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is the process of determining the priority of patients'

treatments based on the severity of their condition. This rations patient 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

treatment efficiently when resources are insufficient for all to be treated

department, or to telephone 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 during emergency room treatment.


is defined as sorting and allocating treatment to patients

based upon the severity of their conditions. Patients are sorted by a who survive. Triage protocols are often used in cases of combat or once. Triage originated in World War I by French doctors treating the

system which sets priorities designed to increase the number of people disaster situations when a large number of patients require treatment at

battlefield wounded at the aid stations behind the front. Much is owed to the work ofDominique Jean Larrey during the Napoleonic Wars. Until else, were frequently a matter of the 'best guess', as opposed to any recently, triage results, whether performed by a paramedic or anyone real or meaningful assessment.[4] At its most primitive, those responsible have divided victims into three categories:

for the removal of the wounded from a battlefield or their care afterwards

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 and 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.[6]

The Importance of Triage


Triage is required for the effective management of an emergency situation. This means patients are not seen according to when they arrive at the hospital, but are seen according to guidelines which to be successful. In order to remove confusion and misgivings, determine who needs care most urgently and where care is most likely guidelines are in place which help health care professionals to know how to prioritize. The importance of this discipline can never be overstated, when one takes into consideration the fact that in 2008,

nearly 120 million emergency department visits were made to hospitals in the US. Triage Guidelines

Typically in an Emergency Room, or what is called an Emergency Department (ED), triage guidelines begin with general policies including registration, documentation and referrals. When the actual triage work starts, guidelines are given to classify patients into priority levels I, II, III and IV based on factors relating to medical needs, social service needs, mental health needs and substance abuse needs. When a caregiver gets several patients at the same time, the guidelines have to be

adhered to and a response has to be undertaken. A lot depends on the judgment the caregiver makes of the situation. The triage level may be be done in consultation with the doctor.

changed if the caregiver feels the need to do so, but this usually has to

Classifying Patients

The ailments that qualify for Priority Level I medical needs include profuse bleeding, acute chest pains, unconsciousness and other severe conditions. Patients who get admitted with such needs are classified as priority Level I and need to be attended to first. This is followed by priority level II, cases which include abscesses, a 2nd or 3rd trimester of pregnancy with no prenatal care or a situation in which the patient has run out of seizure or other life saving medications. Level III ailments include less serious conditions such as unexplaind coughing, or pain

that could suggest the need for treatment but that does not indicate a non-life threatening conditions, small cuts and bruises or other

life-threatening condition. Level IV ailments are minor ailments such as

conditions that neither cause great pain nor threaten overall health and well-being.

Types of triage
Simple triage
Simple triage is usually used in a scene of an accident or "masscasualty 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 of their injuries can 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 medical personnel or techniques. It has been (2003) taught personnel in emergencies.[8] It is not intended to supersede or instruct 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 field-proven 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:

becomes available. The categorization of patients based on the severity

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

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 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 divert scarce resources away from patients with little chance of survival

trauma score of consistently at or below 3. This can be determined by scoring system incorporated in some triage cards.[9]

using the Triage Revised Trauma Score (TRTS), a medically validated 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 of the three categories, and automatically sets the score to 75 create the ISS. A score of 6, for "unsurvivable", can also be used for any 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 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 injuries) had they been treated instead. It becomes the task of the 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 continuous process and categories should be checked regularly to be categorized to a lower priority in the short term. Triage should be a ensure that the priority remains correct. A trauma score is invariably scores taken to see any changes in the victim's physiological might have survived (or perhaps suffered less severe disability from their disaster medical authorities to set aside some victims as hopeless, to

prioritized can include the time spent on medical care, or drugs or other

taken when the victim first comes into hospital and subsequent trauma parameters. If a record is maintained, the receiving hospital doctor can allow definitive treatment earlier.

see a trauma score time series from the start of the incident, which may

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 the available resources and the needs of other patients. Continuous Integrated Triage employs:

need of care while balancing the needs of the individual patients against

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.

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 it physically clears the scene, and provides possible assistants to the "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 patients that are not so severely injured, that they need immediate help, responders. As those who can move, do so, the responders then ask,

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 able to hear these instructions. hear. Deaf, partially deaf or victims of a large blast injury may not be

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 where this could arise include situations where significant numbers of medical personnel are among the affected patients where it may be

survive but requiring advanced medical care.[12] Other possible scenarios

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 water if given immediate basic life supportand often those who are no help.[13] because drowning victims in cold water can survive longer than in warm rescued and able to breathe on their own will improve with minimal or

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 however, patients may be simply marked with coloured tape, or with marker pens, when triage tags are either unavailable or insufficient.

computers, and in some cases, bar code scanners. At its most primitive,

Undertriage and overtriage

Undertriage is the process of underestimating the severity of an illness or injury. An example of this would be categorizing a Priority 1 (Immediate) patient as a Priority 2 (Delayed) or Priority 3 (Minimal). Historically, acceptable undertriage rates have been deemed 5% or less. Overtriage is the process of overestimating the level to which an individual has experienced an illness or injury. An example of this would Priority 1 (Immediate). Acceptable overtriage rates have been typically overtriage is less likely to occur when triaging is performed by hospital medical teams, rather than paramedics or EMTs.

be categorizing a Priority 3 (Minimal) patient as a Priority 2 (Delayed) or up to 50% in an effort to avoid undertriage. Some studies suggest that