Triage - AbsoluteAstronomy.com

Triage is the process of determining the priority of patients' treatments based on the severity of their condition. This rations patient treatment efficiently when resources are insufficient for all to be treated immediately. The term comes from the French

French language

French is a Romance language spoken as a first language in France, the Romandy region in Switzerland, Wallonia and Brussels in Belgium, Monaco, the regions of Quebec and Acadia in Canada, and by various communities elsewhere. Second-language speakers of French are distributed throughout many parts...

verb trier, meaning to separate, sift or select. Two types of triage exist: simple and advanced. Triage may result in determining the order and priority of emergency treatment, the order and priority of emergency transport, or the transport destination for the patient.

Triage may also be used for patients arriving at the emergency department, or to telephone medical advice systems, among others. This article deals with the concept of triage as it occurs in medical emergencies, including the prehospital setting, disasters, and during emergency room treatment.

Triage originated in World War I

World War I

World War I , which was predominantly called the World War or the Great War from its occurrence until 1939, and the First World War or World War I thereafter, was a major war centred in Europe that began on 28 July 1914 and lasted until 11 November 1918...

by French

France

The French Republic , The French Republic , The French Republic , (commonly known as France , is a unitary semi-presidential republic in Western Europe with several overseas territories and islands located on other continents and in the Indian, Pacific, and Atlantic oceans. Metropolitan France...

doctors

Physician

A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...

treating the battlefield wounded at the aid stations behind the front. Much is owed to the work of Dominique Jean Larrey

Dominique Jean Larrey

Dominique Jean Larrey was a French surgeon in Napoleon's army and an important innovator in battlefield medicine.-Biography:...

during the Napoleonic Wars

Napoleonic Wars

The Napoleonic Wars were a series of wars declared against Napoleon's French Empire by opposing coalitions that ran from 1803 to 1815. As a continuation of the wars sparked by the French Revolution of 1789, they revolutionised European armies and played out on an unprecedented scale, mainly due to...

. Until recently, triage results, whether performed by a paramedic

Paramedic

A paramedic is a healthcare professional that works in emergency medical situations. Paramedics provide advanced levels of care for medical emergencies and trauma. The majority of paramedics are based in the field in ambulances, emergency response vehicles, or in specialist mobile units such as...

or anyone else, were frequently a matter of the 'best guess', as opposed to any real or meaningful assessment. At its most primitive, those responsible for the removal of the wounded from a battlefield or their care afterwards have divided victims into three categories:

Those who are likely to live, regardless of what care they receive;
Those who are likely to die, regardless of what care they receive;
Those for whom immediate care might make a positive difference in outcome.

For many emergency medical services

Emergency medical services

Emergency medical services are a type of emergency service dedicated to providing out-of-hospital acute medical care and/or transport to definitive care, to patients with illnesses and injuries which the patient, or the medical practitioner, believes constitutes a medical emergency...

(EMS) systems, a similar model can sometimes still be applied. However once a full response has occurred and many hands are available, paramedics will usually use the model included in their service policy and standing orders. In the earliest stages of an incident, however, when one or two paramedics exist to twenty or more patients, practicality demands that the above, more "primitive" model will be used.

Modern approaches to triage are more scientific. The outcome and grading of the victim is frequently the result of physiological and assessment findings. Some models, such as the START model, are committed to memory, and may even be algorithm

Algorithm

In mathematics and computer science, an algorithm is an effective method expressed as a finite list of well-defined instructions for calculating a function. Algorithms are used for calculation, data processing, and automated reasoning...

-based. As triage concepts become more sophisticated, triage guidance is also evolving into both software and hardware decision support products for use by caregivers in both hospitals and the field.

Simple triage

Simple triage is usually used in a scene of an accident or "mass-casualty incident

Mass-casualty incident

A mass casualty incident is any incident in which emergency medical services resources, such as personnel and equipment, are overwhelmed by the number and severity of casualties...

" (MCI), 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 tag

Triage tag

A Triage Tag is a tool first responders and medical personnel use during a mass casualty incident. With the aide of the triage tags, the first-arriving personnel are able to effectively and efficiently distribute the limited resources and provide the necessary immediate care for the victims until...

s or coloured flagging

Flagging (tape)

Flagging is a colored non-adhesive tape used in marking objects. It is commonly made of PVC or vinyl, and wood fibre cellulose-based biodegradable flagging also exists.-Forestry:In forestry flagging is commonly used to mark trees for various purposes...

