The ENAThe Emergency Nurses Association (ENA), an organization dedicated to patient safety and emergency nursing standards, teaches triage practices and procedures to nurses around the world. The standards and practices discussed here come from the The Victorian Department of Human Services, which developed its triage guidelines in association with the ENA of Victoria (Australia) and based on ENA position papers.
Primary TriagePrimary triage consists of three basic categories of decision. "Expected" triage refers a patient to a doctor based on an obvious problem, while "over triage" patients receive treatment at a higher priority levels than their condition may suggest, and "under triage" patients receive categorization at a lower level than indicated by their symptoms.
Collecting DataDuring primary triage, nurses base their decisions on both objective and subjective information. Objective factors include a "first glance" primary survey and an assessment of physiological issues such as breathing, circulation, level of consciousness, pain, mental or sensory problems, and whether the patient faces additional illness or injury.
Subjective factors include the patient's account of his ailment, symptoms, cause of the problem, health risks, medical history and when the problem started. The nurse must also make sure this information is communicated to other health professionals or interested parties.