Module 1

The Canadian Triage and

Acuity Scale: Education
Manual

Version 2.5, 2012

CTAS National Working Group
© Canadian Association of Emergency Physicians

1
 Course Goals
1. Describe origins and role of triage
2. Review/enhance assessment skills
3. Apply standards of emergency nursing
4. Introduce CEDIS Presenting Complaint List
5. Prioritize patient care using CTAS
6. Demonstrate understanding of ED processes
CTAS Five Level Triage

Level 1 - Resuscitation

Level 2 - Emergent

Level 3 - Urgent

Level 4 - Less Urgent

Level 5 - Non-Urgent
 Module 1

Fundamentals of Triage
 Module One Objectives
 Historical basis of triage
 Purpose and value of triage
 Unique nature of emergency patients
 Professional role and personal
characteristics of the triage nurse
 Triage nursing skills
 Triage process
 Evolution of Triage
 Military roots
 Introduced to hospitals in early 1960s
 Number of cases increasing

 People with non-urgent conditions come to

EDs for treatment
 Initially, a 3-level triage (emergent, urgent,
deferrable/non-urgent) was used
 In 1999, CTAS 5-level triage implementation
guidelines published as recommended national
guidelines
 Origins of CTAS
 National Triage Scale – Australia ACEM 1994
 CAEP Triage and Acuity Scale – Canada 1995
 CTAS – Canada (CAEP, NENA, AMUQ ) 1999
 Paediatric CTAS (above + CPS, SRPC) 2001
 Adult CTAS revision 2004
 CEDIS Complaint list (+ revision) 2003 & 2008
 Adult CTAS revision 2008
 Paediatric CTAS revision 2008
 What is Triage?
The National Emergency Nurses’ Affiliation’s (2002)
definition of triage is: ‘a sorting process utilizing
critical thinking and a standardized set of guidelines
in which an experienced RN assesses patients
quickly upon their arrival in an ED to:
 Assess and determine severity of presenting
problems
 Process patients into a triage category and
streaming to an appropriate location
 Determine access to appropriate treatment
 Effectively and efficiently assign appropriate human
health resources.’
 Rationale for the Development
of CTAS
 A nationalstandard for triage
 Improved patient care
 Increased triage reliability and validity
 Site & personal performance indicators
 National benchmarks
 The Benefits of Triage
 Ensures critically ill or injured receive priority
attention
 Establishes acuity and anticipates resources
needed
 Predicts how long the patient can safely wait
 Supports effective utilization of space and
resources
 Supports surveillance
 Improves communication and public relations
 Avoiding Triage as ‘Access Block’
 Streaming
 Lean processing (six sigma) to improve ED
efficiencies is being broadly implemented
 One goal is shortening the time from arrival to
emergency physician
 Streaming patients directly to the most appropriate
place in the ED is key to success
 This can be accomplished by rapid triage 1st or triaging the
patient after directing them to an appropriate area
 Typical ED design changes include internal waiting rooms,
limiting stretcher time to patients who don’t need them, and
rapid assessment zones
 Triaging with Overcrowding
 Triage Drift
 Concept of ‘normalization toward the mean’
 The knowledge that a patient will need to be assigned to
the waiting room, may lead the triage nurse to ‘uptriage’ a
CTAS 4 or 5 patient in the hopes of shortening their wait
 Similarly there may be subconscious pressure to
‘downtriage’ certain patients based on ED space
limitations
 For example a patient may be assigned a CTAS 3 rather
than CTAS 2 score feeling it unacceptable to assign level 2
patients in the waiting room
 A CTAS 3 patient may also be downtriaged to CTAS 4 to
make them more appropriate for fast track.
 Emergency Patients are Unique
 Unscheduled/episodic
 Anxious and distressed
 Patient and care providers are strangers
 Patients experience symptoms/not a
diagnosis
 Span all ages and
types of emergencies
 Often lack primary care
 Emergency Patients are Unique
“Not all patients are as well as they appear and
not all patients are as sick as they think.”

What are your thoughts on that statement?

What are some unique characteristics?

 Role of Triage Nurse
1. Assessing patients and determining acuity
2. Communicating with health professionals
3. Determines treatment location
4. Initiating treatment protocols/first aid measures
5. Monitoring and reassessing
6. Participating in patient flow
7. Documenting
 Triage Nursing

What makes a good triage nurse?