S.T.A.R.T. model

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 has been (2003) taught to California

California

California is a state located on the West Coast of the United States. It is by far the most populous U.S. state, and the third-largest by land area...

emergency workers for use in earthquakes. It was developed at Hoag Hospital in Newport Beach, California

Newport Beach, California

Newport Beach, incorporated in 1906, is a city in Orange County, California, south of downtown Santa Ana. The population was 85,186 at the 2010 census.The city's median family income and property values consistently place high in national rankings...

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 community emergency response team

Community Emergency Response Team

In the United States a community emergency response team can refer to* one of five federal programs promoted under the umbrella organization Citizen Corps, which is funded in part by the Stafford Act;...

s (CERTs) and firefighter

Firefighter

Firefighters are rescuers extensively trained primarily to put out hazardous fires that threaten civilian populations and property, to rescue people from car incidents, collapsed and burning buildings and other such situations...

s after earthquakes.

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

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

Medical ethics

Medical ethics is a system of moral principles that apply values and judgments to the practice of medicine. As a scholarly discipline, medical ethics encompasses its practical application in clinical settings as well as work on its history, philosophy, theology, and sociology.-History:Historically,...

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

Western Europe

Western Europe is a loose term for the collection of countries in the western most region of the European continents, though this definition is context-dependent and carries cultural and political connotations. One definition describes Western Europe as a geographic entity—the region lying in the...

, 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

Revised Trauma Score

The Revised Trauma Score is a tool for on-site triage for Multiple Casualty Incidents. Its superior efficiency is due to both speed and objectivity. It is designed to provide a comprehensive assessment for medical professionals of any field....

(TRTS), a medically-validated scoring system incorporated in some triage cards.

Another example of a trauma scoring system is the Injury Severity Score

Injury Severity Score

The Injury Severity Score is an established medical score to assess trauma severity. It correlates with mortality, morbidity and hospitalization time after trauma...

(ISS). This assigns a score from 0 to 75 based on severity of injury to the human body divided into three categories: A (face/neck/head), B(thorax/abdomen), C(extremities/external/skin). Each category is scored from 0 to 5 using the Abbreviated Injury Scale, from uninjured to critically injured, which is then squared and summed to create the ISS. A score of 6, for "unsurvivable", can also be used for any of the three categories, and automatically sets the score to 75 regardless of other scores. Depending on the triage situation, this may indicate either that the patient is a first priority for care, or that he or she will not receive care owing to the need to conserve care for more likely survivors.

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 maintained, the receiving hospital doctor can see a trauma score time series

Time series

In statistics, signal processing, econometrics and mathematical finance, a time series is a sequence of data points, measured typically at successive times spaced at uniform time intervals. Examples of time series are the daily closing value of the Dow Jones index or the annual flow volume of the...

from the start of the incident, which may allow definitive treatment earlier.

Continuous integrated triage

Continuous Integrated Triage

Continuous integrated triage

Continuous integrated triage is an approach to triage in mass casualty situations. It is both efficient and sensitive to psychosocial and disaster behavioral health issues that effect the number of patients seeking care , the manner in which a hospital or healthcare facility deals with that surge...

is an approach to triage in mass casualty situations which is both efficient and sensitive to psychosocial

Psychosocial

For a concept to be psychosocial means it relates to one's psychological development in, and interaction with, a social environment. The individual needs not be fully aware of this relationship with his or her environment. It was first commonly used by psychologist Erik Erikson in his stages of...

and disaster

Disaster

A disaster is a natural or man-made hazard that has come to fruition, resulting in an event of substantial extent causing significant physical damage or destruction, loss of life, or drastic change to the environment...

behavioral health issues that affect 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.)
Hospital Triage (i.e., E.S.I. or Emergency Severity Index
Emergency Severity Index
The Emergency Severity Index is a five-level emergency department triage algorithm that provides clinically relevant stratification of patients into five groups from 1 to 5 on the basis of acuity and resource needs...

