Consept of Triage: Leh: Rudi Hamarno

Consept
of Triage
Oleh : Rudi Hamarno
Definition
Triage is a process that sort of patient

as base of life threating .
History : Napoleon Bonaparte (War I)

PRINCIPLES OF TRIAGE
1. Triage should be immediate & timely

2. Asses should be adequate & accurate
3. Decisions are made based on assess .
4. Provide interv accord to acuity condition
5. Patient satisfaction is achieved
6. Complete of documention
TRIAGE CLASSIFICATION
3 Categories  This very general

Original form of triage: suffered from lack of
specificity & too much
subjectivity
1. Highest priority
2. Second priority
3. Lowest priority
4 Category Triage
1. Highest priority (immediate, Class 1,

severe & emergent.)
2. High priority (secondary, Class 2,
moderate & urgent.)
3. Low priority (delayed, Class 3, mild & non
urgent.)
4. Deceased (probable death & Class 4/Class 0.)
Start Method
(Simple & Rapid Treatment)
 Developed in California in early 1980s .

 The triage personnel is minimal training.
 The assessment is done very rapidly
< 60 s the following areas:
1. Ventilation
2. Perfusion & pulses
3. Neurological.
The patients were classified as
follows:
a. The Walking Wounded
b. Critical/Immediate
 Respiration > 30/min

 No radial pulse
 Unconscious or having altered level of
consciousness or altered mental state
c. Delayed
Respiration < 30/min
Pulse present
Normal mental responses
d. Dead/Non-salvageable
Problem
Since the triaging is done by non-medical
staff & only based on ventilation, perfusion &
neurological assessments, certain early
critical situations may be missed eg. Early
shock, spinal shock etc.
General Classification of Triage at
Hospital Setting
 The triage nurse is often given the

responsibility in deciding on the priority
 Most hospitals in Singapore adopt the 3
Categories Triage System
Priority 1 or Emergent or Critical
 Definition
Patients with life threatening injuries or
illness which require immediate
 Area of Care :
Resuscitation Room or
Trolley/Stretcher
 Waiting Time
a. Cardio-vascular collapse or in danger of
imminent collapse : zero waiting time.
b. For others who do not require

resuscitation : not exceed 5 minutes.
Priority 2 or Urgent
Definition
 Urgent patients with major illness or
injuries but who are not in imminent
danger of collapse.
 Patients should be on a trolley, or
a wheelchair.
Area of Care
 Wheelchairs & ambulatory setting.
Waiting Time
 Within 30 minutes of arrival at A&E.
Priority 3 or Non-Urgent
Definition
Patients who are usually ambulatory
with minor problems, old injury or a
condition that has been present for a
long time.
Patient does not require immediate
threat to patients life or limb.
They may be treated just as well in a
private clinic or a polyclinic.
Area of treatment
 Managed in an ambulatory setting in an area
distinct from the P1 & P2 Areas.
 This is so that they do not interfere with the care
given to the other two groups of patients
Example PRIORITY 1
Trauma
1. Multiple Severe Injuries
2. Burns more than 15% 5. Acute breathlessness:asthma
3. Fractures of lower limbs 6. Acute myocardial infarction
4. Attempted suicides 7. Renal colic
5. Drug overdosages 8. Severe gastroenteritis
6. Acute head injuries with loss of 9. Bleeding GIT
consciousness
10. Acute low backache
Non-Trauma 11. Terminally ill patient
1. Airway obstruction 12. Acute abdomen, acute
retention of urine
2. Cardio-pulmonary arrest 13. Severe Dizziness/Syncope/Fits
3. Shock states 14. CVA
4. Acute severe chest pain 15. All patients drowsy or
comatose
16. Patients unable to walk
Trauma Non-Trauma
1. Upper limb fract /disloc 1. Febrile not requiring
2. Multiple superficial critical care attention
wounds 2. Mild abdominal pain
3. Burns < 15% 3. Acute large skin
4. Joint sprains & musc infectious &
strains emergencies, eg.
5. Multiple bee & insect Cellulitis, urticaria, etc
stings & animal bites 4. Abscesses
6. Simple lacerations 5. Acut infect of eye &
7. Foreign bodies of ear, ears
nose, throat & soft 6. Severe headache or
tissues pains of other regions
not requiring-critical
care
PRIORITY 3
Trauma Non-Trauma
1. Old scars 1. Cold lumps & bumps in
2. Deform of bones, limbs the body
/spine 2. Varicose veins
3. Joint contractures 3. Cysts
4. Old malunited fractures 4. Requests for
5. Request for removal of circumcision
metal plates, screws 5. Patching of earlobe
6. Old unreduced 6. Removal of tattoo
dislocations 7. Removal of corns, warts
7. Old un-united fractures 8. Removal of keloids
8. Chronic discharging 9. Chronic rhinitis
wounds 10. Defective hearing
9. Chronic sprains
11.Nasal polyp 17.Psychosomatic
12.Wax in ears problems
13.Cataracts 18.Chronic headaches
14.Upper resp infec on & off
without fever 19.Insomnia
15.Chronic cough
16.Social problem –
requests admission
??
ASSESSMENT
& PRIORITY SETTING
ASSESSMENT GUIDE
a. History
 Taking history from patient & important as
valuable inform
b. Sight
 Patient’s general appearance eg level of
consciousness, respiratory problem, appears to
be breathless, any obvious signs of injury such
as laceration swelling, bleeding. Body language.
c. Smell
 Odour of alcohol, Ketories bodies or malaena stool smell.
d. Touch
 Skin: fever, cold & clammy, sweaty
 Palpate – take pulse rate
 Touch for tenderness & swelling
e. Common Sense
 Use common sense to decide what you want to ask for
relevant key points
The SOAP process
 S :Subjective  A :Assess
 O :Objective  P :Plan
S – Subjective
 Collect subjective data
 Initially use open ended questions eg
“Why did you want to see a doctor?”
 Past History – eg. Hypertension, DM?
Note :
 Trauma Cases : Mechanism of injury
O – Objective
 Collect objective data

