Triaging certainly carries a high level of responsibility. The regional nurse initiated diagnostic imaging/labs are not mandatory for all patients. They are to be considered when Safety Risk Level 3 or 4 overcapacity alert situation as defined in Capacity Management Protocol or as an option for patients when an ED is experiencing greater than four (4) hours wait times; or to assist with ED staffing shortages; or to facilitate efficient patient flow in the ED.
The Shared Health Nurse Initiated labs requisition is currently only used at regional centres. It should be a quick check box and then lab called to draw blood, following site process. The acute community sites currently use a different requisition requiring separate labs to be checked (not per complaint). There is provincial work happening to have a rural requisition. The nurse managed care policy (title changing to Nurse Initiated Care in the Emergency Department) and the adult/pediatric clinical protocols are currently under revision and further information will be shared shortly.

Return visit for therapy is a new CEDIS complaint as of 2016, although it was never added into EDIS at that time. So for the EDIS sites, this is a new CEDIS complaint. The definition for when to use return visit for therapy, as per CTAS, is when the patient is stable with normal vital signs, and progressing as expected. Eg. IV antibiotics, rabies vaccine. Choose another complaint if condition is questionable or worsening. The lowest acuity score when using this CEDIS complaint is a CTAS 4, unless other primary modifiers apply. Not all scheduled visits will be an automatic CTAS 5.

Technically every patient coming through ED are over seen by the ED physician on site/on call. But if there are already orders for a scheduled patient visit (ie. medications, dressing supplies) then a physician won’t necessarily need to be involved in the care. Of course if anything changes with the patient condition, notify the physician or follow nurse managed care protocols.

Other examples of CEDIS complaints that may be used for scheduled visits would include: dressing change, imaging tests/blood tests, wound check, removal of staples/sutures. And these CTAS scores may vary between a CTAS 4 or 5.

Follow the Nurse Managed Care policy (title changing to Nurse Initiated Care in the Emergency Department), which addresses how nurses manage the care of patients that present when an ED is closed/suspended for all CTAS levels. And if you have orders for the patient presenting already, defer to those.

The new CEDIS complaints will not be in the EDIS system yet. Thus you cannot use the new CEDIS complaints until the update happens. The updated EDIS Triage Emergency Note is due to roll out in September. In the meantime, if you wanted to use any new primary or complaint specific modifiers, you would have to do an override for patients with rationale. FYI: There is a provincial paper triage record coming soon. This will be used at acute community hospitals and for EDIS down time.

The COT tool is an Excel program that requires a Microsoft office subscription in order to use it. It is posted on StaffNET in the Self Learning Resources and Modules and under Acute Care then Canadian Triage Acuity Scale. The COT tool was used to create the Interactive Quick Look booklet 2025. This paper tool should be available at every triage space. Individual sites may choose to have a computer or tablet on site with the COT tool for use instead. You will find several CTAS resources posted in this area of StaffNET, we strongly encourage you to check it out.

CTAS defines High risk substances as:
– some recreational drugs (especially non-regulated production) like methamphetamines, cocaine, bath salts, etc.
– Anesthetic and sedation agents (ketamine, propofol, benzodiazepine)
– Antithrombotic medication (warfarin, dabigatran, heparins)
– Chemotherapy/antineoplastic meds
– insulins or other things that effect blood sugar
– neuromuscular blockers
– opioids
– drugs with cardiovascular effects (adrenergics, anticholinergics, antiarrhythmics, inotropes, vaso-actives).

CTAS defines Moderate Risk Substances as:
– drugs that have notable side effect, significant interactions with other medications, or need for monitoring (like regular blood tests etc).
– antipsychotics or mood altering drugs
– NSAIDS
– acetaminophen
– recreational drugs such as cannabis
– herbal supplements and vitamins

After 72hrs, blood sugars for babies seem to regulate and should fall within these normal parameters. Up until that time, blood sugar fluctuates depending on recent maternal factors like diabetes and newborn factors of transition.

CTAS defines acute pain as: new onset pain of less than one month vs. chronic pain as: a well recognized, long standing or frequently recurring pain syndrome experienced by the patient. If the patient is in obvious distress, they should be considered as having acute pain. Changes to these “normal” pain levels or patterns may signal an acute on chronic situation. Reminder: pain is subjective AND objective. It is important to use your assessments as well as pain scores to determine pain. If the pain score (per the patient) does not match the presentation (clinically), the CTAS score can only be adjusted down by 1 level (CTAS 2 to a CTAS 3) but can increase upwards as much is appropriate, as determined by the nurses if threats to life/limb are suspected (ie. CTAS 4 to a CTAS 2). Just be sure to document your assessment and rationale for the override.

For patients whose primary reason for coming to hospital is to see a specialist. These patients should be stable patients. If patients are unstable, a more suitable and specific complaint should be used to describe their presentation. Ie. A stable patient returning a few days after their initial presentation for an upper extremity injury to see the orthopedic surgeon (no primary modifiers apply).

Frailty applies to the neonate or premature infant of age 7 days or less from birth. Premature infants MAY be considered frail up until 7 days past their original due date unless they are currently 3 months of age since birth or older. Corrected age= current age in weeks, minus number of weeks born premature. They would need to be within 7 days of that expected DOB. And would be a CTAS 2.

