Emergency Department, University Hospital, University of São Paulo, São Paulo, Brazil.
School of Nursing, University of São Paulo, São Paulo, Brazil.
Int J Nurs Pract. 2022 Feb;28(1):e13001. doi: 10.1111/ijn.13001. Epub 2021 Aug 28.
Aim of this study is to identify signs and symptoms associated with identifying critically ill patients by rapid triage assessment performed by nurses in an emergency department.
In some emergency services, the immediate assessment of critically ill patients occurs before opening the hospital formal registration and it is based on the nurse's experience. Studies on the topic are essential to improve this process.
This is a cross-sectional, quantitative study.
This study was conducted in a Brazilian emergency department in 2017. Adult patients who presented potentially life-threatening symptoms underwent rapid triage to determine the medical urgency. Those identified as being critically ill were classified as high priority and streamed to the emergency room.
A total of 154 (84.6%) patients were classified as high priority from the total of 182 evaluations. Altered state of consciousness (35.2%) and altered skin perfusion (25.3%) were frequently identified. Signs and symptoms associated with identifying critically ill patients by rapid triage were alterations in ventilation (OR 6.09; p = 0.028), neurological dysfunction (OR 44.96; p < 0.001) and pain (OR 5.80; p = 0.004).
Nurses should value neurological and ventilation alterations and pain in patients during rapid triage, since these signs and symptoms are associated with high care priority.
本研究旨在确定通过急诊科护士进行快速分诊评估来识别危重症患者的相关体征和症状。
在一些急救服务中，对危重症患者的初步评估是在医院正式登记之前进行的，这是基于护士的经验。关于该主题的研究对于改进这一过程至关重要。
这是一项横断面、定量研究。
本研究于 2017 年在巴西一家急诊科进行。有潜在生命威胁症状的成年患者接受快速分诊，以确定医疗紧急情况。被确定为危重症的患者被归类为高优先级，并被分流到急诊室。
在总共 182 次评估中，共有 154 名（84.6%）患者被归类为高优先级。意识状态改变（35.2%）和皮肤灌注改变（25.3%）是常见的发现。通过快速分诊识别危重症患者的体征和症状包括通气改变（OR 6.09；p=0.028）、神经功能障碍（OR 44.96；p<0.001）和疼痛（OR 5.80；p=0.004）。
护士在进行快速分诊时应重视患者的神经和通气改变以及疼痛，因为这些体征和症状与高护理优先级相关。
