TRIAGE IN DISASTER AND EMERGENCY

AND INTENSIVE CARE UNIT:

effectivity and efficiency save life and reduce cost

Triage
Waiting room

Team leader
Yohanes George
 Definition of Triage
Triage is the term derived from the French
verb trier meaning to sort or to choose
Its the process by which patients classified
according to the type and urgency of their
conditions to get the Right patient to the
Right place at the
Right time with the
Right care provider
 Triage Categories

1. Non disaster: To provide the best care for

each individual patient.
2. Disaster/Multi casualty: To provide the most
effective care for the greatest number of
patients.
1. Non disaster or E.D triage
The primary objectives of an ED triage are to:
1. Identify patients requiring immediate care.
2. Determine the appropriate area for treatment
3. Facilitate patient flow through the ED and avoid
unnecessary congestion.
4. Provide continued assessment and reassessment of
arriving and waiting patients.
5. Provide information and referrals to patients and
families.
6. Allay patient and family anxiety and enhance public
relations.
 2. Disaster
1. Definition: an incident, either natural or human-made,
that produces patients in numbers needing services
beyond immediately available resources. May involve a
large numbers of patients or a small numbers of patients
if their needs place significant demands on resources.
2. The key to successful disaster management is to provide
care to those who are in greatest need first and just as
importantly, not provide care to to those who have little
or no chance of survival. Correct triage is essential to
accomplish this goal
 2. Disaster

Learning objectives:
Describe the key elements of disaster triage
Understand the basic principles of Mass
Casualty Triage (START)
 START SYSTEM
Created in the 1980s by Hoag Hospital and the
Newport Beach CA Fire Dept
Allows rapid assessment of victims
It should not take more than 15 sec/ Pt
Once victim is in treatment area more detailed
assessment should be made
 START SYSTEM

Clasification is based on three items:

1. Respiratory
2. Perfusion
3. Mental status evaluation
 Tagging

Complements Triage
Rapid Identification
of patient
Color Coded / Bar
Coded system
Plastic bands can
substitute tags
START SYSTEM
Flow of Patients one triaged.
Please note how both
walking wounded (green)
and non-salvageable (black)
stay out side the
TREATMENT AREA.

Also note that as patients

status can change, triage
should be dynamic in an
effort to asses changes
categories

Noji et al, NEJM

 START First Step

Can the Patient Walk?

YES NO

Green Evaluate Ventilation

(Step-2)
(Minor)
 START Step-2
Ventilation Present?

NO YES

Open Airway

Ventilation Present? > 30/Min < 30/min

NO YES Red/ Immediate

Black Red/ Immediate Evaluate Circulation

(Step-3)
 START Step-3

Circulation

Absent Radial Pulse Present Radial Pulse

Control Hemorrhage
Evaluate Level of
Consciousness
Red/ Immediate
 START Step-4
Level of Consciousness

Cant Follow Simple Can Follow Simple

Commands Commands

Red/ Immediate Yellow/ Delayed

 Contaminated Patients
Patients with exposure (potential or real) to
contaminants should be tagged as BLUE
This category will continue to stay until patient is
adequately decontaminated then follow START as
usual
Some recommend a double tagging with blue
and the standard START color
 START-Overview

Remember RPM:
R- Respirations- 30
P- Perfusion-Radial Pulse
M- Mental-Follows Commands
Non disaster or E.D triage
HOSPITAL TRIAGE SCALE

Australia Triage Scale

Canadian Triage Acuity Scale
Manchaster Triage Scale
Emergency Severity Indeks
 AUSTRALIAN/RSPI TRIAGE SCALE
Pemeriksaan Kategori 1 Kategori 2 Kategori 3 Kategori 4
SEGERA 10 menit 30 menit 60 menit
Airway Obstruksi Patent / bebas Patent / Patent / bebas
total/obstruksi partial bebas

Breathing Distress pernapasan Distress Distress Distress

berat, tidak ada pernapasan pernapasan pernapasan
napas/Hipoventilasi sedang sedang sedang

Circulation Gangguan hemodinamik Gangguan Gangguan Tidak ada

berat/sirkulasi negatif hemodinamik hemodinamik gangguan
Perdarahan yang tidak sedang ringan hemodinamik
dapat terkontrol

Disability GCS < 9 GCS 9 - 12 GCS > 12 GCS normal

Canadian E.D. Triage and Acuity
Scale
1- Resuscitation
2- Emergent
3- urgent
4- less urgent
5- Non urgent
Overview of three category triage acuity systems
category acuity Recommended Examples
reassessment

Class 1 Emergent continuous Cardiopulmonary

arrest, severe
Immediately life or limb
respiratory distress,
threatening
major burns, major
trauma, massive
uncontrolled bleeding
Coma, status epil..

