TRIAGE SYSTEM

Review TRIAGE
• Triage (Trier = to sort out or choose): A process which places the
right patient in the right place at the right time to receive the right
level of care
• Triage: essential, effective system to reduce waiting time, and
patient receive the appropriate treatment (Nuttal; Bailey, Hallam
& Hurst as cited in McNally, 1996).
• Developed in the battlefields
• Concept used for disasters
• Implemented in EDs from 1950s for 2 reasons
 Categories of triage
Daily triage
- To identify the sickest patients: assess and provide treatment to
them first, before providing treatment to others who are less ill.
- The highest intensity of care is provided to the most seriously ill
patients, even if those patients have a low probability of survival.

Incidental triage
- ED: a large number of patients but is still able to provide care
to all victims utilizing existing agency resources.
- Additional resources are used but disaster plans do not have
to be activated.
- The highest intensity of care is still provided to the most
critically ill patients.
Categories of triage (cont’)
• Disaster triage
– A paradigm shift from “rapid, high tech care to
the most unstable or acutely ill”
– To “doing the greatest good for the greatest
number”
– To identify injured or ill patients who have a
good chance of survival with immediate care
that does not require extraordinary resources.
Categories of triage (cont’)
• Tactical-military triage
– Similar to disaster triage, only miliatary
mission objectives

• Special conditions triage

– Ex. epidemic: triage to prevent secondary
transmission
• Susceptible, exposed, infectious, removed,
vaccinated
Triage system
• Phone triage : Criteria Based
dispatch
• Scene triage : START&SAVE vs.
SIEVE & SORT
• ED triage : ESI, ATS, MTS, CTAS
 Emergency
Department “TRIAGE”
 In Hospital: Daily Triage
• Three-tier system
– Emergent Urgent Nonurgent
Class 1 Class 2 Class3
• Four-tier system
– Emergent Emergent Urgent Nonurgent
Class 1A Class 1 Class 2 Class3
• Five-tier system
– Emergent Emergent Urgent Nonurgent Nonurgent
Class 1A Class1 Class 2 ED care Ambulatory Care
Class3 Class 4
- ATS - CTAS - ESI - Manchester - etc
Prehospital and Disaster: Triage
• Simple Triage and Rapid Treatment
(START) system: for triaging adults

• JumpSTART system: for triage pediatric

• Start/Save: when the triage process must

be over an extended period of time
START system
• Can walk Delayed (GREEN)
• RPM (30-60 sec)
– R > 30
– P > 2 seconds Critical (RED)
– M = doesn’t obey command
– R < 30
– P < 2 seconds Urgent (YELLOW)
– M = obeys command
– R = not breathing Expectant: dead
or dying (BLACK)
 Start Triage Minimal
injury

No Is patient breathing? Yes

> 30 BPM < 30 BPM

Open Patient’s Yes Immediate
airway Care No Is radial pulse
present?
No
Control Yes
Dying bleeding
No Assess mental status
Can patient follow
commands?
Yes
Delayed care
Nursing practice during a disaster

Assess situation
Assess victims
Safe life
Call for help Safe limp
First aid
Transfer
Safe function
Assess situation:
• Scene safety: self, patient, other
• Aware of risk, hazards, environment
(second bomb)
• Recognize nature of problem: medical or
trauma, number of patients, do you need
more help?
• Always use basic safety instruction (BSI):
gown, gloves, glass, mask
Assess victims:
• Initial assessment: general impression:
cause, severity, mental status, airway,
breathing, circulation, set priority (Triage)
• History and physical examination
• Detail physical examination
• Ongoing continue assessment
• Communication and documentation
 Nursing assessment
• A: Assess Airway
• B: Breathing
• C: Circulation, V/S, shock
• Burn assessment
• Pain assessment
• Trauma assessment head to toe
• Mental status assessment
• Know indications for intubation
• IV administration (Fluid therapy)
• Emergency medication
 Nursing therapeutics
• Concepts of basis first aid
• Triage and transport & transfer
• Pain management
• Management of hypovolumia and fluid replacement
• Suturing
• Blast injuries/ tissue loss
• Eye lavage
• Decontamination of chemical exposure
• Fractures/immobilization of fracture
• Management of hemorrhage
• Stabilization of crush injuries
• Movement of patients with spinal cord injury
Competencies for RN related
to mass causality incidents

• Critical thinking
• Assessment
• Technical skills
• Communication
• Ethics
• Human diversity

