LPNs As Triage Nurses

This practice scenario has been developed to help nurses understand the LPN scope of practice related to triage nursing in the emergency department.

I am an LPN working in an emergency department and I have been asked to be the triage nurse.  Is this within my scope of practice? As an LPN or RN, what accountabilities do I need to consider?

In the emergency department, it is the triage nurse’s responsibility to perform a preliminary assessment of clients and prioritize them to see a physician or nurse practitioner. Triage nurses are expected to conduct in-depth assessments and apply critical thinking and decision-making skills in their role.  The triage assessment helps determine the client’s overall predictability or complexity.

LPNs may not be a primary triage nurse. However, LPNs who have completed a formal Canadian Triage and Acuity Scale (CTAS) course are authorized to participate in the triage assessment (also known as a rapid client assessment) and health history to determine a preliminary CTAS score.  Employers may have additional educational requirements for LPNs participating in the triage process.

This means that qualified LPNs may work in the triage area for intermittent, defined and limited periods of time. Generally, those times are when the primary triage nurse is temporarily away from the triage area, such as attending to a critical situation, transporting a client or for a meal break.

Accountabilities

When participating in the triage process, the LPN is accountable for their own practice and is expected to collaborate with the RN immediately when they assign a client a preliminary CTAS score of 1, 2 or 3. They may collaborate with the RN within 30 minutes on clients with a CTAS score of 4 or 5.

The RN is accountable to collaborate with the LPN to validate the preliminary CTAS score by reviewing the assessment data to confirm that the preliminary CTAS score is consistent with the presentation of the client. If there is a variance in CTAS scores between the RN and the LPN, the RN must do a more in-depth assessment of the client. Once confirmed, the RN is accountable to assign and document a final CTAS score. The RN is also responsible for the final interpretation to determine the overall predictability or complexity of the client based on the final CTAS score.

The collaboration between the RN and LPN should be documented according to employer policy.

For further information on anything contained within this practice support tool, please contact an NSCN Practice Consultant at practice@nscn.ca.

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