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Different Types of Triage

Article  in  Arşiv Kaynak Tarama Dergisi · December 2017

DOI: 10.17827/aktd.326944

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 Arşiv Kaynak Tarama Dergisi
Archives Medical Review Journal

Different Types of Triage

Triyaj Türleri
Adel Hamed Elbaih
Suez Canal University, Faculty of Medicine, Dept. Emergency Medicine, Ismailia, Egypt

ABSTRACT
Emergency departments of hospitals are one of the most important components of the health care
system. There is an increase in numbers of patients visiting emergency departments leading to
overcrowding, long waiting time and negative impact on patient satisfaction. Several studies have
demonstrated that more than half of emergency department visits are for non-urgent reasons, leading
to unnecessary costs and many adverse consequences. There are several aspects of emergency
department triage which are used to identifty priority of treatment, available resources and time. The
aim of this article is to describe different types of triages.
Key words: Triage, emergency department.

ÖZET
Hastanelerde acil servisler sağlık sisteminin en önemli bileşenlerinden biridir. Acil servisleri ziyaret
eden hasta sayısında artış, kalabalığa, uzun bekleme süresi ve hasta memnuniyeti üzerine olumsuz
etkilere neden olmaktadır. Farklı çalışmalar, acil servis ziyaretlerinin yarısından fazlasının acil olmayan
nedenlerle olduğu; bu durumun da gereksiz maliyetlere ve olumsuz sonuçlara neden olduğunu
göstermiştir. Tedavi önceliği, mevcut kaynaklar ve zaman acil servis triyajının önemli ölçütlerindendir.
Bu yazıda çeşitli türlerdeki triyajların tanımlanması hedeflenmiştir.
Anahtar kelimeler: Triyaj, acil servis.

Introduction
Triage is a fundamental function in emergency departments (EDs), where many patients may
present at the same time. The aim of triage system is to be sure that the patients will be
treated according to their clinical urgency, which refers to the need for time-critical

2017;26(4):441-467
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doi:10.17827/aktd.326944
442 Different Types of Triage

intervention. Also, triage helps in directing the patient to the most suitable area for
assessment and treatment, and collects data that helps to describe the case-mix in the
departmental. Changing patterns of care in some EDs do not eliminate the need for triage1.
Triage is a system used in emergency when the number of injured needing care exceeds the
resources available to perform care so as to treat the greatest number of patient possible.
Triage has evolved to become a critically important part of the ED, as long waits to see the ED
physician /nurse require prompt identification at triage of those patients with high-risk
conditions. The patients arriving at ED usually face long waiting times. Although EDs always
use some sort of triage, either formal or informal, overcrowding of EDs makes accurate
triaging import to avoid delays in critical patient care, which might result in waiting long
times and bad outcomes2. ED triage systems helps in categorizing of emergency patients
according to the disease severity and decide both priority and location of treatment. The
target of every triage systems is to minimize the in-hospital mortality and to decrease time to
treatment, length of stay, and the used resources3.
Five-level triage systems are more effective and useful than other systems; they are the
systems of choice [4]. Four various five-level triage systems are accepted internationally which
are Australasian Triage Scale (ATS), Manchester Triage System (MTS), Canadian Triage and
Acuity Scale (CTAS) and Emergency Severity Index (ESI)4,5. Triage is the procedure of sorting
patients in light of the level of sharpness to guarantee the most extremely harmed and sick
patients get convenient consideration before their condition declines6. Generally, clinicians are
all around prepared in history taking and physical examinations which are utilized to make an
analysis6,7. Conventions in pocket handbooks have been intended to guarantee that crises are
fittingly handled. This is especially applicable in mishap and crisis offices where patients with
basic wounds frequently require timeous consideration regarding avert avoidable weakening
of their condition7. Deferred or poor activity in light of watched irregular physiological
parameters can prompt avoidable and startling deaths7. Identifying patients at danger of
crumbling at an early stage by method for basic rules taking into account physiological
parameters can diminish the quantity of revival methodology required in crisis rooms7. This
can conceivably enhance the hole between problematic consideration and great
consideration, bringing about better results8.
The sudden decay of a patient' condition in doctor's facility is frequently gone before by

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reported confirmation of changes in physiological parameters8. Delays in perceiving the decay

