Emergency Triage E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Advanced Life Support Group
• Sprache: Englisch

Seitenzahl: 182

Veröffentlichungsjahr: 2015

Beschreibung

Emergency Triage: Telephone Triage and Advice complements the highly successful Emergency Triage. The algorithms are rooted in the Manchester Triage System (MTS), which is used in hospitals around the world and which is acknowledged as an effective means of clinical prioritisation.

This telephone iteration of a triage system which prioritises millions of patients each year provides a robust, safe, evidence-based system for managing the clinical risk in patients who are at a distance from health care providers. The basic principles that drive the MTS remain, but this book addresses the specific difficulties of assessment by telephone. The possible triage outcomes are "face-to-face now", "face-to-face soon" and "face-to-face later" together with a self-care option. Information and advice is suggested at every level. The advice ranges from life-saving interventions, which can be carried out until health care arrives, to self-care instructions.

Emergency Triage: Telephone Triage and Advice provides all the necessary information that telephone triage staff must have to hand as well as including examples of questions to be asked. It will be a valuable resource for staff working in emergency departments, health centres and telephone triage organisations. Furthermore hospitals that are already using Emergency Triage will benefit from being linked with a telephone triage system that follows the same protocols.

Updated to Version 1.7 in 2023.

Leseprobe

Table of Contents

Cover

Title Page

Copyright Page

Editors

Acknowledgements

Members of the Original Manchester Triage Group

International Reference Group

Preface

CHAPTER 1: Introduction

Nomenclature and definitions

The development of Telephone Triage

Triage methodology

Advice

Training for triage

Triage audit

Summary

CHAPTER 2: The decision making process and Telephone Triage

Introduction

The development of expertise

Decision-making strategies

Decision-making during triage

Changing current decision-making practice

CHAPTER 3: The Telephone Triage method

Introduction

Identifying the problem

Gathering and analysing information

Evaluating alternatives and selecting one

Implementing the selected alternative

Monitoring and evaluating

CHAPTER 4: The presentation priority matrix

Presentation-priority matrix mapping

CHAPTER 5: Ensuring safety in Telephone Triage

Introduction

Appropriate training

Competence assessment

Audit method

Triage in practice

Peer review

System review

Presentational Flow Chart Index

Abdominal pain in adults

Abdominal pain in children

Abscesses and local infections

Allergy

Apparently drunk

Assault

Asthma

Back pain

Behaving strangely

Bites and stings

Burns and scalds

Chemical exposure

Chest pain

Collapse

Crying baby

Dental problems

Diabetes

Diarrhoea and vomiting

Ear problems

Eye problems

Facial problems

Falls

Fits

Foreign body

GI bleeding

Headache

Head injury

Irritable child

Limb problems

Limping child

Major trauma

Medication request

Mental illness

Neck pain

Overdose and poisoning

Palpitations

Pregnancy

PV bleeding

Rashes

Self‐harm

Sexually‐acquired infection

Shortness of breath in adults

Shortness of breath in children

Sore throat

Testicular pain

Torso injury

Unwell adult

Unwell baby (up to 12 months)

Unwell child

Unwell newborn (up to 28 days)

Urinary problems

Worried parent

Wounds

Discriminator and question dictionary

Index

End User License Agreement

List of Tables

Chapter 1

Table 1.1

Table 1.2

Table 1.3

Chapter 3

Table 3.1

Chapter 5

Table 5.1

Guide

Cover Page

Title Page

Copyright Page

Editors

Acknowledgements

Members of the Original Manchester Triage Group

International Reference Group

Preface

Table of Contents

Begin Reading

Presentational Flow Chart Index

Discriminator and question dictionary

Index

WILEY END USER LICENSE AGREEMENT

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Emergency Triage

Telephone triage and advice

Manchester Triage GroupEDITED BY

Janet Marsden

Mark Newton

Jill Windle

Kevin Mackway‐Jones

FIRST EDITION(VERSION 1.7)

This edition first published 2016 © 2016 by John Wiley & Sons, Ltd. This version updated 2023 (Version 1.7)

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Library of Congress Cataloging‐in‐Publication Data

Emergency triage (Manchester Triage Group)

Emergency triage : telephone triage and advice / Manchester Triage Group ; edited by Janet Marsden,

 Mark Newton, Jill Windle, Kevin Mackway-Jones. – First edition.

  p. ; cm.

