TRIAGE

Definition of TRIAGE
✓ the sorting of and allocation of treatment to patients and
especially battle and disaster victims according to a
system of priorities designed to maximize the number of
survivors.
✓ the sorting of patients (as in an emergency room)
according to the urgency of their need for care.

╺ https://www.merriam-webster.com/dictionary/triage
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The overall goal of TRIAGE
is to place the right patient
in the right place at the
right time for the right
reason.
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Triage Nurse
✓ Patients who need to be seen
immediately
VS
✓ Patients who are safe to wait for care

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TRIAGE
From the French word “trier” which means to
sort or choose.
The French used the word to designate a
“clearing hospital” for wounded soldiers.

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TRIAGE
The U. S. military used triage to describe a
sorting station where injured soldiers were
distributed from the battlefield to distant
support hospitals.

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START Triage
╺ A Simple Triage and
Rapid Treatment
plan designed for
first responders.

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DISASTER TRIAGE
In the event of a catastrophic occurrence, when the
number of incoming patients exceeds the capabilities
of a department, a system of disaster triage is
activated. The goal is the greatest good for the
greatest number of ill or injured.

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MILITARY TRIAGE
╺ A mass casualty event overwhelms immediately
available medical capabilities to include
personnel, supplies, and/ or equipment.
╺ The ultimate goals of combat medicine are the
return of the greatest possible number of
warfighters to combat and the preservation of
life, limb, and eyesight.

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MILITARY TRIAGE
Immediate: This group of injured requires attention within
minutes to 2 hours on arrival to avoid death or major disability.
The procedures in this category should focus on patients with a
good chance of survival with immediate intervention. Injuries
include:
➢ Airway obstruction or potential compromise.
➢ Tension pneumothorax.
➢ Uncontrolled hemorrhage.
➢ Torso, neck, or pelvis injuries with shock.

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MILITARY TRIAGE
➢ Head injury requiring emergent decompression.
➢ Threatened loss of limb.
➢ Retrobulbar hematoma.
➢ Multiple extremity amputations.

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MILITARY TRIAGE
Delayed: This group includes those wounded who are in need of
surgery, but whose general condition permits delay in treatment
without unduly endangering life, limb, or eyesight. Sustaining
treatment will be required (eg, fluid resuscitation, stabilization
of fractures, and administration of antibiotics, bladder
catheterization, gastric decompression, and relief of pain).
Injuries include:
➢ Blunt or penetrating torso injuries without signs of shock
➢ Fractures.
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MILITARY TRIAGE
➢ Soft-tissue injuries without significant bleeding.
➢ Facial fractures without airway compromise.
➢ Globe injuries.
➢ Survivable burns without immediate threat to life (airway,
respiratory) or limb.

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MILITARY TRIAGE
Minimal: This group has relatively minor injuries (eg, minor
lacerations, abrasions, fractures of small bones, and minor
burns) and can effectively care for themselves or be with
minimal medical care. These casualties may also provide a
resource for manpower to assist with movement or potentially
even care of the injured. When a mass casualty incident occurs
in close proximity to a medical treatment facility (MTF), it is
likely that these will be the first casualties to arrive, bypassing or
circumventing the casualty evacuation chain.
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MILITARY TRIAGE
Such casualties may inundate the facility leading to early
commitment and ineffective utilization of resources. To prevent
such an occurrence, it is imperative to secure and strictly control
access to the MTF immediately upon notification of a mass
casualty event.

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MILITARY TRIAGE
Expectant: This group has injuries that overwhelm current
medical resources at the expense of treating salvageable
patients. The expectant casualty should not be abandoned, but
should be separated from the view of other casualties and
intermittently reassessed. These casualties require a staff
capable of monitoring and providing comfort measures. Injuries
include:
o Any casualty arriving without vital signs or signs of life,
regardless of mechanism of injury.
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MILITARY TRIAGE
o Open pelvic injuries with uncontrolled bleeding and class IV
shock.
o Burns without reasonable chance for survival or recovery.
o High spinal cord injuries.

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Types of Hospital TRIAGE
“Traffic Director”
A nonclinical person is stationed at the ED entrance to greet
patients upon presentation. Based on his/her initial impression,
this nonclinical person decides if the patient should go to the
waiting room or an open ED bed.

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Types of Hospital TRIAGE
“Spot Check Triage”
For Emergency Departments that have a lower volume of visits.
These ED’s determine that it is not cost-effective to staff triage
with an RN for 24 hours a day. The RN is notified when a patient
presents. The RN does a quick look or brief assessment and
then assigns a triage acuity.

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Types of Hospital TRIAGE
“Comprehensive Triage”
ENA’s Standards of Emergency Nursing Practice states that,
“The ED RN triages every patient and determines priority of
care based on physical, developmental, and psychosocial needs
as well as factors influencing flow through the emergency care
system.”

