1. The emergency precheck and triage must be undertaken by nurses with abundant professional knowledge, strong sense of responsibility, rich clinical experience and good service attitude.
2. Triage nurses must stick to their post without unauthorized absence. In the case of any absence, there must be other competent nurses taking the place.
3. Triage nurses should receive every patient with enthusiasm, briefly learn about the condition, examine key signs and complete necessary examination (including taking temperature, blood pressure, pulse, etc.) and take it down on the medical record. They should record the relevant information of the patient on the triage registration form.
4. Triage nurses must perform precheck and triage for patients in accordance with the triage criteria for emergency patients and guide them to the relevant area. They should also mark the patients based on their conditions so that relevant medical staff will make timely identification.
5. They should send the patients with acute, critical and severe illness into the Emergency Room, communicate the condition briefly with the medical staff and be responsible for registration.
6. In the case of emergent incident when a great number of the sick and wounded patients arrive in the hospital, they should immediately inform the department head and the nurse in charge and spare no efforts in the precheck and triage at the same time of organizing emergency treatment.
7. Triage nurses are responsible for keeping the order of treatment in every room and conducting intensive inspection to timely identify and handle any change of illness.
8. They should attach importance to the precheck for infectious diseases. For patients with or likely with infectious diseases, they should perform in conformity with the precheck and triage system for infectious diseases.
9. They should establish contact mechanism with the 120 ambulance call, keep the phone on and inform relevant medical staff of making first-aid preparation based on the previous notice by the ambulance call. Upon arrival of ambulance, they should take over the patient and register well.
10. Attachment: Triage Criteria for Emergency Patients
Level |
Identification criteria |
Case |
Triage |
Level I (Endangered) |
The patients with critical and severe illness who are unstable in vital signs, may in no time or have already stopped breathing or heartbeat and may have mortal danger without emergency aid and treatment must be treated immediately. |
Heartbeat or respiratory arrest, constant severe arrhythmia, serious dyspnea, severe coma, acute myocardial infarction, severe trauma, massive haemorrhage, etc. |
Immediate emergency treatment in the Emergency Room |
Level II (Critical) |
The patients with unstable vital signs whose conditions may progress to Level I in a short time or may cause severe disability should be arranged for attendance as soon as possible and be treated with relevant management. |
Respiratory distress, intense chest pain, stroke, hypertensive emergency, severe intoxication, massive hemorrhage of gastrointestinal tract, severe fracture, stomachache lasting for over 36 hours, open wound, active bleeding, etc. |
Emergency treatment in the Emergency Room (attendance within 10 min) |
Level III (Acute) |
The patients with basically stable vital signs who are currently without any symptom for upcoming life-threatening conditions or severe disability should be arranged for treatment in a certain time. |
Chest and back pain, stomachache, hyperpyrexia, closed fracture, multiple trauma, etc. |
Arranging first clinical treatment in the Observation Room, and emergency treatment in the Emergency Room when necessary (Attendance within 30 min) |
Level Ⅳ(Not Acute) |
The patients with stable vital signs and without complication can be received in order. |
Fever, diarrhea, small trauma, no active bleeding, etc. |
Waiting for attendance at emergency clinics |
