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TRIAGE SYSTEMS FOR TRAUMA CARE

Indep Rev July-Aug 2014;16(7-9)

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TRIAGE SYSTEMS FOR TRAUMA CARE


Awais Shuja
FRCS (Ed), FCPS
Assistant Professor of Surgery
Independent Medical College,
Faisalabad.

Correspondence Address:
Awais Shuja
FRCS (Ed), FCPS
Assistant Professor of Surgery
Independent Medical College,
Faisalabad.

Article received on:


06/09/2014
Accepted for Publication:
08/09/2014
Received after proof reading:
25/09/2014

Article Citation: Shuja A, Triage systems for trauma care. Indep Rev July-Sep 2014;16(7-9): 244-249.
Key Concepts
Definition of triage
Principles of triage
Triage scales
Outcomes of triage
trauma triage

Abstract
Triage is the process of determination of the priority of patients treatments based on the severity of their condition.
The purpose of the triage is to ensure that the patient recieves the level and appropriate to clinical need and that recources are most usefully applied. Different triage scales have been developed to help health professionals to classify
patients consistently function of emergency around the world.
Key words: Triage Ipswish triage scale Austration triage scale, Triage severe.

Triage is the process of determining the priority of patients treatments based on the
severity of their condition. This distributes
patient treatment efficiently when resources
are insufficient for all to be treated immediately. The term comes from the French verb
trier, meaning to separate, sift or select. 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, among others.

The term triage may have originated during


the Napoleonic Wars from the work of DomIndep Rev July-Sep 2014;16(7-9) 244-249.

inique Jean Larrey. The term was used further during World War I by French doctors
treating the battlefield wounded at the aid
stations behind the front. Those responsible
for the removal of the wounded from a battlefield or their care afterwards would divide
the 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.

This was the very initial triage system which

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TRIAGE SYSTEMS FOR TRAUMA CARE

has changed into modern day emergency department triage systems

Definition
Triage is the process of categorizing emergency patients according to their need for
medical care, irrespective of their order of
arrival or other factors including sex, age,
socioeconomic status, insurance status, nationality, race, ethnicity or religion. Triage
is a mechanism that is essential for effective
management of modern emergency services.

The triage aims to ensure clinical justice for


the patient , but also is an effective tool for
departmental organization , monitoring and
evaluation.

Principles of triage
The principal purpose of triage is to ensure
that the patient receives the level and quality
of care appropriate to clinical need and that
resources are most usefully applied. Clinical
justice, including clinical efficiency, aims to
ensure that patient receives appropriate and
timely care.
The concept of urgency is central to triage in
trauma care. Urgency incorporates concepts
of timeliness and is different from severity.
Urgent conditions may not necessarily be urgent, while severe illness may not necessarily
be urgent. Both clinical and environmental
factors contribute to the urgency of any particular patient.

Key Objectives of triage


The following are the objectives of the triage
process:
To immediately call of medical attention
and start resuscitation
To assign patient to next available doctor
for management

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To manage waiting list with clinical


justice
To divert patient to appropriate place in
non- urgent problems
To use data of triage for audit and research
To improve clinical services and utilize
resources efficiently
Triage scales
Different triage scales have been developed
to help health professionals to classify patients consistently and to achieve acceptable
outcomes.

Triage scales in use throughout the world


have three elements:the number of categories in the scale, the terminology of the categories in the scale and the processes used to
assign patients to the categories.

All the scales are categorical. A continuous


scale has never been shown to be of value.
The purpose of triage is to determine an action among a selection of alternatives. The
scale must be categorical and categories
aligned with actions.
Triage scales usually have 3 to 5 categories
with algorithms for making diagnosis supported by guidelines. They are now generally
supported by computer based programs and
websites which are faster and more effective
aids to prioritization and decision-making.
The most commonly used scales are
Australian triage scale(ATS)
Canadian triage and acuity scale
Ipswich triage scale
Ipswich triage scale is a five category scale
in which the functional urgency is based on
nurses determination of the patient condition.

