TRIAGE DECISIONS

FRONT-GATE TRIAGE Author: Kathleen Richardson, DNP, NP-C, CEN, Tacoma, WA Section Editors: Andi L. Foley, MSN, RN, CEN, and Patricia Kunz Howard, PhD, RN, NE-BC, CEN, CPEN, FAEN

Earn Up to 7.5 CE Hours. See page 203. or any emergency nurse, triage is a well-known concept and part of our daily duties. Triage training can be on the job or formal education within the facility or through external organizations. Multiple resources exist that specifically address triage processes and competency within the hospital-based emergency department, providing guidance for patient categorization and specific interventions. 1–3 Triage guidelines address age- or condition-specific considerations and include mass-casualty triage procedures. However, no guidelines exist for a third type of triage, front-gate triage. Frontgate triage is unique to the deployed setting because potential patients present in the context of very complex social and organizational rules, often in austere environments, with ethical considerations unique to wartime and limited resources.

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What Is Triage?

Triage originates from military medicine and describes the prioritization of casualties on the battlefield, where available resources were (and are) limited and care activities required prioritization. 4-,8 Consideration of social context is extremely important when making triage decisions and directly impacts the simplicity or complexity of a situation. A mismatch between organizational processes, missions, or resources and the patient’s social and cultural context may create conflicting expectations for both the patient and the health care provider. 7,9 Kathleen Richardson, Member, Mid-Maryland Chapter, is Adjunct Assistant Professor, Uniformed Services University of the Health Sciences, and Doctor of Nursing Practice Residency Director, Madigan Army Medical Center, Tacoma, WA. The views expressed are those of the author and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences, the United States Army, the Department of the Defense, or the United States government. For correspondence, write: Kathleen Richardson, DNP, NP-C, CEN, 5021 80th Ave W, University Place, WA 98467; E-mail: [email protected].

Hospital Triage

Most emergency nurses are familiar with ED triage, where the sickest patients are seen first. 9 Many have also conducted mass-casualty triage, where large numbers of casualties or patients present simultaneously, quickly overwhelming health care facility resources and capabilities. 10 Although many of these patients would be triaged as the “most critical” under normal circumstances, in disaster circumstances these patients may receive the lowest triage priority for treatment. 2,4,7,8

Front-Gate Triage

Triage in the deployed setting is unique to the specific environment, which can be referred to as the social context. Unless the military treatment team is in a country conducting a humanitarian mission, the team’s primary purpose is to care for ill or injured soldiers, to facilitate quick treatment so that soldiers can return to battle, or to provide rapid stabilization and transportation of soldiers to a higher level of care. 11 Often, people from the host nation (local nationals) will come to the United States military medical treatment facility seeking treatment for a myriad of issues, ranging from very minor to very critical. The facility would be overwhelmed if every local national appearing at the front gate of the medical facility was evaluated and treated. The military’s organizational mission and the host nation’s social context are incongruent, resulting in differing care expectations. Nurses at deployed facilities balance fostering ongoing local national relations with maintaining the capacity or readiness to conduct the primary mission of soldier health care. This decision-making process, including whether to treat at the front gate, admit the person to the facility, or send the person elsewhere for care, is known as front-gate triage.

J Emerg Nurs 2014;40:198-200. Available online 26 December 2013. 0099-1767/$36.00 Copyright © 2014 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2013.11.007

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WHO CONDUCTS FRONT-GATE TRIAGE?

Front-gate triage is typically conducted by an emergency nurse or medic, depending on the situation. Both have experience in triage and first aid and use items in a

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“triage bag” to provide immediate treatment to local nationals with minor injuries or illnesses. To facilitate communication with the local nationals, an interpreter is present, if available. WHEN AND WHERE IS FRONT-GATE TRIAGE CONDUCTED?

All front-gate triage occurs outside of the medical treatment facility because safety during deployment is of utmost concern. Most personnel recognize that the red cross indicating a medical facility would not deter an insurgent from doing great damage. Hospitals and health care staff are not exempt from mortar, gunfire, or attempts by insurgents seeking to infiltrate and injure US military personnel. Therefore local nationals who approach the front gate are searched by security personnel, and once the local nationals are deemed safe, the triage team is signaled to approach and perform a rapid evaluation. Entry into the facility by all visitors, including patients or potential patients, requires passing through checkpoints and undergoing security measures. The legitimate need for entry into the facility must be verified. Insurgents have attempted to enter by pretending to be patients. Until a patient can be legitimately identified as someone truly in need of care, entry to the facility is not permitted. If a patient is in need of care, he or she is searched a second time and escorted into the facility. Accompanying family members or attendants must undergo further security checks and not all will be permitted to enter to remain with the patient. Depending on the patient presentation and triage nurse experience, the triage nurse may choose to consult with one of the emergency medicine providers before final disposition. ETHICAL CONSIDERATIONS

