Rapid triage performed by nurses: Signs and symptoms associated with identifying critically ill patients in the emergency department

Aim 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. Background 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. Design This is a cross-sectional, quantitative study. Methods 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. Results 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). Conclusion 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.