Patients seen according to need by practitioners with appropriate skills and competencies

1
Self Presentation
GP/Healthcare Professional referral
Telephone contact
Ambulance Patients
Community /Locality Hospital site UCC medical
staff more likely to be middle grade and/GPSi

• Self care with advice
• re
• Over the counter medication/pharmacy
• Future access
• Worsening advice
• Suggested follow up

Patients seen according to need by
practitioners with appropriate skills and
competencies Practitioners free to move to areas
of high demand Patient flows adjusted to maintain
maximum capacity and flow Care supported by
mutually agreed pathways / map of medicine etc
Presenting patient pool -Primary Care, minor
injury /illness/ critical
Integrated medical /nursing care workforce e.g.
GPs/OOHs/Nurses/NPs/ AE Drs

• Access to
• GP Appointments
• Active case managers
• Community nursing services
• CDM services
• Mental health services
• Social services
• IMC
• RR
• Hospital at home

Specialist services or off site A E
required
2
Rapid triage / assessment and treatment process
All presenting patients will receive
assessment If Urgent Care not required
indicated patients will be signposted and advised
alternatives for access.
Walk in patients
Ambulance conveyed - some assessment may already
have occurred
Further RAPID assessment

• Initial resuscitation as appropriate to facility.
• Transfer to A/E resus /majors
• 999 assistance if A/E not on site

• Further rapid clinical assessment
• If urgent care not appropriate
• Discharge with sign posting to appropriate
  resource
• If self care or limited intervention required
• Discharge with appropriate self care advice
• Follow up advice / care arranged
• Clear sign-posting to further assessment if
  condition worsens
• All other patients will require more detailed
  assessment in Urgent Care facility / service

• Further Rapid clinical assessment
• Likely to need more detailed assessment in Urgent
  Care facility / service

Urgent Care Service (see clinical model for
details)
Discharge
Admit / refer
Arrows size indicative of likely patient flows.
3
Rapid triage / assessment and treatment process
All presenting patients will receive
assessment If Urgent Care not required
indicated patients will be signposted and advised
alternatives for access.
Walk in patients
Ambulance conveyed - some assessment may already
have occurred

• Urgent clinical assessment
• Likely to need more detailed assessment in Urgent
  Care facility / service

LEVEL 1 i.e. GP surgery WiC Non-Professional
Assessment must be Robust Supported by
appropriate Training Risk Assessed

• Initial resuscitation as appropriate to facility.
• Transfer to A/E resus /majors
• 999 assistance if A/E not on site

Urgent Care Service (see clinical model for
details)
Discharge
Admit / refer
Arrows size indicative of likely patient flows.
4
Background

• Developed following involvement in a
  multidisciplinary working group single triage
  assessment.
• Key aims were to review the practicalities of
  using MTS in other settings and whether
  additional presentations were required to
  encompass minor injury and illness care

5
Background Cont..

• Provide further definition for the scope of
  non-professional triage and agree key staff
  groups which were identified as including
• GP receptionists
• MIU/WiC receptionists
• ED receptionists (alongside professional triage)
• OOH receptionists

6
Identified Red Flag Presentations

• Chest pain
• Difficulty in breathing
• Unwell child
• Severe bleeding
• Severe pain

7
Development of Tool

• Developed in conjunction with reception and
  clinical staff
• Incorporated a review of MTS and Clinical
  Solution algorithms
• Needed to be quick, easy to use and clinically
  safe

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9
Child

• Simple illness
• discriminators

10
Adult

• Simple illness
• discriminators

11
All Ages

• Simple injury
• discriminators

12
Standardised Simplified Outcome
13
Rapid triage / assessment and treatment process
All presenting patients will receive
assessment If Urgent Care not required
indicated patients will be signposted and advised
alternatives for access.
Walk in patients
Ambulance conveyed - some assessment may already
have occurred

• Initial resuscitation as appropriate to facility.
• Transfer to A/E resus /majors
• 999 assistance if A/E not on site

LEVEL 2 i.e. A E High Flow WiC Manchester
Triage forms Basis of Prioritisation RGN Level 5
or above Supported by training

• Further clinical assessment
• According to clinical Prioirty

Urgent Care Service (see clinical model for
details)
Discharge
Admit / refer
Arrows size indicative of likely patient flows.
14
Manchester Triage System is a 5 point triage
scale with agreed time frames used to triage
patients presenting to the Emergency Room.
Introduced to the U.K in 1996 and now used in
several countries across Europe.
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5 Point Triage Scale

• NO. NAME COLOUR TIMES
• 1 IMMEDIATE RED 0
• 2 VERY URGENT ORANGE 10
• 3 URGENT YELLOW 60
• 4 STANDARD GREEN 120
• 5 NON URGENT BLUE 240

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Presenting Complaints
17
Asthma Flow Chart

GREEN
Y
Wheeze? Chest Infection?
Airway comprise? Inadequate breathing? Shock? Unre
sponsive child
Y
RED
N
N
Y
Recent problem?
Altered conscious level? Unable to talk in
sentences? Marked tachycardia? Very low
PEFR? Very low oxygen saturation?
ORANGE
Y
N
BLUE
N
N
Low PERF? Low oxygen saturation? Significant
history of asthma? No improvement with own asthma
treatment?
YELLOW
Y
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Burns Scalds Flow Chart

Y
Airway comprise? Inadequate breathing? Shock? Unre
sponsive child
GREEN
Local inflammation? Local infection? Pain?
Y
RED
N
N
Acutely short of breath? Inhalational
Injury? Altered conscious level? Significant
incident history? Sever pain?
ORANGE
Y
Y
N
Recent injury?
N
BLUE
N
Smoke inhalation? Electric injury? Chemical
burn? Moderate pain?
YELLOW
Y
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DISCRIMINATORS The system has built in
discriminators. By clicking on a discriminator
an explanation is given which assists the
Practitioner in interpreting the meaning.

