Triage

Evidence triage is a multifaceted process that consists of the evidence collected, the order in which it is collected, and the methodologies used to collect it, all of which can impact the overall integrity, availability, and admissibility of the evidence.

From: Executing Windows Command Line Investigations, 2016

Chapters and Articles

Triage

Sharon E. Mace MD, Thom A. Mayer MD, in Pediatric Emergency Medicine, 2008

Introduction and Background

Triage is the prioritization of patient care (or victims during a disaster) based on illness/injury, severity, prognosis, and resource availability. The purpose of triage is to identify patients needing immediate resuscitation; to assign patients to a predesignated patient care area, thereby prioritizing their care; and to initiate diagnostic/therapeutic measures as appropriate.

The term triage originated from the French verb trier which means to sort. During the time of Napoleon, the French military used triage to serve as a battlefield clearing hospital for wounded soldiers. The U.S. military's first use of triage was during the Civil War. Triage on the battlefield was a distribution center from which injured soldiers were sorted or distributed to various hospitals. For the military during World Wars I and II, triage was the procedure that determined which injured soldiers were able to be returned to the battlefield. Military triage continued to evolve during the Korean and Vietnam wars with the tenet of doing the “greatest good for the greatest number of wounded and injured.”1 Refinements in battlefield medicine and military triage have continued during more recent conflicts, including Iraq.

Other situations in which the triage process has been employed, in addition to the battlefield, are during disasters, following mass casualty incidents (MCI), and in emergency departments (EDs). Triage during a disaster involves field triage, which sorts disaster victims into categories ranging from the walking wounded to those with injuries who are salvageable to the unsalvageable and the dead.

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Triage

J. Lee Jenkins, in Ciottone's Disaster Medicine (Third Edition), 2024

INTRODUCTION

Triage is the utilitarian sorting of patients into categories of priority to rationally allocate limited resources with the purpose of doing “the greatest good for the greatest number of people.” Triage systems were primarily developed for trauma of war and mass casualty incidents in the field.

Triage after disaster is not one single processing step; rather, triage underlies all aspects of the response, including on-site rescue, evacuation, receiving hospital activities, decontamination, and so on. As the response resources available, the clinical conditions of casualties, and the information available all evolve throughout the time-course of the response, so will response priorities. Triage is a dynamic process.

It has been wisely suggested that disaster responses should match normative practice as much as is practically possible,3,4 and that, of course, would apply to triage methods. Triage clearly works best when the needed resources for triage are set up in advance. This can be possible for scheduled venues, and occasionally for predicted military attacks.5,6 Unfortunately, nature and terrorists rarely cooperate.7,8 On the gripping hand, for massive disasters, normative practice could pose a liability, a set of reflexes that interfere with the truly rational allocation of resources. This trade-off is discussed throughout this chapter. As noted in this chapter’s section Historical Perspective, many disaster responses have been characterized by a general lack of meaningful triage.

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Triage

Elizabeth Foley, Andrew T. Reisner, in Ciottone's Disaster Medicine (Second Edition), 2016

What On-Site/Hospital Documentation Will Be Used?

The triage tag, a minimal document that can be attached to each casualty, might be the only practical method of communicating findings, interventions, and so on, as countless casualties are passed through a chain of emergency care. However, it has been argued that triage tags are impractical to use, and geographic triage (see later) can obviate the need for tags.3 In a disaster, hundreds or thousands of tags for each triage category must be immediately available to the responders, who need to be exceptionally familiar with the tags to use them properly under trying circumstances, and frenzied casualties may not take proper care of the tags. After an enormous disaster (thousands of casualties), tags might be especially challenging to use properly, although they could also be especially useful.

Consideration of the use of triage tags requires some research on the part of the customer, since there are over 120 triage label systems in use internationally.42 Hogan and Burstein47 suggested the following criteria for the optimal triage tag: (1) It must attach securely to each casualty’s body, (2) it must be easy to write on, (3) it must be weather-proof, and (4) it should permit the documentation of the patient’s name, gender, injuries, interventions, care-provider IDs, casualty triage score, and an easily visible overall triage category. It must also permit changes to be made, because triage is always dynamic. One unfortunate potential limitation for such a tag is the presence of contamination that may limit the ability of the triage tag to persist through hospital-based decontamination efforts if the patient is not decontaminated prior to transport.

