Triage

The word triage comes from French word “trier” which means “to sort”. The process of determining the
priority of patients’ treatments based on the severity of their condition. Sorting injured people into
groups based on their need for an immediate medical treatment.
A basic and widely used triage system that has been in use for many years has three categories: emergent,
urgent and nonurgent (Berner, 2005)

a) Emergent- patient have the highest priority, their condition is life threatening and they must be
seen immediately.
b) Urgent- patient have the higher priority or a serious health problem but not immediately life-
threatening ones; must be seen within in 1 hour.
c) Nonurgent- patient have episodic illnesses that can be addressed within 24 hours without
increased morbidity (Berner, 2005). A fourth category that is increasingly used is “fast-track”.
These patients require simple first aid or basic primary care and maybe treated in the ED or
safety referred to a clinic or physician’s office.

TRIAGE

NOTE: Before performing a triage

✓Evaluate every situation before acting

✓perform quick incident scene survey

✓Determine scene hazards

✓Use appropriate PPE

✓Remain in appropriate zone

Triage Tagging

1. Black = expectant (deceased)

2. Red = immediate – client needs

immediate treatment within the
hour but has a chance of survival

3. Yellow = delayed – client not in

immediate danger; treatment may
be delayed for an hour

4. Green = minor – minimal

“walking wounded”
Emergency Severity Index (ESI)

➢ A – intubated, pulseless, apneic, unresponsive = unstable

➢ B – high risk situation (confused, lethargic, or disoriented; in severe pain or distress) = threatened =
stable in less than 60 minutes

➢ C – number of resources needed = could be delayed

➢ D – danger zone = reclassify based on vital signs

Five level of Emergency Severity Index

Level I: Resuscitation

Condition requiring immediate nursing and physician assessment. Any delay in treatment is potentially
life- or -limb- threatening.

Conditions Includes:

- Airway compromise
- Cardiac arrest
- Severe shock
- Cervical spine injury
- Multisystem trauma
- Altered level of consciousness (LOC) (unconsciousness)

Level II: Emergent

Conditions requiring nursing and physician assessment within 15 minutes of arrival.

Conditions include:

- Head injuries
- Severe trauma
- Lethargy or agitation
- Conscious overdose
- Severe allergic reaction
- Chemical exposure to the eyes
- Chest pain
- Back pain
- GI bleeding
- Stroke with deficit
- Severe asthma
- Abdominal pain in patients older than age 50
 - Vomiting and diarrhea with dehydration
- Fever in infants younger than 3 months
- Acute psychotic episode
- Severe headache
- Any pain greater than 7 on scale of 10
- Any sexual assault
- Any neonate age 7 days or younger

Level III: Urgent

Conditions requiring nursing and physician assessment within 30 minutes of arrival.

Conditions include:

- Alert head injury with vomiting

- Mild to moderate asthma
- Moderate trauma
- Abuse or neglect
- GI bleed with stable vital signs
- History of seizure, alert on arrival

Level IV: Less Urgent

Conditions requiring nursing and physician assessment within 1 hour.

Conditions include:

- Alert head injury without vomiting

- Minor trauma
- Vomiting with diarrhea in patient older than age 2 without evidence of dehydration
- Earache
- Minor allergic reaction
- Corneal foreign body
- Chronic back pain

Level V: Nonurgent

Conditions requiring nursing and physician assessment within 2 hours.

Conditions include:

- Minor trauma, not acute

- Sore throat
- Minor symptoms
- Chronic abdominal pain

Primary survey

- A= Airway
 - B= Breathing
- C= Circulation
- D= Disability

Secondary Survey

- E= exposure to environment
- F= full set of vital signs
- G= Give comfort
- H= History Collection
- I= inspect the post surface

Quick Assessment Components

A. For Adults (AMPLE)

- Allergies

- Medications taken

- Past medical history

- Last mealtime

- Event/environment

Quick Assessment Components

B. For Pediatric Clients (CIAMPEDS)

• Chief complaint • Immunizations

• Allergies • Medications taken

• Past medical history

• Event/environment

• Diet and diapers

• Signs and symptoms present (include onset)

History of the Emergency Severity Index

The ESI is a five-level triage scale developed by ED physicians Richard Wuerz and David Eitel in the U. S.
Wuerz and Eitel believed that a principal role for an emergency department triage instrument is to
facilitate the prioritization of patients based on the urgency of treatment for the patients' conditions.
The triage nurse determines priority by posing the question, "Who should be seen first?" Wuerz and
Eitel realized, however, that when more than one top priority patient presents at the same time, the
operating question becomes, "How long can each patient safely wait?" The ESI is unique in that it also,
for less acute patients, requires the triage nurse to anticipate expected resource needs (e.g., diagnostic
tests and procedures), in addition to assessing acuity. Briefly, acuity judgments are addressed first and
are based on the stability of the patient's vital functions, the likelihood of an immediate life or organ
threat, or high-risk presentation. For patients determined not to be at risk of high acuity and deemed
"stable," expected resource needs are addressed based on the experienced triage nurse's prediction of
the resources needed to move the patient to an appropriate disposition from the ED. Resource needs
can range from none to two or more; however, the triage nurse never estimates beyond two defined
resources.

Reference:

http://www.keymedinfo.com/site/667KeyM/Key_Medical_Home_Study_-
_Triage_in_Emergency_Department_Using_ESi_(5_Levels)_Self_Study_8.2015_in_PDF_Format_for_em
ail_and_posting.pdf