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G
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TRIAGE
The best for the most with the
least by the fewest.
 HISTORY
 The word “triage”, arising from the French
“trier” meaning “to sort” has its origins in
Latin.
 DEFINITION
 Triage is a brief clinical assessment that
determines the time and sequence in which
patients should be seen in the ED or, if in the
field, the speed of transport and choice of
hospital destination
 PRIMARY OBJECTIVES
 Promptly identify patients requiring
immediate, definitive care
 Determine the appropriate area for treatment
 Facilitate patient flow through the ED and
avoid unnecessary congestion
 PRIMARY OBJECTIVES
 Provide information and referrals to patients
and families
 Allay patient and family anxiety
 Enhance favorable public perceptions of and
experiences with emergency services
 Triage is not only a necessity, but
a major component of the
Emergency Medical System
 TYPES OF ED TRIAGE
SYSTEMS
 Very diverse
 Developed according to the institution’s and
department’s needs
 Should be tailored to meet the common goals
of triage
 TYPES OF ED TRIAGE
SYSTEMS
 # of patients and severity of injuries <
resources
 Life threatening injuries are treated first
 # of patients and severity of injuries >
resources
 Patients with greatest chance of survival are
treated first
 TYPES OF ED TRIAGE
SYSTEMS
 Type I: Traffic Director-Triage
 most basic type
 greeting or traffic directing is performed by a non-
professional
 how “sick” the patient looks determines
classification as emergent or nonurgent
 TYPES OF ED TRIAGE
SYSTEMS
 Type II: Spot-check Triage
 “quick look” system
 RN or MD obtains info and limited
subjective/objective data related to chief complaint
 emergent, urgent, delayed
 TYPES OF ED TRIAGE
SYSTEMS
 Type III: Comprehensive Triage
 most advanced system of triage
 assessment and prioritization performed by an
experienced RN
 use of sophisticated triage categories
 standards followed for assessment, planning and
intervention
 COMPREHENSIVE TRIAGE
GOALS
 Identification of patients with life-threatening
problems
 Regulation of patient flow
 Efficient use of resources and space
 APPLICATIONS
 TRAUMA
 DISASTER
 PREHOSPITAL
 OUTBREAKS
 EMERGENCY DEPARTMENT
 START SYSTEM
 Simple Triage and Rapid Treatment
 Created in the 1980”s by Hoag Hospital and
the Newport beach CA Fire Department
 Allows rapid assessment of victims
 It should not take more than 15 seconds/
patient
 START SYSTEM
 Classification based on 3 categories:
 Respiration
 Perfusion
 Mental status
 Medical Screening Examination
 Chief complaint - High acuity, high risk, true emergency
 Vital signs - Grossly abnormal
 Mental status - Evidence of abnormalities
 General appearance - Patient looks sick, patient's skin
looks poorly perfused, patient shows signs of
dehydration
 Ability to walk - Patients who cannot walk are at high
risk for true emergency medical conditions.
 METHODS
 The majority of US Emergency Departments
use 3-level triage:
 Emergent– requires immediate evaluation &
treatment
 Urgent–can tolerate a period of time in the waiting
room
 Non-urgent–minor illness/injury that can be
treated within six hours
 Emergent
 Life and limb threatening conditions
 Immediate care within seconds
 cardiac arrest, acute severe chest pain, massive
vomiting of blood, sudden loss of
consciousness, and major trauma with
hypotension
 Reassessment is continuous
 Urgent
 Requires prompt care but will not cause loss of
limb or life if left untreated for hours
 acute dyspnea, acute abdominal pain, acute
chest pain, acute confusion, and severe pain.
 abdominal pain, high fever, acute back pain,
serious extremity injuries, and large or high-
risk lacerations
 Reassessment is every 30 minutes
 Non-urgent
 Disorders are chronic, minor, or self-limiting.
 medication refill, acne, mild adult upper
respiratory tract symptoms, mild sore throat,
blood pressure check, and lumps and bumps.
Keep in mind that no matter how minor, these
patients may still require an MSE if they
request treatment or evaluation
 Reassessment is every 1 to 2 hours
 Who should do triage?
