Triage A process for sorting injured people into groups based on their need for or likely benefit from

immediate medical treatment. Triage is used on the battlefield, at disaster sites, and in hospital emergency rooms when limited medical resources must be allocated. Triage" is a French word meaning "sorting, selection, choice." It came from the French verb "trier" meaning "to sort, select, choose" and has been used in English since 1727 to indicate the action of assorting according to quality. For example, coffee beans have long been triaged. The principle of triage involves dividing patients into three groups: 1. Those who will die anyway, whether they receive medical attention or not 2. Those who will survive anyway, whether they receive medical attention or not 3. Those who will survive only if they receive timely medical attention When resources are limited, medics must attend to members of the third group before the first and second groups in order to save as many lives as possible. Triage can also help you build your authority by focusing your attention on the most significant actions. In this case you divide your tasks, projects, and activities into three groups: 1. Projects that will fail to have a significant impact, whether you do them or not 2. Projects that will succeed anyway, whether you do them or not 3. Projects that will have a significant impact only if you complete them in a timely manner

Triage Categories Non disaster: To provide the best care for each individual patient. Multi casualty/disaster: To provide the most effective care for the greatest number of patients.

Non disaster or E.D triage The primary objectives of an ED triage are to (ENA,1992, P. 1): 1. 2. 3. 4. Identify patients requiring immediate care. Determine the appropriate area for treatment Facilitate patient flow through the ED and avoid unnecessary congestion. 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.

The Importance of Triage Triage is required for the effective management of an emergency situation. This means patients are not seen according to when they arrive at the hospital, but are seen according to guidelines which determine who needs care most urgently and where care is most likely to be successful. In order to remove confusion and misgivings, guidelines are in place which help health care professionals to know how to prioritize. The importance of this discipline can never be overstated, when one takes into consideration the fact that in 2008, nearly 120 million emergency department visits were made to hospitals in the US. Basic Nursing Responsibilities: 1. Establish priorities 2.Provide holistic care 3.Monitors and continuously assesses acutely ill and injured patients 4.Document all procedures made 5.Supervise other allied health personnel 6.Support and attend to families 7.Give health teachings to patients and their families in a time-limited and high-pressured care environment 8.Request for and refill supplies 9.Protect self and others: Use universal precaution

TRIAGE NURSE QUALIFICATIONS 1. Communication skills are crucial. Provider must interact with patient, family, police, EMT and visitors. 2. 3. 4. 5. Must have tact, patience, understanding, and discretion. Organizational skills patient line-ups, inquiries, etc. (constantly under patient scrutiny) Able to perform in hectic situations. Can recognize who is sick. (Depends on experience, skill and expert clinical judgement.)

Personal Qualifications Triage nurses must have many of the same personal characteristics of other acute care nurses. They must be able to actively listen to understand and assess a patient's injury or illness. They must have strong decision-making skills and be able to critically evaluate and make fast decisions when the emergency room fills up quickly. Triage nurses must have excellent interpersonal communication skills so that they can convey messages to patients, doctors and other nurses as well. Critical Qualities of a Triage Nurse

Expert Assessment Skills Non-judgmental Communication Excellent interviewing techniques

II. Categories of triage ED triage: Used daily to prioritize patient assessment and treatment in the emergency department during routine functioning. Priority is given to those most in need. Resources are not rationed. Inpatient triage: Applied day-to-day in a variety of medical settings, such as the ICU, medical imaging, surgery, and outpatient areas, to allocate scarce resources. Priority is given to those most in need based upon medical criteria. Resources are rarely rationed. Incident triage: Used in multiple casualty incidents such as bus accidents, fires, or airline accidents to prioritize the evacuation and treatment of patients. These events place significant stress on local resources but do not overwhelm them. Resources are rarely rationed, and most patients receive maximal treatment. Military triage: Used on the battlefield, modern military triage protocols most reflect the original concept of triage and include many of the same principles. Resources are rationed when their supply is threatened. Disaster triage: Used in mass casualty incidents that overwhelm local and regional healthcare systems. Disaster triage protocols both prioritize salvageable patients for treatment and ration resources to ensure the greatest good for the greatest number. Categories of Triage: 1.Emergent those conditions that require immediate care and intervention, increased risk of mortality (death) or threat to life, limb, or vision. 2.Urgent those conditions that require care ASAP, generally within 1 hour and have the potential for causing deterioration of health state if not treated immediately.

