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Triage |
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Triage (pronounced /ˈtriːɑːʒ/) is a process of prioritizing patients based on the severity of their condition. This facilitates the ability to treat as many patients 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 and advanced.1 The outcome 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, based upon the special needs of the patient or the balancing of patient distribution in a mass-casualty setting.
Note: It is important to note that triage has multiple meanings. The term may also refer to the allocation of space on a priority basis for patients arriving at the emergency department, or to nurse-driven telephone medical advice systems,2 among others. This article deals with the concept of triage as it occurs in medical emergencies, including the prehospital setting, disasters, and during emergency room treatment.
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Triage originated and was first formalized in WWI by French doctors treating the battlefield wounded at the aid stations behind the front. Much is owed to the work of Dominique Jean Larrey during the Napoleonic Wars. Historically, there has been a broad range of attempts to triage patients, and differing approaches and patient tagging systems used in a variety of different countries. Triage has, in fact, existed for a very long time, albeit without a particular appellation applied to the practice. Until recently, triage results, whether performed by a paramedic or anyone else, were frequently a matter of the 'best guess', as opposed to any real or meaningful assessment.3 In fact, triaging used to be taught with an emphasis on the speed of the function, rather than the accuracy of the outcome. At its most primitive, those responsible for the removal of the wounded from a battlefield or their care afterwards have always divided victims into three basic categories:
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. 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.5
Simple triage is usually used in a scene of a 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. The categorization of patients based on the severity of their injuries can be aided with the use of printed triage tags or colored flagging.6
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.7 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.
Simple triage identifies which people need advanced medical care. In the field, triage also sets priorities for evacuation to hospitals. In S.T.A.R.T., casualties should be evacuated as follows:
In advanced triage, doctors may decide that some seriously injured people should not receive advanced care because they are unlikely to survive. Advanced care will be used on patients with less severe injuries. Because treatment is intentionally withheld from patients with certain injuries, advanced triage has ethical implications. It is used to divert 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.
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.8
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.
In advanced triage systems, secondary triage is typically implemented by paramedics, battlefield medical personnel or by skilled nurses in the emergency departments of hospitals during disasters, injured people are sorted into five categories.
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.
In addition to the standard practices of triage as mentioned above, there are conditions where sometimes the less wounded are treated in preference to the more severely wounded. This may arise in a situation such as war where the military setting may require soldiers be returned to combat as quickly as possible, or disaster situations where medical resources are limited in order to conserve resources for those likely to survive but requiring advanced medical care. Other possible scenarios where this could arise include situations where significant numbers of medical personnel are among the affected patients where it may be advantageous to ensure that they survive to continue providing care in the coming days especially if medical resources are already stretched. In cold water drowning incidents, it is common to use reverse triage because drowning victims in cold water can survive longer than in warm water if given immediate BLS and often those who are rescued and able to breathe on their own will improve with minimal or no help.
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 effect 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:
However any Group, Individual and/or Hospital Triage system can be used at the appropriate level of evaluation.
In France, the triage in case of a disaster uses a four-level scale:
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.
In the UK, the commonly used triage system is the Smart Incident Command System, taught on MIMMS (Major Incident Medical Management (and) Support). The UK Armed Forces are also using this system on operations worldwide. This grades casualties from Priority 1 (most urgent) to Priority 4 (expectant, i.e. likely to die).
Another system is the Cruciform and Manchester triage.
In the mid-1980s, The Victoria General Hospital, in Halifax, Nova Scotia, Canada, introduced paramedic triage in its Emergency Department. Unlike all other centres in North America that employ physician and primarily nurse triage models, this hospital began the practice of employing Primary Care level paramedics to perform triage upon entry to the Emergency Department. In 1997, following the amalgamation of two of the city's largest hospitals, the Emergency Department at the Victoria General closed. The paramedic triage system was moved to the city's only remaining adult emergency department, located at the New Halifax Infirmary. In 2006, a triage protocol on whom to exclude from treatment during a flu pandemic was written by a team of critical-care doctors at the behest of the Ontario government.
For routine emergencies, many locales in Canada now employ the Canadian Triage and Acuity Scale for all incoming patients.9 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.10
During the food crisis of the early 1990s the People's republic of North Korea adopted a system of triage to allocate aid and food in order to ensure their military and high ranking cadres were allotted ample rations. This often left the population in the urban northvague in particular to scavenge for food or die.attribution needed
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 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.
Triage in a non-combat situation is conducted much the same as in civilian medicine. A battlefield situation, however, requires medics and corpsmen to rank casualties for precedence in MEDIVAC or CASEVAC. The triage categories, in precedence, are:
After, casualties are given an evacuation priority based on need:
In a naval combat situation, the triage officer must weigh the tactical situation with supplies on hand and the realistic capacity of the medical personnel. This process can be ever-changing, dependent upon the situation and must attempt to do the maximum good for the maximum number of casualties.
Field assessments are made by two methods: primary survey (used to detect & treat life-threatening injuries) and secondary survey (used to treat non-life threatening injuries) with the following categories:
Priorities can quickly change, therefore, triaging is considered to be an ongoing process.
NAVEDTRA 14295, Hospital Corpsman
The German triage system also uses 4, sometimes 5 colour codes to denote the urgency of treatment. Typically, every ambulance is equipped with a folder or bag with coloured ribbons or triage tags. The urgency is denoted as follows:
| category | meaning | consequences | examples |
|---|---|---|---|
| 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 | deceased | collection and guarding of bodies, identification when possible | dead on arrival, downgraded from T1-4, no spontaneous breathing after clearing of airway |
Preliminary assessment of injuries is usually done by the first ambulance crew an scene, after his arrival, the first Emergency physician an scene will take over. As a rule, there will be no cardiopulmonary resuscitation, so patients who do not breathe on their own or develop circulation after their airways are cleared, will be tagged "deceased".
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, have the bleeding stopped, and then be 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.
Alternative care facilities are places that are setup 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 event.
As most health care systems in the developed world continue to plan for an expected influenza pandemic, bioethical issues regarding the triage of patients and the rationing of care continue to evolve. It is anticipated that, as hospitals and treatment centres become overwhelmed, and as shortages of critical technologies begin to occur and supply chains begin to fail, methods will be required for determining who will receive access to life saving technologies, and who will not. To illustrate, the emergency department has all three of its' ventilators currently in use for elderly patients with influenza, who will not survive without them. Paramedics arrive with a forty year old, otherwise healthy patient who is being ventilated due to influenza, but for whom no hospital ventilator is currently available. How will the rationing of the ventilators be determined, by whom and using what criteria? Around the world, practitioners, bioethicists and others are wrestling with these questions. Research continues into alternative care, and various centres propose medical decision-support models for such situations.11 Some of these models are purely ethical in origin, while others attempt to use other forms of clinical classification of patient condition as a method of standardized triage.12
Undertriage and overtriage are two key concepts that are imperative to understanding the triage process. Undertriage is the process of 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 undertriage rates have been deemed 5% or less. Overtriage is the process of overestimating the level to which an individual has experienced 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 overtriage rates have been typically up to 50% in an effort to avoid Undertriage.
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