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PUSAT PERUBATAN UNIVERSITI MALAYA

NAMA DOKUMEN:

GUIDELINES FOR TRIAGE OF PATIENT AT TRAUMA & EMERGENCY DEPARTMENT

NOMBOR DOKUMEN:

DS-0059-E03 MUKA KULIT

TARIKH KELULUSAN : 07-05-2013

TARIKH BERKUATKUASA : 07-05-2013

TARIKH KAJISEMULA : 07-05-2013

PENULIS DOKUMEN : Mohd Idzwan Zakaria Harminder Singh a/l Karam Singh

DISEMAK OLEH : Ketua, Jabatan Trauma dan Kecemasan

DILULUSKAN OLEH : Wakil Pengurusan-QMS

DISAHKAN OLEH WAKIL PENGURUSAN :

DOKUMEN INI ADALAH HAK MILIK SEPENUHNYA PUSAT PERUBATAN UNIVERSITI MALAYA (PPUM). SEBARANG SALINAN SEBAHAGIAN ATAU SELURUHNYA DOKUMEN INI TIDAK DIBENARKAN SAMA SEKALI KECUALI MENDAPAT KEBENARAN SECARA BERTULIS DARI BAHAGIAN PENGURUSAN KUALITI, PUSAT PERUBATAN UNIVERSITI MALAYA.


NAMA DOKUMEN: GUIDELINES FOR TRIAGE OF PATIENT AT TRAUMA & EMERGENCY DEPARTMENT

NOMBOR DOKUMEN: DS-0059-E03 MUKA: 2/20

Tarikh Berkuatkuasa: 07-05-13

No. Kajisemula R00

DEFINITION

Triage in the simplest term is sorting or prioritizing. It is a process by which a

patient or many patients who turn up simultaneously are assessed upon arrival at

Trauma & Emergency to determine the urgency of the problem and to designate

appropriate health care resources to the patient according to their level of acuity.

It is the process by which patients are classified according to the type and urgency of

their conditions to get the:

• RIGHT PATIENTS to the

• RIGHT PLACE at the

• RIGHT TIME with the

• RIGHT CARE PROVIDER

AIM OF TRIAGE

Triage aims to ensure that patients are treated in the order of their clinical urgency

and their treatment is appropriately timely. The priority of care is based on the

urgency rating. Hence triage is to deliver FAST, SAFE & HIGH QUALITY

EMERGENCY CARE.

PRINCIPLES OF TRIAGE

Classification of patients according to:

o Urgency

Based on medical need

Based on injury severity

o Likelihood of survival

o Resource availability

If resources outnumbered victims – treat all of them, &

transport immediately. TRIAGE focus on identifying &

prioritizing treatment needs for each patients.

If victims outnumbered resources – TRIAGE focus on

identifying potential salvageable victims with life threatening

conditions that require immediate treatment & transport (mass

casualty incident or disaster)





No. Kajisemula R00

TYPES OF TRIAGE

HOSPITAL TRIAGE

FIELD TRIAGE

HOSPITAL TRIAGE

It is performed in the hospital. It is a process of sorting out patients according to the

severity of injury and the priority of treatment. The most severe injuries and illnesses

are taken first regardless of the prognosis. Triage system performed according to the

hospital’s operation policy and depends upon these factors:-

• a) Manpower & staffing

• b) Availability of facilities

• c) Zoning of the area based on an acceptable triage system

FIELD TRIAGE

It is performed outside the hospital usually at the incident site. Patient with the

greatest chance of survival is managed first. It determines the speed of transport and

hospital destinations.

TRIAGE SYSTEM

A triage system is formulated:

to determine the order the patients will be evaluated

to determine the care area

to determine the level of care provider





No. Kajisemula R00

Trauma and Emergency Department has adopted the four-category triage scale for

its triage system. The four category triage scale is divided into:

Triage

scale Name Condition Colour Target time

1

Immediate

resuscitation or

critical

Conditions that are threats to

life (or imminent risk of

deterioration) and require

immediate aggressive

intervention for preservation

of life

or

The patient’s condition is

serious enough or

deteriorating so rapidly that

there is the potential of treat

to life, limb or organ system

failure if not treated

or

The potential for time critical

treatment (e.g. thrombolysis,

antidote) to make a

significant effect on clinical

outcome depends on the

treatment commencing within

a few minutes of the patient

arrival to the T&K

Red Within 10

minutes

2 Semi-critical or

Urgent

The patient’s condition may

progress to a life or limb

threatening, or may lead to a

Yellow Within 30

minutes





No. Kajisemula R00

significant morbidity if

assessment and treatment is

not commenced within 30

minutes of arrival

or

There is a potential for

adverse outcome if time-

critical treatment is not

commenced within 30

minutes

or

Human practice mandates

the relief of severe pain,

discomfort or distress

3

Non-urgent

The patient’s condition may

deteriorate, or adverse

outcome may result if

assessment and treatment is

not commenced within one

and a half hour of arrival to

T&K. Symptoms moderate or

prolonged

or

There is potential for adverse

outcome if time-critical

treatment is not commenced

within one and a half hour.

or

Green Within 90

minutes





No. Kajisemula R00

Likely to require complex

work-up and consultation and

/ or inpatient management.

or

Humane practice mandates

the relief of discomfort or

distress within one and a half

hour.