)

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

Practical applied triage

During the early stages of an incident, first responders may be overwhelmed by the scope of patients and injuries. One valuable technique, is the Patient Assist Method (PAM); the responders quickly establish a casualty collection point (CCP) and advise ; either by yelling, or over a loudspeaker, that "anyone requiring assistance should move to the selected area (CCP)". This does several things at once, it identifies patients that are not so severely injured, that they need immediate help, it physically clears the scene, and provides possible assistants to the responders. As those who can move, do so, the responders then ask, "anyone who still needs assistance, yell out or raise your hands"; this further identifies patients who are responsive, yet maybe unable to move. Now the responders can rapidly assess the remaining patients who are either expectant, or are in need of immediate aid. From that point the first responder is quickly able to identify those in need of immediate attention, while not being distracted or overwhelmed by the magnitude of the situation. Using this method assumes the ability to hear. Deaf, partially deaf or victims of a large blast injury may not be able to hear these instructions.

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 basic life support

Basic life support

Basic life support is the level of medical care which is used for patients with life-threatening illnesses or injuries until the patient can be given full medical care at a hospital. It can be provided by trained medical personnel, including emergency medical technicians, paramedics, and by...

and often those who are rescued and able to breathe on their own will improve with minimal or no help.

Labelling of patients

Upon completion of the initial assessment by medical or paramedical personnel, each patient will be labelled with a device called a triage tag

Triage tag

. This will identify the patient and any assessment findings and will identify the priority of the patient's need for medical treatment and transport from the emergency scene. Triage tags may take a variety of forms. Some countries use a nationally standardized triage tag, while in other countries commercially available triage tags are used, and these will vary by jurisdictional choice. The most commonly used commercial systems include the METTAG, the SMARTTAG, E/T LIGHT tm 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. Some of these tracking systems are beginning to incorporate the use of handheld computers, and in some cases, bar code scanners. At its most primitive, however, patients may be simply marked with coloured tape, or with marker pens, when triage tags are either unavailable or insufficient.

Undertriage and overtriage

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. Some studies suggest that overtriage is less likely to occur when triaging is performed by hospital medical teams, rather than paramedics or EMTs.

United States military

Triage in a non-combat situation is conducted much the same as in civilian medicine. A battlefield situation, however, requires medic

Medic

Medic is a general term for a person involved in medicine, especially emergency or first-response medicine, such as an emergency medical technician, paramedic, or a military member trained in battlefield medicine. Also the term is used toward a Nurse in pre-hospital care and/or emergency...

s and corpsmen to rank casualties for precedence in MEDEVAC or CASEVAC.
The triage categories (with corresponding color codes), in precedence, are:

Immediate: The casualty requires immediate medical attention and will not survive if not seen soon. Any compromise to the casualty's respiration, hemorrhage control, or shock control could be fatal.
Delayed: The casualty requires medical attention within 6 hours. Injuries are potentially life-threatening, but can wait until the Immediate casualties are stabilized and evacuated.
Minimal: "Walking wounded," the casualty requires medical attention when all higher priority patients have been evacuated, and may not require stabilization or monitoring.
Expectant: The casualty is expected not to reach higher medical support alive without compromising the treatment of higher priority patients. Care should not be abandoned, spare any remaining time and resources after Immediate and Delayed patients have been treated.

Afterwards, casualties are given an evacuation priority based on need:

Urgent: evacuation is required within two hours to save life or limb.
Priority: evacuation is necessary within four hours or the casualty will deteriorate to "Urgent".
Routine: evacuate within 24 hours to complete treatment.

In a "naval combat situation", the triage officer must weigh the tactical situation with supplies on hand and the realistic capacity of the medical personnel. This process can be ever-changing, dependent upon the situation and must attempt to do the maximum good for the maximum number of casualties.

Field assessments are made by two methods: primary survey (used to detect & treat life-threatening injuries) and secondary survey (used to treat non-life threatening injuries) with the following categories:

Class I Patients who require minor treatment and can return to duty in a short period of time.
Class II Patients whose injuries require immediate life sustaining measures.
Class III Patients for whom definitive treatment can be delayed without loss of life or limb.
Class IV Patients requiring such extensive care beyond medical personnel capability and time.

Canada

In the mid-1980s, The Victoria General Hospital

Queen Elizabeth II Health Sciences Centre

Queen Elizabeth II Health Sciences Centre, in Halifax, Nova Scotia, is a large teaching hospital affiliated with Dalhousie University. Administratively it is part of the Capital District Health Authority.-History:...

, in Halifax, Nova Scotia, Canada

Canada

Canada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean...

, introduced paramedic triage in its Emergency Department. Unlike all other centres in North America

North America

North America is a continent wholly within the Northern Hemisphere and almost wholly within the Western Hemisphere. It is also considered a northern subcontinent of the Americas...

