Triage

Triage is a process of prioritizing patients based on the severity of their condition so as to treat as many as possible when resources are insufficient for all to be treated immediately. The term comes from the French verb trier, meaning "to sort, sift or select." There are two types of triage: simple triage and advanced triage.

Triage is now also applied in system development. Requirements and design options are triaged to avoid wasting effort on ideas that will obviously never succeed.

Simple triage
Simple triage is used in a scene of mass casualty, in order to sort patients into those who need critical attention and immediate transport to the hospital and those with less serious injuries. This step can be started before transportation becomes available. The categorization of patients based on the severity of their injuries can be aided with the use of printed triage tags or colored flagging.

Rapid treatment
S.T.A.R.T. (Simple Triage and Rapid Treatment) is a simple triage system that can be performed by lightly-trained lay and emergency personnel in emergencies. It is not intended to supersede or instruct medical personnel or techniques. It may serve as an instructive example, and has been (2003) taught to California emergency workers for use in earthquakes. It was developed at Hoag Hospital in Newport Beach, California for use by emergency services. It has been field-proven in mass casualty incidents such as train wrecks and bus accidents, though it was developed for use by CERTs and firemen after earthquakes.

Triage separates the injured into four groups:
 * The deceased who are beyond help
 * The injured who can be helped by immediate transportation
 * The injured whose transport can be delayed
 * Those with minor injuries, who need help less urgently

However, these descriptive words are by no means standard; different regions use different designations.

In the UK and Europe, the triage process used is similar to that of the United States, but the categories are different:
 * Dead - those who are pronounced as such by a medically qualified person or paramedic who is legally qualified to pronounce death
 * Immediate - patients who have a trauma score of 3 to 10 (RTS) and need immediate attention
 * Urgent - patients who have a trauma score of 10 or 11 and can wait for a short time before transport to definitive medical attention
 * Delayed - patients who have a trauma score of 12 (maximum score) and can be delayed before transport from the scene

A simplified but effective description of the S.T.A.R.T. is taught in the Israeli army to non-medical personnel: the injured who are lying on the ground silently should be prepared for immediate transportation; injured lying on the ground but screaming are injured whose transportation can be delayed; and the walking wounded need help less urgently. Non-medical personnel have no authority to tag an injured person as deceased.



Evacuation
Simple triage identifies which people need advanced medical care. In the field, triage also sets priorities for evacuation to hospitals. In S.T.A.R.T., casualties should be evacuated as follows:


 * Deceased are left where they fell, covered if necessary; note that in S.T.A.R.T. a person is not triaged "deceased" unless they are not breathing and an effort to reposition their airway has been unsuccessful.


 * Immediate or Priority 1 (red) evacuation by MEDEVAC if available or ambulance as they need advanced medical care at once or within 1 hour. These people are in critical condition and would die without immediate assistance.


 * Delayed or Priority 2 (yellow) can have their medical evacuation delayed until all immediate persons have been transported. These people are in stable condition but require medical assistance.


 * Minor or Priority 3 (green) are not evacuated until all immediate and delayed persons have been evacuated. These will not need advanced medical care for at least several hours.  Continue to re-triage in case their condition worsens. These people are able to walk, and may only require bandages and antiseptic.

Advanced triage
In advanced triage, 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. Because treatment is intentionally withheld from patients with certain injuries, advanced triage has ethical implications. It is used to divert scarce resources away from patients with little chance of survival in order to increase the chances of survival of others who are more likely to survive.

In Western Europe, the criterion used for this category of patient is a trauma score of consistently at or below 3. This can be determined by using the Triage Revised Trauma Score (TRTS), a medically validated scoring system incorporated in some triage cards.

The use of advanced triage may become necessary when medical professionals decide that the medical resources available are not sufficient to treat all the people who need help. The treatment being prioritized can include the time spent on medical care, or drugs or other limited resources. This has happened in disasters such as volcanic eruptions, thunderstorms, and rail accidents. In these cases some percentage of patients will die regardless of medical care because of the severity of their injuries. Others would live if given immediate medical care, but would die without it.

In these extreme situations, any medical care given to people who will die anyway can be considered to be care withdrawn from others who might have survived (or perhaps suffered less severe disability from their injuries) had they been treated instead. It becomes the task of the disaster medical authorities to set aside some victims as hopeless, to avoid trying to save one life at the expense of several others.

If immediate treatment is successful, the patient may improve (although this may be temporary) and this improvement may allow the patient to be categorized to a lower priority in the short term. Triage should be a continuous process and categories should be checked regularly to ensure that the priority remains correct. A trauma score is invariably taken when the victim first comes into hospital and subsequent trauma scores taken to see any changes in the victim's physiological parameters. If a record is provided back in time, the receiving hospital doctor can see a historical trauma score going back in time to the incident. This should allow more definitive treatment to be carried out earlier than might otherwise be the case.

Categories of severity
In advanced triage systems, secondary triage is typically implemented by paramedics, battlefield medical personnel or by skilled nurses in the emergency departments of hospitals during disasters, injured people are sorted into five categories.