 Personal traits
 Cognitive characteristics
 Behavioral characteristics
 Personal Traits
 Flexibility
 Autonomy
 Effective communication
skills
 Assertiveness
 Patience
 Compassion
 Willingness to listen
and learn
 Cognitive Characteristics
 Diverse knowledge base
 Knows when not to act
 Uses critical thinking
 Able to make
decisions quickly
 Able to prioritize
 Behavioural Characteristics
 A patient advocate
 Works well under pressure
 Organized
 Able to improvise
 Applies intuition
 Confidence in judgment
 Trust in/reliance on peers
 Triage Nursing Skills

 Public Relations
 Interviewing
 Critical Thinking
 Communication
 Self-Assessment
Assessment My Strong Areas Needing
Characteristics Work
Characteristics
Personal Traits

Cognitive
Characteristics
Behavioural
Characteristics
 The Process of Triage
 Patient arrives (‘critical look’)
 Screened for infectious disease
 Triage assessment conducted
 Presenting Complaint (CEDIS) documented
 Modifiers considered
 Triage Level assigned (CTAS)
 Assigned to waiting/treatment area
 Symptom relief provided or nursing protocols
initiated
 Waiting patients reassessed
 Patient Arrival
 A variable % of patients arrive by
ambulance. Their acuity ranges across
all triage levels
 More patients arrive by other means of
transport (known as “walk-ins”). Their
acuity also include all levels
 Critical Look
 ‘Critical first look’ across-the-room begins as soon as
the patient arrives in the ED
 Perform a quick check of
A: Airway
B: Breathing
C: Circulation
D: Disability (neurological)
 Should take 3 to 5 seconds
 Take action as indicated

CRITICAL INFECTION PRESENTING 1st ORDER 2nd ORDER

LOOK CONTROL COMPLAINT MODIFIERS MODIFIERS
 Infection Control Screening
 Screening requirements vary by region
 If positive (eg ILI, FRI), appropriate protective
measures (respiratory etiquette, hand washing,
isolation) need to be taken
 Use latest information available (from provincial,
state, or national guidelines)

CRITICAL INFECTION PRESENTING 1st ORDER 2nd ORDER

LOOK CONTROL COMPLAINT MODIFIERS MODIFIERS
 Subjective Assessment
The “story” in the patient’s own words:
 Their account of why they came to the
hospital
 The symptoms they are experiencing
 Pain severity
 The injury history (mechanism of injury)
 Their concerns
Selecting Presenting Complaint (CEDIS)
 Patient driven
 “What concern brought you to the ED today?”
 Headache, Cough, SOB, etc.
 “Which of the complaints bothers you most?”
 “My fever and shaking chills!”
 Nurse driven
 “Patient complains of leg swelling & moderate
thigh pain, but nurse note moderate SOB.”
 Could choose SOB or Lower extremity pain

CRITICAL INFECTION PRESENTING 1st ORDER 2nd ORDER

LOOK CONTROL COMPLAINT MODIFIERS MODIFIERS
 Objective Assessment
Draws on observable indicators (signs):
 Wounds, rashes, bleeding, cough, etc.
 Vital signs
 Reaction to pain
 Other indicators

CRITICAL INFECTION PRESENTING 1st ORDER 2nd ORDER

LOOK CONTROL COMPLAINT MODIFIERS MODIFIERS
 Triage Decision
Based on the critical look, chief complaint,
subjective and objective assessments,
application of modifiers as required, then decide:

What is the patient’s priority?

 Triage Documentation
 Patient Name / Age  Allergies/Medications
 Date and Time  Immunizations
 Presenting Complaint  Relevant Past History
(CEDIS)  Interventions at triage
 Subjective Assessment  Disposition
 Objective Assessment  Reassessment
 1st & 2nd Order
Modifiers
 CTAS Level
 Triage Nurse ID
 When Line-ups Form
 Scan for critically ill patients and
move them to the front of the line
 Anticipate re-prioritization
 Know the status of available
treatment areas
 Stay calm, request help when
required
The goal is to triage patients within
10 to 15 minutes of arrival
 Patients in the Waiting Room
 The number of patients waiting and their wait
times have been increasing.
 Advise patient to return to triage desk if condition
changes
 Depending upon hospital/site policies and
medical directives, triage nurse may need to:
 Initiate
diagnostics
 Provide symptom relief
 Dispense analgesics
 If numbers are overwhelming, call for assistance
 Patients in the Waiting Room

 How do you set priorities for treatment

bed/physician assessment when you have
five CTAS Level 3 patients waiting?

How long can this patient safely wait?

 Patient Reassessment Guidelines
Level 1 – Continuous nursing care
Level 2 – Every 15 minutes
Level 3 – Every 30 minutes
Level 4 – Every 60 minutes
Level 5 – Every 120 minutes

Never change the initial triage level.

Always document acuity level changes & change
priority accordingly
Always document reassessment findings.
 Module One - Review

Questions?
 References
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