Primary Survey
Once the overall urgency of care is determined through the PAT, the triage
provider should complete a more detailed assessment of the patient’s airway,
breathing, circulation, disability, and exposure. This examination should be done
in the specified order so that life-threatening findings are systematically identified
and the patient immediately moved for appropriate intervention. As a general
rule, any pediatric assessment should be completed from least invasive to most
invasive to keep the child calm and allow for accurate assessment. Permit the
child to remain as close as possible to their care provider, utilizing
developmentally appropriate instruction and distraction to increase comfort,
cooperation, and trust. Table 6.4 outlines the goals and “red flag” signs and
symptoms of the primary survey.

Secondary Survey
The triage secondary survey centers on obtaining pertinent information about the
patient’s presentation to the ED and past medical history, with an additional
focused physical assessment based on chief complaint. The patient’s chief
complaint is the subjective reason for visit provided by the patient or care
provider. History taking in triage must be brief, with data obtained from the
child’s accompanying care provider, or the child if possible. Adolescents should
be interviewed separately when presenting with mental health or sexual
complaints. The secondary survey should also include an initial pain assessment
utilizing developmentally appropriate scoring tools.
TABLE 6.5
CIAMPEDS
C
I
A
M
P
E

D
S
CIAMPEDS

Chief complaint
Immunizations and isolation (assess need for )
Allergies (food, medications, dyes, latex, blood )
Medications (current )
Past medical history
Events surrounding the illness or injury
Diet and diapers (PO intake and urine output )
Symptoms associated with illness or injury


The mnemonic CIAMPEDS provides a systematic approach to triage history
taking. Information gathered helps the triage nurse determine potential triage
interventions, isolation requirements, special needs, and triage acuity ( Table 6.5
).
Focused Physical and Pain Assessments
Comprehensive physical assessment is not warranted during the triage process as
it prolongs the triage evaluation and delays definitive care. Once a chief
complaint is determined, a focused physical assessment of the affected area(s)
should be completed as abnormal findings often impact patient triage care and
acuity. For instance, a distended, rigid abdomen or a decreased distal pulse in an
injured extremity warrants expedited physician evaluation, and therefore, higher
triage acuity. Pain assessment utilizing validated, developmental appropriate tools
is incorporated into the triage secondary assessment to provide a baseline for the
ED visit, and to assess for necessary triage intervention.
Vital Signs
Vital signs assessment during the triage process can provide key indicators as to

the severity of illness and compensatory status of the pediatric patient. Table 6.6
depicts normal vital sign parameters by age as drawn from current existing
literature. Pediatric vital signs should be assessed utilizing appropriately sized
equipment to ensure accuracy in values. Blood pressure assessment should be
based on nursing judgment as to patient need as it is not a critical factor in acuity
assignment. As fever can impact acuity for numerous pediatric populations
including neonates, immunocompromised and sickle cell patients, temperature
should be evaluated during the triage process. Higher acuity should be considered
in patients with tachycardia without fever, or tachycardia outside expected range
for fever (every degree Celsius rise in temperature should correlate with a 10%
rise in baseline heart rate). Pulse oximetry should be measured on patients who
present with respiratory or cardiac complaints. If one vital sign parameter is
abnormal, it is important to obtain a full set to determine appropriate acuity
assignment.


TABLE 6.6
HIGH-RISK VITAL SIGNS
Age

Respiratory rate

Heart rate

<6 mo
6–12 mo
1–2 yrs
2–8 yrs
>8 yrs


>60
>50
>40
>30
>20

>180
>160
>160
>140
>100

Oxygen saturation <92%; capillary refill <1 second or >3 seconds.

Triage Decision
Information gathered during the aforementioned aspects of the triage process is
synthesized during this stage to provide appropriate triage interventions and
assignment of acuity. The initiation of nurse-led protocols, standing orders or
clinical care pathways in triage can help expedite patient care, improve ED flow,
and positively impact patient/family satisfaction. Such triage interventions are
delineated by unit, hospital, and state protocols. Examples include administration
of analgesia or antipyretics, initiation of NPO status or PO challenge, application
of ice or basic splints, point-of-care testing, EKGs, simple wound care, x-ray
orders, or clinical care pathways. Triage interventions should be agreed upon and
clearly defined in departmental policy and procedure manuals. Isolation needs
should also be addressed during this phase of triage if a patient is
immunocompromised or suspected to have an infectious disease process. Once
appropriate care is provided, the patient acuity should be assigned based upon the
triage classification system utilized in the facility’s ED. As previously mentioned,
this acuity will determine the patient’s priority and appropriate location of care.


Triage Documentation
Patient acuity, chief complaint, and pertinent subjective and objective data
gathered during the triage process should be recorded in an organized fashion in
the medical record, allowing for baseline patient information and triage decisionmaking factors to be shared with all necessary staff. Any triage care intervention
should also be clearly charted. Additional documentation may be required per
hospital or governmental standards. As safe pediatric care requires weight-based
dosing, patients should have their weight obtained and recorded in kilograms.


Reassessment
With ever increasing ED crowding, patients often must wait to see a provider
after triage is completed beyond recommended ESI-based time frames. Patients in
the waiting room should be reassessed for progression of illness or injury and
response to triage interventions. Individual departments should institute a
reexamination plan based upon their available resources and patient flow, keeping
in mind that assessment itself is strictly a nursing function, and cannot be
delegated to unlicensed support staff.

EMTALA
To ensure appropriate access to emergency services, Congress passed the
Emergency Medical Treatment and Active Labor Act (EMTALA) as part of the
Consolidated Omnibus Budget Reconciliation Act (COBRA) in 1986. EMTALA
requires all hospitals participating in Medicare programs to provide a medical
screening examination (MSE) to each patient who presents to the facility
requesting examination or treatment for an emergency medical condition (EMC)
regardless of ability to pay, legal status, or citizenship. The MSE must be
completed by a physician or qualified medical personnel (e.g., approved member
of medical staff). An EMC is that which places the individual’s health, organs, or
bodily functions at serious risk. Once an EMC is identified, stabilizing treatment

must be provided. If the facility is unequipped to appropriately stabilize, transfer
to a higher level of care should occur with the patient, legal guardian, or power of
attorney’s consent. There are numerous directives which address discrimination,
appropriate treatment area signage, insurance gathering, compliance reporting,
and documentation standards. As such, participating hospitals should clearly
address each EMTALA requirement in institutional policies and procedures.
Triage nurses and emergency room medical staff should have a sound
understanding of current EMTALA guidelines and institutional practices to
ensure continued compliance.

TRENDS IN TRIAGE
Quality indicators evaluating efficiency and effectiveness are often used in ED
settings. The overarching goal is to improve safe patient throughput while
decreasing left-without-being-seen (LWBS) rates. Recognizing the need to
improve throughput in pediatric EDs, the Child Health Corporation of America
Emergency Department group set a national goal to decrease length of stay (LOS)
in pediatric EDs by 25%. Outcome measures in ED LOS are segmented into
door-provider, provider-decision, and decision to discharge or admit time. In
addition to the aforementioned initiation of nurse-led interventions during triage,