of respiratory or cerebral capacities utilizing basic physiological perceptions expand the
danger of cardiopulmonary arrest7,8. Without auspicious and proper intercession,
neighborhood incendiary procedures break down and in the end get to be generalized9. The
essential point of triage is to recognize each one of those patients whose condition is required
to compound ought to quick care not be gotten10. The auxiliary point is to distinguish each
one of those patients who don't require time basic consideration, can be securely triaged into
a non-earnest class. These patients would need to sit tight for a couple of hours or be alluded
to another social insurance supplier10. The aim of this artcile is to describe different types of
triages.
Definition of Triage
Triage is defined as" a dynamic decision-making process that prioritizes the patient’s need for
medical care when arrive EDs"12. Oxford English Dictionary has defined triage as ‘The
assignment of degrees of urgency to illnesses or wounds in order to decide the order of
treatment’13. Now, it is defined as the process of sorting and categorization of patients
according to the degree of severity of condition, and the availability of medical and transport
facilities14. The purpose of triage is to give prompt care and adequate treatment to all patients
arriving to the ED.
Historical Origin of Triage
The word triage was derived from the French verb (trier) which mean to pick or to sort15. This
word entered English as a noun describing the process of sorting agricultural products16.
Triage was first developed in battlefield in the 18th century by Baron Dominique Jean Larrey,
Chief Surgeon of Napoleon’s Imperial Guard17. Larrey set a clear rule for sorting patients for
treatment which was to treat those who are dangerously wounded first without regard to
rank or distinction then those who are injured in a less degree may wait until those who are
badly mutilated have been operated on and dressed18. In 1846 the British surgeon John
Wilson said that surgeons should focus on those patients who need immediate treatment and
those whose treatment is likely to be successful, postponing treatment for those whose
wounds are probably fatal with or without immediate intervention and those whose wounds
are less severe19.

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In 1963 a system called "medical triage" was instituted in Yale-New Haven Hospital which
was an initial screening technic intended to provide brief medical evaluation of incoming
patients, to determine type and priority of service required, and to accomplish appropriate
referral20. Since the early 1990s, many countries have developed and introduced ED triage21.
Development of triage scales in several countries has been influenced greatly by the seminal
work of Fitzgerald leading to development of 5-level scales triage in the 1990s and 2000s22.
Principles of Triage
The triage principle of prioritizing care to large groups of people has been adapted from its
military origin for use in the civilian context of initial emergency department care11. Triage is
the formal process of immediate assessment of all patients who present to the ED. It is an
essential function in the ED as many patients may present simultaneously. An effective triage
system aims to ensure that patients seeking emergency care “receive appropriate attention, in
a suitable location, with the requisite degree of urgency” and that emergency care is initiated
in response to clinical need rather than order of arrival. Triage aims to promote the safety of
patients by ensuring that timing of care and resource allocation is requisite to the degree of
illness or injury. An effective triage system classifies patients into groups according to acuity of
illness or injury and aims to ensure that the patients with life threatening illness or injury
receive immediate intervention and greatest resource allocation In Australia, triage is
predominantly a nursing assessment that begins when the patient presents to the ED. Triage
is the point at which emergency care begins. Triage is an ongoing process involving
continuous assessment and reassessment11.
Types of Triage
There are several types of triage including disaster triage, military triage, ED triage, ICU triage
and telephone triage23. There are several differences between ED triage and Disaster triage. In
ED triage, each patient is assessed according to this patient clinical needs, while
categorization of patients in disaster triage depends also on the limited resources and the
other casualties. EDs triage usually uses 5 level scale while, disaster triage usually uses 3 or 4
level scales25.
Triaging of patients has the accompanying objectives:
1. To distinguish patients with critical life debilitating conditions.

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2. To decide the most reasonable treatment regions for those patients touching base in the
ED.
3. To diminish clog and congestion in crisis territories24.
The goals of the triage framework are the accompanying:
1. To diminish the general length of stay and to decline sitting tight times for Red and
orange patients.
2. The triage framework enhances patient and wellbeing supplier fulfillment, progresses
tolerant stream and reductions stuffing inside the crisis ranges. It empowers the
conveyance of time-basic treatment forever debilitating conditions and in conclusion
guarantees exact arrangement of patients8.
Triage Tag
Triage tag is a tool first responders and medical personnel use during a mass casualty
incident? as Figure 1. Patients generally are tagged. Tags are color-coded as follows8.

Figure 1. Categories of triage tag

Advanced Triage
1. Blue/Expectant: To die
2. Red/Immediate: Immediate surgery or other-life saving intervention transport to
advanced facilities.
3. Green/Wait: 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).
4. Yellow observation: Stable for the moment but requires watching by trained persons and
frequent re-triage, will need hospital care ( and would receive immediate priority care

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446 Different Types of Triage

under note immediately, may wait for a number of hours or be told to go home and came
back the next day ( broken bones without compound and fractures , many soft tissues
injuries)23.
5. White/Dismiss: They have minor injuries, first aid and home care are sufficient, a doctor’s
care is not required
Benefits of triage tags are to improve traffic flow and increase distributed care among injured
patients during data collection. Also information can be obtained and added on to the triage
tag throughout the triage and it helps to assess patients or victims condition where the
priority can go up or down .This eliminates the need to re-triage25.

Figure 2. Emergency department –new patient flow.

