Vital Signs Column

Where vital signs and other clinical information (i.e., Weight, High MOI, Immunocompromised, Blood Disorder) may be entered. See table below for description of fields in the Vital Signs Column.

Tip: See K eyboard Navigation & Shortcuts to optimize navigation of eCTAS screens.

Steps to Completion

Click on a field in the Vital Signs column (a text box or drop-down list will display).

Tip: see table below for description of fields

Enter or select clinically appropriate data.

Note: The Information Icon Information Icon may appear for some dialogue boxes (see table below). Hover over the icon to display useful information ( i.e., scales, definitions)

Note: The Validation Alerts appear when out-of-range values are entered for some fields. Nurses have the option to:

Click the Clear button to remove value and close the dialogue box.
Correct the value (must be corrected to be able to save).

If related modifiers appear in the Modifiers column for a field, select or deselect as clinically appropriate.

Important:

Enter ALL required vital signs before deselecting modifiers because adding additional vital signs may cause deselected modifiers to be selected again.
Entered Vital Signs and Select Modifiers are not cleared when modifiers are deselected (e.g., a patient’s Pain Scale data will be retained, even when associated pain modifiers are deselected).
See modifiers for additional guidelines.

Click the I’m Done button to submit data.

Note: Clinical Alerts provide important reminders and may appear when saving the triage, see table below.

Validation Alerts appear when out-of-range vital values are entered, the entry will save once it has been corrected.

Vital Sign & Other Clinical Information Field Descriptions

Field Name	Description	Examples of Information Icons, Validation Alerts, Clinical Alerts
Temperature	Enter patient temperature in degrees Celsius. Use the drop-down to indicate how temperature was taken (Axillary, Oral, Rectal, Tympanic, Temporal).	A Validation Alert appears when: temperature is outside the range of 20 and 45 degrees C.
Pulse rate	Enter patient pulse rate in beats per minute. Use drop-down list to indicate regularity (Regular or Irregular), and method of pulse rate check (Apical, Brachial, Radial, Pulse Oximetry, VS Monitor). Note: Patients with a bradycardic or tachycardic condition - i.e., heart rate of 39 or below entered or heart rate higher than 120 entered, will trigger some modifers to be: auto-selected: Pulse Rate/Pressure Abnormal (Hemodynamically Stable) modifier, generating a CTAS score of 3 highlighted to draw attention: Shock and Hemodynamic Compromise and Shock	Validation Alert appears when: Pulse rate is outside the range of 9 and 999 beats per minute Clinical Alerts may appear when saving triage and the CTAS score is 3, 4 or 5 and suggested modifiers have not been selected. See scenarios below: Low Pulse/HR Rate High Pulse/HR Rate
Respiratory rate	Enter patient’s respiratory rate in breaths per minute.	Validation Alerts appear when: Respiratory rate is greater than 100 breaths per minute Pulse rate is outside the range of 9 and 999 beats per minute
Blood pressure	May enter: A systolic and diastolic pressure can be entered Indicate which side the BP was taken on using the Right or Left radio buttons. Enter a 2nd BP reading during triage assessment. Note: Modifiers Hypertension modifiers will be triggered for Adults with an entered blood pressure Systolic 200-220 or greater than 220 OR Diastolic 110 - 130 or greater than 130. Modifiers will be selected for the CEDIS complaint of Pregnancy or Postpartum Issue greater than 20 weeks if blood pressure entered is SBP >160 and DBP >100 or SBP >140 and DBP >90.	Validation Alerts appear when: Diastolic value is entered without a Systolic value Systolic is less than 30 and greater than 350 mm Hg Diastolic is less than 0 and greater than 300 mm Hg Systolic is less than Diastolic Clinical Alert may appear when saving triage. See scenario below: Low Systolic Blood Pressure/Hypotension
Sp02	Enter percentage of blood oxygen level. Use the drop-down list to select a Delivery (Room Air or 1L-15L) and Method (N/P, Face mask, ETT, BMV), as required.	Validation Alert appears when: the Sp02 value is out-of-range i.e., Sp02 must be between 1 and 100
Pain Scale	Use the drop-down lists to select level of pain ( scale of 0-10). Location of pain (Central, Peripheral) and the chronicity of pain (Acute, Chronic) are required for Adult patients. patients only require chronicity. Note: Modifiers Some Pain modifiers may be auto-selected and impact CTAS score generation. If a Pain Scale modifiers is deselected, the system will auto-select the next lower pain modifier. Deselection will be logged in the eCTAS audit data Note: Patient is unable or unwilling to respond” checkbox may be used if clinically appropriate. If selected: Modifiers will not be highlighted or auto-selected by the system. See Best Practices to generate clinically appropriate CTAS scores. Unavail will appear as the pain value Unable to obtain will appear in other areas and in reports	The Information icon appears when entering data – hover over icon to see information. What displays is based on cohort, see examples below. Adult: Paediatric: Under 2 years FLACC pain scale 2 years and older FACES scale
GCS	Glasgow Coma Scale (GCS) score options: Select the best eye opening, verbal and motor responses for the patient, the system will calculate score once all 3 responses have been selected. Or Manually enter GCS (3-15) score. The reassessment section also provides a GCS calculator.	Validation Alert appears when: GCS entered is out of range (i.e., must be between 3 and 15) The Information icon appears when entering data: describes the criteria for each response (best eye opening, verbal and motor responses) – information displayed is based on cohort (i.e., Adults & Paediatric).
Capillary Refill	The appropriate value for this field, <2sec or >2sec can be selected.
Blood Glucose	Blood glucose level in mmol/L can be entered.
Weight (clinical data point)	The patient’s weight in Kg can be entered. A conversion chart for pounds to kilograms is available by hovering over the information icon of the Weight vital.	The Information icon appears when entering data – click to see conversion chart for pounds to kilograms
High MOI (modifier)	Indicate if the patient has sustained a high mechanism of injury.	The Information icon appears when entering data – hover to see details. Information displayed is based on cohort (i.e., Adults & Paediatric)
Immunocompromised (modifier)	Indicate if the patient is immunocompromised.	The Information icon appears when entering data – hover to see details.
Blood Disorder (modifier)	Indicate if bleeding disorder is present (blood thinner or blood dyscrasia).	The Information icon appears when entering data – hover to see definitions.