 Includes index.

 ISBN 978-1-118-36938-8 (pbk.)

 I. Marsden, Janet, editor. II. Newton, Mark, 1963– , editor. III. Windle, Jill, editor. IV. Mackway-Jones, Kevin, editor. V. Manchester Triage Group, issuing body. VI. Title. [DNLM: 1. Triage–methods. 2. Emergency Service, Hospital. 3. Telephone. WX 215]

 RA975.5.E5

 362.18–dc23

2015007951

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Editors

Janet Marsden, Professor of Ophthalmology and Emergency Care, Director – Centre for Effective Emergency Care, Manchester Metropolitan University.

Mark Newton Head of Service/Consultant Paramedic responsible for Urgent Care. North West Ambulance Service NHS Trust

Jill Windle, Lecturer Practitioner in Emergency Nursing, Salford Royal Hospitals NHS Foundation Trust and University of Salford.

Kevin Mackway‐Jones, Consultant Emergency Physician – the Manchester Royal Infirmary and the Royal Manchester Children’s Hospital, Medical Director – North West Ambulance Service, Honorary Civilian Consultant Advisor in Emergency Medicine to the British Army, Professor of Emergency Medicine – Centre for Effective Emergency Care, Manchester Metropolitan University.

Acknowledgements

The editors would like to thank all those in the North West Ambulance Service who have contributed their time and expertise to this project and in particular to Stephanie Allmark and Stephen Scholes whose contribution and support remains absolutely invaluable.

Members of the Original Manchester Triage Group

Kassim Ali, Consultant in Emergency Medicine

Simon Brown, Senior Emergency Nurse

Helen Fiveash, Senior Emergency Nurse

Julie Flaherty, Senior Paediatric Emergency Nurse

Stephanie Gibson, Senior Emergency Nurse

Chris Lloyd, Senior Emergency Nurse

Kevin Mackway‐Jones, Consultant in Emergency Medicine

Sue McLaughlin, Senior Paediatric Emergency Nurse

Janet Marsden, Senior Ophthalmic Emergency Nurse

Rosemary Morton, Consultant in Emergency Medicine

Karen Orry, Senior Emergency Nurse

Barbara Phillips, Consultant in Paediatric Emergency Medicine

Phil Randall, Consultant in Emergency Medicine

Joanne Royle, Senior Emergency Nurse

Brendan Ryan, Consultant in Emergency Medicine

Ian Sammy, Consultant in Emergency Medicine

Steve Southworth, Consultant in Emergency Medicine

Debbie Stevenson, Senior Emergency Nurse

Claire Summers, Consultant in Emergency Medicine

Jill Windle, Lecturer and Practitioner in Emergency Nursing

International Reference Group

AustriaStefan KovacevicAndreas LuegerWillibald Pateter

BrazilWelfane CordeiroMaria do Carmos RauschBárbara Torres

GermanyJoerg KreyHeinzpeter MoeckePeter Niebuhr

MexicoAlfredo Tanaka ChavezElizabeth Hernandez DelgadilloNoe Arellano Hernandez

NorwayGrethe DoelbakkenEndre SandvikGermar Schneider

PortugalPaulo FreitasAntonio MarquesAngela Valenca

SpainGabriel Redondo TorresJuan Carlos Medina ÁlvarezGema García Riestra

Preface

It is now 20 years since a group of senior emergency physicians and emergency nurses first met to consider solutions to the muddle that was triage in Manchester, UK. We had no expectation that the solution to our local problems would be robust enough (and timely enough) to become the triage solution for the whole United Kingdom. Never in our wildest dreams did we imagine that the Manchester Triage System (MTS) would be generic enough to be adopted around the world. Much to our surprise, however, both of these fantastic ideas came about, and the MTS continues to be used in many languages to triage tens of millions of Emergency Department attenders each year.

Clinical decisions made by telephone have always been an area of concern for clinicians because not only is the patient not present and it may be difficult to obtain correct information but many of the tools and indicators that we use for decision making are simply not available. It is therefore an inherently more risky process than face‐to‐face triage.

Quite early on in the implementation of MTS in Manchester, departments began to use a simplified version as a structure for telephone conversations. This was superseded by national algorithm‐based telephone helplines and its use in the Emergency Department diminished.

