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triage — news, coverage & facts — IJR

Simple triage

Simple triage is usually used in a scene of an accident or "mass-casualty incident" (MCI), in order to sort patients into those who need critical attention and immediate transport to a secondary or tertiary care facility to survive, those who require low-intensity care to survive, those who are uninjured, and those who are deceased or will be so imminently. In the United States, this most commonly takes the form of the START or SALT triage models, in Canada, the CTAS model, and in Australia the ATS model. Assessment often begins with asking anyone who can walk to walk to a designated area, labeling them the lowest priority, and assessing other patients from there. Upon completion of the initial assessment by the care provider, which is based on the so-called ABCDE approach, patients are generally labelled with their available information, including "patient’s name, sex, injuries, interventions, care-provider IDs, casualty triage score, and an easily visible overall triage category".

An ABCDE assessment (other variations include ABC, ABCD, ABCDEF, and many others, including those localized to non-English) is rapid patient assessment designed to check bodily function in order of importance.

A triage tag is a premade label placed on each patient that serves to accomplish several objectives:

identify the patient.

bear record of assessment findings.

identify the priority of the patient's need for medical treatment and transport from the emergency scene.

track the patients' progress through the triage process.

identify additional hazards such as contamination.

Triage tags take a variety of forms. Some countries use a nationally standardized triage tag, while in other countries commercially available triage tags are used, which vary by jurisdictional choice. In some cases, international organizations also have standardized tags, as is the case with NATO. The most commonly used commercial systems include the METTAG, the SMARTTAG, E/T LIGHT and the CRUCIFORM systems. More advanced tagging systems incorporate special markers to indicate whether or not patients have been contaminated by hazardous materials, and also tear off strips for tracking the movement of patients through the process.

Triage systems by methodology

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 was developed at Hoag Hospital in Newport Beach, California for use by emergency services in 1983.

Triage separates the injured into four groups:

The expectant 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

Triage also sets priorities for evacuation and transport as follows:

Deceased are left where they fell. These include those who are not breathing and repositioning their airway efforts were unsuccessful.

Immediate or Priority 1 (red) evacuation to a medical facility as they need advanced medical care at once or within one 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 people 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 need bandages and antiseptic.

The JumpSTART pediatric triage MCI triage tool is a variation of the S.T.A.R.T. model. Both systems are used to sort patients into categories at mass casualty incidents (MCIs). However, JumpSTART was designed specifically for triaging children in disaster settings. Though JumpSTART was developed for use in children from infancy to age 8, where age is not immediately obvious, it is used in any patient who appears to be a child (patients who appear to be young adults are triaged using START).

The Emergency Severity Index (ESI) is a five-level emergency department triage algorithm, initially developed in 1998 by emergency physicians Richard Wurez and David Eitel, along with emergency nurses Nicki Gilboy, Taula Tanabe, and Debbie Travers. ESI triage is based on the acuity (severity) of patients' medical conditions in acute care settings and the number of resources their care is anticipated to require. This algorithm is practiced by paramedics and registered nurses primarily in hospitals.

The Manchester Triage System (MTS) is a emergency department triage, initially developed in 1990s in Great Britain. The triage groups into 5 priority groups on first contact to doctors. MTS is based on discriminators or modifiers of confirmation or exclusion of several symptoms or clinical conditions. MTS uses 52 cards of reasons for a patient’s presentation in decision-making algorithm.

Triage systems by country

In hospital settings, Australia and New Zealand rely on the Australasian Triage Scale (abbreviated ATS and formally known as the National Triage Scale). The scale has been in use since 1994. The scale consists of 5 levels, with 1 being the most critical (resuscitation), and 5 being the least critical (nonurgent).

In field settings, various standardized triage systems are used, and there is no area wide standard.

