TRIAGE IN EMERGENCY

DEPARTMENT
Lye Meng Hon

Introduction

Definition

French noun derived from the verb trier, which

means to sift or sort.
the methods used to assess patients severity of
injury or illness within a short time after their
arrival, assign priorities, and transfer each patient
to the appropriate place for treatment.

Problems Faced in ED

The volume of admissions to a given emergency

department cannot be predicted with any great
accuracy.
Only a certain proportion of the patients have life
endangering or medically urgent conditions.
Patients with life-threatening injuries or illnesses
need to be reliably identified within minutes of
arrival.
Patient overcrowding.
The demand for medical treatment significantly
outstrip available resources.

A study done in HUSM in year 2000 showed that 55% of ED visits

were inappropriate (problems which can be treated in in the primary
care services in the community).

Aim

To ensure that the patient receives the level

and quality of care appropriate to clinical need
(clinical justice).
Reduce unnecessary delay of treatment.
Departmental resources are most usefully
applied (efficiency).

Triage in Emergency
Department

ED triage systems

Designed to identify the most urgent (or

potentially most serious) cases.
To ensure that they receive priority treatment,
followed by the less urgent cases.
First-come, first-served basis

Triage officers routinely assess all patients

who present for treatment to sort and prioritize
them.

Types of Triage in ED

3-level triage system:

Level 1 = emergent
Level 2 = urgent
Level 3 = non-urgent
Lack of specificity and prone to subjectivity

5-level triage systems

Eg: Australian Triage Scale (ATS), Manchester

Triage Scale (MTS), Canadian Triage Acuity Scale
(CTAS), Emergency Severity Index (ESI)

Art of Triage

Complex and dynamic process

Obtaining adequate and relevant information
in a short amount of time
Decisions are made in a time-sensitive
environment with limited manpower and
information.
Decision made based on pre-existing
guidelines and patients condition.

Roles of Triage Officer

Allocate triage category bases on patient assessment

Initiate appropriate nursing interventions

Liaise with members of the public and other

healthcare professionals.

First aid
Initiation of organizational guidelines, eg: x-ray,
analgesia.

Escort patient and pass over relevant information

Provide patient and public education where

necessary
documentation

Process of Triage

Main complaint and brief history

Vital signs
Physical findings seen, heard, felt or smelt
Setting the priority status of the patient
Decision of preliminary diagnostic testing
should be done
Decision whether treatment should be started
at triage

SOAP System
Larry-Weed SOAP system
S (Subjective) main complaint and brief
history
O (Objective) physical finding and vital signs
A (Assessment) setting of the priority status
based on subjective and objective finding
P (Plan) preliminary diagnostic and
treatment

Malaysian Triage Category

MTC is designed for use in hospital emergency

services throughout Malaysia.
A scale for rating clinical urgency.
Directly relates triage category with a range of
outcome measures (inpatient length of stay, ICU
admission, mortality rate) and resource
consumption (staff time, cost).
Provides an opportunity for analysis of a number
of performance parameters in the Emergency
Department.

MTC
Red
(Critical)
Yellow
(Semi

Critical)
Green (Non-Critical)

Critical (RED)

Critical (RED)

Patients with life threatening injuries or illness

which require immediate attention.
Assessment and treatment simultaneously
within 5 minutes.
Subcategories:

R1 (immediate life-threatening)
R2 (life-threatening)

Clinical Descriptions
1.
2.
3.
4.
5.
6.
7.
8.

