Classification and evaluation of accident patients
| Site: | EHC | Egyptian Health Council |
| Course: | Nursing Procedure Guidelines for the Reception and Emergency Department |
| Book: | Classification and evaluation of accident patients |
| Printed by: | Guest user |
| Date: | Tuesday, 5 May 2026, 11:38 PM |
Description
"last update: 17 March 2025" تحميل الدليل
- Prepared by
Emergency guide
Under supervision
- Prof. Dr. Mohamed Latif, CEO of the Egyptian Health Council
Dr. Kawthar Mahmoud, Head of the Egyptian Nursing Syndicate - Member of the Senate
Supervised by
Dr. sherif wadie, advisor to the minster of health for emergency and urgent care
Prepared by
|
Title |
Name |
NO. |
|
Dean Of Faculty Nursing, Professor of Medical and Surgical Nursing, Tanta University |
Dr Afaf Abdel Aziz Abdel Aziz Basal |
1 |
|
Professor Of Critical Care Nursing |
Prof.Dr/Zeinab Hussain Ali |
2 |
|
Professor And Head of the Department of Medical Surgical Nursing. Faculty-. Benha University |
Prof.Dr Amal Said Taha Refaie |
3 |
|
Supervisor Of the Education Sector at Port Said University |
Prof.Dr Amal Ahmed Khalil Morsy |
4 |
|
Professor Of Medical Surgical Nursing- Faculty of Nursing- Cairo University |
Dr. Hanan Ahmed Al Sebaee |
5 |
|
Head of central administration on secondment at MOHP |
Dr Neveen ab drab al0nabi Mohamed |
6 |
|
Director Of Primary Health Care Nursing Department at MOHP. |
Maysa Hosny Ahmed Tammam |
7 |
|
Supervisor Of Technical Education- EHA |
Nancy Alaa Eldeen Abd-Elbaset Ali |
8 |
|
Supervisor Of Nursing Services Development- EHA |
Sherien Mohamed Saad |
9 |
|
Assistant Professor of Maternity and Neonatal Health Nursing - Faculty of Nursing- Ain Shams University |
Assist.Perof. Dr./Heba Mahmoud Mohammed |
10 |
|
General manager of general administration of health institutes affairs |
Dr Mai Galal Ibrahim Al-Assal |
11 |
|
Participants |
||
|
Director Of Curative Nursing Department MOHP |
Dr. Azza Galal Ahmed Khalil |
12 |
|
Member of the Nursing administration, EHA, Luxor Branch |
Mr. Ahmed Mohamed Ahmed Al Noubi
|
13 |
|
Nursing Specialist at the General Administration of Nursing - Ministry of Health |
MS. Angham Hamdy Abdel Khaleq
|
14 |
|
Nursing Specialist at the General Administration of Nursing - Ministry of Health |
Mr. Ahmed Muhammad Hussein Mubariz |
15 |
|
Nursing Specialist at the General Administration of Nursing - Ministry of Health |
Mr. Abdel-Azim Al-Saeed Abdel-Azim Al-Hanafi |
16 |
|
Nursing Specialist at the General Administration of Nursing - Ministry of Health |
Mr. Shawkat Yusre Hussein
|
17 |
|
nursing specialist at the General Administration of Nursing |
Mr. Karim Ahmed Sadik |
18 |
- triage (Classification)
· It is a process used to determine the condition of patients in terms of the severity and seriousness of the illness, in order to direct the patient to the right place, at the right time, and with the right service provider.
- Procedures
A. Availability of qualified workers during working hours.
There is a qualified medical team of doctors, nurses and technicians working 24 hours a day, 7 days a week in the emergency department.
Triage is initially handled by a qualified nurse with good communication skills.
B. Establish controls to determine care priorities according to the recognized sorting process.
1. Triage is initially handled by a qualified nurse with good communication skills with the following tasks.
Evaluation must be fast in the registration area and waiting area at all times.
Conduct a brief visual assessment
2. Once the patient arrives at the emergency department, the nurse responsible for visual triage sorts the patients (at the emergency entrance) by carefully observing the patient’s general appearance and current complaint
3. In the case of stage 1 patients, the visual triage nurse directs the patient’s family to perform CPR on the patient inside the cardiopulmonary resuscitation room, and the nurse completes the assessment for them immediately
4. In stage 2 patients, the visual triage nurse directs the patient’s family to deal immediately with the patient in the emergency room, and the nurse completes the evaluation for them immediately
5. The visual triage nurse directs the remaining cases that have not been classified to the triage room to be evaluated and have their vital signs measured to determine the classification by the triage room nurse and to complete the triage form
a. The triage assessment should take no more than two to five minutes, to obtain sufficient information to determine the severity of the illness and identify the need for immediate care
6. The nurse records all the information obtained during the screening and evaluation process on the screening form.
a. The priority of care may change as the patient's signs and symptoms develop.
