Triage in Nursing

Triage Defined

Triage is defined as a process of prioritizing patients based on the severity of their condition with the goal of treating as many patients as possible when resources are insufficient for all to be treated immediately. It comes from the French verb trier, meaning to separate, sort, sift or select. Triage can either be simple or advanced.


Simple Triage

In simple triage, patients are categorized based on the severity of their injuries and are usually labeled using triage tags or colored flagging. An example of simple triage is the S.T.A.R.T (Simple Triage and Rapid Treatment), a method used by first responders during a mass casualty incident. In S.T.A.R.T., the patients are evaluated in 60 seconds or less and are labeled with one of the four triage categories:

a.) Minor (Priority 3)
- treatment can be delayed up to three hours or when possible (e.g. abrasions, minor lacerations, sprains)

b.) Delayed (Priority 2)
- needs urgent care and constant observation; tansport when practical (e.g. minor amputations, flesh wounds, fractures, dislocations)

c.) Immediate (Priority 1)
- condition is life-threatening; needs immediate care and transport ASAP (e.g. arterial lesions, major bleeding, major amputations)

d.) Deceased
- the victim is dead so no medical care is required; collection, guarding of bodies, and identification when possible


Advanced Triage

Advanced triage is performed to divert scarce resources from patients who are not likely to survive. Doctors may withhold treatment from seriously injured patients because the available resources are not sufficient to treat all of those who need medical help.

During extreme situations, the medical team decides if a patient is hopeless to avoid saving a hopeless case at the expense of several other patients with a higher chance of survival. Triage, then, has to be continuous to ensure that prioritization remains correct and medical help is given to those who are more likely to survive.

Secondary triage is typically performed by skilled nurses in the ER during disasters. In advanced triage, patients are divided in the following categories:

a.) Black / Expectant
- injuries are so severe that patients are unlikely to survive even with treatment and so the goal is to reduce patients' suffering (e.g. severe trauma, massive burns, septic shock, cardiac arrest) by providing painkillers as necessary

b.) Red / Immediate
- immediate surgery or medical care is required as these patients are likely to survive with treatment

c.) Yellow / Observation
- patients under this category are considered stable but requires observation and re-evaluation

d.) Green / Wait (walking wounded)
- patients under this category will require medical care but not immediately; may be asked to wait or go home and come back the day after (e.g. broken bones without compound fractures, soft tissue injuries)

e.) White / Dismiss (walking wounded)
- these patients have minor injuries and only requires home care (e.g. cuts, scrapes, minor burns)


Emergency Room Triage vs. Disaster Triage

In a controlled environment such as in an emergency room setting, the sickest patient is prioritized and given medical care first. In uncontrolled environments such as in a disaster setting, the patient who is more likely to survive is given priority. Still, whatever the environment, nurses need to develop clinical decision-making skills before they can accurately triage patients.


Emergency Wound Care

The skin is the largest and most visible organ of the body. Intact skin is the body's primary defense mechanism. Once the protective skin barrier is disrupted, individuals are at greater risk for injury.

Impaired skin integrity is a common problem often requiring visits to a hospital's emergency department. Examples of skin integrity disruption are cuts from sharp objects, bites resulting in lacerations, scrapes, contusions, avulsions, abrasions, or puncture wounds.

To prevent complications such as infection and hemorrhage, emergency wound care is necessary no matter how minor a wound is. Emergency wound care, by definition, is the immediate and temporary treatment of wounds in order to prevent infection, hemorrhage, and further injury to the patient. For wounds requiring immediate medical attention, proper emergency wound care may be instrumental in saving the patient's life and ensuring a rapid recovery.

Before a health worker or any individual renders emergency wound care to a patient, it is important for him/her to remember the following:

1.) Only approach the patient if it is safe for you to do so.
2.) Observe universal precautions while rendering first aid measures.
3.) Call for medical help immediately if there are embedded objects in the wound, if the wound is at special risk of infection, or if old wounds are showing signs of infection.

Emergency wound care provided by healthcare professionals usually involves cleansing the wound, application of measures to control bleeding, closing the wound, application of a protective dresssing, and prohylactic treatment for tetanus or rabies as indicated. These simple first aid measures will improve the patient's rate of recovery and prevent further medical problems.