TRIAGE

TRIAGE

• It is the process of prioritizing which

patients are to be treated first and is the
cornerstone of good disaster management.
• It is a process which places the right patient
in right place at right time to receive the
right level of care.
TRIAGE CATEGORIES

1. Daily triage
2. Mass Casualty Incident (MCI) triage
3. Disaster triage
4. Tactical-military triage
5. Special conditions’ triage
TRIAGE CATEGORIES

1.Daily Triage
• Performed by nurses on a routine basis every
day in the emergency department.
• The highest intensity of care is provided to the
most seriously ill patients, even if they have a
low probability of survival.
TRIAGE VATEGORIES

2.Mass Casualty Incident (MCI) Triage

• Emergency department is stressed by a large
number of patients but remains functional;
seriously ill still receive highest intensity of
care.
• Additional resources are used but disaster plans
have not been activated.
TRIAGE CATEGORIES

3. Disaster Triage
• Local emergency services are overwhelmed to the point that
immediate care cannot be provided to everyone who needs it.
• “Do the greatest good for the greatest number.”
• Identify injured patients who have a good chance of survival
with immediate care.
• Four categories exist: lightly injured (can safely wait for care
without risk), seriously injured, critically injured, and
hopelessly injured.
TRIAGE CATEGORIES

4.Tactical-Military Triage
• Military mission objectives rather than
traditional nursing guidelines drive the triage
and transport decisions.
TRIAGE CATEGORIES

5.Special Conditions’ Triage

• Used when patients present from incidents
involving weapons of mass destruction (WMD)
such as radiation, biological, or chemical
contaminants; mandate Personal Protective
Equipments (PPE) for all healthcare personnel,
and decontamination capabilities at the family.
SUCCESSFUL DISASTER TRIAGE PRINCIPLES

• Successful disaster triage principles have

been derived from historical experience:
1. Never move a casualty backward (against the
flow).
2. Never hold a critical patient for further care.
3. Salvage life over limb.
4. Triage providers do not stop to treat patients.
TRIAGE SYSTEM

1. Simple Triage and Rapid Treatment (START)

system (for triaging adults)
2. JumpSTART system (for triaging pediatric
patients)
3. Start/Save
1. START System

• It is a triage system used for prehospital triage. Emergency Medical

Service (EMS) providers are normally the first responders to the
scene of a disaster and are very experienced in triage and the
START system.
• Victims are tagged with a corresponding colored triage tag,
provided with basic field care for stabilization, and transported in
order of priority.
• When a patient arrives at an Emergency Department (ED) with a
tag, the ED triage team must still triage the patient, as the
condition may have changed during transport.
2. JUMPSTART System

• Because the physiological indicators used in START are not appropriate when
assessing young pediatric patients, the JumpSTART system was created to
meet the unique needs of assessing children less than eight (8) years of age.
• Because it may be difficult to determine actual age during a disaster,
JumpSTART should be used if the victim “looks like a child” and START used
if the victim “looks like a young adult or older.”
• NOTE: JumpSTART was designed for use in disaster/multicasualty settings
and NOT for daily EMS or hospital triage. JumpSTART is also intended for the
triage of children with acute injuries and may NOT be appropriate for
primary triage of children with medical illness in a disaster setting.
3. START/SAVE

• The START and SAVE triage techniques are used in

situations in which triage is dynamic and occurs
over many hours to days, and only limited,
austere, field, advanced life support equipment is
readily available.
TRIAGE PROCESS
TRIAGE PROCESS

• Triage should be performed

RAPIDLY
• Utilize START/ JumpSTART
Triage to determine priority
• 30–60 seconds per patient
• Affix tag on left upper arm or
leg
TRIAGE PROCESS

1. Clear the “walking wounded” with verbal instruction:

If you can hear me and you can move, walk to…
• Direct patients to the casualty collection point (CCP) or treatment area
for detailed assessment and medical care
• Assign a Green Minor Manager to the area to control patients and manage
area
• Tag will be issued at the CCP
• These patients may be classified as MINOR
TRIAGE PROCESS