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 whom to exclude from treatment during a flu pandemic was written by a team of critical-care doctors at the behest of the Ontario

Ontario

Ontario is a province of Canada, located in east-central Canada. It is Canada's most populous province and second largest in total area. It is home to the nation's most populous city, Toronto, and the nation's capital, Ottawa....

government.

For routine emergencies, many locales in Canada now employ the Canadian Triage and Acuity Scale (CTAS) for all incoming patients. The system categorizes patients by both injury and physiological findings, and ranks them by severity from 1-5. The model is used by both paramedics and E/R nurses, and also for pre-arrival notifications in some cases. The model provides a common frame of reference for both nurses and paramedics, although the two groups do not always agree on scoring. It also provides a method, in some communities, for benchmarking

Benchmarking

Benchmarking is the process of comparing one's business processes and performance metrics to industry bests and/or best practices from other industries. Dimensions typically measured are quality, time and cost...

the accuracy of pre-triage of calls using AMPDS (What percentage of emergency calls have return priorities of CTAS 1,2,3, etc.) and these findings are reported as part of a municipal performance benchmarking initiative in Ontario

Ontario

. Curiously enough the model is not currently used for mass casualty triage, and is replaced by the START protocol and METTAG triage tags.

United Kingdom

In the UK

United Kingdom

The United Kingdom of Great Britain and Northern IrelandIn the United Kingdom and Dependencies, other languages have been officially recognised as legitimate autochthonous languages under the European Charter for Regional or Minority Languages...

, the commonly used triage system is the Smart Incident Command System, taught on the MIMMS (Major Incident Medical Management (and) Support) training program. 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).

In the UK and Europe, the triage process used is sometimes similar to that of the United States, but the categories are different:

Dead - patients who have a trauma score of 0 to 2 and are beyond help
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

Finland

Triage at an accident scene is performed by a paramedic

Paramedic

or an emergency physician

Emergency physician

An emergency physician is a physician who works at an emergency department to care for acutely ill patients. The emergency physician is a specialist in advanced cardiac life support , trauma care such as fractures and soft tissue injuries, and management of other life-threatening situations.In...

, using the four-level scale of Cannot wait, Has to wait, Can wait and Lost.

France

In France

France

, the Prehospital 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

Physician

called médecin trieur (sorting medic). This triage is usually performed at the field hospital

Field hospital

A field hospital is a large mobile medical unit that temporarily takes care of casualties on-site before they can be safely transported to more permanent hospital facilities...

(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

Psychologist

Psychologist is a professional or academic title used by individuals who are either:* Clinical professionals who work with patients in a variety of therapeutic contexts .* Scientists conducting psychological research or teaching psychology in a college...

to take care of the brief reactive psychosis

Brief reactive psychosis

Brief reactive psychosis - referred to in the DSM IV-TR as "brief psychotic disorder with marked stressor" - is the psychiatric term for psychosis which can be triggered by an extremely stressful event in the life of a patient....

and avoid post-traumatic stress disorder

Post-traumatic stress disorder

Posttraumaticstress disorder is a severe anxiety disorder that can develop after exposure to any event that results in psychological trauma. This event may involve the threat of death to oneself or to someone else, or to one's own or someone else's physical, sexual, or psychological integrity,...

.

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.

France has also a Phone Triage system for Medical Emergencies Phone Demands in its Samu Medical Regulation Centers through the 15 medical free national hot line. "Medical Doctor Regulator" decides what is to be the most efficient solution = Emergency Telemedecine or dispatch of an Ambulance, a General Practitioner or a Physician+ Nurse + Ambulance Man, Hospital based MICU (Mobile Intensive Care Unit).

Germany

Preliminary assessment of injuries is usually done by the first ambulance

Ambulance

An ambulance is a vehicle for transportation of sick or injured people to, from or between places of treatment for an illness or injury, and in some instances will also provide out of hospital medical care to the patient...

crew on scene, with this role being assumed by the first Notarzt arriving at the scene. As a rule, there will be no cardiopulmonary resuscitation

Cardiopulmonary resuscitation

Cardiopulmonary resuscitation is an emergency procedure which is performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person in cardiac arrest. It is indicated in those who are unresponsive...