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Triage

Ksenya Badashova, Robert Shesser, in The Emergency Department Technician Handbook, 2024

Other Triage Systems

There are four other major hospital triage systems used worldwide. They are all 5-level systems and, unlike ESI, their major focus is to try to fit patients into categories of how quickly the patient needs to see a physician. A brief description follows for each of these system.

Manchester Triage System

The Manchester Triage System (MTS) is used most frequently throughout Europe. The MTS employs 52 complaint-based flowcharts with 5 possible levels within each one. Its stated objective is to rapidly assess a patient and assign a priority based on clinical need.

Australasian Triage Scale

The Australasian Triage Scale (ATS) is used throughout Australia and has become the basis for numerous international triage systems. The ATS algorithm stratifies patients into 5 categories based on chief complaint, physical appearance, and relevant physiologic findings. The physiologic findings are derived from 79 clinical descriptors, and it is up to the triage nurse to identify the appropriate clinical descriptors. Its stated objectives are to ensure patients are treated in order of clinical urgency and to allocate patients to the most appropriate treatment area.

Canadian Triage and Acuity Scale

The Canadian Triage and Acuity Scale (CTAS) relies on a catalog of standardized chief complaints that determines the time in which the patient should be seen by a provider. The CTAS acuity level corresponds to a set of chief complaints or symptoms that are further subdivided by acuity. Nurses then have the ability to adjust the acuity level according to their clinical judgment. Its stated objective is to provide patients with timely care.

South African Triage Scale

The South African Triage Scale (SATS) is very similar to the other non-ESI scales. The stated objective of the SATS is to prioritize medical urgency in contexts where there is a mismatch between demand and capacity.

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TRIAGE

John Armstrong, David G. Burris, in Current Therapy of Trauma and Surgical Critical Care, 2008

COMMENTS

Effective triage is a unifying thread through a functioning trauma system. Systems that perform daily care and train disciplines together provide the best preparation for mass casualty incidents—surge capacity and capability are practiced regularly. The Institute of Medicine's 2006 Report on The Future of Emergency Care offers a cautionary assessment of the current state of emergency and trauma care in the United States: the current situation of overcrowding, fragmentation, and resource shortages must be replaced with system planning, coordination, and financing, so that the needs of acutely injured patients are met individually and as a population.

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Responding to a Terrorist Incident

Ian Greaves FRCP, FCEM, FIMC, RCS(Ed), DTM&H, DMCC, DipMedEd, RAMC, Paul Hunt MBBS, DipIMC(RCSEd), MCEM, MRCSEd, DMCC, RAMC, in Responding to Terrorism, 2010

Triage

Principles of triage

Triage is the sorting of patients by priority for treatment, evacuation or transport. Primary triage is carried out in the bronze area, and patients are usually re-triaged (secondary triage) at the casualty clearing station. Triage for transport will be carried out before patients leave the site in order to ensure the most appropriate distribution of casualties to receiving units.

Triage categories

Conventionally, casualties are divided into the categories shown in Table 2.1.

Immediate category

These casualties require immediate life-saving treatment.

Urgent category

These casualties require significant intervention as soon as possible.

Delayed category

These patients will require medical intervention, but not with any urgency.

Expectant category

Expectant patients are those whose injuries are so severe that attempting to save them would divert precious resources from other casualties with a greater chance of survival, with no significant chance of a successful outcome. The decision to invoke the expectant category must be taken at silver level and preferably only after discussion with gold command.

In the event that the expectant category is used, a universal patient triage and label system must be agreed and may include one of the following:

a blue card (not normally available)

a green card overwritten expectant

a green card with the green corners turned back to reveal red underneath.

Triage sieve

The triage sieve (Fig. 2.11) is a simple, rapid and reproducible triage system designed for use at primary triage and first contact with the casualty. It may also be used at secondary triage, depending on the casualty flow. Because it is physiologically based, different values must be used for children. Triage sieves for children appear on pages 71–73.

