Triage

Policy

All team members are trained to recognise patients with urgent health needs, and to respond appropriately for their role.

Non-clinical staff induction includes training in phone triage, monitoring patients in the waiting area, and being able to alert clinical staff if they are concerned about a patient. Team members are trained in CPR as appropriate to their role and practice needs.

Signage in the waiting area advises patients what to do if they have an urgent medical need.

When allocating a triage category, consider the risk of complex health conditions, and lack of access to services that disproportionately affect some groups, such as Māori.

See also Foundation Training – Urgent Health Needs.

Arriving patients

For patients with symptoms of a highly infectious disease see Managing Infectious Patients.

People who arrive showing emergency symptoms are triaged, regardless or whether they have an appointment booked.

• Patients presenting with emergency symptoms are taken to a side room, and triaged immediately by a clinician.

  Examples of emergency symptoms:

  • Collapse
  • Sudden loss of vision
  • Severe chest pain
  • Severe breathing problems
  • Stroke symptoms – speech loss, slurring, facial droop, weakening of limbs
  • Serious bleeding
  • Severe pain or trauma

• Any other patients requiring triage will be seen as soon as possible by the nurse:

  They:

  • take a brief history of the patient's complaint and/or symptoms
  • take vital observations, if indicated
  • enter all observations in the patient's record.
• The nurse decides on the priority of appointments, and documents the reason clearly in the PMS. If necessary, the nurse interrupts the doctor to see the patient immediately.
• All sick children are given appointments as soon as possible, and are seen on the day of request whenever possible.

Staff monitoring the waiting area advise patients waiting for standard appointments of any delays due more urgent needs.

Monitoring the waiting area

Only clinical staff may diagnose a condition or provide medical advice. Avoid contact with the blood or bodily fluids of a patient.

Non-clinical staff monitor the waiting area and:

• alert a clinician immediately if a patient is deteriorating and requires urgent medical attention
• take the patient to a side room, in a wheelchair if necessary
• tell a nurse if patients have been waiting for longer than is acceptable.

Nurses check treatment and observation spaces and alert an appropriate clinician if concerned about changes to a patient's condition.

Urgent phone calls and phone triage

If a patient phones the practice with a life-threatening emergency condition:

• alert a clinician immediately
• advise the patient to call 111 for an ambulance if necessary, or
• call an ambulance on their behalf.

If the patient's condition is urgent but not life-threatening: 

• arrange triage by phone, preferably immediately, or by call-back if the patient consents – advise wait time for call-back.
• ask a clinician to take the call immediately, if the patient does not consent to a call-back. 

For standard consultations by phone see also Telehealth.

Annual clinical emergency drill

Non-clinical staff receive training so that they are prepared for the annual emergency drill.

See also Medical Emergency Drills.

Resources

• Australasian College of Emergency Medicine: Australasian Triage Scale Descriptors for Categories
• NZ Resuscitation Council guidelines

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