, so patients who do not breathe on their own or develop circulation after their airways are cleared, will be tagged "deceased". Also, not every major injury automatically qualifies for a red tag. A patient with a traumatic amputation

Amputation

Amputation is the removal of a body extremity by trauma, prolonged constriction, or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on individuals as a preventative surgery for...

of the forearm might just be tagged yellow, have the bleeding stopped, and then be sent to a hospital when possible. After the preliminary assessment, a more specific and definite triage will follow, as soon as patients are brought to a field treatment facility. There, they will be disrobed and fully examined by an emergency physician

Emergency physician

. This will take approximately 90 seconds per patient.

The German triage system also uses four, sometimes five colour codes to denote the urgency of treatment. Typically, every ambulance is equipped with a folder or bag with coloured ribbons or triage tags.
The urgency is denoted as follows:

Category	Meaning	Consequences	Examples
T1 (I)	Acute danger for life	Immediate treatment, transport as soon as possible	Arterial lesions, internal haemorrhage, major amputations
T2 (II)	Severe injury	Constant observation and rapid treatment, transport as soon as practical	Minor amputations, flesh wounds, fractures and dislocations
T3 (III)	Minor injury or no injury	Treatment when practical, transport and/or discharge when possible	Minor lacerations, sprains, abrasions
T4 (IV)	No or small chance of survival	Observation and if possible administration of analgesics	Severe injuries, uncompensated blood loss, negative neurological assessment
T5 (V)	Deceased	Collection and guarding of bodies, identification when possible	Dead on arrival, downgraded from T1-4, no spontaneous breathing after clearing of airway

Israel

A simplified 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.

Japan

In Japan

Japan

Japan is an island nation in East Asia. Located in the Pacific Ocean, it lies to the east of the Sea of Japan, China, North Korea, South Korea and Russia, stretching from the Sea of Okhotsk in the north to the East China Sea and Taiwan in the south...

, 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.

Evacuation

Simple triage identifies which people need advanced medical care.
In the field, triage also sets priorities for evacuation to hospital

Hospital

A hospital is a health care institution providing patient treatment by specialized staff and equipment. Hospitals often, but not always, provide for inpatient care or longer-term patient stays....

s.
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
MEDEVAC
Medical evacuation, often termed Medevac or Medivac, is the timely and efficient movement and en route care provided by medical personnel to the wounded being evacuated from the battlefield or to injured patients being evacuated from the scene of an accident to receiving medical facilities using...

if available or ambulance
Ambulance
An ambulance is a vehicle for transportation of sick or injured people to, from or between places of treatment for an illness or injury, and in some instances will also provide out of hospital medical care to the patient...

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
Bandages
Bandages are a medical treatment.Bandages may also refer to:* "Bandages" , by Hot Hot Heat* Bandages , by the Edgar Broughton Band...

and antiseptic
Antiseptic
Antiseptics are antimicrobial substances that are applied to living tissue/skin to reduce the possibility of infection, sepsis, or putrefaction...

.

Alternative care facilities

Alternative care facilities are places that are set up 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 or other type of event. Such improvised facilities are generally developed in cooperation with the local hospital, which sees them as a strategy for creating surge capacity. While hospitals remain the preferred destination for all patients, during a mass casualty event such improvised facilities may be required in order to divert low-acuity patients away from hospitals in order to prevent the hospitals becoming overwhelmed.

Secondary (in-hospital) triage

In advanced triage systems, secondary triage is typically implemented by paramedic

Paramedic

s, battlefield medical personnel

Battlefield medicine

Battlefield medicine, also called field surgery and later combat casualty care, is the treatment of wounded soldiers in or near an area of combat. Civilian medicine has been greatly advanced by procedures that were first developed to treat the wounds inflicted during combat...

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-area burns, severe trauma, lethal radiation dose), or in life-threatening medical crisis that they are unlikely to survive given the care available (cardiac arrest
Cardiac arrest
Cardiac arrest, is the cessation of normal circulation of the blood due to failure of the heart to contract effectively...

, septic shock
Septic shock
Septic shock is a medical emergency caused by decreased tissue perfusion and oxygen delivery as a result of severe infection and sepsis, though the microbe may be systemic or localized to a particular site. It can cause multiple organ dysfunction syndrome and death...

, 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.

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.

Hospital triage systems in the United States

Within the hospital system, the first stage on arrival at the emergency room is assessment by the hospital triage nurse. This nurse will evaluate the patient's condition, as well as any changes, and will determine their priority for admission to the Emergency Room and also for treatment. Once emergency assessment and treatment are complete, the patient may need to be referred to the hospital's internal triage system.

