Triage

UPDATED ON Mon, 26 Aug, 2024 BY THOMPSON, RN RAEN.

In the Emergency Department, patients are not attended to on a "first come, first serve" basis; instead, they are prioritized according to the severity of their conditions. Due to the nature of the workload in Accident and Emergency (A&E), a sorting system is essential to ensure that those with the most critical, life-threatening conditions are treated first. The term "triage," derived from a French word meaning "to sort," refers to the process of quickly assessing a patient's acuity. In simple terms, triage involves categorizing patients based on the seriousness of their injuries or illnesses to prioritize treatment. This process is a vital assessment skill for an Emergency Nurse.

In situations where there are multiple patients to care for and resources such as health personnel, ambulances, hospital equipment, and oxygen cylinders are limited, the nurse must prioritize patients through triage to ensure the efficient use of these scarce resources. Triage involves a quick assessment of the patient's airway, breathing, and circulation, along with inquiring about their primary complaint. This practice is also crucial during disasters that result in mass casualties, such as fires, floods, earthquakes, terrorism, or building collapses. In such cases, the triage officer quickly evaluates the injured and assigns them a color-coded tag based on the severity of their condition. The priority of care provided by the Emergency Medical Service (EMS) personnel is determined by this color code. The EMS team then performs life-saving interventions and transports the victims promptly to the appropriate hospital.

Purpose of Triage

The goal of pre-hospital triage is to prioritize patients who require urgent medical attention and transportation to the appropriate hospital. In a hospital setting, triage is used to identify patients who need immediate care and to determine the most suitable treatment area for them. Additionally, triage aims to ensure the efficient use of human and material resources for the patients who need them most.

Acuity category of Triage

Emergency Department use various triage systems, but the basic and widely used triage system is the three (4) categories triage namely: Emergent, Urgent, Non-Urgent and Expectant.

1. Emergent (Red Code):
Is a triage category signifying life threatening injuries or illness requiring immediate intervention. Cases under this category are:
• Airway obstruction and inadequate or poor breathing.
• Open chest or abdominal injuries
• Severe head injury or Coma
• Cardiac Arrest
• Acute heart or renal failure


2. Urgent (Yellow Code): Is a triage category signifying serious injury or illness that is not immediately life threatening. However, if care is not provided for a long period of time, they may suffer irreversible damages. Examples are:
• Major or multiple fractures
• Moderate to severe burns
• Drug overdose or suspected poisoning
• Spinal cord injury
• Intestinal obstruction


3. Non Urgent (Green Code): Is a triage category signifying episodic or minor injury or illness in which treatment may be delayed several hours or longer without increased morbidity. Examples are:
• Soft tissue injuries
• Minor fracture or dislocation
• Nail puncture
• Sprain and Strain
• Chronic backache etc.
Priority 4 (Expectant- Black code): These are victims who are either already deceased or expected to die due to the severity of their injuries, such as those with massive head trauma or extensive full-thickness burns. They should be moved to a holding area and provided with pain relief as needed to minimize suffering, as their injuries are beyond the possibility of life-saving intervention.

Note: Deceased casualties should be covered and kept separate from those who are still alive. Arrangements should be made to transport them to the mortuary. It is important to note that the color codes used in triage can vary between countries.

The most commonly used triage scale in the UK is the National Triage Scale.