Triage

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Typical triage tag used for emergency mass casualty decontamination.

Triage is a system used by medical or emergency personnel to ration limited medical resources when the number of injured needing care exceeds the resources available to perform care so as to treat those patients in most need of treatment who are able to benefit first.

1 History
2 Types
3 Simple Triage and Rapid Treatment
4 Simple triage and evacuation
5 Advanced triage
6 Triage in France
7 Triage in the UK
8 Triage in Canada
9 Reverse triage
10 Alternative Care Facilities
11 Footnotes
12 See also

[edit] History

The word triage is from a French word meaning "sorting", influenced by the Greek tria ("three") ^[1]. Its usual meaning is sorting into three categories, so as to allocate effort most effectively.

Much of the credit for modern day triage has been attributed to Dominique Jean Larrey, a famous French surgeon in Napoleon's army who devised a method to quickly evaluate and categorize the wounded in battle and then evacuate those requiring the most urgent medical attention. He instituted these practices while battle was in progress and triaged patients with no regard to rank. Others have cited the Russian surgeon, Nikolai Pirogov, as developing the triage system during the Crimean War.

[edit] Types

Two basic types exist: simple triage and advanced triage

Simple triage is used at the scene of a mass casualty incident to select patients into those who need immediate transport to the hospital in order to save their lives and those who can wait for help later. This skill is required by first responders performing field triage on the battlefield or at a disaster site to assess the patients' need for transport prior to transportation becoming available. The categorization of patients based on their severity of injury can be aided with the use of printed triage tags or colored flagging.

The Simple triage and rapid treatment (START ) system is an example of simple triage.

Some injuries require immediate medical care. Trauma patients especially require surgery within one hour of injury, the so-called golden hour of emergency medicine. A surgeon can only treat one person at a time, and some procedures require multiple surgeons. Most hospitals have only a few surgeons and would be overwhelmed if presented with several casualties all requiring immediate surgical care. Therefore, patients who require urgent surgical care need to be sent to a number of area hospitals including specialist trauma centers to balance out workload especially since some patients will come by themselves to the nearest hospital which are most likely to be overwhelmed, as well as possibly damaged in the disaster.

This is where START saves many lives. At the scene, people requiring surgical care are sent by helicopter or ambulance to faraway hospitals which have been informed to expect victims requiring immediate surgery and are ready.This is preferable to rushing them to the "nearest" hospital which is overloaded and unable to help.

In advanced triage, doctors may decide that some seriously injured people should not receive certain care because they are unlikely to survive. This does not mean that these patients will not receive any care; it only means that more advanced care will be used on less seriously wounded patients. The available care is then concentrated on those with some hope of survival. This clearly has an ethical implication as treatment is intentionally withheld from some people. The reasoning is that diverting scarce resources away from people with a little chance of survival increases the chances of survival of others who are inherently 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. This has happened in disasters such as volcanoes, thunderstorms, and rail accidents. In these cases some percentage of patients will die regardless of medical care due to the severity of their injuries. Others would live if given immediate medical care, but would die without it.

In this extreme case, any medical care given to people doomed to die can be considered to be care withdrawn from people who might live if they had been given it. It becomes the task of the disaster medical authorities to put aside some victims, to avoid saving one life at the expense of several others.

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.

[edit] Simple Triage and Rapid Treatment

Main article: Simple triage and 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, and those with MINOR injuries the walking wounded who need help less urgently. However these descriptve words are by no means standard and different regions use different designations.

In the UK and Europe, triage is similar to the USA, but the categories used are "DEAD", those who are pronounced as such by a medically qualified person or paramedic who is legally qualified to pronounce death, the "IMMEDIATE" category, who have a trauma score of 3 to 10 (RTS) and need immediate attention, the "URGENT" category, who have a trauma score of 10 or 11 and can wait for a short time before transport to definitive medical attention, and "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 START 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. A non-medical personnel can not decide that an injured is DECEASED.

Color-coded flagging tape can be used to mark patients in a triage situation

[edit] Simple triage and evacuation

Simple triage identifies which persons need advanced medical care. In the field, triage also sets priorities for evacuation to hospitals. In START, persons should be evacuated as follows:

DECEASED are left where they fell, covered if necessary; note that in START a person is not triaged "DECEASED" unless they are not breathing and an effort to reposition their airway has been unsuccessful.

IMMEDIATE priority 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 can have their medical evacuation delayed until all IMMEDIATE persons have been transported. These people are in stable condition but require medical assistance.

MINOR 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.

[edit] Advanced triage

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.

If immediate treatment is successful, the patient may improve (although this may be temporary) and this improvement may allow the patient to be categorised 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.

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 wounds); they should be taken to a holding area and given painkillers to ease their passing.

Red / Immediate: They require immediate surgery or other life-saving intervention, first priority for surgical teams or transport to advanced facilities, "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 layperson'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.

[edit] Triage in France

In France, the triage in case of a disaster uses a four-level scale:

DCD: décédé (deceased), or urgence dépassée (beyond urgency)
UA: urgence absolue (absolute urgency)
UR: urgence relative (relative urgency)
UMP: urgence médico-psychologique (medical-psychological urgency) or impliqué (implied, i.e. lightly wounded or just psychologically shocked).

This triage is performed by a physician called médecin trieur (sorting medic). This triage is usually performed at the field hospital (PMA–poste médical avancé, i.e. forward medical post). The absolute urgencies are usually treated onsite (the PMA has an operating room) or evacuated to a hospital. The relative urgencies are just placed under watch, waiting for an evacuation. The involved are addressed to another structure called the CUMP–Cellule d'urgence médico-psychologique (medical-psychological urgency cell); this is a resting zone, with food and possibly temporary lodging, and a psychologist to take care of the brief reactive psychosis and avoid post-traumatic stress disorder.

In the emergency room of a hospital, the triage is performed by a physician called MAO–médecin d'accueil et d'orientation (reception and orientation physician), and a nurse called IOA– infirmière d'organisation et d'accueil (organisation and reception nurse). Some hospitals and SAMU organisations now use the "Cruciform" card referred to elsewhere.

[edit] Triage in the UK

In the UK, the commonly used triage system is the Smart Incident Command System , taught on MIMMS (Major Incident Medical Management (and) Support). The UK Armed Forces are also using this system on operations worldwide. This grades casualties from Priority 1 (most urgent) to Priority 4 (expectant, i.e. likely to die).

Another system is the Cruciform and Manchester triage.

[edit] Triage in Canada

In the mid-1980's, The Victoria General Hospital, in Halifax, Nova Scotia, Canada, introduced paramedic triage in its Emergency Department. Unlike all other centres in North America that employ physician and primarily nurse triage models, this hospital began the practice of employing Primary Care level paramedics to perform triage upon entry to the Emergency Department. In 1997, following the amalgamation of two of the city's largest hospitals, the Emergency Department at the Victoria General closed. The paramedic triage system was moved to the city's only remaining adult emergency department, located at the New Halifax Infirmary. In 2006, a triage protocol on who to exclude from treatment during a flu pandemic was written by a team of critical-care doctors at the behest of the Ontario government. The protocol was published in the Canadian Medical Association Journal.[1]

[edit] 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, a practice associated with the Russian military. 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.

[edit] 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.