TRIAGE SYSTEMS FOR TRAUMA CARE

Indep Rev July-Aug 2014;16(7-9) IR-333 TRIAGE SYSTEMS FOR TRAUMA CARE Awais Shuja FRCS (Ed), FCPS Assistant Professor of Surgery Independent Medical College, Faisalabad. Correspondence Address: Awais Shuja FRCS (Ed), FCPS Assistant Professor of Surgery Independent Medical College, Faisalabad. Article received on: 06/09/2014 Accepted for Publication: 08/09/2014 Received after proof reading: 25/09/2014 Article Citation: Shuja A, Triage systems for trauma care. Indep Rev July-Sep 2014;16(7-9): 244-249. Key Concepts Definition of triage Principles of triage Triage scales Outcomes of triage trauma triage Abstract Triage is the process of determination of the priority of patients treatments based on the severity of their condition. The purpose of the triage is to ensure that the patient recieves the level and appropriate to clinical need and that recources are most usefully applied. Different triage scales have been developed to help health professionals to classify patients consistently function of emergency around the world. Key words: Triage Ipswish triage scale Austration triage scale, Triage severe. Triage is the process of determining the priority of patient s treatments based on the severity of their condition. This distributes patient treatment efficiently when resources are insufficient for all to be treated immediately. The term comes from the French verb trier, meaning to separate, sift or select. Triage may result in determining the order and priority of emergency treatment, the order and priority of emergency transport, or the transport destination for the patient. Triage may also be used for patients arriving at the emergency department, or telephoning medical advice systems, among others. The term triage may have originated during the Napoleonic Wars from the work of Dominique Jean Larrey. The term was used further during World War I by French doctors treating the battlefield wounded at the aid stations behind the front. Those responsible for the removal of the wounded from a battlefield or their care afterwards would divide the victims into three categories: Those who are likely to live, regardless of what care they receive; Those who are likely to die, regardless of what care they receive; Those for whom immediate care might make a positive difference in outcome. This was the very initial triage system which www.indepreview.com 244

has changed into modern day emergency department triage systems Definition Triage is the process of categorizing emergency patients according to their need for medical care, irrespective of their order of arrival or other factors including sex, age, socioeconomic status, insurance status, nationality, race, ethnicity or religion. Triage is a mechanism that is essential for effective management of modern emergency services. The triage aims to ensure clinical justice for the patient, but also is an effective tool for departmental organization, monitoring and evaluation. Principles of triage The principal purpose of triage is to ensure that the patient receives the level and quality of care appropriate to clinical need and that resources are most usefully applied. Clinical justice, including clinical efficiency, aims to ensure that patient receives appropriate and timely care. The concept of urgency is central to triage in trauma care. Urgency incorporates concepts of timeliness and is different from severity. Urgent conditions may not necessarily be urgent, while severe illness may not necessarily be urgent. Both clinical and environmental factors contribute to the urgency of any particular patient. Key Objectives of triage The following are the objectives of the triage process: To immediately call of medical attention and start resuscitation To assign patient to next available doctor for management To manage waiting list with clinical justice To divert patient to appropriate place in non- urgent problems To use data of triage for audit and research To improve clinical services and utilize resources efficiently Triage scales Different triage scales have been developed to help health professionals to classify patients consistently and to achieve acceptable outcomes. Triage scales in use throughout the world have three elements:the number of categories in the scale, the terminology of the categories in the scale and the processes used to assign patients to the categories. All the scales are categorical. A continuous scale has never been shown to be of value. The purpose of triage is to determine an action among a selection of alternatives. The scale must be categorical and categories aligned with actions. Triage scales usually have 3 to 5 categories with algorithms for making diagnosis supported by guidelines. They are now generally supported by computer based programs and websites which are faster and more effective aids to prioritization and decision-making. The most commonly used scales are Australian triage scale(ats) Canadian triage and acuity scale Ipswich triage scale Ipswich triage scale is a five category scale in which the functional urgency is based on nurse s determination of the patient condition. www.indepreview.com 245 2

3 IPSWICH TRIAGE SCALE The patient should under reasonable circumstances be seen by doctor within: Seconds Minutes An hour Hours Days AUSTRALIAN TRIAGE SCALE Category Description Performance standard ATS 1 Immediate 100% ATS 2 10 min 80% ATS 3 30 min 75% ATS 4 60 min 70% ATS 5 120 min 70% Category Resuscitation Emergency Urgent Less urgent Non urgent The Australian triage system is the most common and universal system, which is a direct triage mechanism and has a 5- level categorical scale. Canadian triage and acuity scale was derived from ATS. It is a 5 categorical scale. Tri age Outcomes There are two stages to the triage process: first, the triage assessment which leads to allocation of a triage category and subsequent processing of the patient; and secondly initiation of treatment to facilitate emergency care with a possible reduction in the patient s discomfort. These triage decisions are linked with 3 type of outcome: correct or expected triage, over triage and under triage. Description Immediate < 15 min < 30 min < 1 hour < 2 hours Correct triage is associated with positive outcome. Outcomes associated with over or under triage result in inappropriate allocation of emergency resources, prolonged waiting times of dangerous complications or prolonging suffering. Trauma triage Trauma triage is the use of trauma assessment for prioritising of patients for treatment or transport according to their severity of injury. Primary triage is carried out at the scene of an accident and secondary triage at the casualty clearing station at the site of a major incident. Triage is repeated prior to transport away from the scene and again at the receiving hospital. www.indepreview.com 246

