TRIAGE

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TRIAGE

Prepared by

Mr. Migron Rubin
M.Sc. Nursing Ist
Year
Pragyan College of Nursing

Bhopal

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INRODUCTION

• The word triage is derived from French word
  trier which means to sort. Emergency triage
  is a sub specialty of emergency nursing which
  requires specific comprehensive educational
  preparation. During the disaster, the goal is to
  maximize the no. of survivors by sorting
  treatable from untreatable victims.

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WHAT IS TRIAGE ?

• Triage is a process which places the right
  patient in right place at right time to receive
  the right level of care.

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Need of disaster triage

• Inadequate resource to meet immediate needs.
• Infrastructure limitations
• Limited transport capabilities.
• Hospital resources overwhelmed.

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Aims of triage

• To sort patients based on needs for immediate
  care.
• To recognize futility (lack of purpose).

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• Medical needs will outstrip the immediately
  available resources.
• Additional resources will become available, if
  given enough time.

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• To ensure that all people requiring emergency
  care are appropriately categorized according to
  their clinical condition.

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Advantages of triage

• Triage helps to bring order organization to a
  chaotic scene.
• It identifies provides care to those who are in
  greatest need.
• Triage helps to make difficult decisions easier.

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• It assures that resources are used in the most
  effective manner.
• It may take some of the emotional burden away
  from those doing triage.

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Triage team

• Triage team leader co-ordinator
• Clinical triage officer
• Head nurse, matron chief organiser.
• Nursing staff
• Follow-up medical groups

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Types of triage

• Simple Triage - Simple triage is used in scene of
  mass casualty, in order to sort patients into
  those who need critical attention immediate
  transport to hospital those with less serious
  injuries. This step can be started before
  transportation becomes available.

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S.T.A.R.T. Simple triage Rapid Treatment

• It is a simple triage system that can be
  performed by lightly trained lay emergency
  personnel in emergencies.

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• Triage separates injured into 4 groups-
• 0 - The injured who are beyond help.
• 1 - The injured who can be helped by immediate
  transportation.

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• 2 -The injured whose transport can be delayed.
• 3 Those with minor injuries, who need help, less
  urgently.

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Advanced Triage

• In this 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.

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• Under triage is the underestimating the severity
  of an illness or injury.
• Over triage is the overestimating of the severity
  of an illness or injury.

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Australasian Triage Scale

• It is also known as National Triage Scale.

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Triage Level 1

• Immediately life threatening or Resuscitation
• People admitted under this level requires
  immediate treatment of patients. Any delay in
  treatment can lead to patients death. It
  includes conditions such as cardiac arrest,
  severe shock, decreased respiratory status, large
  area burn, multi system or cervical trauma etc.

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Triage Level 2

• Imminently life threatening or Emergency
• People admitted under this level requires
  treatment of patients within 10-15 minutes of
  patients arrival. It includes conditions such as
  head injury, severe allergic reaction, GI
  bleeding, sexual assault etc.

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Triage Level 3

• Potentially life threatening/Time critical or
  Urgent
• People admitted under this level requires
  treatment of patients within 30 minutes of
  patients arrival. It includes conditions such as
  mild head injury, moderate trauma, history of
  seizure, any abuse, mild to moderate asthma
  attacks etc.

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Triage Level 4

• Potentially life serious/Situational urgency
  or semi urgent
• People admitted under this level requires
  treatment of patients within 1 hour of patients
  arrival.
• It includes conditions such as vomiting,
  diarrhea, fever, minor trauma.

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Triage Level 5

• Less/ Non urgent
• People admitted under this condition requires
  treatment within 2 hours of patients arrival.
• It includes conditions such as sore throat,
  minor symptoms, abdominal pains etc.

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Emergency severity index (ESI) Triage Scale

• The Emergency Severity Index is a 5 level tool
  for use in emergency department triage.
  Experienced ER nurses use the ESI to rate
  patients acuity on a scale of 1-5.
• Level 1 Immediate life saving intervention is
  required .Example-cardiac resp. arrest etc.

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• Level 2 High risk situation is required
  (Confused, lethargic, disoriented, severe pain or
  distress, hypo or hyperglycemia)
• Level 3 Multiple Resources are required .
  Example- chest pain, GI bleeding etc.

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• Level 4 .It includes patients with less serious
  conditions. Example- vomiting, diarrhoea etc.
• Level 5 No resources are needed. Example minor
  cut or burn.

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E M E R G E N C Y
S E V E R I T Y
I N D E X
Is patient dying ?
Yes
No
Level II, III, IV, V
Level I
Can patient wait ?
Yes
No
Level II
Level III, IV, V
How many resources ?
ONE Level IV

• TWO
• Level III

NON Level V
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Limitations of current practices

• Lacking the clear goal of maximizing the number
  of lives saved.
• Using trauma measures that are problematic and
  grouping into broad color-coded.

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• Not considering size of incident, resources, and
  injury severities and prioritization within its
  categories.
• Not considering differences in injury severities
  and survival probabilities between types of
  trauma (blunt versus penetrating, etc.) and aged.

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• Resulting in inconsistent tagging and
  prioritizing of casualties and substantial over
  triage.
• Inefficient triage leads to costly health care
  and waste of materials.

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Role of triage nurse

• Assessment of patients condition.
• Distribution of patients in various levels of
  triage depending upon patients condition.
• Checking vital signs of the patients.

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• Taking certain steps to control haemorrhage in
  case of trauma accidents.
• Make control over unnecessary crowds so that
  there can be enough space for health care givers
  to provide treatment of patient.
• Providing critical care.

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• Taking patients blood sample, cleaning
  bandaging wounds.
• Administration of medications maintaining
  proper supplies of medical equipments.
• Documentation of the procedure.

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• Referral of the patient, if required.
• Providing education conducting triage training
  program for staff.

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SUMMARY

• Triage is the process of determining the priority
  of patients' treatments based on the severity of
  their condition. Every victim requires treatment
  in time thus triage is necessary.

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• THANKYOU