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CSA w2L1

Triage – slide notes

Dr Claire MacRae

TRIAGE Contents Course Level Learning Outcome ............................................................................................................. 1 Mini Lecture 1: What is Triage? .............................................................................................................. 2 Learning Objective .............................................................................................................................. 2 Definition ............................................................................................................................................ 2 Key Points............................................................................................................................................ 4 Lecture outline .................................................................................................................................... 4 Mini Lecture 2: Zoonotic and Infectious Diseases .................................................................................. 5 Learning Objective .............................................................................................................................. 5 Definitions ........................................................................................................................................... 5 Key Points............................................................................................................................................ 7 Lecture outline .................................................................................................................................... 7 Mini Lecture 3: Compromised Patients .................................................................................................. 8 Learning Objective .............................................................................................................................. 8 Definition ............................................................................................................................................ 8 Key Points............................................................................................................................................ 9 Lecture outline .................................................................................................................................... 9 Mini Lecture 4: Adverse Reactions ....................................................................................................... 10 Learning Objective ............................................................................................................................ 10 Definition ..........................................................................................................................................10 Key Points.......................................................................................................................................... 11 Lecture outline .................................................................................................................................. 11

Course Level Learning Outcome Prepare a management plan for caring and supporting animals affected by ill health

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Triage – slide notes

Dr Claire MacRae

Mini Lecture 1: What is Triage? What is triage and why is it important?

Learning Objective Recognise signs of fear, pain, stress and discomfort in relevant animal species in various situations (OIE)

Definition Triage is a system whereby a patient’s condition is categorised by urgency. Triage is essentially the process of quickly observing and/or examining a patient and/or obtaining a patient history to determine the severity of the patient’s condition in order to decide the urgency of its condition. In a group of animals, this equates to system or prioritising care so that the most urgent cases are attending to first, and the least urgent cases are attended to later. On an individual animal level, the urgency determines how quickly the animal is attended to and in what order treatments may occur. Successful triage dictates the entire management of a case, and the order in which treatments, diagnostics and client communication occurs. Triage applies to all species in all circumstances. It applies over the phone at the first point of contact with the client, as well as in the clinic or in the field. It is dynamic, and can change rapidly as a patient improves or deteriorates. Therefore, effective triage must be repeated at intervals to ensure patients do not decline without being noticed. Triage is NOT about diagnosing the animal! As a Tech you are not legally able to do this, and you are not expected to. Diagnosis is the veterinarian’s job. It is however about recognising what is normal and what is abnormal. If you decide that your findings are abnormal, then you must decide how urgent the case is. In order to determine if something is abnormal, you need to know what normal is first. You should now review the normal parameters for common species, eg dogs, cats, rabbits, birds, cattle, sheep, goats, horses, and wildlife. Remember also, that we are not just looking at TPR numbers, but also at other factors such as general demeanour, mentation, body condition score, presence of absence of wounds, injuries etc. So, we perform a primary survey, then think about our findings and decide if the animal is urgent or not urgent. Some hospitals use a formal categorisation system or levels. They may use colour coding, such as red for the most critical and green for the most stable. Other hospitals may use letters eg, A B C D, or a number system. Such categories are more useful for very busy hospitals, with large numbers of patients waiting at any one time. The first step, be it by phone or in person, is to obtain a brief history, with only as much information as is required to determine urgency. For example, if an owner tells you their dog was hit by a car, you already know this is likely to be urgent. You can further refine this category through your examination of the patient, ie, are its vital signs normal or abnormal, what is its demeanour, are there obvious injuries etc. As another example, if an owner tells you their dog has been vomiting for Page 2 of 11

