Principles of Emergency Care
By definition, emergency care is care that must be rendered with-out delay. In a hospital ED, several patients with diverse health problems—some life-threatening, some not—may present to the ED simultaneously. One of the first principles of emergency care is triage.
The word triage comes from the French word trier, meaning “to sort.” In the daily routine of the ED, triage is used to sort patients into groups based on the severity of their health problems and the immediacy with which these problems must be treated.
Hospital EDs use various triage systems with differing termi-nology, but all share this characteristic of a hierarchy based on the potential for loss of life. A basic and widely used system uses three categories: emergent, urgent, and non-urgent (Berner, 2001). Emergent patients have the highest priority—their conditionsare life threatening, and they must be seen immediately. Urgent patients have serious health problems, but not immediately life-threatening ones; they must be seen within 1 hour. Non-urgent patients have episodic illnesses that can be addressed within 24 hours without increased morbidity (Berner, 2001). A fourth, increasingly used class is “fast-track.” These patients require sim-ple first aid or basic primary care. They may be treated in the ED or safely referred to a clinic or physician’s office.
Triage is an advanced skill; emergency nurses spend many hours learning to classify different illnesses and injuries to ensurethat patients most in need of care do not wait to receive it. Pro-tocols may be followed to initiate laboratory or x-ray studies from the triage area while the patient waits for a bed in the ED. Col-laborative protocols are developed and used by the triage nurse based on his or her level of experience. Also, nurses in the triage area collect crucial initial data: vital signs and history, neurologic assessment findings, and diagnostic data if necessary. The fol-lowing questions reflect the minimum information that should be obtained from the patient or from the person who accompa-nied the patient to the ED. Of course, all answers are docu-mented for reference by other health care providers.
· What were the circumstances, precipitating events, loca-tion, and time of the injury or illness?
· When did the symptoms appear?
· Was the patient unconscious after the injury or onset of illness?
· How did the patient get to the hospital?
· What was the health status of the patient before the injury or illness?
· Is there a medical or surgical history? A history of admis-sions to the hospital?
· Is the patient currently taking any medications, especially hormones, insulin, digitalis, anticoagulants?
· Does the patient have any allergies? If so, what are they?
· Does the patient have any bleeding tendencies?
· When was the last meal eaten? (This is important if general anesthesia is to be given or if the patient is unconscious.)
· Is the patient under a physician’s care? What are the name and location of the physician?
· What was the date of the patient’s most recent tetanus im-munization?
Routine ED triage protocols differ significantly from the triage protocols used in disasters and mass casualty incidents (field triage). Routine hospital triage directs all available resources to the patients who are most critically ill, regardless of potential outcome. In field triage (or hospital triage during a disaster), scarce resources must be used to benefit the most people possible. This distinction affects triage decisions.
For the patient with an emergent or urgent health problem, sta-bilization, provision of critical treatments, and prompt transfer to the appropriate setting (intensive care unit, operating room, general care unit) are the priorities of emergency care. Although treatment is initiated in the ED, ongoing definitive treatment of the underlying problem is provided in other settings, and the sooner the patient is stabilized and moved to that area, the better.
A systematic approach to effectively establishing and treating health priorities is the primary survey/secondary survey approach. The primary survey focuses on stabilizing life-threatening condi-tions. The ED staff work collaboratively and follow the ABCD (airway, breathing, circulation, disability) method:
· Establish a patent airway.
· Provide adequate ventilation, employing resuscitation mea-sures when necessary. (Trauma patients must have the cer-vical spine protected and chest injuries assessed first.)
· Evaluate and restore cardiac output by controlling hemor-rhage, preventing and treating shock, and maintaining or restoring effective circulation.
· Determine neurologic disability by assessing neurologic function using the Glasgow Coma Scale.
· After these priorities have been addressed, the ED team pro-ceeds with the secondary survey. This includes
· A complete health history and head-to-toe assessment
· Diagnostic and laboratory testing
· Insertion or application of monitoring devices such as elec-trocardiogram (ECG) electrodes, arterial lines, or urinary catheters
· Splinting of suspected fractures
· Cleaning and dressing of wounds
· Performance of other necessary interventions based on the individual patient’s condition
Once the patient has been assessed, stabilized, and tested, appropriate medical and nursing diagnoses are formulated, initial important treatment is started, and plans for the proper disposi-tion of the patient are made.