BACKGROUND

The word "triage" is derived from the French verb "trier," to "sort" or "choose." Originally the process was used by the military to sort soldiers wounded in battle for the purpose of establishing treatment priorities. Injured soldiers were sorted by severity of their injuries ranging from those that were severely injured and deemed not salvageable, to those who needed immediate care, to those that could safely wait to be treated. The overall goal of sorting was to return as many soldiers to the battlefield as quickly as possible

Triage
Triage

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.

Triage is used in a number of situations in modern medicine, including:

In mass casualty situations, triage is used to decide who is most urgently in need of transportation to a hospital for care (generally, those who have a chance of survival but who would die without immediate treatment) and whose injuries are less severe and must wait for medical care.

 Triage

is also commonly used in crowded emergency rooms and walkin clinics to determine which patients should be seen and treated immediately. may be used to prioritize the use of space or equipment, such as operating rooms, in a crowded medical facility.

Triage

GOALS OF TRIAGE

1. Rapidly identify patients with urgent,lifethreatening conditions 2. Assess/determine severity and acuity of the presenting problem 3. To ensure that patients are treated in the order of their clinical urgency 4 To ensure that treatment is appropriately and timely. 5. To allocate the patient to the most appropriate assessment and treatment area 6..Re-evaluate patients awaiting treatment

ADVANTAGES OF TRIAGE
1. Streamlines patient flow 2. Reduces risk of further injury/deterioration 3 Improves communication and public relations 4 Enhances teamwork 5. Identifies resource requirements 6 Establishes national benchmarks

Triage Acuity Determinants

1. Chief complaint 2. Brief triage history 3. Injury or illness (signs & symptoms) 4. General appearance 5. Vital signs 6. Brief physical appraisal at triage

GENERAL PRINCIPLES

All patients presenting to an Emergency Department should be triaged on arrival by a specifically trained and experienced registered nurse. The triage assessment and Triage Scale code allocated must be recorded. The triage nurse should ensure continuous reassessment of patients who remain waiting, and, if the clinical features change, re-triage the patient accordingly. The triage nurse may also initiate appropriate investigations or initial management according to organizational guidelines.

GENERAL PRINCIPLES

The triage area must be immediately accessible and clearly sign-posted. Its size and design must allow for patient examination, privacy and visual access to the entrance and waiting areas, as well as for staff security. The triage area should be equipped with emergency equipment, facilities for standard precautions (handwashing facilities, gloves), security measures (duress alarms or ready access to security assistance), adequate communications devices (telephone and/or intercom etc) and facilities for recording triage information. That initial triage of patients occur within 10 minutes of arrival and Must include vital signs.

GENERAL PRINCIPLES
If triage times extend beyond 15 minutes, an additional nurse Should be immediately called. Accurate triage is the key to the efficient operation of an emergency department Effective triage is based on the knowledge, skills and attitudes of the triage nurse Paediatric patients should have their vital signs taken every 30 minutes when indicated and other patients should have an hourly triage reassessment where indicated.

GENERAL PRINCIPLES
Triage is an essential function in Emergency Departments (EDs), where many patients may present simultaneously. Urgency refers to the need for time-critical intervention - it is not synonymous with severity. Patients triaged to lower acuity categories may be safe to wait longer for assessment and treatment but may still require hospital admission. The triage assessment should generally take no more than two to five minutes

TRIAGE SCALE [hospital]

Category 1- RESUSCITATION Immediately Life-Threatening ConditionImmediate simultaneous assessment and treatment Conditions that are threats to life (or imminent risk of deterioration) and require immediate aggressive intervention.

Clinical Descriptors (indicative only) Cardiac arrest Respiratory arrest Immediate risk to airway - impending arrest Respiratory rate <10/min Extreme respiratory distress BP< 80 (adult) or severely shocked child/infant Unresponsive or responds to pain only (GCS < 9) Ongoing/prolonged seizure IV overdose and unresponsive or hypoventilation Severe behavioural disorder with immediate threat of dangerous violence

TRIAGE SCALE [hospital]

Category II EMERGENT Immediately Life-Threatening Condition Assessment and treatment within 10 minutes (often simultaneously) The patient's condition is serious enough or deteriorating so rapidly that there is the potential of threat to life, or organ system failure, if not treated within ten minutes of arrival or Very severe pain Humane practice mandates the relief of very severe pain or distress within 10 minutes

TRIAGE SCALE [hospital]

Clinical Descriptors Category 2 (indicative only) Airway risk - severe stridor or drooling with distress Severe respiratory distress Circulatory compromise - Clammy or mottled skin, poor perfusion - HR<50 or >150 (adult) - Hypotension with haemodynamic effects - Severe blood loss - Chest pain of likely cardiac nature Very severe pain - any cause BSL < 2 mmol/l Drowsy, decreased responsiveness any cause (GCS< 13) Acute hemiparesis/dysphasia

TRIAGE SCALE [hospital]

Fever with signs of lethargy (any age) Acid or alkali splash to eye - requiring irrigation Major multi trauma (requiring rapid organised team response) Severe localised trauma - major fracture, amputation High-risk history: Significant sedative or other toxic ingestion Significant/dangerous envenomation Severe pain suggesting PE, AAA or ectopic pregnancy Behavioural/Psychiatric: - violent or aggressive - immediate threat to self or others - requires or has required restraint - severe agitation or aggression