 * Black / Expectant: They are so severely injured that they will die of their injuries, possibly in hours or days (large-body burns, severe trauma, lethal radiation dose), or in life-threatening medical crisis that they are unlikely to survive given the care available (cardiac arrest, septic shock, severe head or chest wounds); they should be taken to a holding area and given painkillers as required to reduce suffering.


 * Red / Immediate: They require immediate surgery or other life-saving intervention, and have first priority for surgical teams or transport to advanced facilities; they "cannot wait" but are likely to survive with immediate treatment.


 * Yellow / Observation: Their condition is stable for the moment but requires watching by trained persons and frequent re-triage, will need hospital care (and would receive immediate priority care under "normal" circumstances).


 * Green / Wait (walking wounded): They will require a doctor's care in several hours or days but not immediately, may wait for a number of hours or be told to go home and come back the next day (broken bones without compound fractures, many soft tissue injuries).


 * White / Dismiss (walking wounded):They have minor injuries; first aid and home care are sufficient, a doctor's care is not required. Injuries are along the lines of cuts and scrapes, or minor burns.

Note that this scale is more complex than simple triage. Medical professionals should refer to professional texts and training references when implementing advanced triage; this listing is only for a layman's understanding.

Some crippling injuries, even if not life-threatening, may be elevated in priority based on the available capabilities. During peacetime, most amputations may be triaged "Red" because surgical reattachment must take place within minutes, even though in all probability the person will not die without a thumb or hand.

Reverse triage
In addition to the standard practices of triage as mentioned above, there are conditions where sometimes the less wounded are treated in preference to the more severely wounded. This may arise in a situation such as war where the military setting may require soldiers be returned to combat as quickly as possible, or disaster situations where medical resources are limited in order to conserve resources for those likely to survive but requiring advanced medical care. Other possible scenarios where this could arise include situations where significant numbers of medical personnel are among the affected patients where it may be advantageous to ensure that they survive to continue providing care in the coming days especially if medical resources are already stretched. In cold water drowning incidents, it is common to use reverse triage because drowning victims in cold water can survive longer than in warm water if given immediate BLS and often those who are rescued and able to breathe on their own will improve with minimal or no help.

Continuous Integrated Triage
Continuous Integrated Triage is an approach to triage in mass casualty situations which is both efficient and sensitive to psychosocial and disaster behavioral health issues that effect the number of patients seeking care (surge), the manner in which a hospital or healthcare facility deals with that surge (surge capacity) and the overarching medical needs of the event.

Continuous Integrated Triage combines three forms of triage with progressive specificity to most rapidly identify those patients in greatest need of care while balancing the needs of the individual patients against the available resources and the needs of other patients. Continuous Integrated Triage employs:

· Group (Global) Triage (i.e. M.A.S.S. Triage)

· Physiologic (Individual) Triage (i.e. S.T.A.R.T. or Simple Triage and Rapid Treatment)

· Hospital Triage (i.e. E.S.I. or Emergency Severity Index)

However any Group, Individual and/or Hospital Triage system can be used at the appropriate level of evaluation.

Another system is the Cruciform and Manchester triage.

Hospital Triage Systems in the United States
For a typical inpatient hospital triage system, a triage physician will either field requests for admission from the ER physician on patients needing admission or from physicians taking care of patients from other floors who can be transferred because they no longer need that level of care (i.e. intensive care unit patient is stable for the medical floor). This helps keep patients moving through the hospital in an efficient and effective manner.

This triage position is often done by a hospitalist. A major factor contributing to the triage decision is available hospital bed space. The triage hospitalist must determine, in conjunction with a hospital's "bed control" and admitting team, what beds are available for optimal utilization of resources in order to provide safe care to all patients. A typical surgical team will have their own system of triage for trauma and general surgery patients. This is also true for neurology and neurosurgical services.

The overall goal of triage, in this system, is to both determine if a patient is appropriate for a given level of care and to ensure that hospital resources are utilized effectively.

Alternative Care Facilities
Alternative Care Facilities (ACFs) are places that are setup for the care of large numbers of patients, or are places that could be so set up. Examples include schools, sports stadiums, and large camps that can be prepared and used for the care, feeding, and holding of large numbers of victims of a mass casualty event.

History and Origin
Triage originated and was first formalized in WWI by French doctors treating the battlefield wounded at the aid stations behind the front.

Undertriage and Overtriage
Undertriage and Overtriage are two key concepts that are imperative to understanding the triage process. Undertriage is the process of underestimating the severity of an illness or injury. An example of this would be categorizing a Priority 1 (Immediate) patient as a Priority 2 (Delayed) or Priority 3 (Minimal). Historically, acceptable undertriage rates have been deemed 5% or less. Overtriage is the process of overestimating the level to which an individual has experienced an illness or injury. An example of this would be categorizing a Priority 3 (Minimal) patient as a Priority 2 (Delayed) or Priority 1 (Immediate). Acceptable overtriage rates have been typically up to 50% in an effort to avoid Undertriage.

Burstein, J. L. & Hogan, D. E. (2007). Disaster Medicine (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.