TRIAGE

Lee Wallis
Senior Lecturer
Division of Emergency Medicine, UCT/SU
 Triage
• Background
• Cape Triage Group
• Cape Triage Score
– Development
– The CTS
– Validation
• South African Triage Score
• EWS in children
 Triage
• French verb trier
– To sieve / to sort
• Medically:
– The process of applying medical priority to
patients to do the most for the most
 History of triage
• Baron Dominique Jean Larré
– Napoleon’s surgeon
– Changed the treatment of injured soldiers
• Least injured first, return to war
• Little improvement until Vietnam
• Military now use standard civilian priorities

• Triage common to EDs in West for 20+

years
 Triage tools
• Discriminators:
– Demographics
• Old or young triaged out
– Mechanism of injury
• Only for trauma
– Anatomy
• Dependent upon examination – time consuming
– Physiology
• Most reliable

• Intended use:
– Hospital vs Pre-hospital
– Day-to-day vs MCI
– Trauma vs Other
– Adult vs Child
 MCI Pre-hospital triage
• Do the most for the most
– Try to pick out sickest first
– Theoretical evidence for leaving these

• Easy to learn & use

– Close to daily practice

• Physiologic most common

– Triage sieve, Triage sort, START, Careflight etc
– Paediatric Triage Tape
 MCI Hospital triage
• Triage Sort
• RR 0-4
• SBP 0-4
• GCS 0-4
• Total 0-12
• P3 – 12
• P2 – 11
• P1 - other

• + Basic Anatomical information

 Daily Pre-hospital triage
• Often not done

• When done - trauma only

– TS, RTS, TRTS, PHI, CRAMS, ACS TTC, etc

• Children – PTS, adult tools

– Physiologically incorrect

• Most used to identify need for Trauma Centre

care (USA)
 Hospital triage - subjective
• Senior doctor or nurse
• Front door of unit
– Eyeball
– Gut-feel
• Accuracy as low as 35%
• Poorly reproducible

• 24 / 7 coverage
 Hospital triage - objective
• MCI – triage sort or similar
• Day-to-day
– Manchester triage, CTS, ATAS, ESI, PTS
– Complicated, time consuming, training
implications, senior staff
 Cape Triage Group
• Convened Jan 2004
• Joint division of Emergency medicine, UCT / SU
• Jan 2004
• 32 registrars, 5 waiting posts
• Dip PEC, MPhil, MSC, MMed / FCEM
• Private & Public
• Pre-hospital & hospital
• Doctors, nurses, paramedics
– 1 speech therapist….
 CTG: objectives
• Saw the need for triage in W Cape (SA)
setting
• Develop a tool for hospital EU use
• Pre-hospital triage

• Not a MCI tool

 CTS: staffing considerations
Country Doctors Nurses Nurse ratio

South Africa 56.3 471.2 1 : 8.0

Canada 229 897 1 : 4.0

UK 164 479 1 : 3.0

Israel 385 613 1 : 1.6

Australia 240 830 1 : 3.4

Doctors and nurses per 100,000 population per annum for selected countries
 CTS: development
• Look at other countries’ tools
• Look at other options
– EWS
• Derivation phase
• Validation phase
 CTS: Priorities
• 5 colours

• Red Immediate
• Orange 10 mins
• Yellow 60 mins
• Green 4 hours
• Blue Dead
 CTS: the basics
• 2 part tool
– TEWS
– Discriminators
• 3 versions
– Adult, Child, Infant
• 5 colours
 CTS: TEWS
• Triage Early Warning Score
• From MEWS – UK ICU outreach program
• MEWS reduced ICU admission and
mortality / LoS
• Minor modifications to adult version =
TEWS
 CTS: adult
• TEWS Derivation: from MEWS

• Discriminators: committee consensus

• Validation
– 1500 GF Jooste, 2000 Mediclinic, 12,000
CHC EUs
– 2 MPhils
 CTS: child & infant
• TEWS Derivation:
– 1500 healthy school children
– 4000 injured children RXH TU

• Discriminators: committee consensus

• Validation
– 8000 children at CHC EUs

• Age, height, weight related vital signs

• Logistic regression vs neural nets
• PhD
 v1.1
MODIFIED EARLY WARNING SCORE
Score 3 2 1 0 1 2 3
Pulse 40 41-50 51-100 101- 111- >130
110 129
RR 8 9-14 15-20 21-29 >30
Temp 35.0 35.1- 37.3- 38
37.2 37.9
CNS Confu Alert Respo Respo Unres
sed nd to nd to ponsiv
voice pain e
Systo  70 71-80 81-100 101- 200
BP 199
RED YELLOW GREEN
MEWS  6 or MEWS 3 – 5 or MEWS 0 - 2 or
CHEST PAIN or HB < 8 or HB  10
Vx  16 or PV bleeding or
HYPOGLYCAEMI Haematemesis
A (Vx <2.5) or or
AGGRESSIVE
Haemoptysis
PATIENT
 TEWS: Adult
3 2 1 0 1 2 3