4

Non-emergency

The patient’s condition is

chronic or minor enough that

symptoms or clinical

outcome will not be

significantly affected if

assessment and treatment

are delayed up to three

hours.

or

The investigations or

interventions for some of the

illness or injuries could be

delayed or even referred to

other areas of the hospital or

health care system

Blue Within 180

minutes





No. Kajisemula R00

CLINICAL DESCRIPTIONS OF TRIAGE SCALE

TRIAGE

SCALE CLINICAL DESCRIPTIONS

1

Cardiac arrest

All patients who requires ventilation example apnoea, gasping, cyanosis

All patients with airway compromise

o Severe maxillofacial injury

o Inhalational injury

o Stridor

Shock states (SBP 90 and below)

Polytrauma

All chest trauma

All suspected abdominal injury

All penetrating wound to the neck, chest or abdomen

Severe asthma and COAD

Severe respiratory distress ( SpO2 < 95% and respiration of 25 per min and

above)

All head injuries with GCS 13 and below

Altered mental state with GCS 13 and below

Seizures

Pneumothorax – traumatic / tension

Burns with signs of inhalational injury: facial burns, singeing of eyebrows

and nasal hair, carbonaceous sputum, carbon deposits and acute

inflammatory changes in the oropharynx, history of impaired mentation,

confinement in a burning environment, explosion with burns to head and

torso and carboxyhaemoglobin level greater than 10%

Burns > 20% BSA (partial thickness and full thickness)

Burns > 10% (partial thickness and full thickness) for patients age > 50

years old

Significant chemical burns (face, chest)

Significant electrical burns (unconscious, chest pain, shock, history of

altered conscious level) including lightning injury

Overdose with hypotension / unconscious

Abdominal aortic aneurysm

All acute myocardial infarction or high risk unstable angina (ECG changes:





No. Kajisemula R00

ST depression, T wave inversion, pulmonary oedema or cardiogenic shock)

Hypersensitivity reaction involving 2 or more systems

Chest pain related to pulmonary embolism or aortic dissection

GI bleed and hemodynamically unstable

Vaginal bleed and hemodynamically unstable

Severe sepsis (SIRS + evidence of infection + evidence of hypoperfusion

+/- hypotension responding to fluids)

Patient may present with either one/ collection of the Sign and

symptoms below

o Fever

o Lethargy or generalized weakness

o Delirium and confusion

o Shorness of breath

Risk factors for sepsis

o Immunocompromised

o Diabetes mellitus

o Indwelling medical device

o Recent surgery/invasive procedure

o Ambulance personnel pass over as sepsis

o Alcohol or substance abuse

o Chronic disease (heart, lungs, kidney, liver)

o Hematological disorders

Vital signs ( either one )

o RR < 10 or > 25/min

o SPO2 < 95%

o SBP < 90 mmHg and HR > 120/min

o GCS < or = 13

o Lactate > or = 4 mmol/L

o BE < -5

Look for Signs of hypoperfusion (either one)

o Altered mental status

o Narrow pulse pressure

o Tachycardia

o Hypotension

o Poor capillary refill time

o High lactate (> or = 4) – if result available





No. Kajisemula R00

o Acidosis – if results available

Hypoglycaemia

Spinal cord injury

Ectopic pregnancy

Diabetic ketoacidosis

Dextrostix high with CNS involvement

Blood pressure of 220 / 130 with symptoms of target organ failure:

hypertensive encephalopathy, CVA, heart failure, ACS, acute renal failure,

ecclampsia, preeclampsia, HELLP syndrome and MAHA.

