TRIAGE

• Triage


  A system wherein there is assignment of degrees of urgency to wounds or illnesses, to decide the order of treatment of a large number of patient or casualties

  
• Modern Triage Systems


  • 3 level triage to 5 level systems → greater precision and reliability compared to older systems
  • Use of vital signs and clinical descriptors → used to describe physiological conditions and illnesses

  
• Triage System Features


  • Single entry point: For incoming patients for a uniform assessment process
  • Physical plant for triage: Suitable for real quick assessment
  • Organized system of patient information: From patient entry to the ED
  • Data source on ED Activity

  
• Undertriage


  Occurs when patients are triage on the work of prioritization compared to their level of urgency and this has the potential to risk and adverse outcome due to prolonged waiting time
• Overtriage


  Opposite of undertriage → patient is triage to higher prioritization, this increases waiting time for other patient who may then be at risk
• Potential for adverse events highlights the importance of triaging
• Australian Triage Scale (ATS)

  • Modern System, Guidelines an institution can adopt and modify
  • Five level triage system
  • Each category has a maximum waiting time associated with the level of acuity
• ATS Categories


  • Category 1: Immediately life threatening
  • Category 2: Imminently life threatening
  • Category 3: Potentially life threatening
  • Category 4: Potentially life-serious
  • Category 5: Less urgent
• Initial assessment


  1. General appearance, airway, breathing, circulation, disability and environment

  2. Unstable: immediate categorization → assigned to appropriate ATS category and handed over to the waiting staff

  3. Stable: limited history is taken and appropriate ATS category is assigned
• Category 1


  • Highest acuity level
  • Immediately Life Threatening → require immediate aggressive intervention
• Category 1 conditions


  • Cardiac/respiratory arrest
  • Airway occlusion
  • Depressed respiration
  • Extreme respiratory Distress
  • Shock (BP < 80)
  • Unresponsive patients
  • Decreased sensorium (GCS <9)
  • Active seizures
  • Suspected opioid overdoses
  • Severe behavioral disorders with immediate threat of violence
• Category 2


  • 2nd highest acuity level
  • Imminently life threatening → serious enough or deteriorating so rapidly that has potential threat to life or organ failure if not treated within 10 minutes
  • Assessment and treatment within 10 minutes
• Category 2 conditions


  • Very Severe pain
  • Airway risk
  • Severe respiratory distress
  • Circulatory compromise → indicated by cold clammy skin, bradycardia, tachycardia or severe blood loss
  • GCS 9-12
  • Cardiac chest pain of lightly cardiac nature
  • Sepsis
  • Febrile neutropenia
  • Hypoglycemia
  • Acute stroke
  • Fever with lethargy
  • Acid or alkali eye injury
  • Endophthalmitis (suspected)
  • Multiple trauma
  • Severe localized trauma
  • Testicular torsion (suspected)
  • Pulmonary embolism (suspected)
  • Aortic dissection
  • Ectopic pregnancy
  • Significant sedative ingestion
  • Envenomations
  • Violent psychiatric patients
• Category 3


  • Potentially life-threatening conditions
  • Assessment and treatment within 30 minutes → significant morbidity if not treated within 30 minutes
• Category 3 conditions


  • Severe hypertension
  • Moderate to severe blood loss
  • Moderate shortness of breath
  • Prior seizure but now alert
  • Persistent vomiting
  • Dehydration
  • Head injury but awake
  • Stable septic patients
  • Moderately severe pain
  • Abdominal pain
  • Moderate limb injury
  • Stable neonates
  • Children at risk of abuse
  • Psychiatric patients that are potentially aggressive
• Category 4


  • Potentially serious conditions
  • Assessment and treatment within 60 minutes
  • Time critical within one hour
  • Conditions that require workups, specialty consultation or inpatient management
• Category 4 conditions


  • Mild hemorrhage
  • Foreign body aspiration with NO respiratory distress
  • Chest injury with no distress
  • Dysphagia
  • Minor head injuries
  • Vomiting and diarrhea without dehydration
  • Eye inflammation or foreign body with normal vision
  • Minor limb trauma
  • Swollen joint
  • Nonspecific abdominal pain
  • Psychiatric patients with no immediate risk to self or others
• Category 5


  • Less urgent
  • Assessment and treatment within 120 minutes
• Category 5 conditions


  • Clinico-administrative tasks
  • Certificates
  • Prescription refills
  • Minimal pain
  • Asymptomatic patients
  • Minor symptoms
  • Existing stable illness
  • Minor wounds
  • Scheduled revisits
  • Immunizations
  • Psychiatric patients who are clinically well
• Prehospital triage in disaster and multiple casualty situations are a bit different to triage in ED, expectations that there may be casualties that may not be survive despite any medical attention given, and the situations we have is a limited resources that cannot be allocated in such patients
• START


  • Simple Triage And Rapid Treatment
  • Color-coded triage categories

  
• START Triage Categories


  • Black: Victim unlikely to survive given severity of injuries, level of available care, or both
  • Red: Victim can be helped by immediate intervention and transport
  • Yellow: Victim's transport can be delayed
  • Green: Victim with relatively minor injuries
• Sequence of assessment in START triage

  1. See if the patient is ambulatory

  2. Check for spontaneous breathing

  3. Check the respiratory rate

  4. Check the perfusion

  5. Check the mental status

  
• JUMPSTART Triage


  • Was validated and was used for adults similar triage system exists for pediatric patients involved in multiple casualty incidents
  • Difference in START triage adult patient – pulse palpated if there's no breathing, adult patient are not assess for pulse
• AVPU Scale


  • A: Alert (GCS 15)
  • V: Verbal (GCS 12-13)
  • P: Pain (GCS 8-9)
  • U: Unresponsive (GCS 3)
• Triage is DYNAMIC, whether hospital or prehospital setting, a patient triage level is not a setting stone, triage can CHANGE, REASSESS and RETRIAGE as her/his condition dictates