Triage is the process of sorting patients based on the urgency of their condition to determine priority of treatment. The goal is to provide the right care to the right patient at the right time. There are different categories for triage, such as immediate, urgent, less urgent and non-urgent. The triage nurse conducts an initial assessment of the patient's airway, breathing, circulation and disability level to identify life-threatening issues and assign an acuity level for treatment. Re-triage is important as a patient's condition may deteriorate while waiting. The triage nurse plays a key role in efficiently sorting and treating patients based on need.

1. Triage
SHREYA YADAV
Nursing tutor

2. Definition of Triage
• Triage is the term derived from the French verb trier
meaning to sort or to choose
It’s the process by which patients classified according
to the type and urgency of their conditions to get
the Right patient to the Right place at the Right
time with the Right care provider

3. Triage Categories
• Non disaster: To provide the best care
for each individual patient.
• Multi casualty/disaster: To provide the
most effective care for the greatest
number of patients.

4. Non disaster-
The primary objectives of an ED triage
are to-
2. Identify patients requiring immediate
care.
3. Determine the appropriate area
for treatment
4. Facilitate patient flow through the ED
and avoid unnecessary congestion.

5. 2.Provide continued assessment and
reassessment of arriving and waiting
patients.
3.Provide information and referrals
to patients and families.
4.Allay patient and family anxiety
and enhance public relations.

6. Disaster
•
Definition: an incident, either natural or human-
made, that produces patients in numbers needing
services beyond immediately available resources.
May involve a large no. of patients or a small no. of
patients if their needs place significant demands on
resources.
The key to successful disaster management is to
provide care to those who are in greatest need first
and just as importantly, not provide care to to those
who have little or no chance of survival. Correct
triage is essential to accomplish this goal
•

7. Disaster
The triage team
Triage of Victims
- first victims to arrive are frequently
not the most seriously injured.
Critical patients
Fatally Injured Patients
Non critical patients
Contaminated patients

8. Types of E.D. triage
system
•
•
•
Type 1: Traffic Director
Type 2: Spot Check
Type 3: Comprehensive
• Two-tiered systems: intial screening by RN
who greets each patients on arrival, perform
a primary survey and determine whether the
patient is able to wait for further assessment
by a second triage nurse.
Divide tasks among staff members, internal
triage and external triage
•

9. Triage levels
1 Resuscitation
2 Emergent
3 urgent
4 less urgent
5 Non urgent

10. Overview of three category triage acuity
systems
category acuity Recommended
reassessment
Examples
Class 1 Emergent
Immediately life or limb
threatening
continuous Cardiopulmonary
arrest, severe
respiratory distress,
major burns, major
trauma, massive
uncontrolled bleeding
Coma, status
epilepticus
Class 2 Urgent
Requires prompt care, but
will not cause loss of life or
limb if left untreated for
several hours.
Every 30
minutes
Abdominal pain, non
cardiac cp, multiple
fractures, lacerations,
renal calculi,
Class 3 Non urgent
And treatment but time is
not a critical factor
Every 1-2
hrs
Rash, chronic headache,
sprains, cold symptoms

11. TRIAGE LEVELS
IMMEDIATE
1- Resuscitation -- threat to life
Time to nurse assessment
Time to physician assessment
• Cardiac and respiratory arrest
• Major trauma
• Active seizure
• Shock
• Status Asthmatics

12. Triage levels
 Decreased level of consciousness Severe
respiratory distress
 Chest pain with cardiac suspicion Over
dose (conscious)
 Severe abdominal pain
 G.I. Bleed with abnormal vital signs
Chemical exposure to eye
2- Emergent
Potential threat to life,limb or function Nurse
Immediate ,Physician<15 minutes
•
•
•
•
•
•

13. Triage levels
3- Urgent
Condition with significant distress
Time Nurse < 20 min, physician < 30 min Head
injury without decrease of LOC but with vomiting
• Mild to moderate respiratory distress
• G.I. Bleed not actively bleed
• Acute psychosis

14. Triage levels
4- Less urgent
Conditions with mild to moderate discomfort Time
for Nurse assessment <1h
-Time for physician assessment < 1h
Head injury, alert, no vomiting
Chest pain, no distress, no cardiac susp.
Depression with no suicidal attempt

15. Triage levels
5- Non urgent Conditions can be delayed, no
distress Time for nurse and Physician
assessment
•more than 2h
• Minor trauma
• Sore throat with temp. < 39

16. Basic component of
triage
• An “across-the room”
assessment
• The triage history
• The triage physical
assessment
• The triage decision

17. An “ across the room
assessment”
To identify obvious life threat conditions
General appearance
Air way
Breathing
Circulation
Disability
(neurogenic)

18. Characteristics of triage
nurse
• Extensive knowledge to emergency
medical treatment
• Adequate training and
competent skills,language,
terminology
• Ability to use the critical thinker process
• Good decision maker

19. Role of triage nurse
•
•
•
Greet patients and identify your self.
Maintain privacy and confidentiality
Visualize all incoming patients even
while interviewing others.
Maintain good communication between triage
and treatment area
maintain excellent communication with
waiting area.
Use all resources to maintain high standard of
care.
•
•
•

20. Role of triage
nurse
• Teaching -use of thermometer, first aid
avoid lecturing.
• Crowd control.
• Telephone.
• Communicate with team leader and
seek feed back on decisions.

21. Importance of re
triage
• Reassess the patient within 1-2hours of initial
triage and continue to re assess on a regular
basis, patients who may have presented
without cardinal signs of severe illness may
develop them during long waits.

22. •The last person in along line at triage may
have a serious medical problem that requires
immediate attention
•Patient should wait no longer than 5 minutes
for triage
If in doubt about a category, choose the higher
acuity to avoid under triaging a patient