TRIAGE

INTRODUCTION:
Triage is a French verb meaning of “to sort”. most patient entering an emergency department (ED)
are greeted by a triage nurse, who will perform a brief evaluation of the patient to determine a level of
acuity or priority of care .thus the role of the nurse is to make acuity determination and set priorities.
Triage may also be used for patients arriving at the emergency department, or telephoning medical
advice systems, among others. This article deals with the concept of triage as it occurs in medical
emergencies, including the prehospital setting, disasters, and others.
 The term comes from the French verb Trier, meaning to separate, sift or select. Triage may result in
determining the order and priority of emergency treatment, the order and priority of emergency
transport, or the transport destination for the patient care.
 The term triage may have originated during the Napoleonic Wars from the work of Dominique Jean
Larry. The term was used further during World War I by French doctors treating the battlefield
wounded or their care afterwards would divide the victims into three categories.

DEFINITION:
“During the disaster the goal is to maximize the number of service by sorting the treatable from the
untreatable dictums”.

CONCEPTS IN TRIAGE:
Specific triage tools, methods, and systems
 Simple triage
Simple triage is usually used in a scene of an accident or "mass-casualty incident" (MCI), in order to
sort patients into those who need critical attention and immediate transport to the hospital and those with
less serious injuries. This step can be started before transportation becomes available.
Upon completion of the initial assessment by medical or paramedical personnel, each patient may be
labeled which may identify the patient, display assessment findings, and identify the priority of the
patient's need for medical treatment and transport from the emergency scene. At its most primitive,
patients may be simply marked with colored flagging tape or with marker pens. Pre-printed cards for this
purpose are known as a triage tag.

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 Tags

Many triage systems use triage tags with specific formats

Emergency Triage (E/T) Lights – particularly useful at night or under adverse conditions
 Main article: Triage tag
A triage tag is a prefabricated label placed on each patient that serves to accomplish several objectives:
 Identify the patient.
 Bear record of assessment findings.
 Identify the priority of the patient's need for medical treatment and transport from the emergency
scene.
 Track the patients' progress through the triage process.
 Identify additional hazards such as contamination.

Triage tags may take a variety of forms. Some countries use a nationally standardized triage tag,while in
other countries commercially available triage tags are used, and these will vary by jurisdictional choice.
[
The most commonly used commercial systems include the METTAG, the SMARTTAG, E/T LIGHT
tm and the CRUCIFORM systems.
More advanced tagging systems incorporate special markers to indicate whether or not patients have
been contaminated by hazardous materials, and also tear off strips for tracking the movement of patients
through the process. Some of these tracking systems are beginning to incorporate the use of handheld
computers, and in some cases, bar code scanners.

 Advanced triage
Four classifications-
 In advanced triage, doctors and specially trained nurses may decide that some seriously injured
people should not receive advanced care because they are unlikely to survive. It is used to divert

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 scarce resources away from patients with little chance of survival in order to increase the chances of
survival of others who are more likely to survive.
 The use of advanced triage may become necessary when medical professionals decide that the
medical resources available are not sufficient to treat all the people who need help. The treatment
being prioritized can include the time spent on medical care, or drugs or other limited resources. This
has happened in disasters such as volcanic eruptions, mass shootings, earthquakes, thunderstorms,
and rail accidents. In these cases some percentage of patients will die regardless of medical care
because of the severity of their injuries. Others would live if given immediate medical care, but
would die without it.
 In these extreme situations, any medical care given to people who will die anyway can be considered
to be care withdrawn from others who might have survived (or perhaps suffered less severe disability
from their injuries) had they been treated instead. It becomes the task of the disaster medical
authorities to set aside some victims as hopeless, to avoid trying to save one life at the expense of
several others.
 If immediate treatment is successful, the patient may improve (although this may be temporary) and
this improvement may allow the patient to be categorized to a lower priority in the short term. Triage
should be a continuous process and categories should be checked regularly to ensure that the priority
remains correct. A trauma score is invariably taken when the victim first comes into hospital and
subsequent trauma scores taken to see any changes in the victim's physiological parameters. If a
record is maintained, the receiving hospital doctor can see a trauma score time series from the start of
the incident, which may allow definitive treatment earlier.