Code arrest (cardiac/ respiratory) or impending arrest

Hypoventilation: RR< 10/min
Shock state SBP < 80 (adult)or severely shocked child/infant
Airway compromise or immediate risk to airway
Severe respiratory distress. Tachypnoea and/or dyspnoea with SpO2 <95%
Seizuring patient (ongoing/prolonged) and post-ictal states with neurological deficits
Coma/ unconscious or responds to pain only (GCS<9/15)
Alleged poisoning or drug overdose with impairment of conscious level and need urgent
intervention
9. Head injury with GCS 13/15 and below
10. Exsanguinating limb injuries (massive blood loss)
11. Severe crush injuries to limbs
12. Other immediate life threatening conditions
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Severe or moderate asthma/ COAD

Polytrauma/ major trauma
Burns to more than 25% BSA regardless of depth and/ or more than 20% 2nd degree burns
Alleged near-drowning
Gun-shot/ stab wounds to head, neck, trunk or abdomen or trajectory undetermined
Arrhythmia with tachycardia/ bradycardia and unstable.
Hypertensive emergencies: SBP> 220 or DBP >120 with systemic symptoms
Chest pain visceral, non-traumatic associated with parasympathetic and sympathetic symptoms
Acute MI/ unstable angina diagnosed by referral
Acute abdomen, hemodynamically unstable
Hyperglycemia or hypoglycemia with altered conscious level or neurological/ systemic deficit
Baby< 3 months with fever > 38C
Other life threatening conditions
Obstetric emergency (Hamodynamically unstable)

Semi-Critical (YELLOW)

Semi-Critical (YELLOW)

Assessment and treatment starts within 30

minutes.
Usual presentation:

Unable to walk but airway is secure,

hemodynamically stable and on trolleys

Clinical Descriptions
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.

Altered conscious level but not comatose. Head injury = 14/15 or GCS full but pupils unequal
Fractures of long bones of lower limbs/ pupils
Open fracture of upper limbs
Spine injuries (not in shock, no neurological deficit)
Eye injury with loss or impaired vison
Dislocation of major joints
Limb amputation: total or/ near-total (haemodynamically stale)
Burns 15-25% of BSA regardless of depth and/or 10-20% 3 rd degree burns with no compromise to
airway and circulation
Vascular injuries but hemodynamically stable
Patients with acute abdomen but hemodynamically stable
Chemical exposure involving eyes
Alleged poisoning/ drug overdose patient conscious and need no intervention
Severe pain:

Trauma: pain score: 8-10

Non-trauma: pain score 4-7/10

Allergic reaction moderate
Mild to moderate dyspnoea with saturation >95% and/or rate <40/ min
Hyperventilation and unable to maintain posture
Cheat pain visceral and not associated with other symptoms
Hepertensive urgencies: elevated SBP < 220mmHg or DBP <120mmHg with minimal systemic
symptoms but no neurological deficit.
Baby > 3 months with fever > 38C
Infant < 1 month regardless of any symptoms
Significant per vaginal bleed with hemodynamically stable
Other medical urgencies requiring intravenous intervention and intermittent monitoring only:

Dehydration, diarrhea with vomiting, pyrexia >40C, signs of infection, dialysis problem, acute
psychotic episodes, chemotherapy or immunocompromised, acute urinary retention.

Non-Critical (GREEN)

Non-Critical (GREEN)

Assessment and treatment starts within 90 minutes

Usual presentation:

Airway secure, hemodynamically stable patients not in

any distress and ambulant

Subcatagories:

G1 (fast line)
G2 (require initial management or first aid before seen by
doctor)
G3 (patients who can wait)
G4 (triage away to primary care or another center)
G5 (not seen in ED)

Non-Critical (GREEN)
G1 (Fast Lane)

Children < 2 years old

Senior citizen > 65 years old

Acute pain (trauma): pain score <4/10

Chest pain non-visceral, musculoskeletal and not associated with other symptoms
but with history of heart disease

Abuse/neglect/assault stable

Post seizure alert on arrival

POP complications

Elevated blood sugar without any major symptoms

Mild asthma

Closed fracture of upper limbs or ankle with major angulations

Dislocation of small joints

Foreign body

Hemodynamically stable per vaginal bleed

Non-Critical (GREEN)
G2 (Require initial management or 1st aid
before seen by doctor)
Chest pain non-visceral, musculoskeletal
and not associated with other symptoms and
no previous heart disease
Minor allergic reaction

