Derived from the French word “trier,” triage means to separate or sort out. This is how triage status works: in a multi-casualty situation, each individual patient undergoes a brief examination by a specially trained EMS provider, who will determine the apparent severity of the injury or illness. A patient who has a potentially life-threatening condition would obviously receive a higher treatment priority than someone with a sprained ankle or broken finger. Show Emergency Triage Color CodingAfter a triage assessment is completed, a label called a triage tag is placed on the patient. The triage tag identifies the patient and includes information about his or her condition and need for treatment. The triage tag is sometimes color-coded so that a quick glance can give care providers an immediate indication of the triage prioritization. The triage tag is also used to track the patient’s progress through the triage process. There are four color-coded triage tags that identify the condition and current treatment requirements of the victim:
How Are Triage Assessments Performed?When a mass casualty incident occurs, the responsibility to perform a triage assessment typically rests on the shoulders of the emergency responders. The mass casualty triage assessment process can be extremely challenging for multiple reasons. There could be dozens, or even hundreds, of people who need medical attention — many of the injuries are also likely to be of a complex nature. The high degree of chaos and confusion that is normally present at MCI scenes can further complicate the triage process. Because of the high volume of injuries or illnesses during an MCI, it is imperative that triage is administered as quickly as possible. A basic triage process for patient assessment is S.T.A.R.T., which stands for “simple triage and rapid treatment.” S.T.A.R.T. assessments encompass four areas:
During MCI triage, the victims are generally classified in one of three categories based on their apparent need for medical treatment: immediate, delayed or minor. How long should a triage assessment take? Because of the need to attend to as many individuals as possible in a short amount of time, the entire S.T.A.R.T. assessment should be completed in no more than 30 seconds. Triage Support SoftwareSharing information quickly is vital during a mass casualty incident. StatusNet911 software enables emergency medical personnel to promptly alert destination hospitals about the triage status of every incoming patient. This will allow physicians and nurses to prioritize the treatment needs of each patient and deliver the best possible care upon arrival. The health care facility can also provide timely information about the capacity they can handle for each of the different triage levels. StatusNet911 Software Can Be a Lifesaver During an MCIStatusNet911 EMS System Management software from DataTech911 can be an extremely valuable status management tool during an MCI. This user-friendly software solution can provide real-time information to emergency medical personnel regarding triage status. When patients arrive at the hospital or treatment facility, physicians and nurses will be able to provide the best possible care to each individual. StatusNet911 can also be essential for providing timely information to friends and family members regarding the condition of their loved ones. Learn more about how StatusNet911 can be an invaluable asset during the MCI triage process. Topics
pre test 10the nurse should apply which color tag to a nonurgent patients during a mass casualty event? accredited health care institution's are required to take an 'all hazards approach' to disaster planning. which disaster drill uses this approach? A hospital in North Carolina plans a response to a tsunami under the hospital incident command system (hics) model for disaster planning, what is the chief responsible for? An emergency room nurse is working when she hears about a 60-car pileup on the expressway. The nurse knows that a military form of triage may be instituted. What is the rationale for using a military form of triage? It is based on doing the greatest good for the greatest number of people. an rn is designated as a triage officer in a hospital. what action does the nurse take as triage office? Evaluates each patient to determine priorities for treatment. which essential item is added to a personal-readiness supplies 'go bag'? a nurse is performing a mental health assessment for survivors of a terrorist attack. what finding in the group indicates the risk of post-traumatic stress disorder? Experiencing "flashbacks. what is the nurse's role in responding to health care facility fires? - Move bedridden patients from fire area by stretcher-use ABC extinguisher if possible after everyone is out of danger -remove any patient or staff from immediate danger of the fire or smoke how does the general nurse assist the emergency department ED nurse during a disaster? Provide care for stable patients in the ED The nurse should use which color tags for patients who need priority emergency treatment during a disaster? The nurse has been assigned the role of triage nurse after a weather-related disaster. What is the priority action of the nurse? Perform a rapid assessment of clients to determine priority of care. A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at the nurse when dinner is served late. What is the nurse's best response? You seem upset. I have time to talk if you like. A client is receiving follow-up care after surviving a tornado. The client reports insomnia and the nurse notes that the client jumped as the nurse entered the room. Which action by the nurse is most appropriate? Perform additional assessments for post-traumatic stress disorder. An industrial accident has occurred near the hospital, and many victims are brought to the emergency department (ED) for treatment of their injuries. The nurse triages the victim with which injury with a red tag? Multiple fractured ribs and shortness of breath The nurse is working with a paramedic who just finished assisting at the scene of a school shooting where several students were killed. Which statement by the nurse is most therapeutic? Would you like to talk about what happened? A young man comes into the foyer of the hospital and says that he has a container of anthrax, which he opens and pours on the floor. Which is the priority action for the nurse who first comes upon the scene? Begin to evacuate the immediate area. Which is the priority action for the emergency department charge nurse in the event of a mass casualty situation? Directing medical-surgical and critical care nurses to assist with clients who are already in the ED while the ED staff prepares to receive the mass casualty victims An accident has occurred near the hospital, and a victim is brought to the emergency department with severe chest pain, a pulse of 120 beats/min, blood pressure of 100/60 mm Hg, and a respiratory rate of 28 breaths/min. The nurse assesses shortness of bre A nurse is working at the scene of a catastrophic natural event. Which person does the nurse attend to first? Supine person with pale, cool, clammy skin he hospital is overwhelmed when caring for victims after an earthquake that occurred 48 hours ago. Which responsibility of the nursing supervisor is most important at this time? Arranging relief and coordinating breaks so nursing staff can rest and eat The nurse is teaching nursing students about personal emergency preparedness. Which statement by a student indicates that further teaching is indicated? I will get a prescription for antibiotics just in