performing a successful triage at the hospital level. triaging for infants, children, and adults. nevertheless, the triage area must be well secured. the area must be signed. babies less than one-month-old must be seen immediately by a physician without delay in a queue. triaging must be carried out by an adequately trained caregiver.

1. TRIAGING AT THE HOSPITAL
LEVEL
Presented by MS. Mavis Agyeiwaa Kyei
MA, BSc.,Dip.RGN

2. Learning Objectives
• Understand the purpose of triage and the benefits of its
implementation
• Be familiar with the requirements for standardised triage
implementation
• Understand the terminology and key concepts around triage
• Be able to carry out triaging, calculate the TEWS and Assign a
discriminator

3. INTRODUCTION
• Many deaths in hospitals occur within 24 hours of admission. Some of
these deaths can be prevented if very sick patients (especially
children) are quickly identified on their arrival and treatment is
started without delay. In many hospitals around the world, children
are not checked before a senior health worker examines them; as a
result, some seriously ill patients have to wait a very long time before
they are seen and treated. Children are known to have died of a
treatable condition when waiting in the queue for their turn. The idea
of triage is to prevent this from happening

4. Purpose of Triaging
• The purpose of triage is to SORT OUT patients according to medical
urgency for medical attention in contexts where patient load
overwhelms the available resources.
• Thus patients are grouped/ sorted/ranked/classified according to the
severity of their sickness or injury in order to ensure that medical and
nursing staff and facilities are used most efficiently.

5. The benefits of implementing Triage
Triaging helps to:
1. Expedite the delivery of time-critical treatment for patients with life-
threatening conditions.
• 2. Ensure that all patients are appropriately prioritized according to their
medical urgency.
• 3. Improve patient flow esp. at the waiting area/ OPD
• 4. Improve patient satisfaction.
• 5. Decrease the patient’s overall length of stay.
• 6. Facilitate streaming of less urgent patients.
• 7. Provide a user-friendly tool for all levels of health care professionals

6. Checklist for triaging
• A dedicated space/ area for triaging
• The triage area/ space should be well signed
• The triage area should be secured from all forms of distractions and danger
• The triage area /space should at least be able to accommodate a nurse,
patient in a wheelchair and relative or carer
• The triage area /space should have a desk and chair
• Triage paperwork for adult, children and infants
• wall clock with a second hand
• A stethoscope

7. • A thermometer
• Dry dressings and bandages
• Gloves
• Sphygmomanometer (manual, digital or electronic)
• Blood glucose monitor
• A measuring tape OR marks displayed on wall in triage area to measure children (i.e one
mark at 95cm and one at 150 cm)
• Displayed posters of triaging in the area
• manual readily available for triage office as a source of reference document
• Patient information leaflet prominently displayed in the triage waiting area
• Triage register or computer with register
• White board to track and communicate to other staff acuity of those triaged.

8. APPLICATION
Procedure
• The triage area must be immediately accessible and clearly sign-
posted. Its size and design must allow for patient examination, privacy
and visual access to the entrance and waiting areas, as well as for
staff security
• The area should be equipped with emergency equipment, facilities for
standard precautions (hand hygiene facilities, gloves), security
measures (duress alarms or ready access to security assistance),
adequate communications devices (telephone and/or intercom etc)
and facilities for recording triage information.

9. • All patients presenting to an A & E should be triaged on arrival by a
specifically trained and experienced registered nurses. The triage
assessment and TS code/colour allocated must be recorded. The
triage nurse should ensure continuous reassessment of patients who
remain waiting, and, if the clinical features change, re-triage the
patient accordingly. The triage nurse may also initiate appropriate
investigations or initial management according to organisational
guidelines.

10. The Triage Tool
• The Tool consists of 2 parts:
• the Triage Early Warning Score (TEWS) (part 1) and
• the Discriminator List (part 2).
The discriminator list follows after the TEWS. The provider needs to
calculate the TEWS before moving on to the discriminator list.

11. versions of the TS
• There are three versions of the TS, depending on whether the patient
is an adult or not.
• Adults have their own version. However, because children have
different values of heart rate, respiratory rate and blood pressure.
• There are two paediatric versions: one for infants (50cm to 95cm –
one week to almost 3 years), and
• one for children (96cm to 150cm – 3 years to around 12 years).
NB: Neonates aged one month or younger should be seen immediately
by a doctor.

12. The Two Parts to the Tool
• The Two Parts to the Tool The TS consists of 2 parts: the Triage Early
Warning Score (TEWS) (part 1) and the Discriminator List (part 2). The
discriminator list follows after the TEWS. The provider needs to
calculate the TEWS before moving on to the discriminator list.