Symptomatic bradycardia (pulse rate < 60/min with either chest pain,

blackouts, heart failure or hemodynamic unstable)

Bilateral fracture femur

Hemodynamic unstable fracture pelvis

Total amputation or near total amputation of a limb

Near drowning

Vascular injuries

Narrow complex or broad complex tachy arrhythmias

Acute ischemic limb

Massive hemoptysis

Crush injury of the upper and lower limbs

Emergency childbirth

Antepartum hemorrhage

Violent patient

2

Poisoning or drug overdoses cases with stable BP and GCS > 13

Shortness of breath < 25/min and SPO2 > 95%

Hyperventilation syndrome

BP of < 220/120 without symptoms

Drug withdrawal

High grade fever > 38°C, toxic looking, dehydrated but hemodynamically

stable

Sepsis with no evidence of hypoperfusion

o Other patients that didn’t fulfill the red zone criteria

o ABG has to be done (lactate or BE) to ensure patient is not in the

red zone criteria

o Sepsis shouldn’t go to green zone





No. Kajisemula R00

Abdominal pain (age > 50) with visceral symptoms

CVA with major deficit with GCS > 13

Vomiting +/- diarrhea (with suspicion of dehydration)

Mild head injury (GCS > 13)

Trauma patients with unequal pupils with GCS of 15/15

Stable spinal fracture

Stable pelvic fracture

Trauma patients with lower limb fracture but stable

- Tibia fibula fracture

- Femur fracture

Dislocation with inability to walk : knee

Shoulder dislocation with neurological deficit

Upper limb fractures with compartment syndrome

Second degree burns of < 20% BSA

Chemical exposure to the eye

Unspecified drug / medicinal overdose

Appendicitis / cholecystitis

Keratitis, iritis

Head injury: alert but vomiting

Open/close single long bone fracture and hemodynamically stable

Ankle fractures

Moderate asthma (any patients come to emergency department with

asthmatic attack is at least a moderate asthma)

GI bleed with normal vital signs

Post-seizure, alert on arrival

Pain scale 8-10 with minor injuries

Pain scale 4-10 from headache, CVA or backache, renal colic, eye,

abdominal

CA patients: toxic looking and dehydrated

Severe epistaxis

Patient unable to walk (trolley patients)

Chest pain: no visceral symptoms, no previous heart disease

Elbow dislocation

Chronic ischaemic limb

Acute abdomen with stable hemodynamic parameters

Torsion of the testis





No. Kajisemula R00

Dialysis problems

3

G1. Fastrack: (to be seen in less than 20 minutes)

Senior citizen more than 65 years

Acute back pain with pain score less than 4

Acute flank pain with pain score less than 4

Shoulder dislocation without neurological deficit

OSCC case: INSAN, battered or child abuse

Upper limb fractures without compartment syndrome

High glucose-stix but asymptomatic

Bleeding per-vaginal but hemodynamically stable

Jaw dislocation

Cerebral concussion: history of Loss Of Consciuosness +/- Post Traumatic

Amnesia but alert and conscious

Chest pain after minor trauma. Not in distress.

Pain score 4-7

Psychotic patient

Suicidal patient

Needle prick injury

G2. Patients requiring initial management or first aid before seeing a doctor

All patients requiring catheterization (acute urinary retention)

All patients with abrasion wound/s

All patients with laceration wounds (no active bleed after first aid)

All patients for pressure bandaging

POP complication

Moderate bleeding but stable and need dressing

Partial thickness burn adults < 10%

Fracture clavicle

G3. Patients who can wait





No. Kajisemula R00

Earache

Vomiting and diarrhoea. No dehydration.

Allergic reaction (minor: urticaria)

Corneal foreign body

Chronic back pain

Chronic abdominal pain

Ankle sprain

Gastro esophageal reflux

Depression

Pain score< 4

Nail prick

Diarrhoea alone (no dehydration)

Vomiting alone (normal mental status)

Dysphagia

Infected episiotomy

UTI

Foreign body in throat with no airway compromise

Hyperventilation and able to walk

Features of acute tonsillitis (sore throat, cough with T>38°C)

Suspected dengue fever with no hemodynamic compromise

4

Can be seen at outpatient or charge as T4

All trauma patients with prolonged history (>6months)

Skin disease except: Steven-Johnson syndrome, exfoliating dermatitis

Sore throat and running nose with T< 38°C

Extension of medication prescription

Missed appointment

Extension of MC (medical certificate)

Menses

Dressing changes

Cast changes





No. Kajisemula R00

Constipation

Hoarseness of voice

Stuffy nose

Vaginal discharge

Vaginal itchiness

Infertility

Pregnancy test

Ulcer or skin problem in the groin

Chronic insomnia

Assessment of IQ





No. Kajisemula R00

TRIAGE ASSESSMENT.

The features used to assess urgency are generally a combination of the

i. Presenting problem

ii. General appearance

iii. Psychological observation.

The triage assessment should not take more than 2 to 5 minutes to determine the

urgency and immediate care needed. There must be a balance between speed and

thoroughness. Vital signs for assessment should only be measured for T3 category

during the secondary Triage to determine the urgency and to fast track cases or

upgrade the triage to T1 or T2.

