triage 2

Question 1

Time seen by nurse

Answer 1

Where a patient in the ED has contact exclusively with nursing staff acting under the clinical supervision
of a doctor, it is the time of first nursing contact

Question 2

Time seen by nurse practitioner” or Time see by doctor

Answer 2

Where a patient is treated according to a documented, problem specific clinical pathway, protocol or
guideline approved by the Director of Emergency Medicine, it is the earliest time of contact between
the patient and staff implementing this protocol.

Question 3

Waiting Time

Answer 3

This is the difference between the time of arrival and the time of initial medical assessment and treatment. A
recording accuracy to within the nearest minute is appropriate.

Question 4

Documentation Standards

Answer 4

The documentation of the triage assessment should include at least the following essential details:
 Date and time of assessment
 Name of triage officer
 Chief presenting problem(s)
 Limited, relevant history
 Relevant assessment findings
 Initial triage category allocated
 Re-triage category with time and reason
 Assessment and treatment area allocated
 Any diagnostic, first aid or treatment measures initiated

Question 5

SPECIFIC CONVENTIONS
Paediatrics

Answer 5

e same standards for triage categorisation should apply to all ED settings where children are seen – whether
purely Paediatric or mixed departments. All five triage categories should be used in all settings. Children should
be triaged according to objective clinical urgency. Individual departmental policies such as ‘fast-tracking’ of
specific patient populations should be separated from the objective allocation of a triage category

Question 6

SPECIFIC CONVENTIONS Trauma

Answer 6

Individual departments may have policies that provide for immediate team responses to patients meeting certain
criteria. However, the triage category should be allocated according to their objective clinical urgency.

Question 7

Behavioural Disturbance

Answer 7

Patients presenting with mental health or behavioural problems should be triaged according to their clinical and
situational urgency. Where physical and behavioural problems co-exist, the highest appropriate triage category
should be applied based on the combined presentation.

Question 8

While some acutely-disturbed patients may require an immediate clinical response (perhaps combined with a
security response) to ensure their safety, it is recognised that some individuals entering an ED and posing an
immediate threat to staff

Answer 8

n) should not receive a clinical response until the
safety of staff can be ensured. In this situation, staff should act so as to protect themselves and other ED patients
and obtain immediate intervention from security staff and/or the police service. Once the situation is stabilised,
a clinical response can take place as (and if) required, and triage should reflect clinical and situational urgency