Emergency Preparedness 9: Triage Portal
Triage is used to classify patients for care based on the severity of their injuries or illnesses with the objective of doing the most good for the greatest number of people. Triage is essential, particularly when large numbers of patients present themselves to health care facilities with limited resources for treating them.
The basic determination at initiation of triage is to classify patients based on the urgency of the patient’s need for care. Patients can be classified into one of three broad categories:
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Patients with severe injury or illness who must receive immediate treatment in order to have a good chance of survival.
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Patients with less serious illness or injury who will live despite a delay in care.
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Patients with severe injuries or illnesses who will die despite receiving optimal extensive care.
Triage occurs in phases. Primary triage takes place early in an incident, when the provider team first contacts patients. After initial triage of patients, treatment is begun on the most seriously injured or ill patients who are potentially salvable. From this point on, triage needs to be ongoing, since the condition of any given patient may deteriorate over time. Changes in patients’ conditions may require the team to upgrade the patient’s triage category. This ongoing process is referred to as secondary triage.
Adult Triage
The START
Triage System1: START, an acronym
for Simple Triage and
Rapid
Transport, is a widely used triage system. (See algorithm
at the back
of this portal.) START is the adult triage mass casualty incident (MCI)
tool most commonly used in the United States (as well
as many
other countries in the world). START is easy to use and separates
patients into four general categories based on their immediate need for
treatment rather then on a specific diagnosis. START triage categories
include:
Priority |
Treatment Category |
Color |
Priority 1 (P-1) |
Need immediate care |
Red |
Priority 2 (P-2) |
May delay care |
Yellow |
Priority 3 (P-3) |
Hold for later evaluation |
Green |
Priority 0 (P-0) |
Deceased |
Black |
Signs or symptoms used to define a patient’s triage category:
Questions
about four basic sign or symptom complexes are used to divide patients
into one of the triage categories. These complexes with their
accompanying questions include:
Assess ability to walk: Is the patient able to walk?
Assess respiratory effort: Is the patient breathing? What is the patient’s respiratory rate?
Assess pulses/perfusion: Does the patient have a radial pulse?
Assess neurological status: Is the patient able to follow a command to grip both of your hands?
Assess ability to walk
The
initial question is to ask patients able to walk to get up and come to
you. Patients who can independently complete this act, in spite of
their injuries, are categorized as green or Priority 3 (P-3). These
patients should be confined to one site, rather than being allowed to
wander around the treatment scene.
Assess respiratory effort
The
triage process next distinguishes non-walking patients. At this stage,
treatment efforts should be directed only toward correction of airway
problems and severe bleeding. If a patient is not breathing, open his
or her airway manually to assess breathing effort. If the patient
starts to breathe spontaneously, he or she is tagged as red or Priority
1 (P-1). Those who fail to breathe on their own when their airways are
opened are categorized as black (or deceased) or Priority 0 (P-0). For
patients who are initially breathing on their own, quickly access their
respiratory rate. Patients with a respiratory rate > 30/minute
are
tagged red or Priority 1 (P-1). For patients with a respiratory rate
< 30/minute, go to the next assessment step.
Assess pulse/perfusion
The
assessment of circulatory state is performed next. While the evaluation
of capillary refill (assuming a time of > 2 seconds as abnormal)
has
commonly been used as a quick method to assess circulatory status, it
is a poor indicator of perfusion in adults, especially in cold weather.
A better way to assess perfusion is to evaluate the presence of a
radial pulse, which (if present) indicates a systolic blood pressure of
at least 80 to 90 mm Hg. Patients without radial pulses are tagged red
or Priority 1 (P-1). For patients with a respiratory rate <
30/minute and a radial pulse, go to the next assessment step.
Assess neurologic status
The
final step is the assessment of mental status is accomplished by asking
the patient to “grip both of my hands.” If the patient can perform this
simple task, they are categorized as yellow or Priority 2 (P-2). If
they cannot follow this simple command, they are tagged as red or
Priority 1 (P-1).
Triage Tagging/Labeling
Attach a
color-coded tag to each patient as soon as they have been categorized.
This provides each patient with a priority in treatment and prevents
the need to repeatedly re-triage the same patient.
Treatment
Care
rendered to the patients triaged follows the CALS Universal Approach to
Critically Ill or Injured Patients. (Vol I—Acute Care Portals) The red
treatment group of patients (Priority 1) will receive the bulk of the
early medical resources. The yellow treatment group of patients
(Priority 2) needs to be reassessed on a regular basis to be sure they
do not deteriorate. The green treatment group of patients (Priority 3)
needs to be periodically monitored for a change in their status. This
can usually be assigned to an uninjured person who may not have a
medical background. When time allows, the green group will be further
assessed as to their need for further evaluation and/or treatment.
Deceased patients (Priority 0 or black) are placed in an area
designated as the morgue. This area should have access controlled so
that bystanders or the media cannot enter.
Pediatric Patients
The
JumpSTART Pediatric Triage Tool (see JumpSTART algorithm) was designed specifically for the triage of children in the
multicasualty/ disaster setting. JumpSTART was developed in 1995 to
parallel the structure of the START system.
The goals of JumpSTART are to optimize the primary triage of injured children in the MCI setting, enhance the effectiveness of resource allocation for all MCI victims, and reduce the emotional burden on triage personnel who may have to make rapid life-or-death decisions about injured children in chaotic circumstances.
JumpSTART provides an objective framework to help prevent over triage, which might divert resources from more seriously injured patients. Under triage is addressed by recognizing the appropriate pediatric physiologic parameters at decision points.
JumpSTART was designed for use in disaster/multicasualty settings, not for daily EMS or hospital triage. JumpSTART is intended for the triage of children with acute injuries and may not be appropriate for the primary triage of children with medical illnesses in a disaster setting.
Reference
The Start System. Hoag Memorial Hospital in Newport Beach, CA.
START TRIAGE METHOD ALGORITHM*
Taken from the web site of the Canadian Coast Guard, http://www.ccg-gcc.gc.ca/folios/00027/docs/algorithms-eng.pdf
Taken from the JumpSTART Pediatric MCI Triage Tool web site http://www.jumpstarttriage.com/The_JumpSTART_algorithm.php