RULES OF THUMB FOR TRIAGE — Pre-Hospital, Virtual and On-Site

A Rule of Thumb is defined as a “principle with broad application that is not intended to be strictly accurate”. It and is an easily applied educated guess, intuitive judgment, or common sense. Rules of thumb may be used to guide decisions and to reduce error.  Cardinal rules may help avoid root causes of errors of assessment, communication and/or continuity. 

Most of these rules will apply to Pre-hospital and Virtual (telehealth) settings. Please note:  Many of the suggestions here are based on Ms. Wheeler’s research, expert witness experience on malpractice cases, or suggestions by nurses -- class participants.    Several Rules of Thumb are attributed to Jeff Clawson, MD, Pioneer and Founder of Emergency Medical Dispatch (911). 

 Cardinal Rules of Thumb for Triage

  • ·      Time is tissue, Time is muscle. (continuity)

  • ·      Care delayed is care denied. (continuity)

  • ·      Patients who call or are seen frequently within recent hours or days should be seen urgently

  • ·      To Err is Human, to delay is deadly

  • ·      Speed does not equal competence; avoid premature closure.

  • ·      Beware the middle-of-the-night call or contact

  • ·      Never abandon the caller in crisis. (Clawson)

  • ·      When in doubt, always err on the side of caution, and bring the patient in sooner rather than later.

  • ·      “When in doubt, send ‘em out”.  (Clawson, 1998).

  • ·      Always speak directly with patients

  • ·      “If a symptom (or symptoms) is unlike any you have experienced before, make the call, get a reality check”

  • ·      Beware of “failure to improve” on current Rx or Home Treatment

  • ·      Beware the Previous Diagnosis (Any previous Medical Diagnosis); MDs occasionally misdiagnose problems

  • ·      Beware the “Non-Diagnostic Diagnosis” (patient interpretation of symptoms)

  • ·      Be alert for atypical, silent or novel presentations.                         

  • ·      The more vague the symptoms, the greater need for good data collection.

  • ·      Make corrections for own fallibility (UFO)

  • ·      Initiate a “Welfare check” on patients who are alone, frail, or not functioning well

  • ·      Patients who are “too sick to talk” may require an urgent or emergent on-site evaluation.

Trauma-Related Rules

  • ·      Trauma + Suspicious History: Consider Possible Abuse

  • ·      Always consider head/neck injury if there is face or jaw trauma

  • ·      All snakes are considered poisonous until proven otherwise.

  • ·      All chemical and electrical burns have the potential for progressive injury

  • ·      Never remove impaled objects

AGE-BASED RULES (All ages)

  • ·      Assess all sick children (and elderly) for possible dehydration and sepsis

  • ·      The older (or younger) the patient, the greater the risk for hypo- or hyperthermia.

  • PEDIATRICS

  • ·      “Kids get sicker quicker.”

  • ·      Always err on the side of caution, especially with infants and toddlers.

  • ·      < 4 Yrs: Symptoms tend to be very generalized.

  • ·      > 4 Yrs: Symptoms tend to be more specific

  • ·      Infants < 3 Months: Fever of 38ºC or 100.4ºF® – see immediately.

  • ·      Always elicit immunization history. Delayed immunizations or inadequate immunizations place child and community-at-large at risk.

ELDERLY

  • ·      Elderly may present symptoms in silent, atypical or novel ways

  • ·      Elderly are at higher risk for suicide, Highest Completed Suicide: White male, > 65, widower/divorced, retired/jobless.

  • ·      Incontinence in elderly may be related to UTI

  • ·      Developmentally Disabled populations typically age prematurely

TEENAGERS

  • ·      Teen (College Age, Young Adult) is at > risk for suicide or violence when stressed or depressed due to impulsivity

  • ·      Teens:  Overwhelming immune response (Swine flu epidemic, Other)

CHILDBEARING AGE

  • ·      Once an ectopic, always ectopic

  • ·      Any bleeding in pregnancy is an ectopic until proven otherwise

  • ·      Beware all “flu-like” symptoms that can “mask” MI, Infection or sepsis.