Our colleagues in the Greater Manchester Ambulance Service (GMAS) felt that there was a gap in their resources for undertaking telephone decision making. We have discussed ways of developing tools based on the MTS, with its significant evidence base and good safety record which would embed safety and quality into their telephone decision systems.

A huge amount of work has been done by the now North West Ambulance Service (NWAS) along with MTS to test and audit a robust Telephone Triage tool. It has also been piloted in diverse settings, with ambulance services in the Azores and New Zealand, as well as other services in the United Kingdom using it for the whole or part of their day to day work. It has been tested and refined and has a superb audit trail and safety record associated with it.

The basic principles that drive the MTS (recognition of the presentation and reductive discriminator identification) are unchanging – but changes have been made to reflect the difficulties of assessment by telephone. The outcomes of decisions are condensed into ‘face‐to‐face now’, ‘face‐to‐face soon’ and ‘face‐to‐face later’ with a self‐care outcome. Information and advice is suggested alongside every outcome. The advice ranges from life‐saving interventions which can be carried out until health care arrives, to self‐care advice.

We recognise the diversity of health care settings and the need for appropriate information and advice; therefore, the information and advice sections of the Telephone Triage tool can be customised by the user to reflect different health economies while retaining the core which is MTS.

Clinical prioritisation (whether called triage or anything else) remains a central plank of clinical risk management in all emergency care settings. This telephone iteration of a triage system which prioritises millions of patients each year provides a robust, safe, evidence‐based system for managing the risk inherent in patients who are at a distance from health care providers.

Janet Marsden, Mark Newton, Jill Windle, Kevin Mackway‐Jones

January 2015

CHAPTER 1Introduction

Triage is a system of clinical risk management employed in Emergency Departments worldwide to manage patient flow safely when clinical need exceeds capacity. Systems are intended to ensure care is defined according to patient need and in a timely manner. Early Emergency Department triage was intuitive rather than methodological and was therefore neither reproducible between practitioners nor auditable.

The Manchester Triage Group was set up in November 1994 with the aim of establishing consensus amongst senior emergency physicians and emergency nurses about triage standards. It soon became apparent that the Group’s aims could be set out under five headings.

Development of common nomenclature

Development of common definitions

Development of robust triage methodology

Development of training package

Development of audit guide for triage

Nomenclature and definitions

A review of the triage nomenclature and definitions that were in use at the time revealed considerable differences. A representative sample of these is summarised in Table 1.1.

Despite this enormous variation, it was also apparent that there were a number of common themes running through the different triage systems; these are highlighted in Table 1.2.

Table 1.1

Hospital 1

Hospital 2

Hospital 3

Hospital 4

Red

0

A

0

Immediate

0

1

0

Amber

<15

B

<10

Urgent

5–10

2

<10

C

<60

Semi‐urgent

30–60

Green

<120

D

<120

Blue

<240

E

—

Delay acceptable

—

3

—

FGHI

Table 1.2

Priority

Maximum times (minutes)

1

0

0

0

0

2

<15

<10

5–10

<10

3

<60

30–60

4

120

<120

5

<240

—

—

—

Table 1.3

Number

Name

Colour

Maximum time (minutes)

1

Immediate

Red

0

2

Very urgent

Orange

10

3

Urgent

Yellow

60

4

Standard

Green

120

5

Non‐urgent

Blue

240

Once the common themes of triage had been highlighted, it became possible to quickly agree on a new common nomenclature and definition system. Each of the new categories was given a number, a colour and a name and was defined in terms of ideal maximum time to first contact with the treating clinician. At meetings between representatives of Emergency Nursing and Emergency Medicine nationally, this work informed the derivation of the United Kingdom triage scale as shown in Table 1.3.

As practice has developed over the past 20 years, five‐part triage scales have been established around the world. The target times themselves are locally set, being influenced by politics as much as medicine, particularly at lower priorities, but the concept of varying clinical priority remains current.

