Ali Medical Centre Doc.

Code: AMC/NSD-ER/01
Rev. No.:
Triage Policy Eff. Date:
Page No.: 1 of 10

1. PURPOSE
The purpose of this policy is to standardize the application of Triage assessment in
making clinical decision of patients visiting at AMC-ER.
2. Applicability
All Medical and nursing staff working in the AMC-ER
3. Policy Statement
The policy describes prioritization of patients visiting AMC Emergency room (ER)
according to their required level of medical needs. It involves an initial patient assessment
for subsequent management in the most appropriate care area in the ER
4. PROCEDURE
4.1 The Emergency Department of AMC receives and manages all kinds of emergency and
accident cases of all ages 24/7.
4.2 Medico Legal cases will be refer to Government setup after first aid.
4.3 Patients can also be referred from an outside health facility or from consultant clinic
within AMC or from off-campus health facilities including secondary hospitals
4.4 Triage will be done by Registered nurse, technician & Medical Officer. The other team
member of triage team include nursing assistant and FDO will assist nurse and
medical officer.
4.5 At the Triage Area, patient will be assessed and prioritize as per Interagency
Integrated Triage Tool (IITT) which is Novel Three-tier Tool by RNs and MO will be
taken as per need.- Annexure

5. A brief description of interagency integrated triage tool (IITT) is as follows:

5.1 The Interagency Integrated Triage Tool (IITT) is a novel triage system designed for resource-
limited emergency care (EC) settings. The IITT is designed to be applied at the point of ED
arrival. It allocates patients into one of three, color-coded categories based on the presence
of specific signs and symptoms (categories one and two) or the absence of high-risk vital
 Ali Medical Centre Doc. Code: AMC/NSD-ER/01
Rev. No.:
Triage Policy Eff. Date:
Page No.: 2 of 10

signs (category three)

5.1.1 Category 1-EMERGECY (Category Red): Patients in this category require

immediate attention with maximal utilization of resources to prevent loss of life,
limb, or eyesight, high risk for rapid deterioration
6. Category 2-PRIORITY: (Category Yellow):
6.1 Patients who develop a sudden illness or injury within 24-48 hours. Symptoms and
risk factors for serious disease do not indicate a likelihood of rapid deterioration in
the near future
7. Category 2-NON-URGENT: (Category Green)
7.1 Patients with chronic complaints, medical maintenance, or medical conditions posing
no threat to loss of life, limb, or eyesight
The aim of triaging patients by using the IITT is to ensure getting the right patient to the right
resources at the right place and at the right time
 Ali Medical Centre Doc. Code: AMC/NSD-ER/01
Rev. No.:
Triage Policy Eff. Date:
Page No.: 3 of 10

8. REASSESSMENT OF ALL THE PATIENTS WHO WERE ASKED TO WAIT

ARE AS
FOLLOWS:
8.1 Category Red P1 should not wait so no reassessment time line
8.2 Category Yellow P2 reassessment within 30- 60 minutes
8.3 Category Green P3 reassessment within 60 -120 minutes

All P1 and P2 patients will be immediately taken to the resuscitation room and critical area
(Front area) where monitoring will be done as per protocol
9. CRITICAL PATIENTS CATEGORY 1 (RED)
9.1 Assessment of the patients upon arrival in ER
9.2 Initial vital signs would be done at the time of patient arrival in ER and re-assessment
would be done after every 1/2 hours and documented.
9.3 Patients monitoring can also be done as per patient’s condition and Physician orders.
10. NON-CRITICAL PATIENTS CATEGORY 2(YELLOW)
 Ali Medical Centre Doc. Code: AMC/NSD-ER/01
Rev. No.:
Triage Policy Eff. Date:
Page No.: 4 of 10

10.1 Vital signs and assessment would be done when patient is initially received in ED and
then re-assessment every 1 hourly and documented.
10.2 During this reassessment, patient’s prioritization will be reviewed based on objective
findings, which may either remain same or can be upgraded or downgraded and
patient would be managed accordingly
11. CATEGORY 3 (GREEN)
11.1 Vital signs and assessment would be done when patient is initially received in ED.
11.2 As per need “flexible bed management strategies” will be executed in the critical care
and observation area
11.3 During this reassessment, patient’s prioritization will be reviewed based on objective
findings, which may either remain same or can be upgraded and patient would be
managed accordingly
11.4 In case of non-availability of bed in the ER the triage staff will explain the waiting
time and try to answer any concerns raised by the patients and their family
11.5 The physician / consultant help could also be sought if patient does not want to wait
and ask for any alternate options according to the patient condition.

11.6 The pediatric patients less than 16 years of age will be triaged with ESI IV with few
additional points .(Annex)
11.7 Triage policy will be reviewed as per hospital policy every 2 years or earlier in case
11.8 A dedicated fast track room will be assigned for minor procedures like suturing and
cast application, but in situation like ED overcrowding this can be used for patients
care as well
12. URGENT CARE SERVICES AT AMC
12.1 Upon arrival all unstable patient critical or life threatening cases will be immediately
given BLS / ACLS and will be transferred to ICU. In case of non-availability of bed
patient would be shifted to other healthcare facilities
12.2 In case of non-availability of a functional patient care bed, patient will be advised to
wait in the waiting area. Waiting time for different categories of patient will follow
 Ali Medical Centre Doc. Code: AMC/NSD-ER/01
Rev. No.:
Triage Policy Eff. Date:
Page No.: 5 of 10

definite guidelines. Within this specified period, patient’s reassessment will take
place. At this point of time physician’s input (if required) will be duly taken
12.3 During this reassessment, patient’s prioritization will be reviewed based on objective
findings, which may either remain same or can be upgraded or downgraded.