 Continuous integrated triage

Continuous integrated triage is an approach to triage in mass casualty situations which is both efficient
and sensitive to psychosocial and disaster behavioral health issues that affect the number of patients
seeking care (surge), the manner in which a hospital or healthcare facility deals with that surge (surge
capacity) and the overarching medical needs of the event.
Continuous integrated triage 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 and the needs of other patients. Continuous integrated triage employs:
 Group (Global) Triage (i.e., M.A.S.S. triage)
 Physiologic (Individual) Triage (i.e., S.T.A.R.T.)
 Hospital Triage (i.e., E.S.I. or Emergency Severity Index)

 Reverse triage
Usually, triage refers to prioritizing admission. A similar process can be applied to discharging patients
early when the medical system is stressed. This process has been called "reverse triage". During a
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"surge" in demand, such as immediately after a natural disaster, many hospital beds will be occupied by
regular non-critical patients. In order to accommodate a greater number of the new critical patients, the
existing patients may be triaged, and those who will not need immediate care can be discharged until the
surge has dissipated, for example through the establishment of temporary medical facilities in the region.

 Under triage and over triage

Under triage is the underestimating the severity of an illness or injury. An example of this would be
categorizing a Priority 1 (Immediate) patient as a Priority 2 (Delayed) or Priority 3 (Minimal).
Historically, acceptable under triage rates have been deemed 5% or less.

Over triage is the overestimating of the severity of an illness or injury. An example of this would be
categorizing a Priority 3 (Minimal) patient as a Priority 2 (Delayed) or Priority 1 (Immediate).
Acceptable over triage rates have been typically up to 50% in an effort to avoid under triage. Some
studies suggest that over triage is less likely to occur when triaging is performed by hospital medical
teams, rather than paramedics or EMTs.
 Outcomes
This section is for general concepts in triage-based treatment options and outcomes. For specific triage
systems and methods see the sections dedicated to that topic

 Palliative care
For those patients that have a poor prognosis and are expected to die regardless of the medical treatment
available, palliative care such as painkillers may be given to ease suffering before they die.
 Evacuation
In the field, triage sets priorities for evacuation or relocation to other care facilities.

 Alternative care facilities

Alternative care facilities are places that are set up for the care of large numbers of patients, or are places
that could be so set up. Examples include schools, sports stadiums, and large camps that can be prepared
and used for the care, feeding, and holding of large numbers of victims of a mass casualty or other type
of event. Such improvised facilities are generally developed in cooperation with the local hospital, which
sees them as a strategy for creating surge capacity. While hospitals remain the preferred destination for
all patients, during a mass casualty event such improvised facilities may be required in order to divert
low-acuity patients away from hospitals in order to prevent the hospitals becoming overwhelmed
 Specific systems
A triage sign at a Mexican emergency room indicating the waiting time for patients based on the severity
of their condition

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TYPES OF TRIAGE:
1. Practical applied triage
During the early stages of an incident, first responders may be overwhelmed by the scope of patients and
injuries. One valuable technique is the Patient Assist Method (PAM). The responders quickly establish a
casualty collection point (CCP) and advise, either by yelling, or over a loudspeaker, that "anyone
requiring assistance should move to the selected area (CCP)". This does several things at once, it
identifies patients that are not so severely injured, that they need immediate help, it physically clears the
scene, and provides possible assistants to the responders. As those who can move, do so, the responders
then ask, "anyone who still needs assistance, yell out or raise your hands"; this further identifies patients
who are responsive, yet maybe unable to move. Now the responders can rapidly assess the remaining
patients who are either expectant, or are in need of immediate aid. From that point the first responder is
quickly able to identify those in need of immediate attention, while not being distracted or overwhelmed
by the magnitude of the situation. Using this method assumes the ability to hear. Deaf, partially deaf or
victims of a large blast injury may not be able to hear these instructions.
2. Scoring systems:
Examples of scoring systems used:
 In Western Europe the Triage Revised Trauma Score (TRTS) is sometimes used and integrated into
triage cards.
 The Injury Severity Score (ISS) is another example of a trauma scoring system. This assigns a score
from 0 to 75 based on severity of injury to the human body divided into three categories: A
(face/neck/head), B(thorax/abdomen), C(extremities/external/skin). Each category is scored from 0
to 5 using the Abbreviated Injury Scale, from uninjured to critically injured, which is then squared
and summed to create the ISS. A score of 6, for "unsurvivable", can also be used for any of the three
categories, and automatically sets the score to 75 regardless of other scores. Depending on the triage
situation, this may indicate either that the patient is a first priority for care, or that he or she will not
receive care owing to the need to conserve care for more likely survivors.