Initially, front-gate triage may appear to be very linear and straightforward. However, anyone who has conducted front-gate triage would be quick to argue that it is anything but straightforward. 12 For the majority of locations where front-gate triage occurs, local or host nation health care facilities are rudimentary and cannot compare with the level of care one would expect to receive in industrialized countries. 13 It is very difficult, in many cases, to refuse other-than-basic first aid care and to send local nationals away to seek care elsewhere. 11 In a documentary on “host nation” health care in Iraq, an interviewed physician painted a dismal picture of health care, indicating that medications, supplies, and equipment were not available in medical treatment facilities. 13 Firsthand experience validated the documentary claims of

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inadequate health care. To quote a patient, “Please don’t send me to [the local health facility]; I don’t want to die.” Once a local national is admitted to a deployed hospital, he or she receives the same medical and/or lifesaving treatments as any other patient, regardless of nationality or political beliefs. However, after the local national patient is stabilized, he or she will be either sent home or transferred to a local medical treatment facility for further care and follow-up. The question always lingers: Is it the right thing to do to admit a patient into our hospital, provide care that saves his or her life, and then send him or her to a local facility where the same level of care will not be available?

Conclusion

Although this article specifically addresses front-gate triage in a deployed situation, the process could potentially migrate into the civilian setting. Increasing resource constraints and efforts to decrease emergency department utilization for non-emergent conditions will greatly affect health care business practices. These changes may result in only the sickest and most emergent patients being admitted to the emergency department, with all others triaged to primary care providers, urgent care clinics, or community care clinics. Front-gate triage is a complex process with competing priorities weighing into decisions. For emergency nurses, it is important to understand the role and responsibilities associated with conducting this type of triage and to understand and recognize the second and third order of effects related to triage decisions.

REFERENCES 1. Emergency Nurse Association. Emergency nursing triage. Available at: www.ena.org. Published 2013. Accessed March 3, 2013. 2. Gilboy N, Travers D. Triage In: Emergency Nursing Core Curriculum. 6th ed. St Louis, MO: Saunders; 2007:28-40. 3. Board of Certification for Emergency Nursing. CEN content outline. Available at: www.bcencertifications.org. Published 2013. Accessed March 3, 2013. 4. Robertson-Steel L. Evolution of triage systems. Emerg Med J. 2006;23(2):154-5. 5. Oxford Dictionaries Web site. Available at: http://oxforddictionaries. com. Accessed March 3, 2013. 6. Merriam-Webster Dictionary Web site. Available at: http://www. merriam-webster.com. Accessed March 3, 2013. 7. Lahdet EF, Suserud B, Jonsson A, Lundberg L. Analysis of triage worldwide. Emerg Nurs. 2009;7(4):16-9.

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8. Deluhery MR, Lerner EB, Pirrallo RB, Schwartz RB. Paramedic accuracy using SALT triage after a brief initial training. Prehosp Emerg Care. 2011;15(4):526-32. 9. Janssen MAP, van Achterberg T, Adriaansen M, Kampshoff C, Schalk D, Mintjes-de Groot J. Factors influencing the implementation of the guideline triage in emergency departments: a qualitative study. J Clin Nurs. 2011;21(3–4):437-47. 10. Vincent DS, Burgess L, Berg BW, Connolly KK. Teaching mass casualty triage skills using iterative multi-manikin simulations. Prehosp Emerg Care. 2009;13(2):241-6. 11. Duncan R, Pansoy C, Towe L. Grace under fire. Nursing. 2005;32(5):62-4.

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12. Miner C. Iraq’s anatomy—triage at a Baghdad Hospital. Available at: http://kalwnews.org. Accessed March 6, 2013. 13. Baghdad Hospital: inside the red zone. Available at: http://www.hbo. com/documentaries/baghdad-hospital-inside-the-red-zone. Accessed April 8, 2013.

Submissions to this column are encouraged and may be sent to Andi L. Foley, MSN, RN, CEN [email protected] or Patricia Kunz Howard, PhD, RN, NE-BC, CEN, CPEN, FAEN [email protected]

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Front-gate triage.

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