ED Triage
The hospital ED is one of the most important components of the health care system5.There is
an increase in numbers of patients visiting EDs leading to overcrowding, long waiting time
and negative impact on patient satisfaction23. Several studies have demonstrated that more
than half of ED visits are for non-urgent reasons, leading to unnecessary costs and many
adverse consequences24. As a result, EDs developed triage systems to ensure that patients who
had the most urgent medical problems and need immediate care were actually treated first

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Elbaih 447

and that others could safely wait as showing in figure 2 30.There are several aspects of ED
triage which are priority of treatment, available resources and time. In the previous concept
we can identify ED triage as a dynamic process of rapidly and systematically categorizing the
patient according to severity of illness or injury, priority for treatment and efficiently use ED
resources25.
Implantation of ED triage
There was an increase in number of patients presenting to the EDs in the United States in the
1960’s as a result to Healthcare reform, this led to implantation of ED triage systems to ensure
that the patient who need immediate treatment treated first25. Also, in 1970’s in Australia
there was an increase in patients' number who presented to the ED by ambulance, which
resulted in the development of several local 5 level triage systems. These triage systems were
the basis of the ATS which was implemented in 199323. Nowadays, several European countries
(Portugal, the Netherlands and Switzerland) have implemented one of the previous triage
scales26.But in Egypt there is no available ideal triage except in little especial hospital so we
hope to generalized to all hospitals.
The main objective of triage is immediate patient assessment to avoid any possible harmful
delay. Triage aims to ensure that timing of care and resource allocation is according to the
degree of illness or injury27. The benefits of triage are reduction in waiting time especially for
those in need of the most urgent attention and reduction in levels of anxiety in patients, or in
those accompanying them, as they are reassured that their condition either urgent and will
receive immediate attention, or that the situation is under control clinically and can wait with
no harmful result27.
ED Triage Scales
The ideal triage scale must be easy to understand, simple to use, have high inter-rater
agreement, facilitate appropriate location of patients, predict ED resource use requirements
and predict clinical Outcome. Also, it should be applicable across all patient populations and
age groups, allow for quick rating of patients and rapid identification of patients in need of
immediate care28. An effective triage scale should increase the quality of patient care, shorten
patients' length of stay and waiting time by optimizing time of medical assessment and
intervention. It should also have high validity through measuring clinical urgency as opposed

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448 Different Types of Triage

to severity or complexity of illness28.

Different triage scales have been developed to classify ED patients to achieve acceptable
health outcomes. Triage scales usually have 3 to 5 levels supported by triage guidelines and
procedures29. The 1st five-level scale was the Ipswich Triage scale from which all others have
been adapted. The National Triage Scale (NTS) which then became the Australasian Triage
scale (ATS), the Manchester Triage Scale (MTS), the Canadian Emergency Department Triage
and Acuity Scale (CTAS) and the Emergency Severity Index (ESI) have had the greatest impact
on modern ED triage. Other scales as the Soterion Rapid Triage Scale (SRTS) and the 4-level
Taiwan Triage System (TTS) have not distribute as widely around the globe22. Internationally,
five levels triage scales show a greater degree of validity, precision and reliability when
compared either three or four level triage systems29.
The South African Triage Scale (SATS)
In 2004, the South African Triage Group (SATG) (some time ago known as the Cape Triage
Group) was gathered under the sponsorship of the joint Division of Emergency Medicine at the
Universities of Cape Town and Stellenbosch. The point of the SATG was to create a triage scale
for use all through South Africa43. The gathering was multi-disciplinary and contained
specialists, medical caretakers and paramedics. The aftereffect of the SATG's exercises is the
South African Triage Scale (SATS), a physiology and manifestation based scale which
organizes into one of four hues and can be utilized as a part of clinic, Emergency Centers and
additionally in the pre-doctor's facility setting. The SATS has been approved in general society,
private medicinal services setting and also pre-healing facility43.
The SATS has appeared to decrease mortality and bleakness, is effortlessly educated and
caught on, is viable and easy to understand and is solid and exact. The advantages of the
SATS 44 are to speed up the conveyance of time-basic treatment for patients with life-
undermining conditions, to guarantee that all individuals requiring crisis consideration are
properly ordered by clinical condition, to enhance quiet stream to enhance quiet fulfillment,
to abatement the patient's general length of remain, to encourage spilling of less pressing
patients and is its easy to use though levels of wellbeing couldn't care fewer experts.
SATS was produced out of a requirement for a precise and target measure of desperation in
light of physiological parameters and clinical discriminators that is effectively executed in low

