Triage

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This article is about the concept of triage as it occurs in medical emergencies and disasters. For other uses, see Triage (disambiguation).

Typical triage tag, with 'tear-off' sections for decontamination and patient tracking.

Triage station, Suippes, France,World War I.

Only immediate life-saving treatment takes priority over triage.

Triage (pron.: /tri/ (UK English) or /tri/ (US English)) is the process of determining the priority of patients' treatments based on the severity of their condition. This rations patient treatment efficiently when resources are insufficient for all to be treated immediately. The term comes from the French verbtrier, meaning to separate, sift or select.[1] Two types of triage exist: simple and advanced. [2] Triage may result in determining the order and priority of emergency treatment, the order and priority of emergency transport, or the transport destination for the patient. Triage may also be used for patients arriving at the emergency department, or telephoning medical advice systems,[3] among others. This article deals with the concept of triage as it occurs in medical emergencies, including the prehospital setting, disasters, and emergency room treatment. Triage originated in World War I by French doctors treating the battlefield wounded at the aid stations behind the front. Much is owed to the work ofDominique Jean Larrey during the Napoleonic Wars. Until recently, triage results, whether performed by a paramedic or anyone else, were frequently a matter of the 'best guess', as opposed to any real or meaningful assessment. [4] At its most primitive, those responsible for the removal of the wounded from a battlefield or their care afterwards have divided victims into three categories:

Those who are likely to live, regardless of what care they receive; Those who are likely to die, regardless of what care they receive;

Those for whom immediate care might make a positive difference in outcome. [5]

For many emergency medical services (EMS) systems, a similar model can sometimes still be applied. However once a full response has occurred and many hands are available, paramedics will usually use the model included in their service policy and standing orders. In the earliest stages of an incident, however, when one or two paramedics exist to twenty or more patients, practicality demands that the above, more "primitive" model will be used. Modern approaches to triage are more scientific. The outcome and grading of the victim is frequently the result of physiological assessment findings. Some models, such as the START model, are committed to memory, and may even be algorithm-based. As triage concepts become more sophisticated, triage guidance is also evolving into both software and hardware decision support products for use by caregivers in both hospitals and the field.
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Contents
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1 Types of triage

o o o o o o o

1.1 Simple triage 1.1.1 S.T.A.R.T. model 1.2 Advanced triage 1.3 Continuous integrated triage 1.4 Practical applied triage 1.5 Reverse triage 1.6 Labelling of patients 1.7 Undertriage and overtriage 2 Regional variation

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2.1 Canada 2.2 Finland 2.3 France

o o o o o o

2.4 Germany 2.5 Hong Kong 2.6 Israel 2.7 Japan 2.8 United Kingdom 2.9 United States military 3 Triage outcomes

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3.1 Evacuation 3.2 Alternative care facilities 3.3 Secondary (in-hospital) triage 3.4 Hospital triage systems in the United States 4 Limitations of current practices 5 Bioethical implications in triage 6 See also 7 References

[edit]Types [edit]Simple

of triage
triage

Simple triage is usually used in a scene of an accident or "mass-casualty incident" (MCI), in order to sort patients into those who need critical attention and immediate transport to the hospital and those with less serious injuries. This step can be started before transportation becomes available. The categorization of patients based on the severity of their injuries can be aided with the use of printed triage tags or coloured flagging.[7]

[edit]S.T.A.R.T. model
Main article: Simple triage and rapid treatment

S.T.A.R.T. (Simple Triage and Rapid Treatment) is a simple triage system that can be performed by lightly trained lay and emergency personnel in emergencies. [8] It is not intended to supersede or instruct medical personnel or techniques. It has been (2003) taught to California emergency workers for use in earthquakes. It was developed at Hoag Hospital in Newport Beach, California for use by emergency services. It has been fieldproven in mass casualty incidents such as train wrecks and bus accidents, though it was developed for use by community emergency response teams (CERTs) and firefighters after earthquakes. Triage separates the injured into four groups:

The expectant who are beyond help The injured who can be helped by immediate transportation The injured whose transport can be delayed Those with minor injuries, who need help less urgently

[edit]Advanced

triage

In advanced triage, doctors may decide that some seriously injured people should not receive advanced care because they are unlikely to survive. Advanced care will be used on patients with less severe injuries. Because treatment is intentionally withheld from patients with certain injuries, advanced triage has ethical implications. It is used to divert scarce resources away from patients with little chance of survival in order to increase the chances of survival of others who are more likely to survive. In Western Europe, the criterion used for this category of patient is a trauma score of consistently at or below 3. This can be determined by using the Triage Revised Trauma Score (TRTS), a medically validated scoring system incorporated in some triage cards.[9]

A triage sign at a Mexican emergency room indicating the waiting time for patients based on the severity of their condition

Another example of a trauma scoring system is the Injury Severity Score (ISS). This assigns a score from 0 to 75 based on severity of injury to the human body divided into three categories: A (face/neck/head),