Stanley, 2005
 Critical thinking

• Use an ethical and nationally approved

framework to support decision making and
prioritizing needed in disaster situations

• Use clinical judgment and decision making

skills in assessing the potential for appropriate,
timely individual care during an MCI

Stanley, 2005
Assessment
• General
– Assess the safety issues for self, the response
team, and victims in any given response situation,
in collaboration with the incident response team
– Identify possible indicators of a mass exposure
– Describe the essential element included in an
MCI scene assessment
• Specific
– Focus health history
– Assess the immediate psychological response
– Perform health assessment: airway,
cardiovascular, integumentary (wound, burn,
rash), pain, injury from head to toe, GI,
neurologic, musculoskeletal, mental status
spiritual emotional
Stanley, 2005
 Technical skills
• Demonstrate safe administration of medications
• Demonstrate safe administration of immunizations
• Assess the need for and initiate the appropriate
isolation and decontaminated procedures
• Demonstrate knowledge and skill related to
personal protection and safety
• Demonstrate the ability to maintain patient safety
during transport through splinting, immobilizing,
monitoring
Stanley, 2005
Communication
• Describe the local chain of command and
management system
• Identify one’s own role
• Demonstrate appropriate emergency
documentation of assessments, intervention,
nursing action, and outcomes
• Identify appropriate resources for referring
• Describe appropriate coping strategies to
manage self and others

Stanley, 2005
Ethics
• Identify and discuss ethical issue
related to MCI event
• Describe the ethical, legal,
psychological , and cultural
considerations when dealing with the
dying and etc.

Stanley, 2005
Human diversity
• Discuss the cultural, spiritual, and
social issues that may affect on
individual’s response to an MCI
• Discuss the diversity of emotional,
psychological and socio-cultural
response

Stanley, 2005
 ASSESSMENT &
PRIORITY SETTING

33 Triage - SOAP
 Objectives

• To list the steps of the SOAP process

• To describe how to carry out each step of
the SOAP process

34 Triage - SOAP
 Assessment Guide

• History from patient/relative/others

• The 5 senses including Common
Sense

35 Triage - SOAP
 Use the Five Senses

SIGHT SMELL
• general appearance • alcohol
(head to toe) • ketone bodies
• obvious signs of • malaena stools
injuries
• body language

36 Triage - SOAP
 Use the Five Senses

HEARING
• listen attentively
• ? shortness of breath
• ability to talk in complete
sentences

TOUCH
• skin temperature
• palpate for quality of pulse,
tenderness, swelling

37 Triage - SOAP
 Assessment & Priority
Setting
Purpose of Triage
• not to diagnosis
• but to assess and plan intervention

SOAP System
• organized & systematic approach
• formulated by Larry Weed
• problem - orientated medical record system

38 Triage - SOAP
 WHAT IS SOAP?
S - Subjective
Collect data from what patient tells you
O - Objective
What are you actually seeing?
Parameters
A - Assessment
Assess the situation
P - Plan
Establish a plan for the patient
Investigations
Interventions
Priority

40 Triage - SOAP
 Triage Process
S - SUBJECTIVE
Collect subjective data
• Ask open ended questions e.g.
“What is the reason you want to see a doctor?”
• Gather other relevant information
• Obtain brief one-line statements
• AMPLE if not
• SAMPLE

41 Triage - SOAP
 Trauma Cases
Mechanism of injury must be noted
1. Ask how the patient was injured
2. Other Questions
n When did the accident occur?
n How fast was the car travelling?
n Where were you sitting?
n Were you wearing a seat belt?
n Did you hit the dashboard and were you thrown
against another car?
n Did you lose consciousness?

43 Triage - SOAP
 O - OBJECTIVE
Collect objective data :
General
• Mode of arrival to ED
• Level of consciousness; GCS (Trauma Case)
• Patient’s general appearance using your senses

Vital signs
• temperature,pulse, respiration, BP, SpO2 & pain
score

44 Triage - SOAP
 A - Assessment

Assess and evaluate patient based on

subjective and objective data findings

45 Triage - SOAP
 A - Assessment
• Carry out further tests if required
– ECG
– Peripheral blood glucose
– Urine Combur 9
– Urine HCG
– X-ray

• Institute first aid management

– Immobilize fracture
– Put on cervical collar
– First aid dressing
46 Triage - SOAP
P - PLAN
• Establish your priority & direct to appropriate
area.

Triage - SOAP 47