Triage sort

The triage sort (Table 2.2) is a more complex and therefore more time-consuming system designed for secondary triage. Because it requires measurement of the respiratory rate and blood pressure and an assessment of the Glasgow Coma Scale score, it is relatively time-consuming. Lack of staff or pressure of patient flow may mean that the sieve is used for both primary and secondary triage.

Triage in children (Figs 2.12–2.14)

The normal physiological values used in the adult triage sieve can be used in children but will result in significant over-triage. Substitute values are necessary. Sieves are available for children based either on length (top of head to feet) or weight.

Weight=(age in years+4)×2

As an alternative, a paediatric triage tape can be used. The child is laid by the side of the tape and the appropriate protocol read off according to the child's length.

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Use of artificial intelligence in emergency medicine

Göksu Bozdereli Berikol, Gürkan Berikol, in Artificial Intelligence in Precision Health, 2020

Triage

Triage is a classification of patients according to their urgencies. There are many triage systems such as Emergency Severity Index (ESI), Canadian Triage and Acuity Scale, Manchester Triage System, and levels classified as three-level, four-level, and five-level triages (Moll, 2010). The classifications are made via algorithms or criteria based methods. ESI is a five-level algorithm-based triage system which uses the data of the resources, vitals, risks, and status of the patient (Wuerz et al., 2001). An e-triage system can predict a patient’s prognosis and predict a risk-avoiding overtriage or undertriage; it provides assistance for making decisions about patient triage, particularly for the ESI-3 level (Levin et al., 2018).

One of the examples of data mining in the past 5 years is about the prediction of triage waiting times at the department of gynecology and obstetrics (Pereira et al., 2016). That study addressed problems like wrong triage outcomes and triage waiting times and revealed a mean success rate of 94% for five different models using data mining. For the aim to reduce waiting times in pediatric emergency care, a 1205 patients dataset was used with machine-learning techniques to predict lox complexity pediatric emergency patients with a good validity and accuracy results (Caicedo-Torres et al., 2016). Machine-learning methods were used in triaging the abdominal pathology patients with support vector machines and decision tree hierarchical structure models (Butler et al., 2016). The used methods showed 50.9%–67.6% accuracy for correctly diagnosing abdominal pathology (Butler et al., 2016). Another abdominal pain triage for predicting the ESI-4 score was a comparison study between human and artificial intelligence and the overall accuracy was higher in clustering and neural network methods (Farahmand et al., 2017). Not only the hospital triage but also the prehospital environment is studied in which a wearable remote triage system is used with machine-learning methods (Kim et al., 2018). Both triage and survival prediction was found having up to 89% accuracy with artificial intelligence methods such as random forest and deep learning. Artificial intelligence-aided symptom-based triage was tested by Razzaki et al. (2018), compared with human outcomes and found safer than human decisions.

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Burn Management in Disasters and Humanitarian Crises

Herbert L. Haller, ... Leopoldo C. Cancio, in Total Burn Care (Fifth Edition), 2018

Triage and First Aid

Triage is a process whereby patients are sorted according to treatment priority, the purpose of which is to do the greatest good for the greatest number. Several schemes exist to define levels of triage. The Advanced Disaster Medical Response course37 is field oriented and outlines the following:

Level 1 triage occurs at the point of injury.

Level 2 triage occurs at the scene (or nearby) by the most experienced medical provider.

Level 3 triage is performed to determine evacuation priorities.

The Fundamental Disaster Management course37 is ICU oriented and describes the following levels of triage:

Primary triage occurs at the scene.

Secondary triage occurs upon arrival at the hospital.

Tertiary triage occurs in the ICU.

Finally, the ABA approach is burn center oriented and defines the following:

Primary triage is that occurring at the disaster scene or at the ED of the first receiving hospital.

Secondary triage is the selection for transfer of burn patients from one burn center to another when surge capacity is reached.