Non-Critical (GREEN)
G3 (patients who can wait)
Burn < 15% of BSA regardless of depth and/or <10% 3 rd
degree burns
Minor trauma
Head injury alert, no vomiting
Bumps and bruises
Closed fracture of upper limbs
Controllable bleeding with closed fracture of upper limbs or
ankle without major angulations
Nail prick
Simple cut

Non-Critical (GREEN)
G4 (for LOCUM or triage away to OPD or another center)
Chronic trauma injuries > 6 months
Diarrhea alone (no dehydration)
Vomiting alone (normal mental status with no dehydration)
Acute pyrexia <38C for adult < 65 years old or child between 2-12
years old
Simple skin diseases chronic
Menses related complaints
Chronic psychiatric complaints
General medicine conditions or minor illness not requiring monitoring
Sore throat no respiratory symptoms
Earache
Infective eye conditions

Non-Critical (GREEN)
G5 (not seen in ED)
Missed appointment
Medications exhausted
Second opinion seeking
STO
Medical certificate
Specialist clinic cases

Click icon to add picture

THANK YOU

FIELD TRIAGE
Immediate

Patients

Delayed

Deceased

Introduction

In US Unintentional Injury is leading cause of

death for person age 1-44 years.

Traumatic injury is fifth leading cause of death

Emergency medical services have a substantial

impact on the care of injured persons and on
public health.
At an injury scene, EMS providers determine the
severity of injury, initiate medical management,
and identify the most appropriate facility to which
to transport the patient.

Field Triage

Perform when number of casualties

overwhelms healthcare provider.

MCI (Mass-casualty incident)

Have time constraint, limited personnel &

limited resources
To sort victims based on their probability of
survival.

Mass-Casualty Incident

Number of patients and the nature of their

injuries make the normal level of stabilization
and care unachievable
Resources that can be brought to the field
within response time are insufficient to
manage the scene under normal operating
procedures
Stabilization capability of area hospital are
insufficient to handle all the patient.

Objectives of Field Triage

Save maximum number of victims (Do the

greatest good for the greatest number)
Prioritizing patients concentrate on
salvageable patients
Provide immediate critical care
Manage resources
Transfer patient to appropriate centers

START

Simple Triage And Rapid Treatment

Designed for first responders.
Gold standard for field adult multiple casualty
(MCI) triage in the US and numerous countries
around the world
Utilizes the standard four triage categories
Used for primary triage

START

Step-by-step triage and treatment method to

be used by the first rescuers responding to a
multi casualty incident.
Allows rescuers to identify victims at greatest
risk for early death and to provide basic
stabilization maneuvers

First Responders Responsibility

One member becomes Command

Other members starts the Triage process
Start calling for any additional resources
Initiate 5s

Safety assessment
Scene size-up
Send information
Set up
START

START Triage
RESPIRATIONS
NO

Over 30/min

Position Airway

NO

YES

YES

Immediate

Under 30/min

PERFUSION
Cap refill
> 2 sec
Control
Bleeding
Immediate

Dead or
Expectant

Cap refill
< 2 sec.

MENTAL
STATUS

Immediate
Failure to follow
Can follow
simple commands simple commands
Immediate

Delayed

START: Step 1
Triage officer announces that all patients
that can walk should get up and walk to a
designated area for eventual secondary
triage.
All ambulatory patients are initially tagged
as Green.

START: Step 2

Triage officer assesses patients in the order in

which they are encountered

Assess for presence or absence of

spontaneous respirations

If breathing, move to Step 3

If apnoeic, open airway

If patient remains apnoeic, tag as Black

If patient starts breathing, tag as Red

START: Step 3
Assess respiratory rate
If 30, proceed to Step 4
If 30, tag patient as Red

START: Step 4
Assess capillary refill
If 2 seconds, move to Step 5
If 2 seconds, tag as Red

START: Step 5

Assess mental status

If able to obey commands, tag as Yellow

If unable to obey commands, tag as Red

Mnemonic

R
P
M

30
2
Can do