In 1995, the CAEP Triage and Acuity scale was launched in Canada relying on a simplified version of the Australian National Triage Scale. This scale used three categories, emergent, urgent, and non-urgent. This scale was deprecated in 1999 with the introduction of the Canadian Triage and Acuity Scale (CTAS), which is used across the country to sort incoming patients. The system categorizes patients by both injury and physiological findings, and ranks them by severity from 1–5 (1 being highest). The model is not currently used for mass casualty triage, and instead the START protocol and METTAG triage tags is used.

In France, the Prehospital triage in case of a disaster uses a multi-tier scale:

Décédé (deceased), or urgence dépassée (beyond urgency)

Extrême urgence (extreme urgency): requiring care within a half hour.

Urgence absolue (absolute urgency): requiring care within an hour.

Urgence relative (relative urgency): requiring care, but not immediately.

Blessé léger (slightly injured)

Impliqué (involved, but not directly injured)

This triage is performed by a physician called médecin trieur (sorting medic).

The German triage system uses four color codes:

The Manchester Triage System has also been introduced in Germany in 2004, in addition to its German-speaking neighbour countries. The MTS was introduced in Austria in 2009 and in German-speaking parts of Switzerland in 2011 (see also Manchester-Triage-System (in German).

In Hong Kong, triage in accident and emergency departments is performed by experienced registered nurses, and patients are divided into five triage categories: Critical, Emergency, Urgent, Semi-urgent and Non-urgent. In mass casualty incidents, the START triage system is used.

In Japan, the triage system is mainly used by health professionals. The categories of triage, in corresponding color codes, are:

Category I: Used for viable victims with potentially life-threatening conditions.

Category II: Used for victims with non-life-threatening injuries, but who urgently require treatment.

Category III: Used for victims with minor injuries that do not require ambulance transport.

Category 0: Used for victims who are dead, or whose injuries make survival unlikely.

In Portugal, the Manchester Triage System is used.

All public hospitals in Singapore use the Patient Acuity Category Scale (PACS) to triage patient in Emergency Departement. PACS is a symptom-based differential diagnosis approach that triages patients according to their presenting complaints and objective assessments such as vital signs and Glasgow Coma Scale, allowing acute patients to be identified quickly for treatment. PACS classifies patients into four main categories: P1, P2, P3, and P4.

In mass casualty incidents, the START triage system is used.

In Spain, there are two models which are the most common found in hospitals around the country:

The Sistema Estructurado de Triaje (SET), which is an adaptation of the Model Andorrà de Triatge (MAT). The system uses 650 reasons for medical appointment in 32 symptomatic categories, that together with some patient information and basic exploratory data, classifies the emergency within 5 levels of urgency.

The "Manchester", based on the system with the same name in the UK, use 51 reasons for consultation. Through some yes/no questions, addressed in a diagram, it classifies the emergency in 5 severities.

In mass casualty incidents, the Modelo Extrahospitalario de Triaje Avanzado (META) (Advanced Triage Out of Hospital Model) system is used. META is a seven-stage system, classifying patients as: Red 1st, Red 2nd, Red 3rd, Yellow 1st, Yellow 2nd, Green, and Deceased. The system aligns with the ABCDE framework.

In April 2023, the NHS and ambulance services adopted two new triage tools to be used in major incidents, replacing the NASMeD Triage Sieve. These new tools resulted from a multi-stakeholder review led by the NHS but its implementation became more urgent after the Manchester Arena Inquiry made it a monitored recommendation for the NHS and National Ambulance Resilience Unit to adopt.

The Ten Second Triage Tool (TST) was introduced as a way for all emergency services, including the police and fire service, to assess and prioritise mass casualties to provide lifesaving intervention. The tool allows for rapid assessment by removing the need to measure physiological vital signs focusing on what the emergency responder can see.

P1 – Patients who have catastrophic bleeding, a penetrating injury or those who are unconscious

P2 – Patients who are unable to walk but are conscious

P3 – Patients who are able to walk

Not Breathing – Patients who are not breathing (this replaces the deceased category)

The Major Incident Triage Tool (MITT) serves as the more advanced triage tool for emergency medial responders to triage casualties. The tool, derived from the Modified Physiological Triage Tool, can be used on both adults and children, and also includes the assessment of physiological vital signs.