• Asthma Flow Chart
• Examples of discriminators
• Orange
• Altered conscious level? Not fully alert. Either
  responding to voice or pain only or
  unresponsive.
• Unable to talk in sentences? Patients who are so
  breathless that they cannot complete
  relatively short sentences in one breath
• Marked tachycardia? A heart rate of over 120 in
  an adult. In children needs to be related
  to the age of the child.
• Very low PEFR? PEFR of 33 or less of best or
  predicted PEFR
• (In the yellow category this is defined as
  less low PEFR than 50)
• Very low oxygen saturation? Less than 95 on
  oxygen or 90 on air.
• (In the yellow category this is defined as
  low P2O2 is less than 95 on air)

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Burns Scalds Flow Chart

• Examples of discriminators
• GREEN
• Local Infection
• Local infection usually manifests as in
  inflammation (pain swelling redness).
  Confined to a particular site or area with or
  without a collection of pus
• Local Inflammation
• Local inflammation will involve pain and
  swelling and redness confined to a particular
  site or area.
• Pain
• Any expression of pain. Use pain score ladder
  to score

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Rapid triage / assessment and treatment process
All presenting patients will receive
assessment If Urgent Care not required
indicated patients will be signposted and advised
alternatives for access.
Walk in patients
Ambulance conveyed - some assessment may already
have occurred
Further RAPID assessment and treatment possible?
Yes
No

• Initial resuscitation as appropriate to facility.
• Transfer to A/E resus /majors
• 999 assistance if A/E not on site

• Further rapid clinical assessment
• If urgent care not appropriate
• Discharge with sign posting to appropriate
  resource
• If self care or limited intervention required
• Discharge with appropriate self care advice
• Follow up advice / care arranged
• Clear sign-posting to further assessment if
  condition worsens
• All other patients will require more detailed
  assessment in Urgent Care facility / service

• Further clinical assessmentaccording to priority
• Likely to need more detailed assessment in Urgent
  Care facility / service

LEVEL 3 i.e. A E / UCC Manchester Triage forms
Basis of Prioritisation Rapid Assessment /
discharge only by senior clinicians
Urgent Care Service (see clinical model for
details)
Discharge
Admit / refer
Arrows size indicative of likely patient flows.
22
Rapid triage / assessment and treatment process
in level 3 facility
Initial assessment using Manchester Triage
Guidelines (or equivalent)

• Further rapid clinical assessment / treatment
  possible
• If urgent care not appropriate
• Discharge with sign posting to appropriate
  resource
• If self care or limited intervention required
• Discharge with appropriate self care advice
• Follow up advice / care arranged
• Clear sign-posting to further assessment if
  condition worsens
• All other patients will require more detailed
  assessment in Urgent Care facility / service

Rapid Care / Assessment not possible Full
Assessment / Treatment as existing in department
Urgent Care Service (see clinical model for
details)
Discharge
Admit / refer
23
Rapid triage / assessment and treatment process
- LEVEL 3 EXAMPLE - CONDITION LED

• Blue / Green / Yellow and
• Minor Burn Rash not unwell
• Sore Throat ECC / MAP
• D V Back Pain
• Ear Pain Ankle Injury Weight bearing
• Low Mechm RTA Neck Pain

Yes
No

• Further rapid clinical assessment
• If urgent care not appropriate
• Discharge with sign posting to appropriate
  resource
• If self care or limited intervention required
• Discharge with appropriate self care advice
• Follow up advice / care arranged
• Clear sign-posting to further assessment if
  condition worsens
• All other patients will require more detailed
  assessment in Urgent Care facility / service

Rapid Care / Assessment not possible Full
Assessment / Treatment as existing in department
Urgent Care Service (see clinical model for
details)
Discharge
Admit / refer
24
Sample RATT protocol 1

• LOW BACK PAIN for less than 3 months
• If
• No Red Flags
• Presentation under age 20 or over 55
• Non-mechanical pain
• Thoracic pain
• Past history - carcinoma, steroids, HIV
• Unwell, weight loss , fever / chills
• Widespread neurological symptoms or signs
• Structural deformity
• No significant mechanism of injury
• Perform focussed neurological examination
• Document SLR
• No evidence saddle anaesthesia / shincter /
  urinary dysfunction
• Then Discharge with
• Adequate Analgesia
• Mobilisation Advice Sheet
• Self Certification document if required

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Sample RATT protocol 2

• Acute Sore Throat - Adult
• If
• No Red Flags
• No stridor / drooling / inability to swallow
• Dehydration
• Signs of systemic disease
• No history of maligancy / immunosuppresion
• Think of alternative diagnosis in over 12s i.e.
  glandular fever
• Perform focussed clinical examination
• No evidence of abscess / inta-oral cellulitus
• No evidence thyroid swelling
• Look for evidence of candidiasis
• Then Discharge with
• Adequate Analgesia Advice
• Leaflet giving information about diet / self care
• Give advice to seek urgent opinion if they
  develop
• Stridor/Dysphagia
• Difficulty breathing or muffled voice

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Competencies

• Level 1 For low flow / risk units.
• Non-professional training mandatory
• Level 2 i.e Existing A Es
• Manchester Triage
• Band 5 RGN with 18 months AE experience or
  equivalent with MT training
• Level 3 Busy A E / UCC
• Manchester Triage as above PLUS
• RATT
• Nurse Practitioner / ANP
• EM Consultant or Middle Grade
• GP with 6 months EM experience or equivalent UC
  training