Clearly, triage is not a one-time operation but has to be repeated at each step of the way. There are several different algorithms for triage. Paramedics may use simple triage and rapid treatment (START) in both emergency medicine and mass casualties. The sensitivity for START varies from 85%38 to 62%.39 Medic in-field triage is another approach. This is done in an established triage area by medics assisted by teams of helpers. It consists of a brief history (time of accident, mechanism of injury, condition, how the patient was found, primary measures taken, actual discomfort, preexisting condition, medications, and allergies) and a quick head-to-toe examination:

Physical examination—external bleeding; penetrating injuries; thermal burns; chemical burns; neurologic status; and investigation of head, spine, thorax, abdomen, pelvis, and extremities

Vital signs, including respiration rate, pulse oximetry, and temperature

Burn size is estimated by the rule of nines, and there is evaluation of suspected inhalation injury and of the need for intubation.

Triage classifies patients according to the following treatment urgency groups shown in Table 5.1. An easy-to-remember acronym is DIME, which stands for delayed, immediate, minimal, and expectant. The main factors to consider in burn patient triage are TBSA burn and age.

Emergency treatment at the scene is done in a treatment area by appropriately trained providers. Burns needing treatment for shock or intubation should be classified for urgent treatment. Because of the need to resuscitate as soon as possible, resuscitation should begin here!

In mass casualties, cardiopulmonary resuscitation (CPR) is not performed as it binds resources for mostly futile efforts for victims initially classified as dead (no ventilation after airway opened, no pulse). This is especially after rescue from indoor fires (because deadly CO poisoning can be assumed) and in the setting of massive trauma.40

Triage group 4 (in Austria, Germany, Switzerland, and some other countries) includes the unsalvageable, who deserve “expectant” treatment. This may be controversial because the duration of the disparity between supply and demand should be short and, when the period is over, this group's priority may change to 1 or 2. Group 4 needs staff at least for comfort care. Dead victims need neither staff nor transports in the acute phase.

If available, tags are attached to each patient. Tags are used not only to indicate triage category but also to provide each patient with a unique number. These tags facilitate victim identification and registration; tell about patients' history, medical treatment, injuries, urgency of treatment, and classification of injury; and specify the hospital for treatment. The tags must not be removed until all the following have occurred: hospital arrival, identifying the patient, and registering the tag number and treatment data.

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Medical Response to Disasters

Susan Miller Briggs, ... Alfonso C. Rosales, in Field Guide to Global Health & Disaster Medicine, 2023

Disaster Triage

Triage is the process of prioritizing casualties according to the level of care they require. It is the most important, and psychologically most difficult, mission of disaster medical response, both in the prehospital and hospital phases of the disaster. Disaster triage requires a fundamental change in the approach to the medical care of victims.1,3,5,6 The objective of conventional civilian triage is to do the greatest good for the individual patient. Severity of injury/disease is the major determinant for medical care. The objective of disaster triage is to do the greatest good for the greatest number of patients. The determinants of triage in disasters are, however, based on three parameters:

Severity of injury

Likelihood of survival

Available resources (logistics, personnel, evacuation assets).

The major objective and challenge of triage is to rapidly identify the small minority of critically injured patients who require urgent life-saving interventions, including operative interventions, from the larger majority of noncritical casualties that characterize most disasters. In a mass casualty event, the critical patients with the greatest chance of survival with the least expenditure of time and resources are prioritized to be treated first.

Triage is a dynamic decision-making process of matching victims needs with available resources. Many MCIs will have multiple different levels of triage as patients move from the disaster scene to definitive medical care. Disaster medical triage may be conducted at three different levels depending on the level of casualties (injuries) to capabilities (resources).1,4,5

Field Triage

Field triage, often the initial triage system used at the disaster scene in MCIs, is the rapid categorization of victims potentially needing immediate medical care where they are lying or at triage sites. Victims are designated as “acute” or “nonacute”. Simplified color coding may be used. Once the victims are transported to casualty collection centers (fixed or mobile medical facilities), medical triage according to severity of injury/disease may be performed.

Medical Triage

Medical triage is the rapid categorization of victims, at a casualty collection site or fixed or mobile medical facilities, by the most experienced medical personnel available to identify the level of medical care needed based on severity of injury. Triage personnel must have knowledge of the medical consequences of various injuries (e.g., burn, blast, or crush injuries or exposure to chemical, biological, or radioactive agents). Color coding may be used (Fig. 15.3).