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TRIAGE SYSTEMS FOR TRAUMA CARE

IPSWICH TRIAGE SCALE

The patient should under reasonable circumstances be seen by doctor within:


Seconds
Minutes
An hour
Hours
Days

AUSTRALIAN TRIAGE SCALE

Category

Description

Performance standard

ATS 3

30 min

75%

ATS 1
ATS 2
ATS 4
ATS 5

Category

Immediate

100%

10 min

80%

60 min

70%

120 min

Description

Resuscitation

Immediate

Emergency

< 15 min

Urgent

< 30 min

Less urgent

< 1 hour

Non urgent

The Australian triage system is the most common and universal system, which is a direct
triage mechanism and has a 5- level categorical scale.
Canadian triage and acuity scale was derived
from ATS. It is a 5 categorical scale .

Tri age Outcomes


There are two stages to the triage process:
first, the triage assessment which leads to allocation of a triage category and subsequent
processing of the patient; and secondly initiation of treatment to facilitate emergency
care with a possible reduction in the patients
discomfort. These triage decisions are linked
with 3 type of outcome: correct or expected
triage, over triage and under triage.
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70%

< 2 hours

Correct triage is associated with positive outcome. Outcomes associated with over or under triage result in inappropriate allocation
of emergency resources, prolonged waiting
times of dangerous complications or prolonging suffering.

Trauma triage
Trauma triage is the use of trauma assessment
for prioritising of patients for treatment or
transport according to their severity of injury.
Primary triage is carried out at the scene of an
accident and secondary triage at the casualty
clearing station at the site of a major incident.
Triage is repeated prior to transport away
from the scene and again at the receiving hospital.

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TRIAGE SYSTEMS FOR TRAUMA CARE

The primary survey aims to identify and immediately treat life-threatening injuries and
is based on the ABCDE resuscitation system.
This includes:
Airway control with stabilisation of the
cervical spine.
B reathing.
C irculation (including the control of external haemorrhage)
D isability or neurological status.
E xposure or undressing of the patient
Red

T1

Immediate priority

Blue

T4

Expectant priority

yellow
Green

T2
T3

Urgent priority

Delayed priority

while also protecting the patient from hypothermia.

Priority is then given to patients most likely to


deteriorate clinically and triage takes account
of vital signs, prehospital clinical course,
mechanism of injury and other medical conditions.Triage is a dynamic process and patients
should be reassessed frequently. In the UK, the
T system is conventionally used at a major incident:

require immediate life-saving intervention

Require significant intervention within 2-4 hours


Require intervention, but not within 2-4 hours

Treatment at an early stage would divert resources from potentially beneficial causalities, with no significant chance of a
successful outcome

Triage systems are most often used following


trauma incidents but may be required in other
situations, such as an influenza epidemic.
Triage sieve
The triage sieve can be used at the scene of major trauma and involves a rapid assessment:

Can the patient walk?


Yes: Priority 3 (Green - see above).
No:
Is the patient breathing?
No, even after opening airway: Dead.
Yes, after opening airway: Priority 1 (Red).
Yes, without resuscitation:
What is the respiratory rate?
Above 30/minute or less than 10/minute: Priority 1 (Red).
10-30/minute:
What is the pulse rate (or capillary refill time)?
Less than 40 or more than 120 (or capillary
refill time greater than 2 seconds): Priority 1
(Red).
Between 40 and 120 (or capillary refill time
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less than 2 seconds): Priority 2 (Yellow).

Modified sieve systems are available for use in


children.
The triage sort
The triage sort it is one method used for triage
at a casualty clearing station.
A total score of 1-10 indicates priority T1, 11
indicates T2, and 12 indicates T3.

Triage has become an integral part of the


function of emergency around the world and
has demonstrated clinical and organizational
value. There is an opportunity for the emergency medicine community to commit to an
international triage scale and to use that scale
as a basis for collaborative research, comparative analysis and evaluation.

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TRIAGE SYSTEMS FOR TRAUMA CARE


Physiological variable
Respiratory rate

Systolic blood pressure

Glasgow Coma Scale (GCS)

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Value

Score

6-9

10-29

>29

1-5

>90

76-89

50-75

1-49

13-15

9-12

6-8

4-5

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