  • ·      Pregnancy and breast feeding may be risk factors for domestic violence  

SYMPTOM-BASED RULES

  • ·      All severe pain is considered an emergency (ACEP)

  • ·      Beware of any pain that awakens patient or prevents sleep at night

  • ·      Headache: “First, Worst, Cursed, Burst or 51st ” = Emergent

  • ·      “Temperature extremes often trigger medical problems”. (Clawson, 1998)

  • ·      All first-time seizures must be seen.

  • ·      All rashes are contagious until proven otherwise

  • ·      All new or worsening confusion in the elderly is considered emergent.

  • ·      Any teenager who is depressed may be at risk for suicide

  • ·      All new or worsening confusion in the elderly is considered emergent

  • ·      All High-Risk Patients (see list) with moderate to severe symptoms of any kind should be upgraded

 Chest Pain

  • ·      The first symptom of an MI is often denial

  • ·      Smokers who have chest pain are more likely to die and die suddenly (within the hour) of MI.

  • ·      Time is muscle. Patients treated within the first hour have a substantially improved outcome

  • ·      A little chest pain may be as bad as a lot (Clawson)

  • ·      All pain between nose and navel should be regarded as chest pain until proven differently. (Bartlett)

  • ·      “Epigastric pain in males > 35 and females > 45, is considered an MI until proven otherwise”.  (Clawson, 1998).

  • ·      Treat any pain between the navel and nose as chest pain until proven otherwise

  • ·      Treat any chest pain in high-risk caller as myocardial infarction until proven otherwise.

  • ·      Beware atypical or novel presentations 

  • ·      Acute symptoms in women, diabetics and elderly may present as vague, silent or atypical.

  • ·      Age > 70 yrs. Patients over 70 might not experience chest pain.

  • ·      Minority callers may fail to recognize acute symptoms, report fewer symptoms, or attribute them to other causes (non-diagnostic diagnosis).

  • ·      Beware of any pain that awakens patient or keeps them awake at night.

  • ·      Trauma: all chest trauma is considered urgent until proven differently.

Eight E’s” of MI

·       Extremes of:

o   Emotion

o   Extremes of Weather/Temperature

o   Exertion

o   Extreme Age:  >75

o   Eating (“Holiday Heart”?)

o   Epigastric Distress

o   Essential Hypertension

o   Early AM

“SEPSIS”

  • S—Shivering, fever, or feeling very cold

  • ·      E — Extreme pain or general discomfort

  • ·      P — Pale or discolored skin

  • ·      S — Sleepy, difficult to rouse, confused

  • ·      I — “I feel like I might die”

  • ·      S — Short of breath

    References for Rules of Thumb

  • Fast and Frugal Heuristics

    https://www.sciencedirect.com/sdfe/pdf/download/eid/1-s2.0-S1755599X18300600/first-page-pdf

    Good patient care is dependent on high quality accurate and e cient decision making within the un-

    predictable ED. Emergency Medicine (EM) is defined by timely and accurate decision-making ….. Many theories have emerged within the literature about clinical decision making from

    the perspective of analysis of the human thought processes [3]. Within this paper the authors discuss a form of. heuristics called Fast and Frugal heuristics [4]. The authors then use a

    case study to illustrate an example of how fast and frugal heuristics can

    be applied on a daily basis within the emergency setting.

     

    https://www.sciencedirect.com/science/article/abs/pii/S0738399117303592

    A hundred years ago, doctors used rules of thumb to make up for a lack of facts. Modern day’s rule of thumbing is a way of surviving in an overabundance of facts. In a way, you may say that a rule of thumb turns the information the student already have into information the student needs in a particular clinical situation. However, although a rule of thumb may be appropriate in many situations, it is not appropriate in all. Patients, situations and doctors vary a great deal, and the rules of