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Advantages of a Comprehensive Triage
✓ The triage process is conducted by an experienced ED
RN whose competency has been validated.
✓ The ED RN is able to rapidly identify those patients in
need of immediate care.
✓ Laboratory studies, x-ray examinations and
electrocardiograms can be initiated using triage
protocols.
✓ The ED RN is able to provide reassurance to patients
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and families.
Advantages of a Comprehensive Triage
✓ First aid and comfort measures can be provided ( in
some ED’s, this may include medications for fever
control and pain).
✓ Patient teaching can be initiated.
✓ Reassessment can be done.
✓ The ED RN can advocate for patients and work with the
charge nurse to get patients to care.
✓ Patients in the waiting room are safe to wait.
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 The Emergency Nurses Association
recommends that the triage encounter take
no more than 2 – 5 minutes.
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 Patient

Two Tiered Triage System

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EMERGENT

Immediate care required;

Condition is threat to life, limb or vision.
SEVERE

THREE-LEVEL ACUITY RATING SYSTEM

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URGENT

Care required as soon as possible;

Condition presents danger if not treated;
ACUTE but not SEVERE

THREE-LEVEL ACUITY RATING SYSTEM

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NON-URGENT

Routine care required;

Condition minor;
Care can be delayed.

THREE-LEVEL ACUITY RATING SYSTEM

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Level 1: Resuscitation – Conditions that are
threats to life or limb
CANADIAN TRIAGE AND ACUITY SCALE (CTAS)
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Level 2: Emergent – Conditions that are a
potential threat to life, limb or function
CANADIAN TRIAGE AND ACUITY SCALE (CTAS)
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Level 3: Urgent – Serious conditions that
require emergency intervention
CANADIAN TRIAGE AND ACUITY SCALE (CTAS)
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Level 4: Less urgent – Conditions that
relate to patient distress or potential
complications that would benefit from
intervention
CANADIAN TRIAGE AND ACUITY SCALE (CTAS)
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Level 5: Non-urgent – Conditions that are
non-urgent or that may be part of a
chronic problem
CANADIAN TRIAGE AND ACUITY SCALE (CTAS)
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EXAMPLES OF ESI LEVEL 1
Cardiac arrest
Respiratory arrest
Severe respiratory distress
Critically injured trauma patient who presents unresponsive
Hypotension with signs of hypoperfusion
Chest pain, pale, diaphoretic, BP 70 palpatory
Unresponsive patient with a strong odor of alcohol

EMERGENCY SEVERITY INDEX (ESI)

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EXAMPLES OF ESI LEVEL 2
Tachycardia, respiratory distress, pallor, bloating, bleeding,
general appearance or hypotension that accompanies severe
abdominal pain can represent shock and would place the patient
at high risk.
Patients who are drooling and/or striderous may have impending
airway loss. Although less common, epiglottitis, a foreign body
(airway foreign body or esophageal foreign body in a child) and
peritonsilar abscess place patients at risk for airway compromise.

EMERGENCY SEVERITY INDEX (ESI)

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EXAMPLES OF ESI LEVEL 2
Patients with inhalation injuries from closed space smoke
inhalation or chemical exposure should be considered high-risk
for potential airway compromise.
Patients with severe headache associated with mental status
changes, high blood pressure, lethargy, fevers, or a rash should
be considered highrisk
Pediatric - Seizures • Severe sepsis, severe dehydration • Diabetic
ketoacidosis • Suspected child abuse • Burns • Head trauma

EMERGENCY SEVERITY INDEX (ESI)

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EXAMPLES OF ESI LEVEL 3
Patients who are expected to need two or more
resources are designated as ESI level 3.
Patients who need two or more resources have been
shown to have higher rates of hospital admission and
mortality and longer lengths of stay in the ED

EMERGENCY SEVERITY INDEX (ESI)

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EXAMPLES OF ESI LEVEL 4
Patients that are likely to require one resource are ESI
level 4.

EMERGENCY SEVERITY INDEX (ESI)

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EXAMPLES OF ESI LEVEL 5
Patients who are expected to consume no resources
are classified as ESI level 5.

EMERGENCY SEVERITY INDEX (ESI)

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 Resources Not Resources

Labs (blood, urine) History and physical (including pelvic)

ECG, X-Rays, CT, MRI, Ultrasound Point-of-care testing

angiography

IV fluids (hydration) Saline or heplock

IV, IM or nebulized medications PO medications

Tetanus immunization
Prescription refills

Specialty consultation Phone call to PCP

Simple procedure = laceration repair Simple wound care

Foley catheter (dressings, recheck)

Complex procedure = 2 Crutches, splints, slings

conscious sedation
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Triage Nurses MUST POSSESS:

✓ Expert assessment skills

✓ Competent interview and organization
skills
✓ Extensive knowledge base of diseases
and injuries
✓ Vast experience to identify subtle clues
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ENA
Recommendation

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 ✓ https://hospitalmontfort.com/en/canadian-triage-
and-acuity-scale
✓ http://ctas-phctas.ca/wp-
content/uploads/2018/05/participant_manual_v2.
5b_november_2013_0.pdf
✓ https://www.ahrq.gov/sites/default/files/wysiwyg/p
rofessionals/systems/hospital/esi/esihandbk.pdf
✓ https://chemm.nlm.nih.gov/startadult.htm

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