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Roles and Responsibilities - SHED - Ambulance Victoria (AV) Triage Nurse


The AV Triage Nurse, is responsible for the Triage and management of patients arriving to the SHED by Ambulance or Emergency Services vehicles.  All patients arriving at SHED are triaged using the Australasian Triage Scale (ATS). Triage assessment normally can take between 1-5minutes.

Essential role functions include; the determination of patient acuity and level of urgency, basic first aid (if required) and referral to the most appropriate clinical area in the department for treatment. This is a quick reference guide. For further information please refer to: ATS Guideline, Emergency Services Patient Triage and Offload in Sunshine Hospital Emergency Department – Emergency Department and the Microsite for updated practices relating to Covid-19 (


The SHED NUM, SHED Director, SHED Educators are responsible for ensuring that all staff within the department are aware of the Emergency Services Triage Process.

Process Details

  1. Receive handover from previous shift nurse, check and re-stock equipment required for triage assessment (refer to trolley stock check list for guidance)
  2. Triage nurse is responsible for the care of patients in the Emergency Services Triage area and incoming patients that arrive with Ambulance Victoria, Victoria Police, Non-Emergency services and internal hospital code blues
  3. Management of critical patient pre-notification: BAT call to resus and Nurse In Charge (NIC), Section 351, and hospital code blues. Relevant pathways will be initiated e.g. Cath lab and radiology. ED Nurse in Charge will notify Emergency Services Triage Nurse of pre-notification
  4. Emergency Services arrival staff (Ambulance Victoria, Victoria Police, Non-Emergency services) will push ‘buzzer’ on arrival and the SHED. Ambulance Triage Nurse(s) must respond to the arrival alert within 5 minutes of presentation. If unable to triage within 5 minutes the NIC should triage the patient. Please see Appendix 1 for appropriate SHED patient pathway
  5. Prioritise and communicate patients to be seen by clinician according to ATS triage. Liaise with clerical team to ensure patient details are correct
  6. Allocate to appropriate EDIS virtual wait room POD.
  7. Escalation: follow the AV escalation processes outlined in the ED Escalation Guideline.
  8. Aim for AV offload within 20 minutes of “At Destination Time” whilst liaising with emergency services. Ensure EDIS documentation is completed with emergency services staff
  9. Reassess patients every 30 minutes and document in EDIS
  10. Offloading patients- Emergency services will stay with patient until handed over to appropriate receiving bedside nurse in POD.
  11. Victoria Police can only leave a Section 351 patient once signed off by medical officer
  12. Provide compassionate and effective communication to patients and carers
  13. AV Triage Nurse or Emergency Services can activate red Emergency Buzzer on wall for any medical and behavioural emergencies. This will initiate an emergency team to respond
  14. Section 351 and BOC patients please refer to Management of Section 351 Patients in the Emergency Department – procedure
  15. Infectious patient: pre notified airborne precautions – offload into negative pressure room via external resus doors. No notification or resus not available- Apply mask to patient, alert NIC, and offload into negative pressure room. All other infectious precautions- apply mask or contact precautions, offload into single room with priority offloading
  16. Obstetric patient: <16 wks SHED >16wks JK MAC if stable (refer to relevant procedure)
  17. Lock down: Please refer to Emergency Procedures Manual
  18. Provide compassionate and effective communication to patients and carers to ensure a positive patient experience.

Supporting Documentation