Example: The patient is a 3 week old infant who was born at 32 weeks (8 weeks premature) 3-8= -5 weeks old. This patient has not even reached their original due date, and is under 3 months old, so definitely “less than 7 days” and could fall under the frailty score of 2 if this seemed applicable to the child. If the child was 10 weeks old, they would be 10-8=2 weeks old and not under the 7 days. This would generally not apply in this case.

For all other patients, they would score a CTAS 3 using the frailty modifier, if they meet the definition:
– completely dependent for personal care (any age)
– who is wheelchair bound
– suffers from cognitive impairment that limits their awareness of their surroundings or the ability to appreciate time.
– is in the late course of a terminal illness
– is showing signs of cachexia or general weakness
– is over 80 years of age unless obviously physically or mentally robust
**According to NENA, with the frailty definition, ‘completely dependent’ for care speaks to patients of all ages who are present without a care provider. Ie. a vulnerable patient in your waiting room who is dependent on care, but alone.

Stroke window for treatment in our region is 6 hours from last seen normal. That encompasses thrombolysis (4.5hrs) and Endovascular therapy (currently using 6 hours). In some cases stroke patients may be candidates for EVT up to 24 hours post the onset of symptoms or from last seen normal. So perhaps these stroke patients that present beyond 6 hours from last seen normal, should be assessed by a physician promptly as they may still be a candidate for the stroke protocol. Best practice for stroke care is always evolving and these time windows may change over time.

Patients that are receiving chemotherapy (or any patient that is immunocompromised) are given a CTAS 2 in relation to signs of infection using the primary modifier for temperature assessment. If a patient receiving chemotherapy seeks care in the ED but does not have signs of infection/fever, they should be triaged based on their symptom presentation and modifiers that apply. Being immunocompromised (including chemo patients) does not automatically categorize a patient as a CTAS 2.

Use critical thinking to determine what is most appropriate per individual case. CTAS stresses that critical thinking abilities and experience are paramount to the triage process. Nurses are not diagnosing at triage, but there are differential diagnoses that are considered at time of triage based on symptoms. E.g. stroke, appendicitis, testicular torsion, repetitive strain injury, concussion with brief loss of consciousness, period of lucidity after TBI indicating epidural hematoma etc. Knowing the pathophysiology of various medical conditions can help to decide if you will use the LOC/GCS or the pain score assessed at triage or at its worst, perhaps even prior to arrival. Draw on critical thinking, experience and knowledge base when making these decisions.

Example 1: Abdominal pain (differential diagnosis of appendicitis), the pain score may fluctuate over the course of the illness and it might be preferred to use the pain score at its worst. The same fluctuation in pain can occur with testicular torsion-detorsion as well. In both of these situations, using the pain score at its worst would be preferred based on the seriousness of the potential diagnoses and based on what you know about the pathophysiology of these conditions.

Example 2: Brief loss of consciousness after a minor head injury (not a high mechanism of injury) patient is GCS 15 on arrival. Determine the LOC/GCS with what is being observed in your patient at that time. If LOC/GCS changes on reassessment, adjust your reassessment level/notify physician. Keep in mind for this presentation, there is a complaint specific modifier under the CEDIS complaint of Head Injury where you can account for history of loss of consciousness or lack of that will alter the CTAS score as well (CTAS 3 vs CTAS 4). Another good reminder why both primary and complaint specific modifiers need to be reviewed on every patient.

Example 3: A patient presents with upper extremity pain and their pain is 9/10 when rotating their arm. But only 3/10 when the limb is still. Use the pain score when limb is still. You will reassess their pain score at the appropriate interval and can change the reassessment level if needed at that time.

Under the Temperature Assessment, it states a fever as 38 degrees and up for adults and geriatrics. But knowing geriatric differences, CTAS states lower temperature elevations such as 37.5 degrees or higher in the face of a possible infection, or in frail elderly patients, should be considered a fever. Decreased metabolic rates and alterations to the hypothalamus in the elderly often leads to lower body temperatures and changed thermoregulatory responses. This is likely due to a combination of less robust immune systems, decreased cardiac output and decreased muscle mass lessening heat production.

Fever of 37.5 in the elderly will not automatically flag SIRS or produce the SCM notice for EDIS users. So you will need to manually override if you are considering this a fever in the geriatric population.

All gunshots and stabs are reportable. It is not up to nurses to determine the facts of the case or determine what type of gun was used.

As per CTAS, reassessments may be as simple as a visual check on the patient or by asking the patient how they are feeling rather than a full assessment. It would be prudent to re-check certain clinical assessments (eg. Vital signs, pain, blood sugar, LOC) if they were altered at initial triage or if you provided an intervention. If the patient shows or reports signs of deterioration, a full assessment should be done, and the patient’s prioritization may be adjusted so they are seen sooner by an MD/NP/PA. Some Service Delivery Organizations (SDO’s) have reassessment guidelines in a triage policy. Please refer to the triage policy for guidance. Always document your reassessments.

New CEDIS complaints for EDIS users include: leg swelling/edema, heat related issue, post partum issues, multisystem trauma blunt (old wording: major trauma blunt), multisystem trauma penetrating (old wording: major trauma penetrating), return visit for therapy. Many of these came out in 2016 but never made it into EDIS. There were no new CEDIS complaints in the 2024 guideline update.