The development of Telephone Triage

After a period where all Emergency Departments in the Manchester area were using ‘Manchester Triage’ and using it on the telephone to triage callers to the ED (prior to NHS Direct), it became apparent that although all Emergency Department staff were using the same language of triage, the interface with paramedic colleagues still faced a language barrier. Key collaborators within the ambulance service recognised that applications of the Manchester Triage method would be extremely useful within the ambulance service and a further group of clinicians across acute care settings and the ambulance service was set up to explore this. Telephone Triage emerged as one of the products of this collaboration and had been used successfully for both secondary triage (since 2006) and latterly primary triage (2012) of those patients accessing care by telephoning ambulance services in a number of ambulance services across the United Kingdom and internationally.

Triage methodology

In general terms, a triage method can try and provide the practitioner with the diagnosis, disposal or clinical priority. ‘Manchester Triage’ is designed to allocate a clinical priority. This decision was based on three major tenets. First, the aim of the triage encounter is to aid clinical management of the individual patient, and this is best achieved by accurate allocation of a clinical priority. Second, the length of the triage encounter is such that any attempts to accurately diagnose a patient are doomed to fail. Third, it is apparent that diagnosis is not accurately linked to clinical priority. The latter reflects a number of aspects of the particular patient’s presentation as well as the diagnosis; for example patients with a final diagnosis of ankle sprain may present with severe or no pain and their clinical priority must reflect this. In Telephone Triage, the allocation of this clinical priority is inherently linked to a place of definitive clinical care, and in the highest priority, a mode of emergency transport to this care.

In outline, the triage method put forward in this book requires practitioners to select from a range of presentations and then to seek a limited number of signs and symptoms at each level of clinical priority. The signs and symptoms that discriminate between the clinical priorities are termed discriminators and they are set out in the form of flow charts for each presentation – the presentational flow charts. Discriminators that indicate higher levels of priority are sought first, and to a large degree, patients who are allocated to the standard clinical priority are selected by default. In this way, it reflects the effective face to face triage methodology taught by the Manchester Triage Group. The clinical priority is inherently linked to a disposal: where does the patient obtain the definitive care which they require and what is the timescale within which this must be obtained for optimum outcomes. The possible outcomes of Telephone Triage are simplified from the five categories system as there are fewer options available to the Telephone Triage practitioner.

The decisions which must be made are as follows:

Does the patient need immediate and urgent care? (FtF Now)

Do they need to be seen face to face by a clinician soon, but not immediately? (FtF Soon)

Can medical or other care be delayed? (FtF Later)

Can an ‘advice only’ route be followed, where the problem can be managed by giving self‐care advice?

Face to face triage practitioners will note differences between the discriminators seen within face to face triage and those in the Telephone Triage method. For some discriminators used in face to face triage, it is impossible to ascertain without actually having the patient in front of the triage practitioner, whether the dis-criminator is fulfilled or not. Those discriminators are therefore not used in Telephone Triage. Slight changes are made to other discriminators in order for them to be more appropriate in a Telephone Triage setting.

Advice

Advice is presented on the charts at each level and is to highlight issues which can be discussed by the practitioner with the patient or caller. It is important that interim advice is given and that, if the patient is triaged to ‘advice only’, comprehensive advice is given and understanding is checked. The patient must know what to do should the situation change. A key premise of the advice in these charts is that it is general and may be adapted for use in specific settings. The algorithms, as in the case of the face to face algorithms, are evidence based and validated and must not be modified.

The decision making process is discussed in Chapter 2 and the triage method itself is explained in detail in Chapter 3.

Presentation priority matrix

Patients who are in the ‘FtF Now’ category are best served by the Emergency Ambulance Service and Emergency Departments, whatever their locations. Those requiring ‘FtF Soon’ or ‘FtF Later’ may have care delivered in a number of locations and by various providers. Thus the time to care in the ‘FtF Soon’ category will vary, depending upon those services available in that health economy. A mapping exercise should be undertaken locally to agree the appropriate dispositions arising from the triage decision (see Chapter 4). It is essential that the practitioner undertaking Telephone Triage is able to use up-to‐date details about current local services such as dental emergency arrangements, telephone numbers of primary care facilities and the location of pharmacy provision.

Training for triage

This book and the accompanying course attempt to provide the training necessary to allow introduction of a standard triage method. It is not envisaged that reading the book and attending a course can produce instant expertise in triage. Rather this process will introduce the method and allow practitioners to develop competence at using the material available. This is the first step towards competence in using the system and must be followed up by audit and evaluation of the system in use.

Triage audit