urgent-care/SOPs/Patient-Care/SOP-UC-001-Triage-Protocol.md

# Standard Operating Procedure: Urgent Care Triage Protocol

| Document ID | SOP-UC-001 |
|-------------|-------------|
| Title | Urgent Care Patient Triage and Acuity Assessment |
| Revision | 1.0 |
| Effective Date | [DATE] |
| Author | [AUTHOR] |
| Approved By | [APPROVER] |
| Department | Urgent Care |

---

## 1. Purpose

To establish standardized procedures for triaging patients presenting to urgent care to ensure appropriate prioritization, timely care, and identification of emergent conditions requiring ED transfer.

## 2. Scope

This procedure applies to all patients presenting to urgent care including:
- Walk-in patients
- Scheduled same-day appointments
- Patients referred from other providers
- Pediatric and adult patients

## 3. Responsibilities

### 3.1 Triage Nurse/Medical Assistant
- Conduct initial patient assessment
- Assign acuity level
- Obtain vital signs
- Identify emergent conditions
- Initiate appropriate protocols

### 3.2 Urgent Care Provider
- Review triage findings
- Evaluate patients per acuity
- Make disposition decisions
- Authorize ED transfers

### 3.3 Front Desk Staff
- Check in patients
- Alert clinical staff to arrivals
- Facilitate registration

## 4. Definitions

| Term | Definition |
|------|------------|
| Triage | Process of prioritizing patients based on clinical urgency |
| Acuity | Severity of patient's condition |
| ESI | Emergency Severity Index (reference scale) |
| ED Transfer | Patient requiring emergency department level care |
| Chief Complaint | Primary reason for visit |

## 5. Triage Levels

### 5.1 Urgent Care Acuity Scale

| Level | Description | Examples | Target Time |
|-------|-------------|----------|-------------|
| 1 - Emergent | Life/limb threatening, requires ED | Chest pain, stroke symptoms, severe dyspnea | IMMEDIATE ED transfer |
| 2 - Urgent | Significant symptoms, needs prompt attention | High fever, moderate dyspnea, severe pain | <15 minutes |
| 3 - Semi-Urgent | Moderate symptoms, stable | Lacerations, minor fractures, UTI symptoms | <30 minutes |
| 4 - Non-Urgent | Minor symptoms, stable | Minor cold symptoms, prescription refills | <60 minutes |
| 5 - Not Appropriate | Outside scope, needs referral | Chronic disease management, specialist care | Redirect to PCP |

## 6. Procedure

### 6.1 Initial Contact

1. **Patient Arrival**
   - Acknowledge patient within 5 minutes of arrival
   - Brief visual assessment
   - Determine if immediate attention needed

2. **Quick Look Assessment**
   Rapidly evaluate:
   - Level of consciousness
   - Respiratory effort
   - Skin color
   - Obvious distress
   - Visible injuries

### 6.2 Triage Assessment

#### 6.2.1 Chief Complaint

Document in patient's own words:
- Primary symptom
- Duration
- Severity (0-10 scale for pain)

#### 6.2.2 Vital Signs

| Parameter | Normal Adult Range | Action if Abnormal |
|-----------|-------------------|-------------------|
| Temperature | 97.0-99.0°F | Assess for fever source |
| Heart Rate | 60-100 bpm | Assess for underlying cause |
| Respiratory Rate | 12-20/min | Oxygen, escalate if distressed |
| Blood Pressure | <140/90 mmHg | Repeat, assess symptoms |
| SpO2 | ≥95% on RA | Oxygen, consider ED transfer |
| Pain Score | 0/10 | Pain management protocol |

#### 6.2.3 Brief History

| Element | Document |
|---------|----------|
| Onset | When did symptoms start? |
| Provocation | What makes it better/worse? |
| Quality | Describe the symptom |
| Radiation | Does pain travel? |
| Severity | Rate 0-10 |
| Time | Constant or intermittent? |
| Medications | Current medications |
| Allergies | Drug and other allergies |
| Last meal | Time of last food/drink |
| Medical history | Relevant conditions |