III. TYPES OF TRIAGE Types of triage Simple triage Simple triage is used in a scene of mass casualty, in order to sort patients into those who need critical attention and immediate transport to the hospital and those with less serious injuries. This step can be started before transportation becomes available. The categorization of patients based on the severity of their injuries can be aided with the use of printed triage tags or colored flagging. Advanced triage In advanced triage, doctors may decide that some seriously injured people should not receive advanced care because they are unlikely to survive. Advanced care will be used on patients with less severe injuries. Because treatment is intentionally withheld from patients with certain injuries, advanced triage has ethical implications. It is used to divert scarce resources away from patients with little chance of survival in order to increase the chances of survival of others who are more likely to survive.

IV. EMERGENCY TRIAGE TAG Triage tags are used by emergency responders in the field, during mass casualties. These tags help responders to quickly identify who needs care right away and who can wait. This is extremely important when there are more patients than responders.

Coding of Triage 1. Emergent: Red, Priority I: life, limb, eye threatening that needs immediate attention, monitoring is continuous. Chest pain Cardiac arrest Severe respiratory distress Chemicals in eye Trauma Acute neurologic deficits 2. Urgent: Yellow, Priority II: needs treatment in 20 minutes to 2 hours, monitoring is every 30-60 minutes. Fever more than 40C (104F)

diastolic BP more than 130mmHg kidney stones simple fracture abdominal pain asthma without respiratory distress 3. Non-urgent: Green, Priority III: can wait hours or days, monitoring is every 1-2 hours. Sprain Minor laceration Cold symptoms Rash Simple headache 4. Dead: Black (sometimes still with life signs but injuries are incompatible with survival COLOR Red tags - (immediate) are used to label those who cannot survive without immediate treatment but who have a chance of survival. Yellow tags - (observation) for those who require observation (and possible later re-triage). Their condition is stable for the moment and, they are not in immediate danger of death. These victims will still need hospital care and would be treated immediately under normal circumstances. Green tags - (wait) are reserved for the "walking wounded" who will need medical care at some point, after more critical injuries have been treated. White tags - (dismiss) are given to those with minor injuries for whom a doctor's care is not required. Black tags - (expectant) are used for the deceased and for those whose injuries are so extensive that they will not be able to survive given the care that is available.

Categories of a triage tag a.tear off section - Personal Property can be tracked using the tag number; Evidence can be collected and sorted using the serial number on the tag. b.main body - Decontamination solutions can be documented; New sections have been included to address the specific concerns of nerve agent exposures. The tag also includes pertinent information such as name, address, medical history, allergies, medications, etc.; An adhesive strip has been added to allow the tag to be easily attached to the hospital's patient chart. C. peel off stckers - Peel-off decals are designed to make patient tracking more efficient; Peel-off decals help to ensure accurate documentation of victims throughout the triage-treatment-transport process; The NJ Disaster Triage Tag allows minors and others to be associated with caretakers.

Benefits of triage tag Alerts care providers to patient priority Prevents re-triage of the same patient Serves as a tracking system

The FIRST assessment that produces a RED tag stops further assessment Only corrections of life-threatening problems should be managed during triage ( i.e. airway obstruction or severe bleeding ) 4/15/2011

Special Considerations To initially mark patient categories, colored ( ribbons ) should be considered When using Triage Tags, if the patients condition or the triage priority changes, the bottom portion of the tag should be removed, leaving only the injured information Add a new tag to identify the new triage priority, and if time permits, the reason for the change4/15/2011 Triage Reminders 1. You DO NOT decide who lives or dies 2. The sooner your start Triage the sooner the medical care process starts 3. Triage is an ongoing process that is repeated many times 4. If you forget any of the above rules,