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asset settings43.
The Cape Triage Score (CTS)
The Cape Triage Score (CTS) has been inferred by the Cape Triage Group (CTG) for use in crisis
units all through South Africa. It can likewise be utilized as a part of the pre-clinic setting ,
despite the fact that it is not intended for mass setback circumstances44. The CTS involve a
physiologically based scoring framework and a rundown of discriminators, intended to triage
patients into one of five needs bunches for medicinal consideration. Three variants have been
created, for grown-ups, youngsters and newborn children43. The need to organize the
consideration of Egyptian patients in both the pre-clinic and emergency unit (EU) setting is
self-evident. Such prioritization is termed triage – the procedure of sorting patients as per
therapeutic need. As there is no broadly acknowledged triage framework in Egypt, the need to
plan and actualize such a framework was recognized. Numerous universal triage frameworks
exist, however none of these frameworks are suitable for use in Egypt. In-doctor's facility
triage frameworks incorporate the Manchester Triage, The Canadian Triage Assessment Scale
(CTAS)21 and the Australian Triage Score (ATS)43.
Implementation of each of these triage tools requires extensive training, making their
widespread adoption in Egypt problematic20. Moreover, the time taken to triage every patient
surpasses necessities for the Egyptian setting, where persistent numbers are more noteworthy
and the pathology frequently more progressed43.
Pre-healing center triage apparatuses are regular to a wide range of nations; in any case, they
do not have the affectability and specificity to make them alright for crisis unit use besides,
some are accepted just for injury triage, 3-6.while others are excessively point by point,
making it impossible to be of roadside use43. Precise pre-healing center triage is crucial for
suitable use of assets, exact notice of getting doctor's facilities, quality administration and
review of the emergency vehicle administration43. Nonappearance of a triage framework
prompts delayed holding up times ,poor administration of clinical hazard and expanded
dismalness and mortality. With a specific end goal to augment the effective utilization of
assets what's more, to minimize danger to the patient, a powerful triage frame work with
high affectability and specificity is required44. Without objective clinical parameters, varieties
in patient appraisal are unavoidable. The expressions "stable" and "unstable" neglect to
mirror the patient's clinical condition precisely43. The CTG set objectives that included

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450 Different Types of Triage

characterizing imperative sign parameters, while guaranteeing that the triage framework
remained easy to understand keeping in mind the end goal to empower fast and exact sorting
of crisis patients43.
The shading classifications are as per the following:21.
1. red – prompt need revival cases)
2. Orange – extremely pressing need conceivably life/appendage debilitating pathology);
3. yellow-critical need (huge pathology);
4. Green – postponed need (minor wounds/sickness);
5. Blue – dead.
The orange class diminishes the quantity of patients in the possibly substantial yellow class
while constraining the red class to revival cases. For effortlessness, the orange class won't be
utilized as a part of the pre-clinic setting. The CTS inference process has been through both
master supposition and in-healing center forthcoming studies. Three versions have been
adapted. The adult version is intended for those over 12 years of age or 150 cm in height, the
child version has been developed for those 95-150 cm or 3-12 years old, and the infant version
for those under 95 cm or less than 3years of age43,44.
Australasian Triage Scale (ATS)
ATS is a 5 point scale that is used throughout Australia and New Zealand to sort patients by
clinical urgency. Also, it was the starting point for the development of MTS in United Kingdom
and CTAS in Canada. ATS standardized approach to triage has been shown to facilitate access
to emergency care services based on urgency and regardless of patient demographics45.
History
ATS was formally called NTS (National Triage Scale) which was implemented in 1993 as the 1st
triage system used in all publicly funded EDs in Australia. ATS was formulated in 2000 as a
result of revision of NTS and the main difference was the description of each categories25.
Categories of ATS
After application of ATS in Australia there were varying degrees of consistency which led to
publication of The Consistency of Triage in Victoria’s Emergency Departments Project which
aimed to improve the consistency of triage through development of physiological

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Elbaih 451

discriminators that would allow for the use of objective and subjective data in the triage
decision-making process45.
ATS consist of five categories which link patient history, signs and diagnosis to clinical
urgency45. LeVasseur and others described each category of ATS in indicative manner as shown
in Table 133. Also, we should consider presence of risk factor for serious injury or illness as
Presence of one or more risk factors may result in allocation of the patient to a higher level of
acuity.
These risk factors include:
1. Patient age ˃ 65
2. Presence of co morbidities as cardiovascular, respiratory or renal disease, D.M, cancer or
immune-compromised patient
3. Patient with cardiac risk factors as obesity, smoking or high cholesterol
4. History of collapse, seizure or apneic episodes.
5. Mechanism of injury in trauma patients as length of the fall ˃ 5m or presence of
penetrating injury.
6. Patients with high risk alerts as history of violence or sexual assault.
7. Other factors as rash which may be due to anaphylactic reaction or change in body temp.
Emergency Severity Index (ESI)
ESI is 5 level triage scale and it is mainly in use in the USA. ESI has shown marked
improvement in reliability and validity over traditional triage systems. Also, it demonstrated
excellent inter-rater reliability and validity at predicting resource utilization, LOS and six-
month mortality41.
History
ESI was developed by Wuerz et al. due to poor reliability and validity of the 3 level triage scale
that was in use in USA. The concept of this triage was asking about not only who needs to be
seen first, like other 5 level triage scales, but also asking about what does that patient need?41.
In 1999, version 1 of ESI was implanted in two university based EDs. In 2000, ESI version 1 was
revised and developed to version 2 that included pediatric criteria and other changes like
heart rate, which become over 100 beats/min42. In version 2, it was required to up-triage a
patient in level 3 to level 2 if violated that danger vital zone so version 3 was developed to

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452 Different Types of Triage

consider up-triage and not be required to up-triage in all cases42.