case I have to work in an area that has been infected with anthrax. The hospital administration has arranged for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? You are free to express your feelings; whatever is said here stays here. The nurse is caring for a client whose wife just died in an accident. The client says to the nurse, "I can't believe that my wife is gone and I am left to raise my children all by myself." Which response by the nurse is most appropriate? You sound anxious about being a single parent. The emergency department nurse manager is explaining concepts of emergency and disaster preparedness to a group of students. Which statement by the nurse manager is most accurate? An internal disaster is something that occurs inside the health care facility. The emergency department (ED) is expecting a large number of casualties after a bridge collapse. Which is a priority consideration for the ED leadership when activating the disaster plan? The ED may receive many unexpected victims with minor injuries from the bridge collapse. A nursing administrator is evaluating the hospital's response to a recent internal disaster. The administrator assesses that goals for disaster planning have been met when which outcome is assessed? The hospital was able to maintain client, staff, and visitor safety during the disaster. A nursing administrator is reviewing a hospital's disaster planning. The administrator evaluates the plan that addresses which component as being the best? All possible catastrophes in the community A nursing instructor is debriefing students who participated in a community-wide disaster drill. Several students are upset with the black-tagged triage category. Which statement by the nursing instructor is best? In a disaster, extensive resources are not used for one person at the expense of many others. A nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurse's interests? The Medical Reserve Corps A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is concerned about maintaining licensure in several different states. What statement by the nursing supervisor best addresses these concerns? Deployed DMAT providers are federal employees, so their licenses are good in all 50 states. A community disaster has occurred and the hospital's emergency department (ED) has efficiently triaged, treated, and transferred most clients to appropriate units. The hospital incident command officer wants to "stand down" from the emergency plan. Which Do all other areas of the hospital have the supplies and personnel they need now? A hospital has "stood down" from a mass casualty disaster. The staff have rested and eaten. Which action by the nursing supervisor takes priority? Restocking the emergency department (ED) A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention by the nurse is most beneficial? Offer the family choices as appropriate and possible. An emergency department (ED) supervisor has noted an increase in sick calls and bickering among the ED staff after a week with multiple trauma incidents. What action by the supervisor is most helpful? Arrange critical incident stress debriefing. A client has been treated in the emergency department after a tornado and is awaiting discharge instructions. This client is close to losing control, although other family members are attempting to calm him down. Which response by the nurse is most helpfu Offer the client the choice of waiting in the treatment room or the waiting room. A large number of victims arrive at the emergency department after a bus is hit by a train. Which interventions are performed immediately for red-tagged victims? (Select all that apply.) -Intubating a cyanotic client in respiratory distress-Initiating IV fluids for a client with a blood pressure of 96/60 mm Hg and a pulse of 144 beats/min -Attaching an external pacemaker for a client with a heart rate of 44 beats/min The triage nurse is assessing a client who has been brought to the emergency department (ED) by emergency medical services (EMS) following a mass casualty incident. Which assessment questions are used to determine the appropriate triage category for the c Can you wiggle your toes?"-"Are you having any difficulty breathing?"-"Can you tell me what day it is?" -"Do you have any abdominal or back pain? Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies clients with which injuries with yellow tags? (Select all that apply.) -Partial-thickness burns covering both legs-Neck injury and numbness of both legs-Small pieces of shrapnel embedded in both eyes -Bruising and pain in the right lower abdomen A hospital is receiving large numbers of casualties from a disaster. Which clients does the supervisor identify as appropriate for discharge or transfer to another facility? (Select all that apply.) Client who had open reduction and internal fixation of a femur fracture 3 days ago The nurse working with survivors of a disaster wants to assess them for post-traumatic stress disorder. For which clients does the nurse perform further assessment before administering the Impact of Event Scale-Revised? (Select all that apply.) -Older adult survivor with minor injuries A wing of a hospital is on fire. Which actions by the nurse promote safe evacuation of clients? (Select all that apply.) -Direct ambulatory clients on where to go to be safe.-Use ambulatory clients to help push clients in wheelchairs.-Manually ventilate clients who are on ventilators. -Move bedridden clients in their beds if possible. A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event? Provide water and healthy snacks for energy throughout the event. A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond? You seem upset. I have time to talk if youd like. A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? Multiple fractured ribs and shortness of breath An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims. The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? You are free to express your feelings; whatever is said here stays here. A nurse is caring for a client whose wife died in a recent mass casualty accident. The client says, I cant believe that my wife is gone and I am left to raise my children all by myself. How should the nurse respond? You sound anxious about being a single parent. A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, Why are the individuals with black tags not receiving any care? How should the nurse respond? In a disaster, extensive resources are not used for one person at the expense of many others. After a hospitals emergency department (ED) has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to stand down from the emergency plan. Which question should Do all areas of the hospital have the supplies and personnel they need? A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first? Provide a calm location for the family to cope and discuss needs. An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. Which action should the nurse take? Arrange for critical incident stress debriefing. A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.) -A 35-year-old female with severe chest pain: red tag A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? (Select all that apply.) -Client who had open reduction and internal fixation of a femur fracture 3 days ago A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select all that apply.) -Hospital incident commander Assumes overall leadership for implementing the emergency plan |
Which tag would be assigned to a disaster survivor who has an open fracture with a distal pulse?
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