P1 – Life-threatening injury

P2 – Unconscious but breathing

P3 – Non-life-threatening injury

Dead – No signs of life or non-survivable injury

A multitude of triage systems exist in the United States, and there is no national standard. Among local, regional, state, and interstate systems, the START triage method is most commonly used.

The U.S. armed forces utilize a four-stage system, A battlefield situation, care providers rank casualties for precedence, treat those who they can safely, and transport casualties who need it to a higher level of care, either a Forward Surgical Team or Combat Support Hospital.

The triage categories (with corresponding color codes), in order of priority, are:

Limitations of current practices

Notions of mass casualty triage as an efficient rationing process of determining priority based upon injury severity are not supported by research, evaluation and testing of current triage practices, which lack scientific and methodological bases. START and START-like (START) triage that use color-coded categories to prioritize provide poor assessments of injury severity and then leave it to providers to subjectively order and allocate resources within flawed categories. Some of these limitations include:

lacking the clear goal of maximizing the number of lives saved, as well as the focus, design and objective methodology to accomplish that goal (a protocol of taking the worst Immediate – lowest chances for survival – first can be statistically invalid and dangerous)

using trauma measures that are problematic (e.g., capillary refill) and grouping into broad color-coded categories that are not in accordance with injury severities, medical evidence and needs. Categories do not differentiate among injury severities and survival probabilities, and are invalid based on categorical definitions and evacuation priorities

ordering (prioritization) and allocating resources subjectively within Immediate and Delayed categories, which are neither reproducible nor scalable, with little chance of being optimal

not considering/addressing size of incident, resources, and injury severities and prioritization within its categories – e.g., protocol does not change whether 3, 30 or 3,000 casualties require its use, and regardless of available resources to be rationed

not considering differences in injury severities and survival probabilities between types of trauma (blunt versus penetrating, etc.) and ages

resulting in inconsistent tagging and prioritizing/ordering of casualties and substantial overtriage

Research indicates there are wide ranges and overlaps of survival probabilities of the Immediate and Delayed categories, and other START limitations. The same physiologic measures can have markedly different survival probabilities for blunt and penetrating injuries. For example, a START Delayed (second priority) can have a survival probability of 63% for blunt trauma and a survival probability of 32% for penetrating trauma with the same physiological measures – both with expected rapid deterioration, while a START Immediate (first priority) can have survival probabilities that extend to above 95% with expected slow deterioration. Age categories exacerbate this. For example, a geriatric patient with a penetrating injury in the Delayed category can have an 8% survival probability, and a pediatric patient in the Immediate category can have a 98% survival probability. Issues with the other START categories have also been noted. In this context, color-coded tagging accuracy metrics are not scientifically meaningful.

Poor assessments, invalid categories, no objective methodology and tools for prioritizing casualties and allocating resources, and a protocol of worst first triage provide some challenges for emergency and disaster preparedness and response. These are clear obstacles for efficient triage and resource rationing, for maximizing savings of lives, for best practices and National Incident Management System (NIMS) compatibilities, and for effective response planning and training.

Inefficient triage also provides challenges in containing health care costs and waste. Field triage is based upon the notion of up to 50% overtriage as being acceptable. There have been no cost-benefit analyses of the costs and mitigation of triage inefficiencies embedded in the healthcare system. Such analyses are often required for healthcare grants funded by taxpayers, and represent normal engineering and management science practice. These inefficiencies relate to the following cost areas:

tremendous investment in time and money since 9/11 to develop and improve responders' triage skills

cited benefits from standardization of triage methodology, reproducibility and interoperability, and NIMS compatibilities

avoided capital costs for taxpayer investment in additional EMS and trauma infrastructure

wasteful daily resource utilization and increased operating costs from acceptance of substantial levels of overtriage

prescribed values of a statistical life and estimated savings in human lives that could reasonably be expected using evidence-based triage practices

ongoing performance improvements that could reasonably be expected from a more objective optimization-based triage system and practices