CSA w2L1

Triage – slide notes

Dr Claire MacRae

three days you might be concerned that this could be urgent, however, after examining the animal, you may find it to be bright and happy, (BAR), with all vital signs normal. This may lead you to determine that this animal’s condition is not as urgent as first thought, and allow you to categorise this patient at a lower triage level. A history can be a single word, for instance ‘snakebite’ or ‘limping’, and this is enough to tell you how urgent the case is. When obtaining a history, it is also important to determine if an incident (eg hit by a car – HBC) is said to have occurred, whether this incident was witnessed and confirmed or is it only the owner’s suspicion. Many a ‘choking’ dog has kennel cough, and plenty of cats with ‘a broken leg’ merely have a cat fight abscess (CFA). If the owner thinks the animal has been poisoned, do they know this for sure? Or do they just suspect it? If we KNOW an animal has been HBC for instance, we will likely give it a high priority, however, if the owner only suspects it was hit by a car because it is limping, this will alert us to perform a more thorough triage evaluation. Other points to consider when taking a history include descriptions of any vomitus or diarrhoea, descriptions of behaviour at home, or of ‘events’ (eg seizure vs other). Again, with experience, this information will help you to determine the urgency of the case. The order of triage steps will change depending on the patient. Triage is an art that takes practice, and with experience can be done very quickly. After some time, you should be able to determine within seconds if an animal’s condition is critical and needs immediate attention. In cases such as this, do not waste time taking a history. That can come later. In these sorts of cases, it is usually best to take the animal to the treatment room for immediate treatment by the veterinarian. If there are enough staff present, then you may be sent back to speak with the owner an obtain a history while the animal receives life-saving treatment from the team. Assuming our animal is not quite this critical, after we have obtained a history we must then observe the animal. With experience, this history and observation can occur simultaneously. We are not just looking at the TPR numbers to determine urgency, we are also looking at the patient’s demeanour, mentation, attitude, general appearance, and presence or absence of wounds or injuries. Again remember that history is important. For instance, a cat that is known to have been hit by a car but does not appear to have any external injuries may still be suffering from life-threatening conditions such as shock or internal bleeding. If we evaluated this animal without the history, we may mistakenly decide that its condition is not urgent, leading to rapid deterioration and even possible death. After our general observation, we then can perform a TPR. Our initial primary survey may simply include checking the mucous membranes as this is a very simple and quick observation that can be done without equipment. With a stethoscope of course, we can also take a heart rate and listen for abnormal heart rhythms and sounds, and with a thermometer we can obviously take a temperature. In most cases, a temperature is not necessary during the primary survey performed by a Technician, but in some cases it may be a very important factor in determining urgency. After our history, observation, and TPR/examination, it is then time to think, assimilate the information, and decide how urgent the case is. Think: does all of this information lead you to determine that the animal appears to be showing normal signs, or are there abnormalities in your exam and/or history taking? if so, does this indicate

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Dr Claire MacRae

that the animal may be suffering from fear, pain, distress, or disease? If yes then now what do we do? Acting appropriately in these situations depends on the individual circumstance. If you are in a clinic setting, taking the animal to the treatment area if it is urgent is appropriate. If you are in the field, either alerting the veterinarian or performing limited first aid may be required.

Key Points Triage is all about assigning priority of care for patients so that they do not die waiting to see a veterinarian! It is the technician’s job to recognise abnormal signs and decide how urgent the case is so that it may be seen and treated in the appropriate time frame.

Lecture outline Slide 1

Title slide (supplied)

What is TRIAGE? Dr Claire MacRae, VN Bsc(EqSc) BS(PreVet) DVM, School of Animal and Veterinary Sciences

Slide 2

Uni copyright slide (supplied)

Uni copyright slide (supplied)

Slide 3

LectureLO1 W2L1.A1 CVTEA

LO1 Recognise signs of fear, pain, stress and discomfort in relevant animal species in various situations **Dr Claire MacRae - Introduction **What is Triage and why is it important? **Triage is NOT about diagnosis (that is the Vet’s job!) **About recognising what is normal, what is abnormal, and deciding on the urgency of the patient’s condition

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TRIAGE

**PRIORITY of patient urgency **Primary Survey. Categories/levels. Applies to all species

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OBTAIN HISTORY

**Info from owner/carer – what happened/what is the problem? Can be one word! Eg snakebite ** If Incident – witnessed or not **If possible toxicity – access **If vomiting, what does it look like etc etc **Order may vary depending on patient – do not waste time with history or full exam if patient is critical

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OBSERVATION FIRST

**What else might we be looking for apart from the TPR numbers? ** Demeanour, wounds, injuries, pt ** Remember, history is important

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NUMBERS NEXT

**We need to know normal before we can recognise abnormal E **Must know normal TPRs for a variety of species.

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THEN THINK AND DECIDE **Do these numbers and other obs tell us if the animal is frightened, in pain, in distress? **Are they signs of disease? **Or are they normal?

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AND ACT APPROPRIATELY

**We have recognised that animal has fear/pain/distress/disease - now what? **Situational: field = first aid. Clinic = take animal to the treatment area. Other = remove from situation

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KEY POINTS

**Triage is priority of care so that urgent patients don’t die while waiting! **It is YOUR role to recognise abnormal signs so we can have the most urgent patient treated first

Slide 11

Uni of Adelaide supplied TAIL

(supplied)

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Triage – slide notes

Dr Claire MacRae

Mini Lecture 2: Zoonotic and Infectious Diseases What are infectious diseases and zoonoses and why are they important to know about?

Learning Objective Recognise suspicious signs of possible notifiable, reportable and zoonotic disease and take appropriate action, including observing the appropriate health and safety recommendations (RCVNS)

Definitions • • • •

Zoonotic - a zoonotic disease is one that is transmitted from animals to humans Infectious - an infectious disease is one that is caused by pathogenic organisms such as bacteria, viruses, and fungi Contagious - a disease that is transmitted (usually) between members of the same species Reportable/Notifiable - diseases which must legally be reported to the Emergency Animal Disease Watch Hotline. This is usually because they have significant impacts on human health. Mostly they are rare or not present at all in Australia, and they are often zoonotic.