Table 1. Description of ATS categories
Clinical Descriptors (indicative
ATS categories Response Description of Category
only)
Cardiac arrest
Respiratory arrest
Immediate
Immediately Life- Respiratory rate <10/min
simultaneous
ATS 1 Threatening BP< 80 (adult)
assessment and
Unresponsive or (GCS < 9)
treatment
Uncontrolled hemorrhage or
hypoventilation
Moderate respiratory distress
Assessment and Circulatory compromise
treatment Important time-critical -Hypotension with hemodynamic
within 10 treatment effects
ATS 2 minutes or -Severe blood loss
(assessment and Very severe pain severe pain , (GCS< 13(
treatment often Major multi trauma, severe localized
simultaneous) trauma – major fracture, amputation
High-risk history
Severe hypertension
Moderately severe blood loss
Potentially Life-
Assessment and Moderate shortness of breath
Threatening
ATS 3 treatment start Head injury with short LOC
or
within 30 mins Moderate pain
Situational Urgency
Moderate limb injury, deformity,
severe laceration
Normal vital signs, Chest injury
Assessment and Potentially serious or without rib pain or respiratory
treatment start Situational Urgency distress
ATS 4
within 60 or Minor head injury, no LOC
minutes Significant Severity Minor limb trauma
low/moderate pain
Less Urgent Minimal pain
Assessment and
or Minor symptoms of existing stable
treatment start
ATS 5 Clinico-administrative illness
within 120
problems Minor wounds
minutes
Immunization only

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Later ESI version 4 was developed but due to some limitation in ESI level 1 and 2 criteria in
version 3. In version 4 ESI level 1 criteria expanded to include those ESI level 2 who needs
immediate intervention to prevent further deterioration42. In 2009, the American Hospital
Association reported that in USA 57% of the hospitals used ESI, 25% used 3-level, 10% used
4-level, 6% used other 5-level systems, 1% used 2-level and 1% did not use any triage
systems42.
Categories of ESI
ESI is 5 level triage system using a flowchart-based triage algorithm. It does not define
waiting time to be seen by a physician. It use both patient acuity and expected resource needs
to categorize patients from level 1 to level 5 and this is a unique feature of this system30.

Figure 3. ESI (v.4) conceptual algorithm

ESI consists of five categories, at first we assess the acuity level only to determine levels 1 and
2 then we determine the number of resources needed to determine levels 3, 4 and 5. Gilboy
et al. described the concept of the ESI algorithm as shown in Figure (3) 11.This algorithm uses
four decision points (A, B, C, and D) to sort patients into one of the five triage levels. The four
decision points uses 4 key questions which are:
A. Does that patient require immediate life-saving intervention?
B. Should not wait?
C. How many resources will be needed?
D. What are his vital signs?

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454 Different Types of Triage

The answer of these questions guide the user to the right triage decision as shown in Figure
411.

Figure 4. ESI triage algorithm

A. Immediate life-saving intervention required: This stage represents ESI level 1 as patients
are seen immediately because timeliness of interventions can affect morbidity and mortality.
Some examples of life-saving and not life-saving interventions are described in Table 2:
11
.Also, we must assess the patient's level of responsiveness to identify the patient who has a
recent or sudden change in level of conscience and requires immediate intervention by using
the AVPU (alert, verbal, pain, unresponsive) scale as shown in Table 3. Patient that score a P
(pain) or U (unresponsive) on the AVPU scale meets ESI level-1 criteria.
B- Should not wait?: There are three condition in which the patient cannot wait as if the
patient in high-risk situation and require time-sensitive treatment or his condition will
deteriorate rapidly or has a potential threat to life, organ or limb. The 2nd condition is when
the patient is confused, disoriented or lethargic and this refers to acute alternation in LOC,

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which indicates that the brain may be compromised. the 3rd one is when the patient in severe
pain or distress and this can determined by clinical observation or patient rating of pain
greater than or equal to 7 on 0-10 pain scale. These three conditions will make the patient in
ESI level2 30.
Table 2. Immediate Life-saving and not life-saving interventions
Life-saving Not life-saving
Intubation Oxygen administration
Surgical airway Nasal cannula
Airway/breathing
Emergent CPAP Non-rebreather
Emergent BiPAP
Defibrillation Cardiac Monitor
Electrical Therapy Emergent cardioversion
External pacing
Chest needle decompression Diagnostic tests
Pericardiocentesis ECG
Procedures
Open thoracotomy Labs
Intraosseous access Ultrasound
Significant IV fluid resuscitation IV access
Hemodynamics Blood administration Saline lock for medications
Control of major bleeding
Atropine Heparin
Medications Dopamine Pain medication
naloxone IV nitroglycerin
Table 3. Four levels of the AVPU Scale
AVPU level Level of consciousness
Alert: The patient is alert, awake and responds to voice. The patient is oriented to
A time, place and person. The triage nurse is able to obtain subjective
Information.
Verbal: The patient responds to verbal stimuli by opening their eyes when someone
V
speaks to them. The patient is not fully oriented to time, place, or person.
Painful: The patient does not respond to voice, but does respond to a painful
P stimulus, such as a squeeze to the hand or sternal rub. A noxious stimulus is needed
to elicit a response.
Unresponsive: The patient is nonverbal and does not respond even when a painful
U
stimulus is applied