The primary survey aims to identify and immediately treat life-threatening injuries and is based on the ABCDE resuscitation system. This includes: Airway control with stabilisation of the cervical spine. B reathing. C irculation (including the control of external haemorrhage) D isability or neurological status. E xposure or undressing of the patient while also protecting the patient from hypothermia. Priority is then given to patients most likely to deteriorate clinically and triage takes account of vital signs, prehospital clinical course, mechanism of injury and other medical conditions.triage is a dynamic process and patients should be reassessed frequently. In the UK, the T system is conventionally used at a major incident: 4 Red T1 Immediate priority require immediate life-saving intervention yellow T2 Urgent priority Require significant intervention within 2-4 hours Green T3 Delayed priority Require intervention, but not within 2-4 hours Blue T4 Expectant priority Treatment at an early stage would divert resources from potentially beneficial causalities, with no significant chance of a successful outcome Triage systems are most often used following trauma incidents but may be required in other situations, such as an influenza epidemic. Triage sieve The triage sieve can be used at the scene of major trauma and involves a rapid assessment: Can the patient walk? Yes: Priority 3 (Green - see above). No: Is the patient breathing? No, even after opening airway: Dead. Yes, after opening airway: Priority 1 (Red). Yes, without resuscitation: What is the respiratory rate? Above 30/minute or less than 10/minute: Priority 1 (Red). 10-30/minute: What is the pulse rate (or capillary refill time)? Less than 40 or more than 120 (or capillary refill time greater than 2 seconds): Priority 1 (Red). Between 40 and 120 (or capillary refill time less than 2 seconds): Priority 2 (Yellow). Modified sieve systems are available for use in children. The triage sort The triage sort it is one method used for triage at a casualty clearing station. A total score of 1-10 indicates priority T1, 11 indicates T2, and 12 indicates T3. Triage has become an integral part of the function of emergency around the world and has demonstrated clinical and organizational value. There is an opportunity for the emergency medicine community to commit to an international triage scale and to use that scale as a basis for collaborative research, comparative analysis and evaluation. www.indepreview.com 247

5 Physiological variable Value Score Respiratory rate 10-29 4 References 1. Baker LC, Baker LS. Excess cost of emergency department visits fornonurgent care. Datawatch, 1994, 13(5):162 71. 2. Doobinin KA et al. Nonurgent pediatric emergency department visits: care-seeking behavior and parental knowledge of insurance. Pediatric emergency care, 2003, 19:10 4. 3. Lee TJ et al. Does telephone triage delay significant medical treatment? Advice nurse service vs on-call pediatricians. Archivesof pediatrics & adolescent medicine, 2003, 157:635 41. 4. Kalemoglu M et al. Non-urgent patients in an emergency medical service. Revistamedica de Chile, 2004, 132:1085 9. 5. Carter AJE, Chochinow AH. A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department. Canadian journal of emergency medicine, 2007, 9:286 95. >29 3 6-9 2 1-5 1 0 0 Systolic blood pressure >90 4 76-89 3 50-75 2 1-49 1 0 0 Glasgow Coma Scale (GCS) 13-15 4 9-12 3 6-8 2 4-5 1 3 0 Emergency nurse experience of triage decision making in Hong Kong. AccidEmergNurs 2005;13:206e13. 8. Duckett SJ, Jackson T. Paying for hospital emergency care under a single-payer system. Ann Emerg Med 2001;37:337e9. 9. Mizek R, Phiri W. Australasian Triage Scale: consumer perceptions. Emerg Med Australas 2005;17:212e17. 10. O Brien D, Williams A, Blondell K, et al. Impact of streaming fast track emergencydepartment patients. Aust Health Rev 2006;30:525e32. 11. Kosowsky JM, Shindel S, Liu T, et al. Can emergency department triage nurses predict patients dispositions? Am J Emerg Med 2001;19:10e14. 12. Vertesi L. Does the Canadian Emergency Department Triage and Acuity Scale identifynon-urgent patients who can be triaged away from the emergency department? CJEM2004;6:337e42. 6. Sadeghi S, Barzi A, Sadeghi N, et al. A Bayesian model for triage decision support. Int J Med Inf 2006;75:403e11. 7. Chung JY. An exploration of Accident and 13. Schull M, Kiss A, Szalai J. The effect of low-complexity patients on emergency departments waiting times. Ann Emerg Med 2007;49:257e64. 14. Field S, Lantz A. Emergency department use by www.indepreview.com 248

CTAS levels IV and V patients. CJEM2006;8:317e22. 15. Jelinek GA. Towards an International Triage Scale. Eur J Emerg Med 2001;8:1e2. 16. McNair R, Gurney D. It takes more than string to fly a kite: five level acuity scales areeffective but education clinical expertise and compassion are still essential. J EmergNurs 2005;31:600e3. 17. Cooper RJ. Emergency department triage: why we need a research agenda. AnnEmerg Med 2004;44:524e6. 6 www.indepreview.com 249