2. Now use START/JumpSTART to assess and

categorize the remaining patients…

USE COLORED RIBBONS ONLY

TRIAGE PROCESS

3. Categorize the patients by assessing each

patient’s RPMs…
Respirations

Pulse/perfusion

Mental Status
Using RPM to Classify Patients
CATEGORY (COLOR) START INDICATORS JumpSTART INDICATORS
R = Respiratory rate >30/min R = <15 or >45 breaths/min
P = Capillary refill >2 sec P= weak or non-existent distal
Critical (RED) pulse
M = Does not obey commands M = unresponsive or who gives an
inappropriate response to pain

R = <30/min R = between 15 and 45 breaths/min

Urgent (YELLOW) P = <2 sec P = with existent distal pulse

M = Obeys commands M= responsive or gives an appropriate
response to pain

Expectant: dead or dying (BLACK) R = Not breathing

• Respiration (position upper airway or determine respiratory rate)
• Perfusion/blood circulation (check capillary refill time)
• Mental status (determine patient’s ability to obey commands)
Using RPM to Classify Patients

• Assess for mental status in JumpSTART by

using AVPU system:
• Alert
• responds to Vocal stimuli
• responds to Painful stimuli
• Unresponsive
TRIAGE PROTOCOL (START)
TRIAGE PROCESS

If the patient is IMMEDIATE/RED upon initial assessment…then,

before moving the patient to the treatment area, attempt only
life-saving interventions:

Airway, Needle Decompression, Tourniquet, Antidote

DO NOT ATTEMPT ANY OTHER

TREATMENT AT THIS TIME
TRIAGE TAGS

• Many different types of tag systems are available. Tags are designed to be
attached to a patient’s arm or leg – not their clothing – and should contain as
much information about the patient as is possible (e.g., name, triage number,
triage category, decontamination status, presenting injury/complaint,
interventions performed, date/time, allergies, medication history, etc.).
• Some triage tags have perforated colored tabs for the different triage
classifications, so if the patient’s condition changes and deteriorates, the tag
may be torn again to the revised triage level/color. Others are all one color
(red, yellow, green, or black), and some include contamination or
decontamination information.
• All tags must be waterproof, easy to write on, easy to read, and clearly visible
when attached to the patient.
WHY TRIAGE AND TAG?

• Sorting of patients to provide for the survival of the

most patients
• Assignment of resources in the most efficient method
• Most severe survivable injuries receive rapid
treatment
• Accountability of patients
• Family reunification
TRIAGE TAGS

Apply ribbon to upper arm or upper thigh

TRIAGE TAGS

RED Triage Category (Immediate/Critical)

Adult Pediatric
Respirations > 30 BPM Respirations < 15 or > 45
CR > 2 seconds or CR > 2 seconds or no
no palpable radial pulse palpable radial or brachial
Cannot follow simple pulse
commands Inappropriate “Pain”
(e.g., posturing) or
Pneumothorax “Unresponsive”
Hemorrhagic Shock
Closed Head Injury
TRIAGE TAGS

YELLOW Triage Category (Delayed)

Adult: respirations, capillary refill, and mentation are normal
• Isolated burns
• Extremity fractures
• Stable other trauma
• Most patients with
medical complaints
Pediatric: “A,” “V,” or appropriate “P”
(e.g., withdrawal from pain stimulus)
TRIAGE TAGS

GREEN Triage Category (Minor)

• “Walking wounded”
• Psychological
casualties
• Always look for
children being
carried and assess
them
TRIAGE TAGS

GREY Triage Category (Expectant)

• This category is not currently in use and must
not be utilized until approved
• It is included on the paper tags in anticipation
of national recognition and acceptance in the
future
• GREY is for the patient that is not likely to
survive even with emergent interventions
TRIAGE TAGS