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

Neurology

Neurology is a medical specialty dealing with disorders of the nervous system. Specifically, it deals with the diagnosis and treatment of all categories of disease involving the central, peripheral, and autonomic nervous systems, including their coverings, blood vessels, and all effector tissue,...

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.

Bioethical implications in triage

Bioethical concerns have historically played an important role in triage decisions, such as the allocation of iron lung

Iron lung

A negative pressure ventilator is a form of medical ventilator that enables a person to breathe when normal muscle control has been lost or the work of breathing exceeds the person's ability....

s during the polio epidemics of the 1940s and of dialysis machines

Dialysis

In medicine, dialysis is a process for removing waste and excess water from the blood, and is primarily used to provide an artificial replacement for lost kidney function in people with renal failure...

during the 1960s. As many health care systems in the developed world continue to plan for an expected influenza pandemic

Influenza pandemic

An influenza pandemic is an epidemic of an influenza virus that spreads on a worldwide scale and infects a large proportion of the human population. In contrast to the regular seasonal epidemics of influenza, these pandemics occur irregularly, with the 1918 Spanish flu the most serious pandemic in...

, bioethical issues regarding the triage of patients and the rationing of care continue to evolve. Similar issues may occur for paramedics in the field in the earliest stages of mass casualty incidents when large numbers of potentially serious or critical patients may be combined with extremely limited staffing and treatment resources.

Ventilator rationing

In a potential influenza pandemic, it is anticipated that, as hospitals and treatment centers become overwhelmed, shortages of critical equipment such as ventilators will occur. Medications may run short. Supply chains may fail. Methods will be required for determining who will receive access to life saving technologies, and who will not. For example, if a hypothetical emergency department has all three of its ventilators currently in use for elderly patients with influenza, who will not survive without them, how should it act when paramedics arrive with a forty year old, otherwise healthy patient who is being ventilated due to influenza, but for whom no hospital ventilator is available. A similar concern arises as to whether long-term patients in chronic care facilities should be removed from life-support to provide their ventilators to acutely ill influenza patients.

A New York State Workgroup headed by psychiatrist Tia Powell

Tia Powell

Tia Powell is an American psychiatrist and bioethicist. She is Director of the Montefiore-Einstein Center for Bioethics and a Professor of Clinical Epidemiology and Clinical Psychiatry at Albert Einstein College of Medicine in The Bronx, New York...

proposed guidelines for such triage in 1997. The Workgroup excluded certain groups of patients from eligibility for life support during a pandemic: those with metastatic cancer, severe brain damage, multiple cardiac arrests and organ failure. Among those excluded were dialysis patients. Bioethicist Jacob Appel

Jacob M. Appel

Jacob M. Appel is an American author, bioethicist and social critic. He is best known for his short stories, his work as a playwright, and his writing in the fields of reproductive ethics, organ donation, neuroethics and euthanasia....

of New York University

New York University

New York University is a private, nonsectarian research university based in New York City. NYU's main campus is situated in the Greenwich Village section of Manhattan...

has questioned the automatic exclusion of dialysis patients and also the WorkGroup's decision not to include nursing home ventilators among those machines available for triage. Emergency medicine expert Art Kellerman of Emory University

Emory University

Emory University is a private research university in metropolitan Atlanta, located in the Druid Hills section of unincorporated DeKalb County, Georgia, United States. The university was founded as Emory College in 1836 in Oxford, Georgia by a small group of Methodists and was named in honor of...

has argued that "[t]his kind of thinking, as scary or even horrifying as it may seem, is absolutely critical and is much better done now than on the fly in the middle of a pandemic."

Research continues into alternative care, and various centers propose medical decision-support models for such situations. Some of these models are purely ethical in origin, while others attempt to use other forms of clinical classification of patient condition as a method of standardized triage.

Simple triage

S.T.A.R.T. model

Advanced triage

Continuous integrated triage

Practical applied triage

Reverse triage

Labelling of patients

Undertriage and overtriage

United States military

Canada

United Kingdom

Finland

France

Germany

Israel

Japan

Evacuation

Alternative care facilities

Secondary (in-hospital) triage

Hospital triage systems in the United States

Bioethical implications in triage

Ventilator rationing

See also