Abdominal pain, non

Class 2 Urgent Every 30 cardiac cp, multiple
Requires prompt care, but
will not cause loss of life or minutes fractures, lacerations,
renal calculi,
limb if left untreated for
several hours.
Rash, chronic headache,
Class 3 Non urgent Every 1-2 hrs sprains, cold symptoms
And treatment but time is not
a critical factor
 TRIAGE LEVELS
1- Resuscitation -- threat to life
Time to nurse assessment IMMEDIATE
Time to physician assessment IMMEDIATE
Cardiac and respiratory arrest
Major trauma
Active seizure
Shock
Status Asthmatics
 TRIAGE LEVELS
2- Emergent
Potential threat to life,limb or function
Nurse Immediate, Physician <15 minutes
Decreased level of consciousness
Severe respiratory distress
Chest pain with cardiac suspicion
Over dose (conscious)
Severe abdominal pain
G.I. Bleed with abnormal vital signs
Chemical exposure to eye
 TRIAGE LEVELS

3- Urgent
Condition with significant distress
Time Nurse < 20 min, physician < 30 min
Head injury without decrease of LOC but
with vomiting
Mild to moderate respiratory distress
G.I. Bleed not actively bleed
Acute psychosis
 TRIAGE LEVELS

4- Less urgent
Conditions with mild to moderate discomfort
Time for Nurse assessment <1h
Time for physician assessment < 1h
Head injury, alert, no vomiting
Chest pain, no distress, no cardiac susp.
Depression with no suicidal attempt
 TRIAGE LEVELS

5- Non urgent
Conditions can be delayed, no distress
Time for nurse and Physician assessment
more than 2h
Minor trauma
Sore throat with temp. < 39
BASIC COMPONENT OF TRIAGE
An across-the room assessment
The triage history
The triage physical assessment
The triage decision
ACROSS THE ROOM ASSESSMENT
To identify obvious life threat conditions
General appearance

Disability
(neurogenic)

Airway Circulation
Breathing
 ACROSS THE DOOR ASSESSMENT

The triage nurse must scan the area where

patients enter the emergency door, even while
interviewing other patient.
The triage antenna should be seeking clues to
problems in all people who enter the triage area
If any patient doesnt look right kindly but
quickly interrupt any current interaction and go
investigate.
 ACROSS THE ROOM ASSESSMENT
Airway
Abnormal airway sounds, strider, wheezing grunting
Unusual posture e.g.. Sniffing position, inability to speak,
drooling or inability to handle secretion
Breathing
Altered skin signs, cyanosis, dusky skin, tachypnic
bradypnea, or apnea periods, retractions, use accessory
muscles, nasal flaring, grunting, or audible wheezes
 ACROSS THE ROOM ASSESSMENT

Circulation
Altered skin signs, pale, mottling, flushing
Un controlled bleeding
Disability (neuro.)
LOC
Interaction with environment
Inability to recognize family members
Unusual irritability
Response to pain or stimuli
Flaccid or hyper active muscle tone
CHARACTERISTICS OF TRIAGE NURSE

Extensive knowledge to emergency medical

treatment
Adequate training and competent
skills,language, terminology
Ability to use the critical thinker process
Good decision maker
 ROLE OF TRIAGE NURSE
Greet patients and identify your self.
Maintain privacy and confidentiality
Visualize all incoming patients even while
interviewing others.
Maintain good communication between triage and
treatment area
maintain excellent communication with waiting
area.
Use all resources to maintain high standard of care.
 IMPORTANCE OF RE-TRIAGE
Reassess the patient within 1-2hours of initial
triage and continue to re assess on a regular basis,
patients who may have presented without cardinal
signs of severe illness may develop them during
long waits.
Patients who appear intoxicated actually may have
life threatening problems such as DKA, and should
not be permitted to keep it off in the waiting room.
 CONCLUSION

The last person in along line at triage may

have a serious medical problem that requires
immediate attention
Patient should wait no longer than 5 minutes
for triage

If in doubt about a category, choose the higher

acuity to avoid under triaging a patient