3. S.T.A.R.T. model:
Main article: Simple triage and rapid treatment
S.T.A.R.T. (Simple Triage and Rapid Treatment) is a simple triage system that can be performed by
lightly trained lay and emergency personnel in emergencies. [22] It is not intended to supersede or instruct
medical personnel or techniques. It has been taught to California emergency workers for use
in earthquakes. It was developed at Hoag Hospital in Newport Beach, California for use by emergency

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services. It has been field-proven in mass casualty incidents such as train wrecks and bus accidents,
though it was developed for use by community emergency response teams (CERTs) and firefighters after
earthquakes.

TRIAGE SEPARATES THE INJURED INTO FOUR GROUPS:

 The expectant who are beyond help
 The injured who can be helped by immediate transportation
 The injured whose transport can be delayed
 Those with minor injuries, who need help less urgently

Triage also sets priorities for evacuation and transport as follows:

 Deceased are left where they fell. These people are not breathing and an effort to reposition their
airway has been unsuccessful.
 Immediate or Priority 1 (red) evacuation by MEDEVAC if available or ambulance as they need
advanced medical care at once or within 1 hour. These people are in critical condition and would die
without immediate assistance.
 Delayed or Priority 2 (yellow) can have their medical evacuation delayed until all immediate persons
have been transported. These people are in stable condition but require medical assistance.
 Minor or Priority 3 (green) are not evacuated until all immediate and delayed persons have been
evacuated. These will not need advanced medical care for at least several hours. Continue to re-
triage in case their condition worsens. These people are able to walk, and may only
require bandages and antiseptic.

Hospital systems
Within the hospital system, the first stage on arrival at the emergency room is assessment by the hospital
triage nurse. This nurse will evaluate the patient's condition, as well as any changes, and will determine
their priority for admission to the Emergency Room and also for treatment. [23] Once emergency
assessment and treatment are complete, the patient may need to be referred to the hospital's internal
triage system.
For a typical inpatient hospital triage system, a triage physician will either field requests for admission
from the ER physician on patients needing admission or from physicians taking care of patients from
other floors who can be transferred because they no longer need that level of care (i.e. intensive care unit
patient is stable for the medical floor). This helps keep patients moving through the hospital in an
efficient and effective manner.
This triage position is often done by a hospitalist. A major factor contributing to the triage decision
is available hospital bed space. The triage hospitalist must determine, in conjunction with a hospital's
"bed control" and admitting team, what beds are available for optimal utilization of resources in order to
provide safe care to all patients. A typical surgical team will have their own system of triage for trauma
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and general surgery patients. This is also true for neurology and neurosurgical services. The overall goal
of triage, in this system, is to both determine if a patient is appropriate for a given level of care and to
ensure that hospital resources are utilized effectively.
Care afterwards would divide the victims into three categories:
 Those who are likely to live, regardless of what care they receive;
 Those who are likely to die, regardless of what care they receive;
 Those for whom immediate care might make a positive difference in outcome.

For many emergency medical services (EMS) systems, a similar model may sometimes still be applied.
In the earliest stages of an incident, such as when one or two paramedics exist to twenty or more
patients, practicality demands that the above, more "primitive" model will be used. However once a full
response has occurred and many hands are available, paramedics will usually use the model included in
their service policy and standing orders.

As medical technology has advanced, so have modern approaches to triage which are increasingly based
on scientific models. The categorizations of the victims are frequently the result of triage scores based on
specific physiological assessment findings. Some models, such as the START model may be algorithm-
based. As triage concepts become more sophisticated, triage guidance is also evolving into
both software and hardware decision support products for use by caregivers in both hospitals and the
field.
PRIORITIES OF CARE AND TRIAGE CATEGORIS:
Standard triage categories categories are usually developed within each ED. Most common triage system
conceits of five level of activity.
 TRIAGE LEVEL I- RESUCSCITATION
I. Condition requring immediate nursing and physician assessment .any delay in treatment is potentially
life .or limb –threatening .
2. includes conditions such as :
a) Airway compromise.
b) Cardiac arest.
c) Sevear shock.
d) Cervical spine injury.
e) Multisystem trauma.
f) Altered level of consiousness (LOC)(unconsciousness)
g) Eclampsia.
 TRIAGE LEVEL II-EMERGENT
I. Condition requring nursing assessmen and physician assessment within 15 minutes of arrival.
II. Conditions include.
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 a) Head injuries.
b) Severe trauma.
c) Lethargy or agitation.
d) Conscious overdose.
e) Severe allergic reaction.
f) Chemical exposure to the eyes.
g) Chest pain. Back pain.
h) GI bleeds with unstable vital sing.
i) Stroke with defect. Severe asthma. Abdominal pain in patient older than age 50.m. vomiting and
diarrheal with dehydration.
j) Fever in infants younger than 3 months.
k) Acute psychotic episode.
l) Severe headache.
m) Any pain greater than 7 on scale of 10.
n) Any sexual assault.
o) Any neonate age 7 days or younger.
 TRIAGE LEVEL III- URGENT
I. Condition requiring nursing and physician assessment within 30 minutes of arrival.
II. Conditions includes.
a) Alert head injury with vomiting.
b) Mild to moderate asthma.
c) Moderate trauma.
d) Abuse or neglect.
e) GI bleed with stable vital signs.
f) History of seizure, alert on arrival
 TRIAGE LEVEL IV- LESS URGENT
I. Condition requiring nursing and physician assessment within one hour.
II. Condition include:
a) Alert head injury without vomiting.
b) Minor trauma.
c) Vomiting and diarrhoea in patient older than age 2 without evidence of dehydration.
d) Earache.
e) Minor allergic reaction.
f) Corneal foreign body.
g) Chronic back pain.

