Triage Overview

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Triage is the process of determining the priority of a patient to medical care based on the acuity  (severity  of  condition)  and  capacity  of  the  system  to  address  the  condition,  so  as  to  optimize outcome. 

Importance of triage   

Triage  enables  quick  identification  of  patients  who  need  immediate  attention,  and  can  thus  improve  patient  outcomes  by  avoiding  potential delays.  It  helps  in  organizing,  monitoring,  evaluating and determining the department resources that patients might need. 

Triage system 

The triage system is based on recommendation of Emergency Medicine expert’s basic principles of  triage, which uses specific criteria to categorize patients into three main levels of acuity:   

Emergency:  all  patients  with  immediate  life  or  limb  threats  who  are  deemed salvageable, but likely to further decompensate without immediate intervention will be triaged in this level. This category can also be labeled as RED

Priority: those seriously injured/ill patients with potential to decompensate if not treated  within  1  hour  are  triage  as  priority cases.  This  category  can  also  be labeled as YELLOW

Queue:  this  level  includes  all  the  walking  wounded  or  those  with  less  serious injury/sickness who are unlikely to decompensate. Patients in this category can safely wait for their turn. However, they should be monitored as their conditions may  change  and  warrant  immediate care.  This  category  is  also  labeled  as GREEN.

Figure 1. Summary of triage flow and timelines of care 

EMERGENCY CRITERIA (Tick here if Yes)

 

Unresponsive 

  

Pregnant with Heavy bleeding 
 

Stridor 

  

Pregnant with Severe abdominal pain 
 

SpO2 <90% 

  

Pregnant with Seizures 
 

Respiratory distress or cyanosis 

  

Pregnant with Severe headache 
 

Weak pulse or Capillary refill>3 sec 

  

Pregnant with Visual changes 
 

Heart rate <50 or >150 

  

Pregnant with SBP≥160 or DBP ≥110 
 

Heavy bleeding 

  

Pregnant with Active labour 
 

Active convulsions 

  

Pregnant with Trauma 
 

Hypoglycemia 

  

Age < 2years with Temp <36oC or >39oC 
 

High-risk trauma* 

  

Child <14 with severe dehydration 
 

Poisoning or dangerous chemical exposure*

  

Adult with signs of meningitis
 

Threatened limb*

  

Acute chest or abdominal pain (>50 years old) 
 

 Snake Bite

  

ECG with acute ischaemia
 

 Violent or aggressive

  

Other (state):

PRIORITY CRITERIA (TICK here is Yes)
 

 Vomits everything or ongoing diarrhoea (adult)

  

Severe pain (no Red criteria)
 

Unable to feed or drink 

  

Visible acute lime deformity
 

Severe Pallor

  

Open fracture
 

 On-going bleeding (no emergency criteria)

  

Suspected dislocation
 

Recent fainting

  

Other trauma/burns (no Red criteria)
 

Altered mental status (no emergency criteria)

  

Sexual assault
 

Acute general weakness

  

Acute tersticular/scrotal pain or priapism
 

Acute focal neurology

  

Unable to pass urine
 

Acute visual disturbance

  

Wheezing (no Red criteria)
 

New rash worsening over hours or peeling (no emergency criteria)

  

Exposure requiring time-sensitive prophylaxis (example: animal bite, needle-stick injury)
 

Any infant 8 days to 2 months old

  

Child below 14 years old with malnutrition
 

Child below 14 years old with dehydration

  

Child below 14 years old with ongoing diarrhoea
 

Referral patient (no emergency criteria)

  

Other, state:

QUEUE CRITERIA (Tick here if Yes)
 

Patient with no Emergency or priority criteria indicated in above tables