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

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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]