Many diseases fall into more than one category. For example Hendra is all four. Anthrax is also all four, though it is not highly contagious between animals. Parvovirus is infectious and contagious but not zoonotic or notifiable. Examples of common or well-known zoonotic diseases include: • • • •

Ringworm which may affect many species especially kittens Leptospirosis which also affects multiple species including cattle and dogs Cryptosporidiosis in ruminants especially calves Hendra virus in horses

Examples of common infectious animal diseases: • • • •

Parvovirus in dogs Cat flu in cats Salmonella in many species Can you think of any other infectious diseases?

Examples of contagious animal diseases include: • • • • •

Parvovirus in dogs again Cat flu in cats again Strangles in horses Cheesy gland in sheep and goats Can you think of others?

Examples of notifiable animal diseases in Australia include: • •

Anthrax in ruminants Rabies in dogs and other carnivores Page 5 of 11

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Triage – slide notes

Dr Claire MacRae

Leptospirosis many species Hendra virus in horses COVID19 in humans!

Using our triage skills of history taking, observation, examination, and thinking, we then decide if the animal may have an infectious, zoonotic, contagious, or notifiable disease. If we suspect that it does, we then need to act accordingly remembering that some of these diseases may have significant human health consequences. In most cases, personal protective equipment (PPE) is important both to protect human health and reduce transmission of disease to other patients. Minimum PPE includes gloves and face masks, but in most cases should also include gowns, caps, booties, and glasses. As well as PPE, it is important to recognise that many of these diseases are highly transmissible (contagious) and therefore should be placed in isolation away from other animals, and if in a clinic, away from high traffic areas. Ideally clinics should have a dedicated isolation ward. In the field, animals may need to be placed in isolated yards or loose boxes located well away from other animals. If it is suspected that an animal may have an infectious, zoonotic, contagious, or notifiable disease, it is important that PPE and isolation of the animal is continued until a diagnosis is reached. This is where effective phone triage becomes extremely important. If over the phone it sounds as if a puppy may have parvovirus, a kitten may have cat flu, or a horse may have salmonella, the owner should be instructed to keep the animal in the vehicle or float, and telephone the clinic on arrival rather than bring the animal into the clinic. Keep in mind that many of these diseases are transmitted by fomites (is, objects/surfaces) and they may be transmitted on the owner’s clothing or other equipment such as halters, collars and leads. Patient side testing should then be performed, for example snap tests for parvovirus can quickly and easily be performed while the dog remains in the car. This means that the clinic building, staff, and other dogs are not exposed to parvovirus if it is diagnosed in this patient. If the test is negative, then the dog can be allowed into the clinic. It is extremely important that the major clinical signs of these infectious, zoonotic, contagious, or notifiable diseases are quickly recognised. No single disease has one single clinical sign, however, some have ‘red flag’ signs. Examples: • • • •

Parvovirus: diarrhoea with blood Cat flu: sneezing Anthrax: sudden death Hendra virus: acute respiratory distress and neurological signs.

Of course, these signs may be attributable to other diseases, and these diseases mentioned also have other signs. With experience, technicians should be able to quickly develop a reasonable suspicion that animals may be suffering from a zoonotic, infectious, contagious, or notifiable disease and take the appropriate steps to isolate the patient and arrange patient side testing to confirm.

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Triage – slide notes

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Key Points •

•

• •

The potential for an animal to be suffering from a zoonotic, infectious, contagious, or notifiable disease must quickly be recognised by the technician, especially as it may prove to be a disease that is harmful to humans The technician must then act appropriately to be able to isolate the patient, perform cageside or field testing as appropriate, and recognise the need for PPE in most circumstances. The technician must be aware of which diseases may be significant zoonoses, and which are notifiable, and inform the team as soon as possible Along with the potential for negative impacts on human health, and the concern for potential transmission to other patients, suspicion of a zoonotic, infectious, contagious, or notifiable disease also affects triage status

Lecture outline Slide 1

Title slide (supplied)

Zoonotic and Infectious Diseases. Dr Claire MacRae, VN Bsc(EqSc) BS(PreVet) DVM, School of Animal and Veterinary Sciences

Slide 2

Uni copyright slide (supplied)

Slide 3

LectureLO2 W2L1.A2 OIE

LO2 Recognise suspicious signs of possible notifiable, reportable and zoonotic disease and take appropriate action, including observing the appropriate health and safety recommendations **Definition zoonotic – transmitted from animals to humans **Definition infectious – caused by infectious agents eg bacteria, viruses, fungi **Definition contagious – transmitted between members of the same species

Slide 4