7. The triage nurse informs patients and their families about the classification level and the expected waiting time before the physician’s evaluation.
8. The triage nurse re-evaluates waiting patients as necessary.
a. The triage assessment is not intended to make a diagnosis of the patient's condition.
- AUSTRALIAN TRIAGE SCALE
First group: Resuscitation (Red card) :
Cases that require immediate evaluation and treatment by a nurse and doctor. Immediate intervention is required. Any delay in treatment may pose a risk to the patient’s life. Cases include:
Airway is exposed to risk
Cardiac and respiratory arrest
severe shock
Neck and spine injury
Multiple organ damage
Long-term seizures or seizures during pregnancy
Severe behavioral disturbance with threats of serious violence
Severe drop in blood circulation (blood pressure less than 80 in adults).
Penetrating wounds in the chest, abdomen and pelvis
third degree burns
Severe bleeding that affects the physiological functions of the body.
· The patient is treated in the triage room and moved to the cardiopulmonary resuscitation room if possible
· The nurse tests the patient's vital signs (breathing, pulse, and level of consciousness) and confirms that the patient needs cardiopulmonary resuscitation or BLS .
· The nurse calls the code blue team by informing switch 100, 101 to call the CPR team
· The Code Blue team follows the advanced cardiopulmonary resuscitation protocol on the patient
Second group (urgent or emergency sorting) Orange card:
These patients are in critical condition or are rapidly deteriorating and there is a possibility of a threat to their lives or failure of an organ or body system and require rapid intervention if treatment is not provided within 10 minutes of arrival. The cases that require treatment at the present time and in cases of severe pain include the following cases:
Blood clot or poisoning
severe difficulty breathing
Increase in heart rate of more than 50 or less than 50 in adults
Severe blood loss
Low blood pressure with effects on blood circulation in the body
Hypoperfusion
blood poisoning
Consciousness level less than 13
stroke
Fever with lethargy or meningitis
compound fracture or amputation
Head injuries
Severe injury, heart-related chest pain
lethargy, strange weakness, or irritability
Deliberate overdose
hypersensitive
Eyes exposed to a chemical
Gastrointestinal bleeding with unstable vital signs
· The nurse directs the patient to the emergency room or the examination and waiting area (emergency hall) according to the type of injury
· The doctor evaluates the patient's condition and requests the necessary diagnostic tests, where the patient is transferred to the examination site (x-rays - laboratory).
· The nurse and the doctor follow up with the patient until the results of the diagnostic tests appear.
· The doctor arrives at the final diagnosis, on the basis of which he determines the patient’s destination, either admission to intensive care, operations, the inpatient department, or transfer according to the case and protocol of the emergency department
Group 3: Urgent sorting (green card):
These are cases that may pose a risk to the patient’s life, cause illness, or cause adverse outcomes if the nurse and doctor do not evaluate and provide treatment within half an hour of arrival. These cases include:
Head injury with vomiting and brief loss of consciousness
Severe high blood pressure
Moderate blood loss for any reason
shortness of breath
persistent vomiting
drought
Chest pain not related to the heart
Abdominal pain without serious signs
Moderate injury to the limbs, such as crushing or tearing
sensory disturbance
Moderate asthma attack
Moderate injury
Physical harm or the effects of neglect or violence
Gastrointestinal bleeding with stable vital signs
Previous history of heart attack
· The nurse directs the patient to the examination room or the examination and waiting area (emergency room)
· The doctor evaluates the patient's condition and requests the necessary diagnostic tests, where the patient is transferred to the examination site (x-rays - laboratory)
· The doctor gives the patient treatment according to the emergency protocol
· The doctor reaches the final diagnosis and determines the patient's destination, whether to enter specialized medical departments, be discharged home, or be transferred to another hospital
Group 4 Less urgent (blue):
There may be a possibility of danger to the patient's life or it may deteriorate if intervention is not provided within an hour of arrival. These cases include:
Minor bleeding
Head injury without vomiting or loss of consciousness
Minor body injury
Difficulty swallowing without shortness of breath
Ankle sprain
Vomiting and diarrhea in a patient older than two years without dehydration
ear pain
Mild sensitivity
Foreign body in the cornea
Group 5, non-urgent sorting (white)
Cases that require evaluation within two hours of the case’s arrival include:
Slight rise in temperature for several days
Pain in one limb
Pain in the pharynx or larynx
Chronic abdominal pain
Reassess
Black color:
· The patient is considered dead if there is no pulse and no breathing
· The emergency procedure policy for the arrival of a deceased person is followed
- Assessment, reassessment and care management according to approved clinical guidelines and protocols
· The doctor re-triages every 10 minutes for ORANGE cases and every 30minutes for GREEN cases while RED cases are under continuous monitoring and management
· All evaluations and re-evaluations are conducted in accordance with the evaluation and re-evaluation policy by qualified doctors and nurses and in accordance with the hospital’s regulations and laws
· All evaluations, re-evaluations and examination results are documented in the patient's medical file
Assessment of trauma patients at the reception