Evacuation Triage

Evacuation triage assigns priorities to disaster victims for transfer to definitive care facilities. Burns, blast and crush injuries, and pediatric trauma are among key priorities for early transfer because of the complexity of injuries and frequent need for multidisciplinary surgical teams.8,9

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Burn management in disasters and humanitarian crises

Thomas L. Wachtel, K. A. Kelly McQueen, in Total Burn Care (Third Edition), 2007

Triage in a resource-rich environment

Triage ought to be conducted in a simple, straightforward, and experienced manner. Triage should be prognostic with a view toward singling out those among the burned who are likely to survive.25 The two most important aspects of triage have to do with who will perform triage and where. The initial triage will most likely be at the site of a burn disaster by bystanders followed shortly thereafter by other first responders. The triage area is an important consideration. Because of the nature of some burn disasters, it is important to establish triage stations somewhat removed from an immediate scene.16 This would be in response to hazards to the rescue and triage personnel such as bomb threats and potential explosions, interference by a crowd, or simply the fact that better facilities for triage are nearby and available. A safe triage area must be secured so that additional burn victims are not created because of lack of scene safety. The lobby of a hotel might serve as a good triage area, since it has good access and egress, appropriate space to work, and serves as a known location to all rescue workers and medical personnel.20 Sorting should, ideally, be performed at the site by an expert in burns.13,84,92 Expert triage may minimize the requirement for specialized burn beds.31 Few casualties with burn wounds of 30–70% TBSA (14% of those admitted) were encountered following fire disaster.31 Since bed availability in specialized centers is limited, it is clear that accurate triage is essential.31 With lack of sophistication at the scene, burn victims may be taken to the nearest hospital emergency department or accident ward for triage16 before they are transported to tertiary verified burn centers.16,58,83,84,93–95 The rapid evacuation of casualties to nearby hospitals is a realistic aim for all but the most isolated locations, aided by the fact that most burn victims are themselves initially mobile and cooperative50 (see Figure 5.4).

The organization of salvage work is affected by the number of casualties, the seriousness of their injuries, and the general conditions of a disaster.25 The actual triage of patients will be influenced not only by the total number of casualties and bed availability but also by such factors as depth and locations of wounds, complications such as inhalation injury, and extremes of age.31,52 With effective triage, the demand for care in a specialized burn center can be minimized for small minor burns. In the case of the Ramstein air disaster, the triage sites formed de novo where large numbers of patients were encountered, medical personnel congregated naturally, and supplies could be obtained for initial resuscitation. The patients were then carried a short distance to staging areas for helicopter pick up or for ambulance or bus loading. In the Ramstein disaster, complete triage on the scene was not possible. The triage response of emergency services at the air base was criticized,35,82,83 mainly because most of the victims were transported by a ‘load and go’ system to nearby hospitals who were use to patients being treated in the prehospital setting by trained anesthesiologists.

Patients must be triaged into categories for systematic referral to appropriate facilities. The triage category is based on the severity of injury and the potential for salvage. The overall goal is to do the most good for the most people. In general, when resources are unlimited and a disaster plan incorporates additional resources, even the most severely injured burn victim will receive optimal care if the triage is accomplished in the most favorable manner. Where resources are limited, triage may require a method for selecting casualties on a true priority basis. It may mean developing an expectant category for those so severely injured that they are not likely to survive (Figure 5.5).

The problem of triage can be simplified and facilitated by a flexible adaptation of certain formulas. The gravity of burns can be expressed in terms of the extent of TBSA burned and age of the patient. In Czechoslovakia, the sum of age and extent of burn that is greater than 90 has established an empirical 50% chance of survival. By flexibly bringing this number up or down, depending on the overall situation, one can extend or narrow the number of burn casualties who ought to be transported first.25 Immediate triage is essential in the presence of large numbers of burned patients. It has been observed that if a long period elapses before rescue teams can start triage and resuscitation, most of the severely injured die and many of the initially moderately injured develop serious complications.35 Triage may identify five important groups for victims of burn disasters13,59 (Table 5.6).

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