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456 Different Types of Triage

C- How many resources will be needed? Resource prediction used only on less acute patients
in ESI levels 3 to 5 as following:
If no resources needed then it is ESI level 5
If one resource needed then it is ESI level 4
If two or more resources needed then it is ESI level 3 and in this case we will move to the next
question.
We count the number of different types of resources, not the individual tests or x-rays
(examples: CBC and electrolytes equals one resource; CBC plus chest x-ray equals two
resources).Examples of resource and not resource are demonstrated in table 4 11.
Table 4. ESI resources and not resources
Resources Not Resources
Labs (blood, urine)
History & physical (including pelvic)
ECG, X-rays
Point-of-care testing
CT-MRI-ultrasound angiography
IV fluids (hydration) Saline or heplock
PO medications
IV or IM or nebulized medications Tetanus immunization
Prescription refills
Specialty consultation Phone call to PCP
Simple procedure =1
Simple wound care
(lac repair, Foley cath)
(dressings, recheck)
Complex procedure =2
Crutches, splints, slings
(conscious sedation)

D-What are his vital signs? If the patient categorized as ESI level 3, we should asses his vital
signs which include HR, RR and O2 saturation. If the patient exceeded limits of vital signs
danger zone, we should consider up-triage this patient to ESI level 2. This decision depends
also on objective assessment of the patient, pain level, past medical history, current
medication, age, gender and clinical judgment and knowledge of the person who do the
triage. Danger vital zone criteria in adult patients could bedefined as HR ˃ 100, RR ˃ 20,
SaO2 ˂ 92% 11.
Triage Decisions
Triage decisions are complex clinical decisions often made under conditions of uncertainty

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Elbaih 457

with limited or obscure information, minimal time and with little margin for error. Triage
nurses must also be able to discriminate useful cues from large amounts of information in
order to perform triage safely. It is the responsibility of the triage nurse to rapidly identify and
respond to actual life-threatening states and to also make a judgement as to the potential for
life- threatening states to occur. Triage decisions are made in response to the patient’s
presenting signs or symptoms and no attempt to formulate a medical diagnosis is made. The
allocation of a triage category is made on the basis of necessity for time-critical intervention to
improve patient outcome, potential threat to life or need to relieve suffering. The decisions
made by a triage nurse are a pivotal factor in the initiation of emergency care. Therefore the
accuracy of triage decisions is a major influence on the health outcomes of patients. As all of
these characteristics make triage decision-making inherently difficult, it may be argued that
triage nurses require advanced clinical decision making expertise. Triage decisions can be
divided into primary and secondary triage decisions. Primary triage decisions relate to the
triage assessment, allocation of a triage category and patient deposition whilst secondary
triage decisions relate to the initiation of nursing interventions in order to expedite
emergency care and promote patient comfort31.
Telephone Triage
The recognition of the need for formalized telephone triage and its development first occurred
in the United States. Telephone triage was first described as a useful tool in the emergency
setting in the United Kingdom in 1991. Various benefits have been attributed to this strategy
including reduced attendance at the ED due to explanations and self-care advice, redirection
of patients to more appropriate agencies, identification of problems before the patient
attends the department, cost effectiveness and patient empowerment. Giving advice by
telephone has always been an integral part of the nurse’s role although none has been
recognised as having a particularly distinct identity32.
Early studies suggested that patient assessment by telephone was subjective, poorly
structured and carried out by untrained personnel. Decisions were made hastily without
ascertaining the full facts. Recommendations arising from these studies were that a
designated telephone advisor be the first point of contact for telephone advice, protocols for
informed advice for common problems should be developed and that adequate
documentation was essential. Where these strategies have been implemented in practice,

