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Roles and Responsibilities - SHED - Triage Nurse


The Triage Nurse is responsible for triaging and the initial management of patients arriving to the Sunshine Emergency Department. All patients arriving at SHED are triaged using the Australasian Triage Scale (ATS). Triage assessment normally can take between 1-5 minutes.

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.

The SHED NUM, SHED Directors and SHED Educators are responsible for ensuring that all staff within the department is aware of the Emergency Triage roles and responsibilities.

Role 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. Prioritise the order of patients to be seen by clinician according to ATS.
  3. Liaise with clerical team to ensure patient details are correct.
  4. Allocate patients to the appropriate EDIS virtual wait room. Liaise with the waiting room nurses to ensure appropriate reassessment of patients and up-triaging patients when clinical deterioration is identified.
  5. Stream patients into virtual wait room based on COVID-19 criteria.
  6. Complete the infectious screening tool (Infectious Diseases Admission Screen Tool AD24) on all patients, identify allergies and ensure the appropriate colour wristband has been applied to each patient.
  7. Support the waiting room nurse, and ensure that patients in the waiting room are reassessed in line with the ATS triage scale wait time standards.
  8. Ensure clear communication with NIC; escalation of deteriorating patients, patients or visitors with an increasing BOC (behaviours of concern) or more than 5 patients waiting in line to be triaged.
  9. Liaise with security staff to ensure the safety of staff, patients and carers within the waiting room.
  10. Provide compassionate and effective communication to patients and carers.
  11. Infectious patients: notifying the NIC if concerns for airborne/contact/droplet precautions and implementing the appropriate measures while in the waiting room to minimise further exposure to other patients.
  12. Obstetric patients: referral to JKWCH Maternity Assessment Centre (MAC) if greater than 16 weeks pregnant, vitally stable, with a presenting complaint not requiring emergency investigation.

Supporting Documents