent is not something that is necessarily obtained by the Triage Person during his or her assessment, however there should be awareness of the local policies and procedures regarding obtaining of written consent.

Duty of care
The Triage Person should be aware of the management systems in place at the individual institutions to facilitate this documentation.

Similarly, if it is the practice of the institution to transfer the care of patients to other health care providers such as general practitioners, accurate and concise documentation of any treatment administered and any recommended course of action should be made.

Some patients choose to leave prior to medical assessment. If such a patient advises the Triage Person they are not waiting, the Triage Nurse should document this decision, as well as any advice given to the patient, including possible adverse outcomes.

 

 

Confidentiality

Health professionals must maintain any information that has been provided
in-confidence to them. It is also expected that the patient is in receipt of privacy from health professionals.
Safeguard are in place to protect patient’s information. These include health legislation at both federal and state level.

The Triage Person also has a responsibility to ensure the patient’s privacy is respected both during the triage assessment and while the patient waits in the waiting room. The Commercial entity’s  policy regarding patient’s privacy and rights should also be readily accessible to the Triage  Nurse.

A health care professional is obliged to treat the patient’s medical information as private and confidential. However, in certain circumstances there is a legal requirement to
override a patient’s privacy and confidentiality; for example, children at risk. Otherwise, a breach of a patient’s privacy constitutes a breach of the duty of care.

 

Mandatory Reporting Responsibilities

If there is any suspicion that a child or children may be in need of care or may be being maltreated, the nurse has a legal responsibility to report it to the relevant authorities and refer to their jurisdiction.

Although this reporting may not occur from the triage desk, the Triage Person needs to be aware of the legal requirements and of the procedures and documentation requirements of the hospital, in order to fulfill these obligations.

Preservation of forensic evidence

Persons performing the triage role must be familiar with the hospital’s procedures for dealing with the preservation of forensic evidence involving a patient who is a possible victim of crime (e.g. rape or assault).These procedures should include liaison with police
officers as appropriate, with the patient’s consent.

 

 

ROLE PLAY
1. A parent rings regarding their child, who has a rash, that has just appeared. The child has no other symptoms and the caller feels they need an urgent appointment.


ROLE PLAY
2. An elderly patient calls the surgery concerned
that they may have accidentally taken twice their prescribed dose of their blood pressure
medication (they have no symptoms at present).


 

ROLE PLAY
3. A 72yo male presents to the surgery complaining of chest pain which has developed as he was waiting in the pharmacy next door.


 

ROLE PLAY
4. A patient calls the surgery for a second time wanting to see a doctor about a persistent
severe headache.


 

 

THE DON’TS IN PHONE TRIAGE


.Don’t argue or intimidated the caller
.Don’t judge or blame the caller
.Don’t use inappropriate slang
.Don’t lecture the caller or minimise their
concerns.

 

THE DO’S IN PHONE TRIAGE

.Do use open ended questions
.Do use clarifying questions
.Do use reflective listening
.Do reiterate instructions that you give the caller
.Ask if the caller is comfortable with the instructions

 

PHONE STRATEGIES
.Use the disclaimer:
.“Please take action if any of your symptoms worsen, or change.”
.This implies a shared responsibility with the caller.

 

DOCUMENTATION
Purpose of documentation
.Decrease legal risks
.Demonstrate good standard of your care
.Demonstrate quality
.Demonstrates the plan of care

 

BENEFITS OF EFFECTIVE TRIAGE
.Increased safety of patients
.Improved legal protection for commercial enterprises
.Consistent decisions
.Guidelines provided for outcomes and timings
.Action/advice charts to assist staff
.Ambulance triage support  can be obtained

 

 

KinkajouErasmus