Triage is a process of prioritizing patients based on the severity of their condition so as to treat as many as possible when resources are insufficient for all to be treated immediately. The term comes from the French verb trier, meaning to separate, sort, sift or select. There are two types of triage: simple triage and advanced triage.
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. It is not intended to supersede or instruct medical personnel or techniques. It may serve as an instructive example, and has been (2003) taught to California emergency workers for use in earthquakes. It was developed at Hoag Hospital in Newport Beach, California for use by emergency services. It has been field-proven in mass casualty incidents such as train wrecks and bus accidents, though it was developed for use by CERTs and firemen after earthquakes.
Triage separates the injured into four groups:
However, these descriptive words are by no means standard; different regions use different designations.
In the UK and Europe, the triage process used is similar to that of the United States, but the categories are different:
A simplified but effective description of the S.T.A.R.T. is taught in the Israeli army to non-medical personnel: the injured who are lying on the ground silently should be prepared for immediate transportation; injured lying on the ground but screaming are injured whose transportation can be delayed; and the walking wounded need help less urgently. Non-medical personnel have no authority to tag an injured person as deceased.
In Western Europe, the criterion used for this category of patient is a trauma score of consistently at or below 3. This can be determined by using the Triage Revised Trauma Score (TRTS), a medically validated scoring system incorporated in some triage cards.
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, 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 provided back in time, the receiving hospital doctor can see a historical trauma score going back in time to the incident. This should allow more definitive treatment to be carried out earlier than might otherwise be the case.
Note that this scale is more complex than simple triage. Medical professionals should refer to professional texts and training references when implementing advanced triage; this listing is only for a layman's understanding.
Some crippling injuries, even if not life-threatening, may be elevated in priority based on the available capabilities. During peacetime, most amputations may be triaged "Red" because surgical reattachment must take place within minutes, even though in all probability the person will not die without a thumb or hand.
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:
However any Group, Individual and/or Hospital Triage system can be used at the appropriate level of evaluation.
This triage is performed by a physician called médecin trieur (sorting medic). This triage is usually performed at the field hospital (PMA–poste médical avancé, i.e. forward medical post). The absolute urgencies are usually treated onsite (the PMA has an operating room) or evacuated to a hospital. The relative urgencies are just placed under watch, waiting for an evacuation. The involved are addressed to another structure called the CUMP–Cellule d'urgence médico-psychologique (medical-psychological urgency cell); this is a resting zone, with food and possibly temporary lodging, and a psychologist to take care of the brief reactive psychosis and avoid post-traumatic stress disorder.
In the emergency room of a hospital, the triage is performed by a physician called MAO–médecin d'accueil et d'orientation (reception and orientation physician), and a nurse called IOA– infirmière d'organisation et d'accueil (organisation and reception nurse). Some hospitals and SAMU organisations now use the "Cruciform" card referred to elsewhere.
Another system is the Cruciform and Manchester triage.
For routine emergencies, many locales in Canada now employ the Canadian Triage and Acuity Scale for all incoming patients. The system categorizes patients by both injury and physiological findings, and ranks them by severity from 1-5. The model is used by both paramedics and E/R nurses, and also for pre-arrival notifications in some cases. The model provides a common frame of reference for both nurses and paramedics, although the two groups do not always agree on scoring (particularly when there is a shortage of available beds in the E/R) results. It also provides a method, in some communities, for benchmarking the accuracy of pre-triage of calls using AMPDS (What percentage of Delta calls have return priorities of CTAS 1,2,3, etc.)and these findings are reported as part of a municipal performance benchmarking initiative in Ontario. Curiously enough the model is not currently used for mass casualty triage, and is replaced by the START protocol and METTAG triage tags.
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 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.
|T1 (I)||acute danger for life||immediate treatment, transport as soon as possible||arterial lesions, internal haemorrhage, major amputations|
|T2 (II)||severe injury||constant observation and rapid treatment, transport as soon as practical||minor amputations, flesh wounds, fractures and dislocations|
|T3 (III)||minor injury or no injury||treatment when practical, transport and/or discharge when possible||minor lacerations, sprains, abrasions|
|T4 (IV)||no or small chance of survival||observation and if possible administration of analgesics||severe injuries, uncompensated blood loss, negative neurological assessment|
|T5 (V)||deceased||collection and guarding of bodies, identification when possible||dead on arrival, downgraded from T1-4, no spontaneous breathing after clearing of airway|
Also, not every major injury automatically qualifies for a red tag, a patient with a traumatic amputation of the forearm might just be tagged yellow, his bleeding stopped and he being sent to a hospital when it is possible.
After the preliminary assessment, a more specific and definite triage will follow, as soon as patients are brought to a field treatment facility. There, they will be disrobed and fully examined by an emergency physician. This will take approximately 90 seconds per patient.
1) Those who are likely to live, regardless of what care they receive; 2) Those who are likely to die, regardless of what care they receive; 3) Those for whom immediate care might make a positive difference in outcome.
The truth is that for many EMS systems, a similar model can sometimes still be applied. Once a full response has occurred and many hands are available, virtually every paramedic will use the model included in their service policy and standing orders. In the earliest stages of an incident, however, when there are one or two paramedics and twenty or more patients, sheer practicality demands that the above model will be used. As in virtually all aspects of EMS, there are times when 'back to basics' is the only approach that will be effective.
Modern approaches to triage are more scientific. The outcome and grading of the victim is frequently the result of physiological and assessment findings. Some models, such as the START model, are committed to memory, and may even be algorithm-based.
Burstein, J. L. & Hogan, D. E. (2007). Disaster Medicine (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
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