### 6.3 Level 1 - Emergent (ED Transfer Required)

**Immediate recognition and action for:**

| Condition | Signs/Symptoms | Action |
|-----------|---------------|--------|
| Cardiac emergency | Chest pain, diaphoresis, SOB, arm/jaw pain | Call 911, ECG if available |
| Stroke | Facial droop, arm weakness, speech difficulty | Call 911, note time of onset |
| Respiratory failure | SpO2 <90%, severe distress, cyanosis | Oxygen, call 911 |
| Anaphylaxis | Airway swelling, hypotension, urticaria | Epinephrine, call 911 |
| Severe trauma | Major bleeding, altered consciousness | Stabilize, call 911 |
| Sepsis | Fever, tachycardia, hypotension, AMS | IV access, fluids, call 911 |
| Active seizure | Convulsions, unresponsive | Protect, time seizure, call 911 |

**ED Transfer Protocol:**
1. Call 911 immediately
2. Notify provider
3. Initiate stabilizing measures
4. Document time and interventions
5. Provide EMS with clinical information
6. Send documentation with patient

### 6.4 Level 2 - Urgent

**Requires provider evaluation within 15 minutes:**

| Condition | Characteristics |
|-----------|----------------|
| High fever | >103°F adult, >102°F child <3 months |
| Moderate respiratory distress | SpO2 92-95%, increased work of breathing |
| Severe pain | 8-10/10 |
| Significant bleeding | Controlled but significant |
| Dehydration with vomiting | Unable to keep fluids down |
| Acute abdominal pain | Severe, localized |
| Altered mental status | Confusion, not baseline |
| Syncope | Recent loss of consciousness |
| Diabetic emergency | Hypoglycemia, ketoacidosis symptoms |

### 6.5 Level 3 - Semi-Urgent

**Provider evaluation within 30 minutes:**

| Condition | Characteristics |
|-----------|----------------|
| Lacerations | Requiring sutures, bleeding controlled |
| Possible fractures | Deformity, point tenderness, stable |
| Moderate pain | 5-7/10 |
| UTI symptoms | Dysuria, frequency, no fever |
| Ear pain | Moderate, no fever |
| Minor burns | <5% BSA, superficial |
| Sprains/strains | Ambulating, stable |
| Rash with mild symptoms | No systemic symptoms |

### 6.6 Level 4 - Non-Urgent

**Provider evaluation within 60 minutes:**

- Upper respiratory symptoms (mild)
- Minor sore throat
- Minor skin conditions
- Medication refills
- Minor eye complaints (non-trauma)
- Minor injuries not requiring sutures

### 6.7 Level 5 - Redirect

**Outside urgent care scope:**

- Chronic disease management
- Routine physical exams
- Mental health crisis (redirect to crisis line/ED)
- Dental emergencies (redirect to dentist/ED)
- Specialty care needs
- Workers' compensation (per facility policy)

### 6.8 Pediatric Considerations

#### Age-Specific Concerns

| Age | Automatic Elevation Criteria |
|-----|------------------------------|
| <3 months | Any fever ≥100.4°F → ED |
| <2 years | Fever >103°F, lethargy, poor feeding → Urgent |
| All pediatric | Respiratory distress, dehydration, altered behavior → Urgent |

#### Pediatric Vital Sign Norms

| Age | HR | RR | Systolic BP |
|-----|----|----|-------------|
| Infant | 100-160 | 30-60 | 70-90 |
| 1-3 years | 90-150 | 24-40 | 80-100 |
| 4-6 years | 80-140 | 22-34 | 90-110 |
| 7-12 years | 70-120 | 18-30 | 90-120 |
| >12 years | 60-100 | 12-20 | 100-120 |

### 6.9 Geriatric Considerations

- Lower threshold for escalation
- Atypical presentations common
- Consider polypharmacy
- Falls assessment
- Cognitive baseline consideration

## 7. Documentation

Complete FRM-UC-001 Triage Assessment including:
- Time of arrival and triage
- Chief complaint
- Vital signs
- Allergies and medications
- Brief history
- Assigned acuity level
- Interventions initiated
- Provider notification time

## 8. Re-Triage

Re-assess waiting patients:
- Every 30 minutes for Level 2
- Every 60 minutes for Level 3-4
- Immediately if condition changes
- Document all re-assessments

## 9. Quality Metrics

| Metric | Target |
|--------|--------|
| Time to triage | <10 minutes |
| Appropriate acuity assignment | >95% (audit) |
| ED transfers identified at triage | >99% |
| Patient complaints re: wait time | <5% |

## 10. References

- Emergency Severity Index (ESI) guidelines
- Emergency Nurses Association guidelines
- Pediatric Assessment Triangle
- State nursing practice acts

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## Revision History

| Rev | Date | Description | Author |
|-----|------|-------------|--------|
| 1.0 | [DATE] | Initial release | [AUTHOR] |