Trauma assessment is a fundamental process that aims to determine the extent and severity of injuries sustained by a patient as a result of an accident or serious injury, and to provide the necessary care as quickly as possible. This assessment aims to determine medical priorities to ensure the patient's safety and preserve his life
The assessment includes several methodological steps, usually following the “ ABCDE ” approach, which is an acronym for the basic emergency assessment stages:
A – Airway :
Ensure that the airway is open and clear. If the patient is unconscious or has an airway obstruction, the airway is opened using techniques such as head tilt, chin lift, or insertion of a breathing tube
B – Breathing :
Evaluate the breathing process and its efficiency. Ensure that the patient is breathing effectively, and find out if there are any breathing difficulties or injuries affecting the lungs (such as an open chest or a collapsed lung)
C – Circulation :
Checking the pulse, blood pressure, and amount of blood flowing to the extremities. Ensuring that the heart is working properly and that blood circulation is sufficient to transport oxygen and nutrients to the tissues
D – Disability (neurological disabilities or disorders):
Assessing the patient's state of consciousness using the Glasgow Coma Scale . Examining nerve functions and determining whether there is any paralysis or sensory impairment
E – Exposure (full exposure and comprehensive examination) :
Fully examine the patient's body to identify any other unseen injuries, such as deep wounds or burns. Control body temperature and prevent hypothermia. Additional steps: Medical history: It is important at an advanced stage to know the patient's medical history and medications. Imaging and diagnosis: Some injuries may require imaging methods such as X-rays or CT scans to determine the severity of internal injuries.
Secondary assessment:
After the patient’s vital status is stabilized, a secondary assessment is performed, which includes a more detailed examination of less serious injuries, and gathering historical information related to the accident or injury. The importance of assessing trauma patients: Evaluating trauma patients quickly and accurately helps in: Saving the patient’s life: Rapid intervention in critical injuries such as airway obstruction or severe bleeding can be crucial in saving the patient’s life. Reducing complications: Early intervention helps prevent the development of complications that may worsen the patient’s condition. Prioritizing: In disasters or mass accidents, assessment helps in sorting patients according to priority to provide the necessary care. Conclusion: Assessing trauma patients is a vital process that requires medical training and expertise to identify serious injuries and intervene quickly to preserve the patient’s life. The process is based on the ABCDE methodology , which helps in focusing on the most important vital functions in the body and ensuring their stability before proceeding with assessment and treatment
Patient assessment at reception
The patient's journey through the reception (or emergency) department includes a series of steps aimed at providing health care effectively and quickly. These steps can vary slightly depending on the health system and hospital, but in general they include the following :
1. Initial reception
- Reception and Registration : When a patient arrives at the emergency department, he or she is registered by the receptionist. Registration includes collecting basic information such as name, date of birth, contact information, and health insurance if applicable .
- Initial triage : The receptionist or initial assessment nurse determines the severity of the condition based on the patient's symptoms. This may include measuring vital signs such as blood pressure, respiratory rate, and pulse .
2. Initial medical assessment
- Medical Evaluation : The patient is examined by a physician or nurse. The medical evaluation includes collecting a complete medical history, performing physical examinations, and determining the need for additional tests or interventions .
- Prioritization : Based on the medical assessment, the patient's condition is classified according to priority. There may be a classification according to the four-stage system (red, yellow, green, blue)or another system to determine the severity .
3. Diagnosis and examinations
- Examinations and tests : If necessary, additional tests such as blood tests, X-rays, or other imaging tests are ordered to accurately determine the diagnosis .
- Initial treatment : Based on the assessment and diagnosis, appropriate treatment is initiated. Treatment may include medications, fluids, or emergency interventions .
4. Monitoring and treatment
- Monitoring : The patient's health condition is continuously monitored during the treatment period in the emergency department. The condition is updated as needed and the treatment plan is modified based on the development of the condition .
- Specialist consultation : If the case requires specialized interventions, specialist doctors are consulted or the patient is referred to the appropriate department .
5. Exit or transfer
- Discharge decision : After the patient's condition has stabilized and received the necessary treatment, a decision is made regarding his discharge. The patient is given clear instructions regarding home care and medications, if needed .
- Transfer to hospital : If the condition requires continuous care or advanced interventions, the patient is transferred to the appropriate hospital department or intensive care unit .
- Documentation : All treatment details and evaluations are documented in the patient’s file to ensure good follow-up and provide a comprehensive medical record .
6. Education and follow-up
- Education: The patient and family are instructed about follow-up care, medications, warning signs, and when to return to the hospital .
Follow-up : A follow-up appointment may be scheduled with a specialist doctor or at the emergency clinic to review the condition and ensure that no complications have occurred .