 General
 Method of arrival to A&E
 Level of consciousness GCS (Trauma
Case)
 P/ general appearance using your senses
 Vital signs (T,P,RR,BP)
A – Assess
 Assess & evaluate patient from

the S & O data collection.
decide
action plan.
P – Plan
1. Establish your
priority
 Immobilize fracture
2. Carry out further test:
 Put on cervical collar
 ECG
 First aid dressing
 Blood glucose mon
 X – ray
 Urine labstix
 Urine for inspection
 First aid manag
?
Role of Field Triage Team
 The first team to arrive will take charge of

triage
 Not to be stretcher bearers.
 Explain role of stretcher bearers to them
when assigned.
 Show the locations of P1, P2, P3
 Ensure that all P1 & P2 casualties are
transported via stretchers.
 Deploy to assist in other areas when no more
patients require triage.
 Ensure that not more than 2 P1 casualties are
evacuated in the same ambulance.
 Load & go philosophy of field care.
Triage Team
 Each team consist of 1 doctor & 1 nurse
 The number depent of availability,
requirement dan space
 During disaster, fungtion is mainly to
alocate priority of treatment
 The equitment :
1. Triage tag , Stretchers
2. 1 box of dressing & OFT/NFT
Mettag
• Priority 0 = black
• Priority 1 = red
• Priority 2 = yellow
• Priority 3 = green
Triage Proses
1. Mobility ?
If victim can walk and has injury : P 3
2. Cek ABC
Airway by chin lift / jaw thrust
B+
B-
Cek RR
P0
10 -
30 x
< 10 x
> 30 x
Circulation ?
P1
Normal < 2 dtk P2
Delay > 2 dtk
Problems
1. Language
2. No Visible Patient
3. Terms
4. Evaluation
Responsbilities
 It is to assess, sort out all calls & give first
aid advice.
 How does one do assessment over the
phone ?
 This can only be done subjectively.
Subjective
 What is the main complaint ?

 What is the duration ?
 Are there any associated symptom eg. fever,
sweating ?
 What is the patient’s past medical history?
 It is good practice to write down the information
on a piece of paper placed in front of you.
 Another way of avoiding misunderst&ing is to
repeat what the caller has just said eg. Am I
correct, your child has fever for five days ?
Objective
There are 4 categories where these calls are

sorted into:
Decide if p/ needs to call for an ambulance
ie dial 995.
Decide if p/ needs to be seen in an A&E
Dept.
Decide if p/ can be seen by general
practitioner or a doctor in a polyclinic.
Decide if first aid advice is all that is
required.
General Conduct over the phone:
1. Always identify yourself

2. Be calm & sound confident
3. Speak clearly
4. Substitute medical terms or explain them if
used
5. Be patient with the caller
?
Thank ........

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Consept

Triage is a process that sort of patient

History : Napoleon Bonaparte (War I)

1. Triage should be immediate & timely

3 Categories  This very general

1. Highest priority (immediate, Class 1,

 Developed in California in early 1980s .

 Respiration > 30/min

 The triage nurse is often given the

b. For others who do not require

 Collect objective data

 Assess & evaluate patient from

 The first team to arrive will take charge of

 What is the main complaint ?

There are 4 categories where these calls are

1. Always identify yourself

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