Stretcher/
Mobility Walking With Help
Immobile

RR less than 9 9-14 15-20 21-29 more than 29

more than
HR less than 41 41-50 51-100 101-110 111-129
129

SBP less than 71 71–80 81-100 101-199 more than 199

Temp less than 35 35-38.4 38.5 or more

Reacts to Unresponsiv
AVPU Alert
Voice
Reacts to Pain
e

Trauma No Yes

over 12 years / taller than 150cm

 TEWS: Child
3 2 1 0 1 2 3

Stretcher/
Mobility Walking With Help
Immobile

RR less than 15 15-16 17-21 22-26 27 or more

HR less than 60 60-79 80-99 100-129 130 or more

SBP less than 70 70-79 80-130 131-149 150 or more

Temp less than35 35-38.4 38.5 or more

Reacts to Unresponsiv
AVPU Alert
Voice
Reacts to Pain
e

Trauma No Yes

3 to 12 years old / 96 to 150 cm tall

 TEWS: Infant
3 2 1 0 1 2 3

Normal for Stretcher/

Mobility age Immobile

RR less than 20 20-25 26-39 40-49 50 or more

HR less than 70 70-79 80-130 131-159 160 or more

SBP less than 60 60-69 70-110 111 or more

Temp less than 35 35-38.4 38.5 or more

Reacts to Unresponsiv
AVPU Alert
Voice
Reacts to Pain
e

Trauma No Yes

younger than 3 years / smaller than 95cm

 Step 1

CTS: step by stepMeasure vital signs

and document the
findings

Step 2
Take a brief history directed at the main
complaint and document this

Step 3

Calculate the TEWS

and document the
total value

Step 4

Match the score to the list and observe the discriminator list for
issues not picked up by the TEWS

Step 5
Document the
triage code
and act
accordingly
 Example
• 10 year old, electrical burn
– Walking (0) RR 24 (1) HR 110 (1) SBP 115 (0)
Temp 37 (0) alert (0) trauma (1)
• TEWS total = 3
– YELLOW
 Colour RED ORANGE YELLOW GREEN BLUE

TEWS 7 or more 5-6 3-4 0-2 DEAD

Target time to
Immediate less than 10 mins less than 60 mins less than 240 mins
treat

Mechanism of
injury

Discriminators: Adult High energy transfer

Shortness of breath - acute

Coughing blood

Chest pain

• Final Triage Seizure – current

Haemorrhage - uncontrolled

Seizure - post ictal

Haemorrhage - controlled

– ORANGE
Focal neurology - acute

Level of consciousness
reduced

Psychosis / Aggression

Threatened limb

Dislocation - finger or
Dislocation - other joint ALL
toe

Presentation Fracture - compound Fracture - closed OTHER DEAD

Burn over 20% PATIENTS

Burn - electrical
Burn –
Burn - other
face / inhalation
Burn - circumferential

Burn - chemical

Poisoning / Overdose Abdominal pain

Diabetic - glucose
Hypoglycaemia - Diabetic - glucose over
over 17 (no
glucose less than 3 11 & ketonuria
ketonuria)

Vomiting - fresh blood Vomiting - persistent

Pregnancy & trauma

Pregnancy & abdominal
trauma or pain
Pregnancy & PV bleed

Pain Severe Moderate Mild

Senior Healthcare Professional’s Discretion

 CTS: management aids
• Series of management pointers
– Including:
• Diabetes – test glucose
• Low temp – blankets
• Chest pain – ECG
• Aimed at ENA
 CTS: benefits
• GF Jooste, 4 CHCs:

• Reduced waiting times

– 590 mins mean, to 30 mins red, 60 orange, 400 green

• Decreased EU length of stay

• Improved patient flow, decreased overcrowding in EU

• Reduction in mortality 2% to 0.7%

– Morbidity?

• Improved patient and health provider satisfaction

 CTS: validity
Adult CTS vs disposal Children CTS vs disposal

• Overtriage, undertriage
100%

80%
100%

80%

60% DNW/MD 60%

Home
40% Referred 40%

• What should a triage tool

Died
20%
20%

0%
0%
R O Y G B MD
identify?
R O Y G B MD

– Injury severity Infants CTS vs disposal

– Resource usage
100%
80%

– Death / High care / Admission

60%
40%
20%
– Urgency of Intervention
0%
R O Y G B MD
 CTS: Implementation
• 1 Jan roll out W Cape
• All EUs
– Primary Care
– Secondary & tertiary care
• DoH funded and supported
• Intensive training program
• Educational materials
• Posters, keycards, patient leaflets
 Future developments: CTS
• 1 year M&E manager
– Audits
– QA
– Performance indicator thresholds
• CTS living tool
– Modify as needed
– Keep same format
 Future developments: SATS
• CTS taken on by 4 provinces so far
• Call for SA Triage Group
– First meet June 2006, Durban
– Represent all provinces
• Develop a SATS
– Based on CTS
 Future developments: EWS
• MEWS part of TEWS for in-patient
monitoring
– Mortality and morbidity benefit, LoS reduction
• Validate child & infant versions
• Funding for age – group specific EWS
from UK