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telephone triage has been found to be a safe and effective method of prioritisation.
Formalized advice giving by telephone has the potential to be a valuable tool in many
settings–a fact that has been recognized in the development of NHS Direct, the telephone
advice and help line, in the United Kingdom. The demarcation line between telephone advice
and telephone triage is debatable. It is suggested that triage occurs when a formalized
process of decision making takes place which allows identification of clinical priority and
allocation to predetermined categories of urgency of need for medical evaluation and care32.
Telephone Triage Methodology
When undertaken effectively, triage involves a decision about clinical priority, which is based
on presentation rather than diagnosis. Telephone triage should be undertaken in exactly the
same way. The methodology described here builds on the effective face-to-face triage
methodology taught by the Manchester Triage Group. The possible outcomes are, however,
simplified from the five category system as there are fewer options available to the telephone
triage practitioner.
The decisions which must be made are as follows:
1. _Does the patient need immediate and urgent care? (Medicine now)
2. _ Do they need care within the next few hours? (Medicine soon)
3. _ Can medical or other care be delayed? (Medicine later)
Patients who are in the medicine now category are best served by the emergency33 ambulance
service and emergency departments, whatever their locations. Those in the other two
categories may have care delivered in a number of locations and by various providers. Thus
the time to care in the Medicine Soon category will vary, depending upon the setting in which
the telephone triage is located. In ED based triage this might mean that the patients should
make their way to the ED as soon as possible. In primary care based triage, the patient might
be seen the same day in the nearest available clinic. It is essential that the practitioner
undertaking telephone triage is aware of (or has access to information about) current local
service organisations such as dental emergency arrangements, telephone numbers of primary
care facilities and the location of all night pharmacies34.
Making Decision
On receiving the telephone call, the practitioner must gather some basic information from the

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caller about the nature of the problem. This will dictate which presentational flow chart is
selected. Once the decision has been made, questioning techniques are used to elicit
information in order to decide what priority should be allocated. The methodology is
reductive – working from more serious to less serious discriminators, and the nurse is
prompted to cover all possibilities by the information contained on the flow charts35. The
practitioner must decide whether the criteria for each discriminator are fulfilled, and which of
the discriminators present leads to the highest clinical priority. An example chart for back pain
is shown above. Discriminator definitions remain the same when undertaking triage by
telephone. The questions normally asked by the triage practitioner must be modified to take
into account the remoteness of the patient, the levels of anxiety and the possibility that the
caller is not the patient35.
Telephone Triage Practitioner
Telephone triage, like face-to-face triage, should be undertaken by experienced practitioners.
The availability of protocols and charts does not remove the need for expert clinical
knowledge. Arguably the decisions made in telephone triage call for a higher level of skill and
knowledge than when the patient is present. Furthermore the questioning skills of the
practitioner must be very highly developed in order to obtain the most useful information
from a troubled caller in the least possible time36.
Like face-to-face triage, telephone triage works well when it is carried out correctly and less
well when corners are cut, or important aspects such as pain are ignored. Systems must be
auditable and this relies on good training of competent practitioners using their skills and
knowledge and the tools available to them to the best effect. The telephone triage
methodology provides an effective and auditable tool for the prioritisation of patients
presenting to immediate care settings by telephone36.
Triage Methods
Triage methods used for the assessment of a single casualty are not necessarily applicable to
the assessment of many casualties. In the assessment of a single patient, sufficient time may
be available for a relatively detailed clinical history and physical examination. If many
casualties require rapid assessment then methods of triage which take time or require special
equipment are of little value, as the time taken to assess a single casualty may delay and

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460 Different Types of Triage

prejudice the care of other victims. The principal solution to this problem has been the
development of objective triage scores. Few UK pre-hospital care services routinely use any
form of formalized triage score at the present time. Major incident triage in the UK will
therefore usually be performed by personnel who may never have performed formal triage
before. An objective, simple and quick method of assigning priorities is required37.
Objective methods have the advantage that they are reproducible, require little in the way of
clinical skills or experience, and can be quickly and reliably taught to personnel with minimal
medical training. For experienced clinicians any additional information may be used in
conjunction with an objective scoring system to reach a final triage categorization.
If a triage scoring system is to be of use in major incidents then it must be quick, reproducible,
easy to use (in the environment in which it is to be used), should be able to describe major
incident outcomes, dynamic. Of the many methods in use for a small number of casualties, the
TRTS is the only score that satisfies such criteria. The score has been further modified by the
Advanced Life Support Group for use within the environment of a major incident. The
resulting method, the triage sieve/triage sort system, is described below13 (Figure 5).
In the initial stages of a major incident a large number of triage decisions need to be made
quickly. Typically this is at the scene of the incident itself but rapid triage may be needed at
the Casualty Clearing Station, or at the hospital reception. The method used to triage the
casualties must be fast, easy, safe and must give the same result whoever carries it out. Since
the accuracy of any method depends upon the amount of information used to reach a decision
and gathering information takes time, there is a trade-off between speed and accuracy. All
patients will be retriaged and any necessary refinements can then be made38.
The aim of the triage sieve is to convert the chaos of a large number of injured casualties into
some sort of medical order. Since the greatest number of patients are likely to have minor
injuries, the most effective first step in establishing order is the separation of the priority 3
(delayed) patients from the rest. At this stage it is reasonable to assume that patients who can
walk do not require urgent or immediate treatment, and all such patients are therefore
categorized as priority 3 (delayed). Once this has been done the state of the airway, breathing
and circulation is considered those patients who remain after the mobility sieve has been
applied must be either priority 1 (immediate), priority 2 (urgent) or dead. They are sorted into

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Elbaih 461

the appropriate category by looking at simply assessed aspects of airway, breathing and
circulation39.