go back to rule number 1. Types of Triage Systems Triage is a system employed by health personnel to sort incoming patients according to the level of severity of condition. The whole concept of triage is based on managing limited resources in health institutions, including space and manpower. Triage originated on the battlefield and was used primarily by physicians to sort wounded soldiers into manageable categories such as critical and beyond salvage. This allowed them to focus on those who needed immediate care. Simple Triage and Rapid Treatment This is the most basic form of triage, which is used at the scene in cases involving mass casualties such as earthquakes, hurricanes and accidents. This system is used to sort patients into those who need urgent care, those who need care and those with less serious injuries. The purpose of this is to determine the casualties who will be transported to the hospitals first. After they have been sorted, they are separated into four groups: the deceased who have already passed away and are beyond help, the wounded who can be saved by immediate transportation and medical attention, the wounded who can survive a little wait and finally, those who have minor injuries. These groups are then affixed with printed triage tags for easy identification. This system was initially developed for use by firefighters and community emergency response teams (CERTs) after earthquakes. Triage in a Hospital Emergency Room The process of triage determines a patients priority in the mind of physicians, particularly as it relates to patient treatment. It is necessary to ration patient treatment, especially when hospital resources are insufficient for all to be treated immediately. Based on the severity of their condition, patients in the emergency room may experience a difference in the order of emergency treatment. Additionally, triage may determine where a patient is kept or sent. A patient will have his or her own opinion about their right to receive medical treatment, but in cases of mass casualties or serious injury, the hospital physicians final decision about whether to provide treatment to the patient is what will make the difference. A system is always necessary for an institution function as it desires. While there are obvious ethical implications in triage, for an emergency room to function correctly, it must have a system. In the end, triage is necessary for a hospital emergency room to work efficiently and treat all of its patients in the most effective way. In the past, triage was much more primitive. It was often simplified into three basic categories: those who were likely to live, those who were likely to die, and those whose life may depend on medical care. This system of triage still applies today, however, apart from hospitals triage systems. For example, in emergency medical services systems, an overabundance of patients may cause paramedics to use the above model. There is no doubt that instinct plays a large part in the effectiveness of emergency medical services. Conversely, triage in the emergency room usually follows two types of triage simple triage and advanced triage. Simple Triage: Simple triage is used primarily in a mass-casualty incident, an incident which emergency room medical services are overwhelmed by casualties, and is used to sort patients into two categories: those who need critical attention and those with less serious injuries. Patients are categorized and often flagged with printed triage tags to distinguish one category from the other. The S.T.A.R.T model of triage is a simple system that is easily performed by hospital emergency personnel in emergency room situations. It has been field-proven for mass casualty incidents such as public transportation accidents and natural disasters. In the S.T.A.R.T. model, hospital emergency rooms separated patients into four different groups: 0: the deceased

1: the injured who can be helped by immediate transportation 2: the injured whose transport can be delayed 3: those with minor injuries, who need less help Advanced Triage: Advanced triage, on the other hand, determines whether or not seriously injured people should receive advanced care due to their unlikeliness to survive. This is where the ethical implications come in. Since treatment is intentionally withheld from patients, people will always comfort the procedure with ethical right-or-wrong questions. But again, advanced triage is just as necessary to preserve scarce resources for those who can benefit from it more. Those implementing the triage process often undertriage or overtriage patients, leading to complications with incorrect patient labeling. Triage is constantly changing and checked to ensure that the priority remains correct: to ensure that the hospital emergency room provides medical care to those who need it the most.

Overtriage and undertriage Effective triage requires balance not only between the demands on the system and the supply of resources but also between overtriage and undertriage. Overtriage and undertriage are related to the accuracy with which patients are triaged. Undertriage occurs when the severity of a patients illness or injury is not appropriately recognized, which results in delayed treatment that places the patient at risk of dying. Particularly in day-to-day situations, undertriage is minimized through the use of protocols that tend to overtriage patients to higher levels of care than they require (1, 7). Such protocols are not foolproof, however, because overtriage has been shown to decrease overall survival rates among critically ill or injured victims (1, 9, 10) (see Figure 13-3). Overtriage may increase mortality by depleting resources, fatiguing staff, and impairing efficient flow of critically ill or injured patients through the system to definitive care. The accuracy of triage depends on both the reliability of the protocol in predicting patient outcomes and how the protocol is applied by the triage officers. Triage is a dynamic process that makes it more likely to correct inevitable instances of undertriage and overtriage.