 Early studies showed little difference in
predicted outcomes of patients when
physicians, as opposed to nurses, perform
triage
 However, more recent studies suggest that
experienced emergency medicine (EM)
physicians and EM nurses actually may
provide the best triage
 Pitfalls
 Failure to recognize and attend to a patient
who complains of severe pain
 Failure to recognize or acknowledge high-risk
chief complaints
 Failure to take adequate vital signs
 Pitfalls
 Failure to adequately document the triage
and/or MSE
 Failure to retriage patients initially assigned to
the waiting room: Patients assigned to a
waiting room should have vital signs retaken
every 2 hours
 CASES
 Case 1: A 36-year-old man presented
to the ED with severe chest pain. His
vital signs were blood pressure,
140/90 mm Hg; pulse, 120 beats per
minute (bpm); respiration, 20 breaths
per minute (bpm); and temperature,
99°F. Although the patient's pulse was
120, his respiratory rate was normal,
and he looked well.
 Case 2: A 43-year-old man presented to the
ED, complaining of a severe headache. The
patient had normal vital signs except for a
temperature of 39°C. The ED was very busy
and crowded.
 Case 3: A 65-year-old man
presented to the ED
complaining of groin pain.
He said the pain was
severe and he did not feel
well. His vital signs were
blood pressure, 150/95 mm
Hg; pulse, 108 bpm;
respiration, 22 bpm; and
temperature, 38°C.
 Case 4: A 55-year-old man
presented to the ED
complaining of abdominal
pain. He stated that he
thought his condition was
secondary to eating too
much greasy fast food too
rapidly. His vital signs
were blood pressure,
150/100 mm Hg; pulse,
100 bpm; respiration, 22
bpm; and temperature,
37°C.
 Case 5: A 22 year old
female came in due to acute
onset diarrhea. She had
about 6 episodes and had
severe epigastric pain. BP:
120/80, HR: 89 and RR: 23.
 Case 5: A five year old
female came in due to fever
and chills of five days
duration. HR: 110, RR: 30
and T: 40°C. The patient
had maculopapular rashes
all over.
 TRIAGE
EXAMINATION
YEAR LEVEL VI
2007
36/F
fell from a ladder on
outstretched hand
with gross deformity,
L forearm
40F, smoker
CC: Vaginal
bleeding
VS: BP 80/50
HR 90
RR 24
55M, hypertensive,
smoker
CC: Chest pain
VS: BP 90/50
HR 90
RR 24
56M, cook
CC: difficulty of
breathing
VS: BP 130/80
HR 90
RR 28
58M, smoker
CC: LLQ pain
VS: BP 120/80
HR 100
RR 24
19M, vendor
hit-and-run victim
unconscious
VS: BP 130/80
HR 90
RR 24
22F, student
CC: R shoulder pain
VS: BP 120/80
HR 80
RR 20
36M, non-smoker
CC: low back pain
VS: BP 130/80
HR 88
RR 22
44M, smoker
CC: amputated
index finger
VS: BP 130/80
HR 90
RR 24
41M, smoker
CC: foreign body
sensation R eye
VS: BP 130/80
HR 90
RR 24
56M, laborer,
smoker
CC: unconscious
VS: BP 130/80
HR 90
RR 24
40M, carpenter,
HPN
CC: fall
VS: BP 100/80
HR 90
RR 24
25M, student
CC: dog bite
VS: BP 120/80
HR 80
RR 20
30M, bodybuilder
CC: chest pain
VS: BP 130/80
HR 94
RR 26
40M, smoker
CC: electrocuted/fall
VS: GCS 15
BP 130/80
HR 90
RR 24
43M, smoker
CC: numbness,
lower extremities
VS: BP 130/80
HR 90
RR 24
40M, smoker
CC: epigastric pain
VS: BP 140/80
HR 92
RR 20
12M, vendor
CC: side-swiped by
a truck
VS: BP 120/80
HR 90
RR 24
40M, jockey
CC: fall
VS: BP 130/80
HR 90
RR 24
 QUESTIONS?
 The process we understand as triage was first
described by Baron Dominique Jean-Larrey
 First systematic description in civilian
medicine was from E. Richard Weinerman in
Baltimore in 1964