In sepsis during assessment at Secondary Triage look for

o Skin: cellulitis, wound

o Urine: dysuria, frequency, odour

o Abdomen: pain, peritonism

o Chest: cough, SOB

o Neuro: decreased mental alertness, neck stiffness, headache

– Vital signs: has 2 or > of the following:

• RR < 10 or > 20/min

• SPO2 < 95%

• SBP < 100mmHg

• PR > 90/min

• Altered level of consciousness

• T > 38°C or < 36°C

Sepsis should not go to Triage 3 ( Consultation )





No. Kajisemula R00

TRIAGE SKILLS

Requires communication skills

- Listening

- Using senses

- Sight

- Touch

- Smell

- Sound

Chief complaint: patient’s statement of the problem

How do you triage?

Ask simple but straight questions

i. What happened ?

ii. When did it start? ( be exact with time )

iii. What were you doing when it started?

iv. How long did it last?

v. Does it come and go?

vi. Is it still present?

vii. Where is the problem? Describe character and severity if painful (PAIN

SCORE).

viii. Radiation?

ix. Aggravating or alleviating factors?

x. If pain is was present: Character and intensity (PAIN SCORE) to be

documented.

xi. Previous history of same? If yes, what was the diagnosis?

Perform a quick physical examination by look, listen, feel and move technique

i. Physical appearance - color, skin , activities.

ii. Degree of distress - severe, no acute distress

iii. Emotional response - anxious , indifferent.





No. Kajisemula R00

Complete vital signs and physical assessment to be done at the secondary

Triage.

Additional Information.

i. Allergies

ii. Medications ( List if available )

iii. LMP ( Last Menstrual Period) - Gestation





No. Kajisemula R00

TRIAGE GUIDELINES

The triage officer should have rapid access or be in view of the registration and

waiting areas at all times

i. Greet the patient and family in a warm empathetic manner.

ii. Perform a brief visual assessment.

iii. Document the assessment.

iv. Give a triage acuity using appropriate guidelines.

v. Move patient to the respective treatment area.

vi. Pass over the case for T1 and T2 cases to the AMO / nurse in charge

or emergency physician.

vii. Keep family and relatives aware of the delays

viii. Reassess the patient if waiting too long (secondary triage)

ix. Instruct relatives to inform the Triage officer if there is any change in

patient condition.

Triage is not a static process. It is important to remember that triage is a dynamic

process and patients may move up or down during reassessment. Effective triage

requires the use of senses of SIGHT, HEARING, SMELL AND TOUCH. There may

be many non verbal clues: facial grimaces, cyanosis, fear . Always listen to what the

patient is saying and pay attention to questions they are reluctant or unable to

answer . Touch the patient, assess the heart rate and skin temperature. Notice

odours such as ketones, alcohol or infection.

Remember, the purpose of triage is to gather enough information to make a

clinical judgment for priority care, not a final medical diagnosis. Do not

prejudge patients based on appearance or attitude

SPECIAL CONSIDERATIONS

No patient that has been triaged to a treatment area can be downgraded

without prior seen by an Emergency Physician.

All upgraded patient must be accepted, managed and can only be downgraded

by an Emergency Physician.





No. Kajisemula R00

TRIAGE OFFICER QUALITIES.

A Triage Officer should be experienced and knowledgeable, able to act fast and

should also have

i. Excellent communication skills

ii. Strong clinical judgment skills

iii. Organizational skills – patient line ups, inquiries (constantly under

scrutiny)

iv. Extensive Emergency clinical skills

The UMMC Triage Scale is a scale for rating clinical urgency designed for use at

UMMC. The scale directly relates triage category with a range of outcome measures

(in patient length of stay, ICU admission, mortality rate) and resource consumption

(staff, time , cost). It provides an opportunity for analysis of a number of performance

parameters in the emergency department





No. Kajisemula R00

Patient arrives in T+K

Primary Triage

(Nurse/AMO)

Is patient critical ? Is patient semi critical ? Is patient Is patient non

non urgent ? emergency ?

Yes Yes Yes Yes

RED YELLOW GREEN BLUE

Direct patient to

RUKA /GP or other

outpatient service

or charge as T4

Resuscitation and Stabilization

Secondary triage

(Nurse/AMO)

Duties:

NIBP, PR, RR, T, SpO2 ,

Pain score,

Complete registration (Clerk) ECG for all low risk chest pain

First Aid, Bandaging

Complete registration

(Clerk)

Continuous monitoring of

patients in green zone

(CONSULTATION)





No. Kajisemula R00

Abbreviations:

T+K: Trauma dan Kecemasan

AMO: Assistant Medical Officer

RUKA: Rawatan Utama Kesihatan Awam

GP: General Practice

NIBP: Non Invasive Blood Pressure

PR: Pulse Rate

RR: Respiratory rate

T: Temperature

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