TRIAGE

Introduction
Triage is the process of determining the priority of patients, treatment based on the
severity of their condition. Triage is the process of sorting people based on their need for
immediate medical treatment as compared to their chance of benefiting from such care.

Definition
Triage is the term derived from French verb trier meaning to sort or to choose. It is the
process by which patients classified according to the type and urgency of their conditions to
gets
 the Right patient
 to the Right place
 at the Right time
 with the Right care provider.

Objectives of triage protocol

 Identifying the patient.
 Identifying the priority of the patient's need for medical treatment and transport from
the emergency scene.
 Track the patient's progress through the triage process.
 Identify additional hazards such as contamination

Principles Of Triage
The main principles of triage are:
 Every patient should receive and triaged by appropriate skilled health-care
professionals
 Triage is a clinic-managerial decision and must involve collaborative planning
 The triage process should not cause a delay in the delivery of effective clinical
care

Advantages of triage
 Helps to bring order and organization to a chaotic scene
 It identifies and provides care to those who are in greatest need
 Helps make the difficult decisions easier
 Assure that resources are used in the most effective manner
 May take some of the emotional burden away from those doing triage

Types of triage
 Simple triage
 Advanced triage
 Continuous triage
 Reverse triage
 Under triage or over triage

Simple triage- It is usually used in a scene of an accident or "mass-casualty incident"

immediate transport to hospital and those with less serious injuries.
Advance triage- In advance triage, doctors and specially trained nurses may decide that
some seriously injured people should not receive advanced care because they are unlikely to
survive, in order to increase the chances for others with higher likelihood.
Continuous integrated triage- It is an approach to triage in mass casualty. It combines three
forms of triage with progressive specificity to most rapidly identify those patients in greatest
need of care while balancing the needs of the individual patients against the available
resources. Continuous integrated triage employs
a. Group triage
b. Individual triage
c. Hospital triage
Reverse triage- This process of triage can be applied to discharging patients early when the
medical system is stressed.
Under triage- It is the under estimating the severity of an illness or injury. An example of
this would be categorizing as
* Priority 1 (immediate)
*Priority 2 (delayed)
* Priority 3 (minimal)
Over triage- It is over estimating of the severity of illness or injury. An example of this
would be categorizing as
* Priority 1 (minimal)
*Priority 2 (delayed)
* Priority 3 (minimal)

THE TRIAGING PROCESS

Triaging should not take much time. In the client who does not have emergency signs, it
takes on average twenty seconds.
 Assess several signs at the same time. A client who is smiling or crying does not have
severe respiratory distress, shock or coma.
 Look at the client and observe the chest for breathing and priority signs such as
severe malnutrition.
 Listen for abnormal sounds such as stridor or grunting.
WHO SHOULD DO TRIAGE?
All clinical staff involved in the care of sick should be prepared to carry out rapid assessment
to identify the few clients who are severely ill and require emergency treatment.
HOW TO DO TRIAGE
Before starting triage, one should follow ABCD steps
A- Airway
B- Breathing
C- Circulation/ coma/ convulsion
D- Dehydration
When ABCD has been completed the client should be assigned to
 Emergency (E)
 Priority (P)
 Non-urgent and placed in the Queue (Q).

Triage category
four color-coded categories –
 red,
 yellow
 green
 black
depending on injury severity and prognosis Triage category is identified by use of a coloured
band or trauma/disaster tag that is placed on the patient to document that triage has been
done.

TRIAGE tags
EMERGENCY SIGNS IN PATIENTS-
Triage of patients involves looking for signs of serious illness or injury. These emergency
signs are connected to the Airway - Breathing - Circulation/Consciousness - Dehydration and
are easily remembered as ABCD. Each letter refers to an emergency sign which, when
positive, should alert you to a client who is seriously ill and needs immediate assessment and
treatment.
Assess airway and breathing
The most common cause of breathing problems during emergencies is pneumonia. However,
other causes can also lead to breathing problems, including anemia, sepsis, shock and
exposure to smoke. Obstructed breathing can be caused by infection (for example croup) or
an object in the airway.
Assess the circulation for signs of shock
Common causes of shock include dehydration from diarrhoea, sepsis, anaemia (for e.g. due
to severe blood loss after trauma, poisoning or severe malaria).
The client has shock (a blood circulation problem) if the following signs are present:
 cold hands
 capillary refill longer than 3 seconds OR
 weak and fast pulse.

 To check the pulse, first feel for the radial pulse. If it is strong and not obviously
rapid, the pulse is adequate. No further examination is needed.
 If you cannot feel a radial pulse or if it feels weak, check a more central pulse.
 Lift up the forearm and try to feel the brachial pulse, or if the client is lying down,
feel for the femoral pulse.
Assess for convulsion and coma
Signs of convulsions include:
 sudden loss of consciousness
 uncontrolled, jerky movements of the limbs
 stiffening of the client's arms and legs
 unconscious during and after the convulsion
Assess the client for unconsciousness or lethargy.
 If the client is not awake and alert, try to rouse the client by talking to him or her.
 Then shake the arm to try to wake the client.
 If there is no response to shaking, squeeze the nail bed of a fingernail to cause mild
pain.
 If the client does not respond to voice or shaking of the arm, the client is
unconscious.
Assess for severe dehydration
Death most commonly due to severe dehydration
Assess for sunken eyes, severely reduced skin pinch, lethargy or unconscious or irritability to
drink needs emergency treatment with replacement fluids

Role of nurse in triage team

 Extensive knowledge to emergency medical treatment

 Adequate training and competent skills, language, terminology
 Ability to use the critical thinker process
 Good decision maker
 Greet patients and identify yourself.
 Maintain privacy and confidentiality
 Visualize all incoming patients even while interviewing others.
 Maintain good communication between triage and treatment area maintain excellent
communication with waiting area.
 Use all resources to maintain high standard of care.
 Crowd control.
 Communicate with team leader and seek feedback on decisions

Bibliography

 Nancy.S. Principles and practice of nursing: senior nursing procedure.4th edition. vol2.
New Delhi: N.R. Brothers;2011.
 Paul.S. TRIAGE. SlideShare a Scribd company [Internet];2017 DEC 03. Available from;
https://www.slideshare.net/subhankarnrs/triage-83240979
 https://www.slideshare.net/subhankarnrs/triage-83240979
TRIAGE