13. 1. Triage Early Warning Score (TEWS)
• In order to generate a total score, the provider has to observe the
basic vital signs of the patient. Each vital sign monitors a different
physiological system:
• Blood pressure and Heart rate monitor the cardiovascular system
(heart and blood flow). What happens when you check blood
pressure/pulse that is too high or too low
• Respiratory rate monitors the respiratory system (lungs) •

14. • Temperature monitors thermoregulatory system (infections,
hypothermia) • Alertness, Verbal response, Reaction to pain and
Unresponsiveness (AVPU) monitors the central nervous system (brain)
• Mobility monitors the musculoskeletal system (bones and muscles)
• Trauma refers to the presence of ANY injury (bump, bruise, cut etc)
By comparing the observed basic vitals of the patient with a
parameter on the TEWS calculator (horizontally) a score can be read
off (vertically). These scores are added together which gives the
provider a total TEWS

15. Discriminator List
• The second part or the discriminator list is the part that generates the
actual triage colour (red, orange, yellow, green, blue) which will
determine urgency level and essentially also when the patient will be
attended to. As with the TEWS, there are separate versions of this for
infants, children and adults respectively

16. • The TEWS will only identify and classify a patient into an appropriate
triage code if the physiology of the patient is altered from normal.

17. Triage Interventions and Management Aids
• Management of the patient starts when the triage provider’s analysis
starts. It is therefore critical that this management continues after the
triage process has been completed.

18. • COLOUR ACTION
• RED Refer to the resuscitation room for emergency management
ORANGE Refer to the patient waiting area for urgent management
YELLOW Refer to the patient waiting area for management
• GREEN Patient for potential streaming
• BLUE Refer to doctor for certification

19. • It is also possible for the triage provider to commence management
when treatment is readily available and the provider’s qualification
allows the intervention. Appropriate interventions directed at
observed abnormalities during triage decreases the patient’s
morbidity and increases patient satisfaction.

20. • Adult Triage Score. (TEWS) PLS INSERT PICTURE
•
• Adult Discriminator List PLEASE INSERT PICTURE
•
• Children Triage Score (3-12 YEARS, 96-150CM) TEWS) PLS INSERT PICTURE
•
• Children (3-12 yrs, 96-150CM) Discriminatory List
•
• Infant Triage Score TEWS. PLS INSERT PICTURE
•
• Infant DISCRIMINATOR. PLS INSERT PICTURES
•

21. • Intervention at triage area (PLS REFER TO DOWNLOAD)
• Flow Chart PLS REFER TO DOWNLOAD)

22. •
• CASE SCENARIO
• A nine-month old baby boy is carried into the children’s section of the outpatient department in his mother’s arms. He appears to
be asleep. At the triage desk he is seen by a nurse and found to have lips and tongue that are grey/blue in colour, and he is taken
straight into the resuscitation room as an emergency. In the resuscitation room he is given oxygen at 15 litres/minute by face mask
with a non-rebreather reservoir bag. He is noted to be grunting and breathing very fast. His hands are cold to touch and the
capillary refill time is prolonged to four seconds. An intravenous cannula is placed. A blood sample is taken at the same time for
blood glucose, full blood count and blood culture. An intravenous infusion of normal saline is commenced at 20ml/kg to run as fast
as it can go. Other treatments are given, depending on the result of the investigations and the response to the treatment he
receives. It is now 18 minutes since the baby came through the outpatient department’s door, and his situation is stable. It is now
time to take a full history and carry out a full examination to make a definitive diagnosis. He is diagnosed as having very severe
pneumonia, and receives specific treatment for this.
• However, before coming to this diagnosis, no time was wasted, his status was stabilized, based on a few leading signs and
symptoms, even when the medical staff did not know exactly what was wrong with him. This was good triage and emergency
management. Would it have happened like this in your hospital?
•
•
•

23. • Terminology and key concepts
• Triage, from the French word “trier”, literally means: “to sort”. The
aim is to bring “the greatest good to the greatest number of people”
– this is achieved through prioritizing limited resources to achieve the
greatest possible benefit. Patients are sorted with a scientific triage
scale in order of urgency - the end result is that the patient with the
greatest need is helped first
• Patient to triage: for the hospital or clinic context this refers to a
patient that appears relatively stable and is able to mobilize
him/herself to the designated triage area. This will be the type of
triage used for most hospital and clinic cases

24. • FLOWCHART
DO QUESTIONS

25. • Intervention at triage area