After finishing my studies, I went back to university due to the shortage of nursing job vacancies that characterizes the current situation of my country, and I was lucky to coincide with some of my old college mates in the same expert. We were chatting, telling stories, remembering old times and then, we spoke about our final degree project. There was a friend who presented the project with the same tutor as me, and this situation gave me the inspiration to realise a new post whose main theme concerned Triage.
To be honest, this has been an issue that has never interested me, because one always thinks to oneself that disasters always look far away (and this is a false sense of invulnerability, so characteristic of human beings). However, if we look back on timeline, we can remind episodes of MVA (multiple victim accident) in Spain such as the terrorist attack in 11th March 2004, the airplane crash of Spanair® in 2008, Lorca’s earthquake in 2011 and even the same last year, the Alvia railway accident of Santiago de Compostela. Internationally, we could remember some accidents like Fukushima Nuclear Power Station, Haiti’s disaster… without forgetting the armed conflicts that are still active especially in the areas of the Middle East and Africa. A triage of the victims based on severity has been proceeded in all of these are situations.
Then, it is quite evident the need for a triage system in each country to manage properly a health support for any type of incident that could happen.
And, in this moment, I wondered to myself… What is the origin of Triage?
The Triage comes from the French word “trier” and was a term used by fishermen to select the best pieces of their capture. It began to be used in the military health, to establish criteria for assistance to wounded soldiers depending on the severity of their injuries and their possible evolution.
Triage has three basic pillars: it must be performed quickly (not to delay the care of the rest), exhaustively (fully assessing the patient – from head-to-feet system), accurately and safely (reassessment is not possible). This system is part of the responsibilities of nursing and medicine in emergencies. Despite of being a main labour of these two groups, also healthcare staff (nursing assistants, technicians …) and non-medical staff (policemen, firemen …) in special situations, such as big accidents or disasters, might carry out a basic triage line if they has been given previously training on it. Hence, some specific knowledge and skills should be needed to carry it out correctly; otherwise the consequences of a bad triage could be really serious.
However, it is necessary to differentiate between the concepts of “Classification” and “Triage”. The first one takes place when there is a balance between the demand of the patients (clinical condition) and assistance that could be provided, and the second one is used in situations where that balance is broken and there is an overload of emergency services (prognosis is the most important).
I asked my friend more about her project, because I was finally really interested about what was the triage. I would like to thank her let me read it, therefore her project has helped me to create a mental map of the triage.
Well, one interesting point is that there are many different types of triages depending on whether we are in or outside the hospital setting, and also what is our contextual framework (if is a simple accident, multiple victims, disaster …).
At inpatient category there are six systems:
- The Australian Triage Scale (ATS)
- The Canadian Emergency Department Triage and Acuity Scale (CTAS)
- The Emergency Severit Index (ESI)
- The Manchester Triage System (MTS)
- The Andorra Triage Model (MAT – Modelo Andorrá de Triatge)
- The Spanish Triage System (SET – Sistema Español de Triage) that originally derived from MAT.
In Spain the most commonly used are the last three ones, limiting the MAT to the county of Navarra.
At outpatient category, other systems are used:
- Basic and elemental: the patient walks or not
- SHORT: acronym of Spanish walks out (sale caminando), speaks without difficulty (habla sin dificultad), obey simple commands (obedece órdenes sencillas), breath (respira) and stop bleeding (taponar hemorragias).
- START: Simple Triage and Rapid Treatment
- META: from Spanish Extrahospitaly Model of Advanced Triage (Modelo extrahospitalario de triage avanzado)
The use of any of them will depend on the experience of chosen staff and the severity of the incident. A large amount of bibliography supports the advantages to use advanced methods over the basic, although one side defends situational variable as selector of the most appropriate method to it. In other words, the staff will chose the model that will be most appropriate to the situation. It is a challenge that requires to be updated of the thousands of possible diseases that affect the body and human mind, which results in a very comprehensive recycling and extensive knowledge of clinical nursing. They can deal with different kinds of patients, from oedematous floaters eyes to critically ill.
Both inside and outside the hospital and regardless of the model of triage employee, patients are classified by colours depending on their acuteness and in the outpatients, also on their prognosis. There is an international code with four colours:
- Red: critical, potentially recoverable patients requiring immediate medical attention. Priority I
- Yellow: serious patients requiring medical care that could be delayed 1 or 2h. Priority II
- Green: patients with minor injuries, medical care could be delayed more than 6 hours. Priority III
- Black: patients with injuries incompatible with life, agonizing and hopeless. Priority 0
Depending on the model, it can be use a fifth colour to notify an accident CBRN decontamination (Chemical, Biological, Radiological and Nuclear risk) or, in the case of end of life patients, to assess a palliative treatment (compassionate analgesia). The colours used in these cases are usually blue or white.
Performing patients’ triage is complicated. Only the experienced eye is able to realise it correctly through a deep physical observation and a great dialectical skills. Collecting verbal data can be an arduous task because sometimes the victims are not able to explain or convey what happens to them, sometimes tending to exaggerate, omitting some facts or symptoms and also there are several options for location / derivation due to similarity between clinical features that present some pathologies.
Moreover, at the hospital frame, not all patients who visit the Accident & Emergency unit has got an urgent pathology. According to a study of paediatric A&E unit at Central Hospital of the Social Security Institute in Paraguay, only a quarter of the patients who attended the units were classified as urgent. These data were collected and analysed through the implementation of a system of triage, and concluded that more than three-quarters of emergency patients were seen within thirty minutes after admission.
I wouldn’t like to extend anymore but, after learning a bit more about the Triage, I think that it is an interesting topic to study more in details, because I am fear that I have not touched the top of the iceberg. So soon I promise to develop and search more information about the types of triage. I hope you are as motivated as me…
Bibliography:1. Morillo Rodríguez, F. J; Abad Esteban, F; Acebedo Esteban, F. J; Aranda Fernández, A; Barrado Muñoz, L; Cabezas Moreno, A. et al. Manual de enfermería en la Asistencia Prehospitalaria Urgente. Elselvier. Madrid 2007. Págs: 588 – 596 2. Garcia – Largo Moreno, E. Enfermería en el triage extrahospitalario. Revisión bibliográfica. Madrid 2013. 3. Soler, W; Gómez Muñoz, M; Bragulat, E; Álvarez, A. El triaje: herramienta fundamental en urgencias y emergencias. An. Sist. Sanit. Navar. 2010, Vol. 33, Suplemento 1. Págs: 55 – 68. Consultado el día 01 de abril de 2014. Disponible en: http://scielo.isciii.es/pdf/asisna/v33s1/original8.pdf 4. Medina, J; Ghezzi, C; Figueredo, D; León, D; Rojas, G; Cáceres, L. et al. Triage: experiencia en un Servicio de Urgencias Pediátricas. Rev. bol. ped. v.46 n.1 La Paz 2007. Consultado en la base de datos Scielo el día 04 de abril de 2014. Disponible en: http://www.scielo.org.bo/scielo.php?pid=S1024-06752007000100013&script=sci_arttext&tlng=en 5. Illescas Fernández, G. J. Triage: atención y selección de pacientes. Revista Trauma. Vol. 9, No. 2. Mayo-Agosto 2006. Págs: 48-56. Consultado el día 05 de abril de 2014. Disponible en: http://www.medigraphic.com/pdfs/trauma/tm-2006/tm062e.pdf
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