This is a concise, user-friendly orientation guide and reference for new and seasoned nurses, paramedics, preceptors, educators, management teams, and anyone else in triage situations. It features a consistent format with pithy information guidelines covering key processes and practices Triage Nurses use daily. Chapters address core elements of triage such as tips for success for triage orientees and triage preceptors, point-of-entry, evaluation processes, understanding a variety of acuity scales, “red-flag” diagnoses and how to handle them, coordination and communication with other health care team members, documentation guidelines, and care considerations for special populations.

Lynn Sayre Visser, MSN, BS, RN, CEN, CPEN, CLNC, is a registered nurse with more than two decades of experience, including work in pre-hospital care, emergency department (ED), intensive care unit, postanesthesia recovery, and organ procurement settings. She is a gifted triage educator and has been instrumental in a number of front-end process improvement projects including the implementation of a medical provider in the triage area. Mrs. Visser’s involvement in the advancement of triage education, triage practice, and quality patient care earned her, along with Mrs. Montejano, a nomination for the Emergency Nurses Association Team Award. Her professional scholarship includes 20 years of membership in Sigma Theta Tau Nursing Society, along with contributions to journal articles, book chapters, blogs, and learning modules, both as an author and as a reviewer. She co-authored “What is a Triage Nurse?” published in the Journal of Emergency Nursing and is the author of “On the Other Side of the Rails” in the Journal of Radiology Nursing. Her involvement with the Emergency Nurses Association includes the honors of being the 2011 national conference blogger, an EMINENCE program mentee, two-time academic scholarship recipient, and a conference poster presenter.

Anna Sivo Montejano, MSN Ed, RN, CEN, has 30 years of experience in emergency nursing and triage education. She has taught nursing theory and aided the professional development of nurses as a preceptor, mentor, and clinical instructor. She has been a certified emergency nurse for more than 25 years. Her ED contributions include work as a staff nurse, primary preceptor, and assistant nurse manager, as well as in educational development. Mrs. Montejano has worked to improve the quality and efficiency of patient care through projects such as the change process of rapid medical screenings and rapid triage assessments, as a project manager for a major ED expansion, and as an advanced cardiac life support instructor. She co-authored “What Is a Triage Nurse?” published in the Journal of Emergency Nursing. She is the recipient, along with Mrs. Visser, of a nomination for the Emergency Nurses Association Team Award for her involvement with improvements in triage processes. She received her master’s degree in nursing with a focus on education from the University of Phoenix, and her bachelor of science in nursing from California State University, Fresno.

Valerie Aarne Grossman BSN, RN, MALS, is a registered nurse with more than three decades of diverse nursing experience, including direct patient care, hospital leadership, professional service, and writing for publication. She has worked in a variety of settings, including ED, telephone triage, radiology, and administration. She has volunteered her service to such groups as the Emergency Nurses Association, the Association of Radiology and Imaging Nurses, RAD-AID.org, and the National Certification Corporation, as well as serving on the Research Subject Review Board at the University of Rochester, the New York State Board for Nursing, and SCORE Board (Stakeholders for Care in Oncology and Research for the Elderly). She serves on the editorial boards for the Journal of Hospital Administration and the Journal of Radiology Nursing, as well as the international advisory board for the journal Nurse Education Today. She is the author of numerous peer-reviewed journal articles, chapters, and books, including the Quick Reference to Triage and Emergency Nursing: 5 Tier Triage.

Contents

Reviewers

Foreword Rebecca S. McNair, RN, CEN

Preface

Acknowledgments

Part I: Setting the Stage for Success at Triage

1. Orienting to Triage

Lynn Sayre Visser

2. Precepting at Triage

Lynn Sayre Visser

3. Tips for Success at Triage

Lynn Sayre Visser and Anna Sivo Montejano

4. Personal Awareness for the Triage Nurse

Anna Sivo Montejano

Part II: Point-of-Entry Processes in Triage Nursing

5. The Patient Arrival

Anna Sivo Montejano

6. Customer Service in Triage Nursing

Lynn Sayre Visser

7. Legal Concerns in Triage Nursing

Deb Jeffries

Part III: Nursing Essentials for Effective Triage

8. Triage Acuity Scales

Deb Jeffries

9. Documentation

Rebecca S. McNair

10. Core Measures

Lynn Sayre Visser

Part IV: Current Trends Impacting Triage Nursing

11. Urgent Care Triage

Valerie Aarne Grossman

12. Electronic Medical Record Considerations

Dawn Friedly Gray

13. Provider in Triage

Lynn Sayre Visser

14. Advanced Triage Protocols

Dawn Friedly Gray

Part V: “Red Flag” Patient Presentations

15. Introduction to “Red Flag” Presentations

Lynn Sayre Visser

16. Respiratory Emergencies

Polly Gerber Zimmermann and Lynn Sayre Visser

17. Cardiac Emergencies

Polly Gerber Zimmermann

18. Neurological Emergencies

Reneé Semonin Holleran

19. Abdominal Emergencies

Polly Gerber Zimmermann

20. Obstetric and Gynecological Emergencies

Polly Gerber Zimmermann and Lynn Sayre Visser

21. Psychiatric Emergencies

Anna Sivo Montejano

22. Ocular Emergencies

Anna Sivo Montejano and Lynn Sayre Visser

23. Musculoskeletal Emergencies

Reneé Semonin Holleran

24. Environmental Emergencies

Anna Sivo Montejano

25. Contagious Presentations

Anna Sivo Montejano and Lynn Sayre Visser

26. Trauma at Triage

Reneé Semonin Holleran

Part VI: Special Considerations in Triage Nursing

27. Special Populations

Anna Sivo Montejano

28. Pediatric Triage

Deb Jeffries

29. Geriatric Triage

Anna Sivo Montejano

30. Patient and Staff Safety

Anna Sivo Montejano

31. Case Studies

Anna Sivo Montejano and Lynn Sayre Visser

Abbreviations

Resources

Additional Reading

Index