Yazan Chaiah (180128)

EMERGENCY Youssuf Alaa Ali (180303)

TRIAGE
Abdulrahman Alturkmani (170133)

SYSTEMS
Omar Temsah (180158)
 TABLE OF CONTENT

What is
Introduction START
triage?

jumpSTART CTAS ESI

 INTRODUCTION

 The term 'triage' comes from the French verb trier, meaning
to separate, sort, shift or select
 All patients arriving for emergency care need to be assessed
and classified to prioritize those who have the most urgent
medical problems and are in need of immediate care.
 INTRODUCTION

Emergency medicine services (EMS) are the front-line

personnel that are the first eyes and ears on patients.
Their clinical decision making is important when it
comes to the patient’s outcome.
 TRIAGE

• Triage is the process of categorizing ED patients according to their need for medical care,
irrespective of their order of arrival.. or other factors including sex, age, socioeconomic status,
insurance status, residential status, nationality, race, ethnicity or religion
• It involves prioritizing ED patients in accordance with clinical severity and time urgency, compared
with patients with non urgent illnesses who can wait longer to be seen or who need referral to a
more appropriate health care setting
 IMPORTANCE OF TRIAGE

• Triage is important for redistributing and reducing waiting times and admission rates, increasing the
efficiency and effectiveness of the ED, enhancing patient and family satisfaction, improving the
quality of health care, managing funding and assessing the effectiveness of ED activities
• The universal goal of triage is to supply effective and prioritized care to patients while optimizing
resource usage, timing, and patient satisfaction
 Types of triage

Prehospital ED

START jumpSTART ESI CTAS

 START AND
JUMPSTART
START – SIMPLE TRIAGE AND RAPID
TREATMENT
• Most common triage system used in the United States
• <60 seconds
• Used by first responders to quickly classify victims during
mass casualty incidents (MCI)
• For > 8 year olds
• Evaluation of victims and assigning to categories:
expectant, immediate, delayed, and minor.
Triage Tags
• RPM: respiratory rate, perfusion, and mental status
START

• Primary Triage
• Responders may first ask to indicate each victim’s status, and to walk/relocate to a certain area
• Classifying immediate tags: respiratory rate >30, capillary refill >2 seconds, and unable to obey commands
• Immediate > Delayed > Minor (the walking wounded)

Immediate: Life-threatening injury; needs medical attention within the next hour
Delayed: Non-life-threatening injuries; needs medical attention, few hours delayed
Minor: Minor injuries; may need medical attention in the next few days
Deceased/Expectant: Deceased, or injuries so severe that life-saving treatment unavailable
After all patients have been evaluated, responders use the START classifications to determine priorities for treatment or evacuation to a
hospital
JUMPSTART

• jumpSTART pediatric triage MCI triage tool

• Variation of START; designed specifically for triaging children in disaster settings (<8 y/o)
• Child triaged red if: RR <15 or >45; have no peripheral pulse; mental status is age-inappropriate
(AVPU scale)
• Child triaged yellow if: RR 15-45; have palpapble peripheral pulse, and have age-appropriate mental status
• Child triaged expectant: if no return of spontaneous breathing AND no palpable peripheral pulse (unlike
START)
• Palpable pulse -> five assisted ventilations -> if apneic = expectant
CTAS
THE CANADIAN TRIAGE AND ACUITY SCALE (CTAS)

● A triage nurse is responsible for triaging the patients using 4 steps.

1. The critical look (ABCD)

2. Subjective assessment (SOCRATES)
3. Objective assessment (Distress, physical appearance)
4. Selecting presenting complaint

● Modifiers provide additional information to help determine CTAS level

 Level 5
Level 4 Non-urgent
Level 3 Less urgent Seen within 90 mins
Urgent Seen within 60 mins
Level 2
Emergent Seen within 30 mins
Seen within 15 mins
Level 1
Resuscitation
Seen immediately
CTAS LEVEL 1: RESUSCITATION
● Threats to life or limb
● Signs of distress and vital signs are unstable
● Requires immediate and aggressive intervention
● E.g:
○ Cardiac arrest
○ Respiratory arrest
○ Severe respiratory distress (i.e: Sat: <90%, cyanosis, unable to speak)
○ Major poly-trauma in shock
○ Altered level of consciousness (GCS 3-9)

● All patients with these conditions should go directly to resuscitation and the triage documentation should be done
later on
CTAS LEVEL 2: EMERGENT
● Potential threat to life, limb, or function
● Requires rapid medical intervention
● E.g:
○ Moderate respiratory distress (i.e: Sat:<92%, Stridor, not able to speak in sentences)
○ Hypertension with symptoms (SBP>220 DBP>130)
○ Altered level of consciousness (GCS: 10-13)
○ Fever (3 SIRS criteria)
○ Severe abdominal pain or headache
○ Chest pain (Cardiac or noncardiac features)
● Triage for these patients should be done at the bedside whenever is possible.
CTAS LEVEL 3: URGENT
● Could potentially progress to serious problem requiring medical intervention
● Associated with significant discomfort and affects ability to function
● Vital signs normal (or upper and lower end of normal)
● E.g:
○ Mild respiratory distress (i.e: Sat:92-94%, able to speak, SOB on excretion)
○ Hypertension with no symptoms (SBP>220 DBP>130)
○ Moderate abdominal pain or headache (4-7/10)
○ Vomiting or diarrhea (mild dehydration)
○ Moderate trauma (patients with fractures)
CTAS LEVEL 4: LESS URGENT
● Conditions that relate to patient’s age, distress, or potential for deterioration
● Would benefit with intervention or reassurance within 1-2 hours
● E.g:
○ Confusion (chronic, not progressing)
○ Mild dysuria (UTI complaints)
○ Constipation with mild pain
CTAS LEVEL 5: NON-URGENT
● Acute and non-urgent or part of chronic problem with or without deterioration
● Investigations and interventions could be delayed or referred to other parts of the hospital
● E.g:
○ Diarrhea (mild, no dehydration)
○ Minor bites
○ Dressing change
○ Medication request
MODIFIERS
● Can be divided to first and second order modifiers