TRIAGE SCALE [Category hospital ] III URGENT

Potentially Life-Threatening-Assessment and treatment start within 30 mins The patient's condition may progress to life or limb threatening, or may lead to significant morbidity, if assessment and treatment are not commenced within thirty minutes of arrival. or Situational Urgency There is potential for adverse outcome if timecritical treatment is not commenced within thirty minutes or Humane practice mandates the relief of severe discomfort or distress within thirty minutes

TRIAGE SCALE [Clinical hospital ] Descriptors (indicative only)

Severe hypertension Moderately severe blood loss - any cause Moderate shortness of breath SAO2 90 - 95% BSL >16 mmol/l Seizure (now alert) Any fever if immunosuppressed eg oncology patient, steroid Rx Persistent vomiting Dehydration Head injury with short LOC- now alert

TRIAGE SCALE [hospital]

Moderately severe pain - any cause - requiring analgesia Chest pain likely non-cardiac and mod severity Abdominal pain without high risk features mod severe or patient age >65 years Moderate limb injury - deformity, severe laceration, crush Limb - altered sensation, acutely absent pulse Trauma - high-risk history with no other highrisk features Stable neonate

TRIAGE SCALE [hospital]

Child at risk Behavioural/Psychiatric: - very distressed, risk of self-harm - acutely psychotic or thought disordered - situational crisis, deliberate self harm - agitated / withdrawn / potentially aggressive

TRIAGE SCALE [hospital]

Category IV LESS URGENT Assessment and treatment start within 60 mins The patient's condition may progress to life or limb threatening, or may lead to significant morbidity, if assessment and treatment are not commenced within thirty minutes of arrival. or Situational Urgency The patient's condition may deteriorate, or adverse outcome may result, if assessment and treatment is not commenced within one hour of arrival in ED. Symptoms moderate or prolonged. or Humane practice mandates the relief of discomfort or distress within one hour

TRIAGE SCALE [hospital]

Clinical Descriptors (indicative only) Mild haemorrhage Foreign body aspiration, no respiratory distress Chest injury without rib pain or respiratory distress Difficulty swallowing, no respiratory distress Minor head injury, no loss of consciousness Moderate pain, some risk features Vomiting or diarrhoea without dehydration Eye inflammation or foreign body - normal vision

TRIAGE SCALE [hospital]

Minor limb trauma - sprained ankle, possible fracture, uncomplicated laceration requiring investigation or intervention - Normal vital signs, low/moderate pain Tight cast, no neurovascular impairment Swollen "hot" joint Non-specific abdominal pain Behavioural/Psychiatric: - Semi-urgent mental health problem - Under observation and/or no immediate risk to self or others

TRIAGE SCALE [hospital]

Category V - Less Urgent Assessment and treatment start within 120 mins The patient's condition is chronic or minor enough that symptoms or clinical outcome will not be significantly affected if assessment and treatment are delayed up to two hours from arrival or Clinico-administrative problems Results review, medical certificates, prescriptions only

TRIAGE SCALE [hospital]

Clinical Descriptors (indicative only) Minimal pain with no high risk features Low-risk history and now asymptomatic Minor symptoms of existing stable illness Minor symptoms of low-risk conditions Minor wounds - small abrasions, minor lacerations (not requiring sutures) Scheduled revisit eg wound review, complex dressings Immunisation only Behavioural/Psychiatric: - Known patient with chronic symptoms - Social crisis, clinically well patient

Documentation Standards

Date and time of assessment Name of triage officer Chief presenting problem(s) Limited, relevant history Relevant assessment findings Initial triage category allocated Retriage category with time and reason Assessment and Treatment area allocated Any diagnostic, first aid or treatment measures initiated

TRIAGE SCALE casualty]

[mass

In a disaster or mass casualty situation, different systems for triage have been developed. One system is known as START (Simple Triage And Rapid Treatment). In START, victims are grouped into four categories, depending on the urgency of their need for evacuation. If necessary, START can be implemented by persons without a high level of training. The categories in START are: the deceased, who are beyond help the injured who could be helped by immediate transportation the injured with less severe injuries whose transport can be delayed those with minor injuries not requiring urgent care.

TRIAGE SCALE casualty]

[mass

Another system that has been used in mass casualty situations is an example of advanced triage implemented by nurses or other skilled personnel. This advanced triage system involves a color-coding scheme using red, yellow, green, white, and black tags:

RED TAG - (immediate) are used to label those who cannot survive without immediate treatment but who have a chance of survival.

TRIAGE SCALE casualty]

[mass

YELLOW TAG - (observation) for those who require observation (and possible later re-triage). Their condition is stable for the moment and, they are not in immediate danger of death. These victims will still need hospital care and would be treated immediately under normal circumstances. GREEN TAG - (wait) are reserved for the "walking wounded" who will need medical care at some point, after more critical injuries have been treated.

TRIAGE SCALE casualty]

[mass

WHITE TAG - (dismiss) are given to those with minor injuries for whom a doctor's care is not required. BLACK TAG - (expectant) are used for the deceased and for those whose injuries are so extensive that they will not be able to survive given the care that is available.