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 TRIAGE LEVEL V- NONURGENT
I. Condition requiring nursing and physician assessment within two hour.
a) Condition include
b) Minor trauma, not acute.
c) Sore throat.
d) Minor symptoms.
e) Chronic abdominal pain.
CLASSIFICATION OF TRIAGE ACCORDING TO COLUR CODE

1. RED-MOST URGENT 1ST PRIORITY

These clients have reasonable chance of survival of only if the receive only if they receive immediate
treatment emergency treatment is initiated immediately and continued during the transportation.
Example: respiratory insufficiency, cardiac arrest, hemmorrage, severe abdominal injury etc.
2. ORANGE –EMERGENCY 2ND PRIORITY
Condition requring nursing assessment and physician assessment within 15 minutes of arrival.
Conditions include-
 Head injuries,
 severe trauma,
 Lethargy or agitation
 Conscious overdoses.
3. YELLOW -URGENCIA MENOR (EMERGENCY) 3RD PRIORITY
These victims can wait for transportation after they receive initial emergency treatment victims includes.
Example: immobilized closed fracture, soft tissues without hemorrage, burns less than 40% of the
body .etc.

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4. GREEN (VERDE)-LESS URGENT 4TH PRIORTY
Victim in this categories are ambulatory have tissue injures and may be dazed.
They can be treated by non- professionals and held for observation if necessary. Condition requiring
nursing and physician assessment within one hour.
Condition include:
 Alert head injury without vomiting.,
 Minor trauma.
 Vomiting and diarrhoea in patient older than age 2 without evidence of dehydration.
5. AZUL (BLACK) DYING/DEAD
At the disaster site or primary triage simple support can alleviate the psychological trauma experienced
by survivors. These measures include the following.
At the disaster site or primary triage point simple support measures can alleviate the psychological
trauma experienced by survivors. These measures include the following.
 Keeping families together, especially children with parents.
 Assigning a companion to tighten or injury victims or placing victims in group when they can
help each other.
 Encouraging individuals to share their feeling and support each rumours.
CONCLUSION:
As medical technology has advanced, so have modern approaches to triage which are
increasingly based on scientific models. The categorizations of the victims are frequently the result of
triage scores based on specific physiological assessment findings. Some models, such as
the START model may be algorithm-based. As triage concepts become more sophisticated, triage
guidance is also evolving into both software and hardware decision support products for use by
caregivers in both hospitals and the field

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 BIBLIOGRAPHY

BOOK REFERENCES:-
 SHEBEER. P. BASHEER, “A Concise, “Text Book Of Advance Nursing Practice” First Edition
2012, EMMESS Medical Publishers Bangalore, Pp243-245.

 BRAR NAVDEEP KAUR RAWAT HC, “Text Book Of Advance Nursing Practice”, first Edition
2012, Jaypee Brothers New Delhi, Pp 490

 BRUNNER AND SUDDARTH‘ , Textbook Of Medical Surgical Nursing, Edition 13th ,Published
By Lippincott Publishers, Printed In 2009, Pp 416-417.

 JOYEE M BLACK AND HAWKS J.H., “A Text book of Medical Surgical Nursing”, Clinical
Management For Positive Outcomes, Edition 7th , Printed In 2009, Pp 489

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