● First order modifiers

○ Vital signs:
■ Respiratory distress
■ Hemodynamic status
■ Level of consciousness
■ Temperature
○ Pain score
○ Bleeding disorder
○ Mechanism of injury
● Second order modifiers
○ Blood glucose level
○ Degree of dehydration
○ Blood pressure
MODIFIERS EXAMPLES:
 EMERGENCY
SEVERITY
INDEX (ESI): A
TRIAGE TOOL
FOR THE ED
EMERGEN The ESI triage algorithm yields rapid,
CY reproducible, and clinically relevant
stratification of patients into five groups, from
SEVERITY level 1 (most urgent) to level 5 (least urgent).
INDEX
(ESI)

The ESI provides a method for categorizing

ED patients by both acuity and resource needs.
DECISIVE POINT A: IS THIS PATIENT
•DYING?
Starts with a decisive question (decision point A): does this patient requires immediate life-saving interventions?
• If yes, this patient is automatically triaged as ESI level 1

• The triage nurse evaluates the patient’s ABCs:

• Does this patient have a patent airway?
• Is the patient breathing?
• Does the patient have a pulse?
• Is the nurse concerned about the pulse rate, rhythm, and quality?
• Is the nurse concerned about this patient's ability to deliver adequate oxygen to the tissues?
• Was this patient intubated pre-hospital because of concerns about the patient's ability to maintain a patent airway, spontaneously
breathe, or maintain oxygen saturation?
• Does the patient require an immediate medication, or other hemodynamic intervention such as volume replacement or blood?
• Does the patient meet any of the following criteria: already intubated, apneic, pulseless, severe respiratory distress, SpO2 < 90
percent, acute mental status changes, or unresponsive?
WHAT
HAPPENS
TO ESI
LEVEL 1
PATIENTS?
AVPU SCALE
DECISIVE POINT B: SHOULD THE PATIENT
WAIT?
• Is this a high-risk situation?
• Is the patient confused, lethargic, or disoriented?
• Is the patient in severe pain or distress?
• Patients who answer yes are ESI Level 2.

• The high-risk patient is one who could easily deteriorate, one who could have a threat to life, limb, or organ. This is
where the experience of the nurse comes into play.
• The clinical experience of the nurse allows for pinpointing the unusual presentations of diseases that may progress
with rapid deterioration.
DECISION POINT C: RESOURCE NEEDS

• How many different resources do you think this patient is going to consume for the physician to
reach a disposition decision? None, One, or Many?
• None = ESI Level 5
• One = ESI Level 4
• Many = Go to Decision Point D
DECISION
POINT D:
THE
DANGER
ZONE
VITALS
DANGER ZONE VITALS PRESENT?

Yes! No.
Consider Consider
ESI Level 2 ESI Level 3
ESI IN SUMMARY

• In summary, the ESI is a five-level triage system that is simple to use and divides patients by acuity
and resource needs.
• The ESI triage algorithm is based on four key decision points.
• A. Does this patient require immediate lifesaving intervention?
• B. Is this a patient who should not wait?
• C. How many resources will this patient need?
• D. What are the patient's vital signs?

• The experienced ED RN will be able to triage patients using this system rapidly and accurately.
TRIAGE IN • Triage ensures that patients receive care in an
appropriate and timely manner by the emergency
SUMMARY department staff, thus limiting their injuries and
complications.
• Nurses must have the proper clinical judgement skills
to scan a crowded emergency department for
critically ill patients and move them to the front.
• There are various triage systems, but the final goal of
triage is to supply effective and prioritized care to
patients while optimizing resource usage and timing.
THANK YOU.
REFERENCES

● http://ctas-phctas.ca/wp-content/uploads/2018/05/participant_manual_v2.5b_november_2013_0.p
df
● https://www.ncbi.nlm.nih.gov/books/NBK557583/
● https://riverview.org/downloads/pdfs/rvh-ems-start-and-jump-start-mci-triage-tools.pdf
● https://www.researchgate.net/publication/51701713_Emergency_Department_Triage_An_Ethical
_Analysis/figures?lo=1&utm_source=google&utm_medium=organic
● http://www.emro.who.int/emhj-volume-16-2010/volume-16-issue-6/article-18.html
● https://remm.hhs.gov/startadult.htm
● https://remm.hhs.gov/startpediatric.htm
● https://www.uptodate.com/contents/prehospital-care-of-the-adult-trauma-patient?search=triag
e&sectionRank=1&usage_type=default&anchor=H5&source=machineLearning&selectedTitl
e=1~150&display_rank=1#H5