BLACK Triage Category (Deceased)

• Obvious mortality or death
(pulseless and apneic)
• Decapitation
• Blunt trauma arrest
• Injuries incompatible with life
(future GREY)
• Brain matter visible
(future GREY)
FRONT

BACK
TRIAGE TAGS

Triage Tag Sections

• Patient information • Vital signs
• Triage status • Medical history
• Chief complaint • Treatment
• Transporting unit • Family contact
• Peel-off bar codes • Wrist band
• Transport record

* Triage tags should be used in all MCI scenarios, even when

handheld device is employed
TRIAGE TAGS

PATIENT INFORMATION
This information is important not only for
patient identification but can also help with
family reunification. Frequently, the urgency
of the situation prevents obtaining this
information “up front.” It can be entered
when time allows.
TRIAGE TAGS

The paper triage

tag includes a
TRIAGE STATUS
GREY category for
Tags with a GREY
future use based
category are in use but
on anticipated
the category itself has not
national
been approved for use in
acceptance. the triage of patients.

IT WILL NOT BE
USED IN THE
TRIAGE OF
PATIENTS UNTIL
APPROVED.
TRIAGE TAGS

CHIEF COMPLAINT
The Chief Complaint section allows for
the categorization of trauma or medical
illness along with the opportunity to note
the body part or region involved. The
Comment section provides the
opportunity to include additional or more
specific information. For example, the
burn category is demarcated by a circle
and/or “X,” but you can describe the
burns as first, second, or third degree in
the comments section.
TRIAGE TAGS

TRANSPORTING UNIT
This section is filled out
by Transportation Group
Supervisor or Ambulance
Disposition Coordinator or
designee.
TRIAGE TAGS

PEEL-OFF BAR CODES

The peel off bar codes
are to be utilized to track
a patient through the
triage and transport
process. They can also be
used to identify and track
patient belongings.
TRIAGE TAGS

• Detachable as a TRANSPORT RECORD

tear-off and as a
peel-off sticky
This section has come to
label be known as the “Ticket”
• Used to document and contains a synopsis of
patient movement the patient’s personal
• Must be affixed to information, medical
Transport Tactical status, and transport
Worksheet with history.
the unit, priority,
and destination
marked and
initialed.

Commonly called
the “Ticket”
TRIAGE TAGS
Removable
wrist band has
been added
with an area
for DOB and
name

WRIST BAND
This is the new removable
wrist band. It can be
placed on the patient to
assist while utilizing the
HC Standard Patient
Tracking System.
 TRIAGE TAGS

VITAL SIGNS
This section allows the care provider to sequentially document the
R(espiration), P(ulse), and M(ental status) critical to the START (Simple
Triage And Rapid Treatment) and JumpSTART process described earlier.

Mental status is indicated by the common AVPU system: Alert,

responsive to Verbal stimuli, responsive to Painful stimuli, or
Unresponsive.

Blood pressure and oxygen saturation, while not part of the START
process, provide information that can help in making decisions for
medical care.

There are three sections to allow information to be recorded at different

times. After all, triage is a dynamic process.
TRIAGE TAGS

MEDICAL HISTORY
Medical history is usually
obtained as time allows.
 TRIAGE TAGS

TREATMENT
This section allows for the
documentation of the
treatments provided by
multiple providers at
different times in the
patient’s course of care.
Timed delivery of care is
especially important for
something like tourniquet
application.
TRIAGE TAGS

FAMILY CONTACT
This information is also
critical to family
reunification efforts.
TRIAGE SUMMARY

• Triage allows for effective and efficient care,

helping to increase the survivability for as
many patients as possible
• Assignment of resources will increase
efficiency
• Most severely injured patients will receive
rapid treatment and transport in logical order
• Ensures accountability of all patients
• Allows for family reunification
Thank You All for
Listening!
GOMER P. PONSO
UC-CON