/// QUARTERLY BEAT / OCTOBER 2022
QUARTERLY BEAT / OCTOBER 2022 ///
An individual’s objective is not intuitive, assessment will determine the urgency of care. The question remains how can we ensure that our technicians are triaging the patients appropriately? • Training • Use of Protocols A 1994 study out of the University of Pennsylvania established the first veterinary scoring system which applied to animals presenting after acute trauma. This is referred to as the Animal Trauma Triage (ATT) scoring system. This system was used to aid in categorization, outcome prediction and in determining the need for immediate medical or surgical intervention. In this system physical exam findings were categorized into six classifications and scored on scale 0-3. The higher the ATT score indicates the need for immediate treatment and provides the veterinarian with survival prediction. A 2012 JVECC study looked at the evaluation of a veterinary triage list. This list was modified from a human triage scoring system but was modified to apply to common conditions that are seen in veterinary medicine. The Veterinary Triage List (VTL) can be applied to all emergency patients as compared to the Animal Trauma Triage System which was devised to provide stratification of veterinary trauma patients (4). The VTL aids the technical staff in categorizing the patient, determining the urgency of care, and establishing wait times. The results of this study suggested that the use of the VTL was more effective at categorizing emergency patients with target waiting times as compared with intuitive triage performed by veterinary technicians. (4)
a primary survey to quickly identify urgency of care and begin intervention. The primary survey uses both subjective and objective evaluations to guide appropriate treatment. Items required in the “resuscitation area” include: • Multiparameter -ECG, ETCO 2 , SpO 2 , NIBP • Intravenous catheters of variable sizes and accessory supplies for their proper placement • IVF/pressure bags • Oxygen • Crash Cart (ET tubes/trach tubes, defibrillator, ambu bag, drugs, etc.) • Suction unit including tubing and suction tips • Diagnostic equipment for the minimum data base blood work, blood gas evaluation, electrolytes, and lactate • Ultrasound • Immobilization board RESPIRATORY SYSTEM The main goal of respiratory evaluation is to determine ventilation status and oxygen delivery. Evaluation includes visualization, palpation, and auscultation. Determining patency of the upper airway should be assessed first. The noise (stertor/stridor) of breathing and effort should be assessed to determine if the upper airway is compromised. If the upper airway is patent, the next step in evaluation should include obtaining a respiratory rate and effort. During the primary survey an SpO 2 and arterial blood gas can be used to help assess the blood oxygen levels and ventilation status. If there is any clinical evidence or subjective evidence of oxygen deprivation or respiratory distress, oxygen support should be initiated as soon as possible. CARDIOVASCULAR The assessment of the cardiovascular system is to determine the effectiveness of oxygen delivery to the tissues and if the cardiovascular system is compromised. This includes evaluation of mucous membrane color, capillary refill time, heart rate, rhythm, and blood pressure. It is important to remember that in the earlier stages of shock the patient vitals may only be slightly outside of the normal range. Also, abnormally normal values may be present as in the case of cats in the hospital with a heart rate under 160 beats per minute. NEUROLOGIC Evaluation of the nervous system should include the patient’s level of consciousness, cranial nerve deficits and stance or gait abnormalities.
VETGIRL U HIGHLIGHTS
Tech Triage: What’s your superpower?
BY TIFFANY GENDRON CVT, VTS (ECC) Veterinary CE Coordinator, VETgirl
Triage is a process of sorting and treating patients based on assessment of perceived illness. The most critical patients are awarded priority of treatment. In veterinary medicine we have used human triage models and applied these principles to create veterinary triage scoring systems. Although there are a number of triage scoring systems the goal is similar, to accurately assess a patient’s status based on parameters to better classify the patient and their need for care. Triage occurs over the phone, in the lobby and/or within the initial treatment room. It is important to remember that hospitalized and triaged patients alike require reassessment of their status on a constant basis as their status can change at any time. This allows the veterinary professional to triage the order of treatment required based on the patient’s status. This follows the veterinary technician practice model. Regardless of where the initial triage takes place, clear and concise communication and assessment are essential to provide expedited patient care.
• Vomiting/Diarrhea-character and frequency • Toxin exposure if indicated HOSPITAL TRIAGE Proper communication is one of the most important aspects of a successful triage system. The triage should begin with the veterinary technician introducing themselves to the client, determining the patient’s name and using this information to develop an open dialog during the examination. Explain to the client what you are doing and obtain a brief medical history as outlined above. To make an initial assessment the veterinary technician must be familiar with normal vs. abnormal vital parameters and the use of an established triage scoring system can improve these assessments.
PHONE TRIAGE The phone triage is going to be performed by either a client service representative or a veterinary technician based on the practice. This further signifies the importance of staff training. Knowing what questions to ask is a critical aspect of phone triage communication. For this reason, some hospitals may develop a telephone communication script for their staff to utilize. This triage should be quick and concise if immediate care is required the attending staff needs to clearly convey this message to the client. Telephone triage should include: • What is your primary concern today with your pet? • How is the animal doing (Owner’s chief concern)? • Signalment • Pertinent medical history (i.e., diabetic, asthmatic) • Any medications the patient is receiving • Determine urgency- this is based on what the client can provide to you • Respiratory (fast, slow, hard, loud) • Cardiovascular (mm color, heart rate fast or slow) • Neurologic (mentation, seizures, paralysis) • Urogenital (dystocia, urination status, uterine prolapse, paraphimosis) • Eating/Drinking- include frequency
Table 2. Veterinary Triage List Color Urgency
Target Wait 0 Minutes 15 Minutes
Red
Immediate Very urgent
Orange Yellow
Urgent
30-60 Minutes 120 Minutes 240 Minutes
Green
Standard Nonurgent
Blue
THE STAT! TRIAGE A patient requires immediate attention when there is an imminent and immediate risk to the life of the patient or in a situation where end-organ damage can be prevented with immediate therapy, as for example in ethylene glycol toxicosis. There are also other urgent presentations that require immediate intervention such as active bleeding, toxin ingestion, severe pain, and trauma. If an animal requires immediate treatment the patient should be expedited to a “resuscitation area”. This area should be stocked with all the necessary equipment required to facilitate immediate intervention. During this time the veterinary team will conduct
Table 1: Vital Parameters for Adult Small Animals TPR Values Temp, o F
Heart Rate Respiratory Rate
Dog Cat
100.0-102.2 60-160 bpm 16-32 bpm 100.0-102.2 140-220 bpm 20-42 bpm
The veterinary technician’s assessment is what determines the prioritization and allocation of resources, diagnostics procedures, and treatments.
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