B(thorax/abdomen), C(extremities/external/skin). Each category is scored from 0 to 5 using the Abbreviated Injury Scale, from uninjured to critically injured, which is then squared and summed to create the ISS. A score of 6, for "unsurvivable", can also be used for any of the three categories, and automatically sets the score to 75 regardless of other scores. Depending on the triage situation, this may indicate either that the patient is a first priority for care, or that he or she will not receive care owing to the need to conserve care for more likely survivors. The use of advanced triage may become necessary when medical professionals decide that the medical resources available are not sufficient to treat all the people who need help. The treatment being prioritized can include the time spent on medical care, or drugs or other limited resources. This has happened in disasters such as volcanic eruptions, thunderstorms, and rail accidents. In these cases some percentage of patients will die regardless of medical care because of the severity of their injuries. Others would live if given immediate medical care, but would die without it. In these extreme situations, any medical care given to people who will die anyway can be considered to be care withdrawn from others who might have survived (or perhaps suffered less severe disability from their injuries) had they been treated instead. It becomes the task of the disaster medical authorities to set aside some victims as hopeless, to avoid trying to save one life at the expense of several others. If immediate treatment is successful, the patient may improve (although this may be temporary) and this improvement may allow the patient to be categorized to a lower priority in the short term. Triage should be a continuous process and categories should be checked regularly to ensure that the priority remains correct. A trauma score is invariably taken when the victim first comes into hospital and subsequent trauma scores taken to see any changes in the victim's physiological parameters. If a record is maintained, the receiving hospital doctor can see a trauma score time series from the start of the incident, which may allow definitive treatment earlier.

[edit]Continuous

integrated triage

Continuous Integrated Triage is an approach to triage in mass casualty situations which is both efficient and sensitive to psychosocial and disaster behavioral health issues that affect the number of patients seeking care (surge), the manner in which a hospital or healthcare facility deals with that surge (surge capacity) [10] and the overarching medical needs of the event. Continuous Integrated Triage combines three forms of triage with progressive specificity to most rapidly identify those patients in greatest need of care while balancing the needs of the individual patients against the available resources and the needs of other patients. Continuous Integrated Triage employs:

Group (Global) Triage (i.e., M.A.S.S. triage)[11] Physiologic (Individual) Triage (i.e., S.T.A.R.T.)

Hospital Triage (i.e., E.S.I. or Emergency Severity Index)

However any Group, Individual and/or Hospital Triage system can be used at the appropriate level of evaluation.

[edit]Practical

applied triage

During the early stages of an incident, first responders may be overwhelmed by the scope of patients and injuries. One valuable technique, is the Patient Assist Method (PAM); the responders quickly establish a casualty collection point (CCP) and advise ; either by yelling, or over a loudspeaker, that "anyone requiring assistance should move to the selected area (CCP)". This does several things at once, it identifies patients that are not so severely injured, that they need immediate help, it physically clears the scene, and provides possible assistants to the responders. As those who can move, do so, the responders then ask, "anyone who still needs assistance, yell out or raise your hands"; this further identifies patients who are responsive, yet maybe unable to move. Now the responders can rapidly assess the remaining patients who are either expectant, or are in need of immediate aid. From that point the first responder is quickly able to identify those in need of immediate attention, while not being distracted or overwhelmed by the magnitude of the situation. Using this method assumes the ability to hear. Deaf, partially deaf or victims of a large blast injury may not be able to hear these instructions.

[edit]Reverse

triage

In addition to the standard practices of triage as mentioned above, there are conditions where sometimes the less wounded are treated in preference to the more severely wounded. This may arise in a situation such as war where the military setting may require soldiers be returned to combat as quickly as possible, or disaster situations where medical resources are limited in order to conserve resources for those likely to survive but requiring advanced medical care.[12] Other possible scenarios where this could arise include situations where significant numbers of medical personnel are among the affected patients where it may be advantageous to ensure that they survive to continue providing care in the coming days especially if medical resources are already stretched. In cold water drowning incidents, it is common to use reverse triage because drowning victims in cold water can survive longer than in warm water if given immediate basic life supportand often those who are rescued and able to breathe on their own will improve with minimal or no help. [13]

[edit]Labelling

of patients

Many triage systems are now computerized

Upon completion of the initial assessment by medical or paramedical personnel, each patient will be labelled with a device called a triage tag. This will identify the patient and any assessment findings and will identify the priority of the patient's need for medical treatment and transport from the emergency scene. Triage tags may take a variety of forms. Some countries use a nationally standardized triage tag, [14] while in other countries commercially available triage tags are used, and these will vary by jurisdictional choice. [15] The most commonly used commercial systems include the METTAG,[16] the SMARTTAG,[17] E/T LIGHT tm[18] and the CRUCIFORM systems.[19] More advanced tagging systems incorporate special markers to indicate whether or not patients have been contaminated by hazardous materials, and also tear off strips for tracking the movement of patients through the process. Some of these tracking systems are beginning to incorporate the use of handheld computers, and in some cases, bar code scanners. At its most primitive, however, patients may be simply marked with coloured tape, or with marker pens, when triage tags are either unavailable or insufficient.

Typical triaging systems

SMART TAG system. Note the bar code for patient tracking.

METTAG system in Japanese.

Even simple tape can be used as a last resort.

Emergency Triage (E/T) Lights particularly useful at night or under adverse conditions