Danger signs
Danger zone vital sign
< 3 months > 180/>50
3months -3 yrs. >160/>40
3years -8yrs >150/>30
8 years and above >100/>20
HR/RR/ SaO2 <92
 Ali Medical Centre Doc. Code: AMC/NSD-ER/01
Rev. No.:
Triage Policy Eff. Date:
Page No.: 6 of 10

13. THE FOLLOWING ALGORITHM DESCRIBES THE PROCESS OF TRIAGING

PATIENTS IN ESI V 4.0
13.1 Examples of IITT Level-1 Conditions
13.1.1 Respiratory arrest
13.1.2 Cardiopulmonary arrest
 Ali Medical Centre Doc. Code: AMC/NSD-ER/01
Rev. No.:
Triage Policy Eff. Date:
Page No.: 7 of 10

13.1.3 Major head trauma with hypoventilation

13.1.4 Active seizures
13.1.5 Unresponsiveness
13.1.6 Petechial rash in a patient with altered mental status (regardless of vital signs)
17.2 Respiratory failure
17.2.1 Hypoventilation
17.2.2 Cyanosis
17.2.3 Decreased muscle tone
17.2.4 Decreased mental status
17.2.5 Bradycardia (late finding, concerning for impending cardiopulmonary arrest)
17.3 Shock/sepsis with signs of hypo perfusion
17.3.1 Tachycardia
17.3.2 Tachypnea
17.3.3 Alteration in pulses: diminished or bounding
17.3.4 Alteration in capillary refill time >3-4 seconds
17.3.5 Alteration in skin appearance: cool/mottled or flushed appearance
17.3.6 Widened pulse pressure
17.3.7 Hypotension (often a late finding in the prepubescent patient)
17.4 Anaphylactic reaction (onset in minutes to hours)
17.4.1 Respiratory compromise (dyspnea, wheeze, stridor, hypoxemia)
17.4.2 Reduced systolic blood pressure
17.4.3 Hypo perfusion (e.g., syncope, incontinence, hypotonic)
17.4.4 Skin and/or mucosal involvement (hives, itch-flush, swollen lips, tongue or
uvula
17.4.5 Persistent gastrointestinal symptoms
17.4.6 Examples of ESI Level-2 Conditions
 Ali Medical Centre Doc. Code: AMC/NSD-ER/01
Rev. No.:
Triage Policy Eff. Date:
Page No.: 8 of 10

17.5 Syncope
17.6 Immune compromised patients with fever

17.7 Hemophilia patients with possible acute bleeds

17.7.1 Joint pain or swelling
17.7.2 History of fall or injury
17.7.3 Vital signs and/or mental status outside of baseline
17.8 Febrile infant <28 days of age with fever ≥38.0°C rectal
17.9 Hypothermic infants <90 days of age with temperature <36.5°C rectal
17.10 Suicidality
17.11 Rule out meningitis (headache/stiff neck/fever/lethargy/irritability)
17.12 Seizures--prolonged postictal period (altered level of consciousness)

17.13 Moderate to severe croup

14. Lower airway obstruction (moderate to severe)

14.1 Bronchiolitis
14.2 Reactive airway disease (asthma)
14.3 Respiratory distress
14.4 Tachypnea
14.5 Tachycardia
14.6 Increased effort (nasal flaring, retractions)
14.7 Abnormal sounds (grunting)

15. ANNEXURE – II
15.1 Use of the IITT for Pediatric Triage
15.1.1 Triage tools such as the ESI algorithm are designed to prioritize ED patients for
treatment
15.2 Triage Assessment: What Is Different for Pediatric Patients?
 Ali Medical Centre Doc. Code: AMC/NSD-ER/01
Rev. No.:
Triage Policy Eff. Date:
Page No.: 9 of 10

15.3 The goal of the triage nurse is to rapidly and accurately assess an ill child in order to
assign a triage level to guide timely routing to the appropriate emergency department
area for definitive evaluation and management
15.4 The ESI version 4 requires that the triage nurse follow the same algorithm on all
patients, pediatric and adult. While the algorithm is the same regardless of age, the
decision process in the pediatric patient must take into account age- dependent
differences in development, anatomy, and physiology
15.5 The triage nurse needs a good sense of what constitutes “normal” for children of all
ages. This knowledge will make it easier to recognize things that should be concerning
(e.g., the 6-month-old who is not interested in his or her surroundings or the 2-week-
old
15.6 Weights should be obtained on all pediatric patients in triage or treatment area.
15.7 Oxygen saturation should be measured in infants and children with respiratory
complaints or symptoms of respiratory distress
15.8 The guidelines for children with fever (100.4°F or 38°C or greater) who are in the first
28 days of life assign ESI level 2
15.9 Pediatric patients who meet the ≥7 criterion should be considered for triage as an ESI
level 2

Prepared by Reviewed by Approved by

Ali Medical Centre Doc. Code: AMC/NSD-ER/01
Rev. No.:
Triage Policy Eff. Date:
Page No.: 10 of 10

QAM CEO