Figure 5. Triage sieve

Airway patency (not security) is assumed in conscious patients and is assessed in the
unconscious by performing a simple opening manoeuvre (chin lift or jaw thrust) and seeing if
breathing occurs. Casualties who cannot breathe despite simple opening manoeuvers are
dead. Patients who only breathe after their airway is cleared are priority 1(immediate). Some
patients may need a simple airway adjunct to maintain airway patency and this can be
inserted at this stage. Those who can breathe have their respiratory rate counted. If the rate is
low (9 or less, 30 or more) then the casualty is priority 1 (immediate). If the rate is 10–29
breaths per minute then an assessment of the circulation is carried out. An assessment of
circulation is difficult even within the hospital, and no single measure will reliably give an
accurate overall picture. Despite this reservation the capillary refill time fulfils other criteria in
that it can be measured simply and quickly in the nail bed. Pressure is applied over the quick
of the nail for 5 seconds and then released—the time taken for the colour to return is the
refill time. If this time is over 2 seconds then the patient is assigned priority 1 (immediate),
and if it is 2 seconds or less then the casualty is priority 2 (urgent). If it is not possible to
measure CRT then a pulse rate of greater than 120 can be used to determine priority 1 status39.

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462 Different Types of Triage

The triage sieve should take no more than 20 seconds for each non ambulant patient, and first
look triage can therefore be done very rapidly. This broad-brush approach gives some urgently
needed direction to the health service response which can then be focused on the care of the
priority 1 patients. Since the sieve is so quick it is easily repeated at any stage of the response
and should be applied whenever a large number of patients need to be rapidly assessed40. As
triage decisions become more complex the triage methods become more refined.

Figure 6. Triage sort (secondary triage)

The triage sort is the next step up from the triage sieve and consists of a formal physiological
appraisal of the patient. No anatomical descriptors of injury are sought at this stage since the
treatment that is being considered (i.e. the need for resuscitation) does not depend on such
information. The triage sort is based on the TRTS as developed by Champion. It uses
respiratory rate (RR), systolic blood pressure (SBP) and the Glasgow coma scale (GCS) to assign
a score of between 0 and 12 for each patient The TRTS (triage sort) is relatively quick to
perform and yields consistent valid results41.

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Elbaih 463

It compliments and extends the triage sieve method discussed earlier in that it uses one of the
same measure values (respiratory rate), substitutes a more complex measure of circulatory
function (systolic blood pressure) and introduces an assessment of conscious level. The need
to measure both blood pressure and perform Glasgow Coma Scores increases the time needed
to assess each patient; a skilled assessor should still be able to categorize a patient within 1
minute42. If the fourth (expectant) priority is used then a TRTS of between 1 and 3 should be
used as its definition.
The triage sort described here is appropriate in situations where slightly more time can be
spent in assessing each patient (either because there are less patients, because there are more
people to carry out the assessment or because the speed of assessment is less important than
the accuracy). The physiological measures used in this score are the same as those commonly
measured when patients are being monitored. The triage revised trauma score is therefore
doubly useful in that it serves both as a triage tool, and as a clinically useful tool for
monitoring the patient’s condition. If anatomical information is required then the triage sort
must be combined with some form of survey as described below43.
Triage and Order of Intervention
The triage priority of an individual casualty is only one of a number of factors that should be
considered when the order of interventions is being decided. This point needs to be
emphasized since the triage category is too often seen as an absolute guide to order. The
other factors to be considered will vary according to the intervention that is being
considered44. The obligation doctor responsible for the EC must guarantee persistent
reassessment of those patients who stay holding up and, if the clinical elements change, re‐
triage the patient in like manner41.
Conclusion
Triage is a method of quickly identifying victims who have immediately life-threatening
injuries and who have the best chance of surviving by different types of triage e.g. Start
Triage, Triage Sieve, Triage Sort (secondary triage) and these mainly used in disasters but also
used ED (Emergency Daily) triage e.g. The South African Triage Scale (SATS), Emergency
Severity Index Triage (ESIT) and Australasian Triage Scale (ATS) and all these methods of
triage aimed to ensure that the patient who need immediate treatment treated first without

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464 Different Types of Triage

any possible harmful delay, Priority of treatment, available resources and the main benefits of
triage are reduction in waiting time and overcome Crowdness patients in ER. Nowadays,
several European countries have implemented one of the triage scales so we can apply in our
hospitals
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Correspondence Address / Yazışma Adresi Geliş tarihi/ Received: 20.03.2017

Adel Hamed Elbaih Kabul tarihi/Accepted: 20.04.2017
Department of Emergency Medicine
Suez Canal University
Ismailia, Egypt
E-mail:[email protected]

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