Introduction
The triage system is one of the most important measures in response to mass casualty incidents (MCIs) caused by emergencies and disasters.
Definitions
Triage is the process of prioritizing patient treatment during mass casualty events based on the severity and extent of the injuries, in the order by which patients’ care and treatment is sorted based on their priority need.
The triage assessment involves a combination of the presenting problem and general appearance of the patient and may be combined with pertinent physiological observations.
Key Aspects of Emergency Room Triage
- Initial Assessment – Patients are quickly evaluated by a triage nurse who checks vital signs, symptoms, and medical history.
- Priority Classification – Using systems like the Emergency Severity Index (ESI) or Canadian Triage and Acuity Scale (CTAS), patients are categorized from life-threatening (highest priority) to non-urgent (lowest priority).
- Resource Allocation – Patients needing immediate intervention (e.g., cardiac arrest, stroke) are prioritized over those with minor injuries.
- Continuous Monitoring – If a patient’s condition worsens while waiting, their priority level may be reassessed.
Categories of Triage
- Generic Triage
| Triage Category | |||
| Color Codes | Category | Meaning | Description |
| Red | I | Immediate | The patient requires immediate treatment, the highest priority response, for example: Cardiac arrest Respiratory arrest Traumatic brain injury Stroke Severe stridor |
| Yellow | II | Urgent | Patients with injury patterns in need of urgent treatment; the patient is stable at the moment and not in any immediate danger, but will require observation, for example: Airway risk-severe dyspnea Drooling with distress Severe respiratory distress |
| Green | III | Delayed | Patients will require medical treatment; patients with less serious or minor injuries, non-life-threatening conditions will eventually need help but can wait for others, for example: Persistent vomiting Dehydration |
| Blue | IV | Non-urgent | Patients who have injuries requiring extensive treatment that exceeds the medical resources available in the situation. |
| Black | V | Dead | Deceased or mortally wounded; black may not mean the person has already died. |
2. Canadian Triage and Acuity Scale (CTAS)
The Canadian Triage and Acuity Scale (CTAS) is a five-level triage system used in emergency departments to prioritize patient care based on urgency and resource needs. Here’s how priority classification works:
CTAS Levels & Their Priorities
- CTAS Level 1 – Resuscitation (Immediate Care)
- Patients with life-threatening conditions requiring immediate intervention (e.g., cardiac arrest, major trauma, airway obstruction).
- Goal: Immediate treatment to stabilize the patient.
- CTAS Level 2 – Emergent (Rapid Care)
- Patients with serious but stable conditions that could deteriorate quickly (e.g., severe chest pain, stroke symptoms, major fractures).
- Goal: Treatment within 15 minutes to prevent worsening.
- CTAS Level 3 – Urgent (Timely Care)
- Patients with moderate conditions requiring medical attention but not immediately life-threatening (e.g., abdominal pain, mild respiratory distress).
- Goal: Treatment within 30 minutes.
- CTAS Level 4 – Less Urgent (Delayed Care)
- Patients with minor conditions that require medical evaluation but can safely wait (e.g., mild infections, minor injuries).
- Goal: Treatment within 60 minutes.
- CTAS Level 5 – Non-Urgent (Routine Care)
- Patients with non-emergency conditions that could be managed in a primary care setting (e.g., prescription refills, mild skin rashes).
- Goal: Treatment within 120 minutes.
3.Emergency Severity Index (ESI)
The Emergency Severity Index (ESI) is a five-level triage system used in emergency departments to prioritize patient care based on acuity and resource needs. Here’s how priority classification works:
ESI Levels & Their Priorities
- ESI Level 1 – Immediate (Resuscitation)
- Patients with life-threatening conditions requiring immediate intervention (e.g., cardiac arrest, major trauma, airway obstruction).
- Goal: Immediate treatment to stabilize the patient.
- ESI Level 2 – Emergent (High Risk)
- Patients with serious but stable conditions that could deteriorate quickly (e.g., severe chest pain, stroke symptoms, major fractures).
- Goal: Treatment within 15 minutes to prevent worsening.
- ESI Level 3 – Urgent (Moderate Acuity)
- Patients with moderate conditions requiring medical attention but not immediately life-threatening (e.g., abdominal pain, mild respiratory distress).
- Goal: Treatment within 30 minutes, with two or more resources needed (e.g., labs, imaging, IV fluids).
- ESI Level 4 – Less Urgent (Low Acuity)
- Patients with minor conditions that require medical evaluation but can safely wait (e.g., mild infections, minor injuries).
- Goal: Treatment within 60 minutes, requiring one resource (e.g., X-ray or prescription).
- ESI Level 5 – Non-Urgent (Minimal Acuity)
- Patients with non-emergency conditions that could be managed in a primary care setting (e.g., prescription refills, mild skin rashes).
- Goal: Treatment within 120 minutes, requiring no resources beyond a physical exam.
Goals
- To ensure that patients are treated according to the clinical urgency.
- To ensure that treatment is appropriate and timely.
- To allocate the patient to the most appropriate assessment and treatment area.
- To provide ongoing assessment of patients.
- To provide information to the patient and families regarding services, expected care, and waiting time.
Components of Disaster Triage
- Sorting.
- Prioritizing.
- Allocating resources.
General Guidelines on Triage
- Ensure that patients are identified quickly, and given prompt care.
- Healthcare facility administrators need to provide public and patients with information on prevention measures before and on arrival at the healthcare facility.
- They should also ensure that physical infrastructure and supplies needed for triage are in place.
- Clear communication and training of healthcare facility staff is essential to ensure that the triage process is implemented systematically by healthcare workers.
- Ensure that patients arriving at emergency rooms are given clear directions.
- Ensure the availability of appropriate personal protective equipment (PPE) (i.e., mask, eye protection, gown, and gloves).
- Confirm the availability of hand hygiene stations (e.g. alcohol-based hand rub stations) in the triage area, including the waiting area.
Role of Nurse
- Provide clinical triage support and ongoing education for other staff in the practice.
- Comply with the practice triage policy and procedures.
- Report and review any incidents in which there is a failure in triage processes that result in actual or potential harm to a patient.
- Nurses are expected to promptly and appropriately respond to calls/approaches from the other staff, relating to urgent presentations/calls during consultations.
Documentation
- Date and time of assessment.
- Name of the triage officer.
- Chief presenting problem(s).
- Limited, relevant history.
- Relevant assessment findings.
- Implementation of the Advanced Trauma Life Support (ATLS) in emergency departments.
- Re-triage of category with time and reason.
- Assessment and treatment areas allocated.
- Any diagnostic, first aid, or treatment measures initiated.
Special Considerations
- Special attention is needed for children and elderly patients, as their symptoms may be less obvious.
- Conditions like cardiac arrest, stroke, or respiratory failure require immediate prioritization.
- EMS providers use structured criteria to determine transport destinations based on injury severity
- Ensure limited medical resources are directed to those in critical need.
- Clearly document triage decisions and communicate effectively with the medical team.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
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