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The Origins of Triage +
Use of the ATS
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Jane Bebbington
Senior Lecturer, The University of Auckland
Nurse Educator, Auckland City Hospital
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• Introduce myself
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• Apologies - “I am an ED nurse” – have done
both paeds & adult (but out of date with
paeds)
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• My work setting might be very different to
yours – size / resources
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Function of Triage
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• to ensure pts are treated in order of clinical
urgency + treatment is appropriately timed
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• allocation to most appropriate assessment +
treatment area
(+ contributes information that helps to
describe departmental casemix)
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• urgency refers to need for time-critical
intervention - not synonymous with severity
(ACEM, 2005)
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1
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Triage … origins of the word
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French verb ‘trier’ - picker or sorter
Triage differentiated between high + low quality
products
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In 1820s French coffee beans were sorted into
three grades (Mezza, 1998):
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- best quality
- middling
- triage
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Military Origins
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• Roman Wars
• Baron Dominique Jean Larrey (1766-1842)
• WW I - resource availability / rationing (NATO, 1975)
• WW II
• Korea - “greatest good for the greatest number”
• Vietnam - staging options - “good for everyone”
• Military Hospitals
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Triage in NZ Emergency Departments
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Increasing use of emergency departments for urgent + non
urgent problems
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Ipswich, NTS (Fitzgerald, 2000)
The Healthcare Standards - all NZ EDs must use NTS + “that
all pts must be subject to triage on arrival” (1994, p. A&E1)
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NTS replaced with Australian Triage Scale
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2000 - Australasian Triage Scale (last updated Nov 2005)
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Use of ATS (2005)
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• Use combination of presenting problem + general
appearance (+/- physiological observations)
• Takes no longer than 2 - 5 mins
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• Obtain enough info to determine urgency +
immediate care needs
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• Balance speed / thoroughness
• Triage not intended to make a diagnosis, although
this may be possible
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• Vital signs only if needed to estimate urgency, - time
permits
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Safety
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Encounter whole spectrum of acute illness, injury,
mental health problems & challenging behaviour
may present there
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Aims - safety of:
- patient
- myself
- staff
- department
- organisation (Bebbington, 2000)
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Stop the clock
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• Usually it is "Time seen by doctor“
• Can be nursing staff acting under clinical
supervision (of a dr) - "Time seen by nurse“
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• If there is a documented, clinical pathway,
protocol, or guideline approved by Director of
Emergency Medicine - time of contact between pt
& staff implementing pathway
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• Emergency nurse practitioner …. In the future ..
Will be able to stop the clock without any medical
involvement
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3
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Documentation stds
•
•
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•
•
•
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•
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Date / time of assessment
Name of triager
Chief presenting problem(s)
Limited, relevant history
Relevant assessment findings
Allocated initial triage category
Retriage category / time & reason
Placement area
Any diagnostics, first aid or treatment
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(ACEM, 2005)
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Paeds
Same stds for triage apply to all ED settings where
children are seen
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All 5 triage categories should be used in all settings
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Children should still be triaged according to objective
clinical urgency
(ACEM, 2005)
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4
ATS
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ATS 1
Immediate
ATS 2
Within 10 minutes
ATS 3
Within 30 minutes
ATS 4
Within 60 minutes
ATS 5
Within 120 minutes
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ATS 1
Response
Immediate
simultaneous
assessment &
treatment
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Description
Immediately Life-Threatening
Conditions = threats to life (or
imminent risk of deterioration) &
require immediate aggressive
intervention
What are some clinical
descriptors for triage category 1?
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Clinical descriptors
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Cardiac arrest
Respiratory arrest
Immediate risk to airway - impending arrest
Respiratory rate <10/min
Extreme respiratory distress
BP< 80 (adult) or severely shocked child/infant
Unresponsive or responds to pain only (GCS < 9)
Ongoing/prolonged seizure
IV overdose & unresponsive or hypoventilation
Severe behavioural disorder with immediate threat of
dangerous violence
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5
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ATS 2
Response
Description
Assessment &
treatment within
10 mins (often
simultaneous)
Imminently life-threatening
condition is serious enough /
deteriorating with potential
threat to life, or organ system
failure
Or
Important time-critical treatment
e.g. thrombolysis / antidote
Or
Very severe pain
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What are some clinical descriptors
for triage category 2 ?
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Clinical descriptors
Airway risk e.g. stridor / drooling
Severe respiratory distress
Circulatory compromise
Clammy / mottled skin, poor perfusion
HR< 50 or >150 (adult)
Hypotension with symptoms
Severe blood loss
Shocked child / infant
Chest pain (likely cardiac nature)
Very severe pain
BSL < 3 mmol
Drowsy, decreased responsiveness (GCS< 13)
Acute hemiparesis / dysphasia
? Meningococcaemia
continued
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Fever with signs of lethargy (any age)
Acid or alkali splash to eye
Major multi trauma
Severe localised trauma - major fracture,
amputation
High Risk Hx
Significant sedative or other toxic ingestion
Significant/dangerous envenomation
Severe pain suggesting PE / AAA / ectopic
Behavioural/Psychiatric:
violent or aggressive
immediate threat to self or others
requires or has required restraint
severe agitation or aggression
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ATS 3
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Description
Response
Assessment &
treatment start
within 30 mins
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Potentially life threatening
condition may progress to
life / limb threatening or
lead to morbidity
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Situational Urgency
i.e. potential for adverse
outcome
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Severe pain / distress
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What are some clinical descriptors
for triage category 3 ?
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Clinical descriptors
Severe hypertension
Moderately severe blood loss
Mod SOB
SAO2 90 – 95%
BSL > 16
Seizure now alert
Fever if immunosuppressed
Persistent vomiting
Dehydration
HI with LOC now alert
Moderate pain
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continued
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Chest pain – likely non cardiac
Abdo pain without high risk features
Mod limb injury – deformity / severe crush / laceration
Limb – altered sensation, acute loss of pulse
Trauma – high risk Hx, no other high risk features
Stable neonate
Child at risk abuse / ?NAI
Behavioural / Psych (NB these do not match NZ MOH
Mental heath triage guidelines)
Very distressed / risk of self harm
Acutely psychotic
Deliberate self harm
Agitated / withdrawn
Potentially aggressive
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ATS 4
Description
Response
Assessment &
treatment start within
60 mins
What are some clinical
descriptors for triage
category 4 ?
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Potentially serious
i.e. condition may
deteriorate or may have
adverse outcome or
symptoms moderate or
prolonged
Situational urgency
i.e. potential for adverse
outcome
Significant complexity or severity
Humane practice
relief of discomfort or
distress within 60 mins
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Clinical descriptors
Mild haemorrhage
FB aspiration
Chest injury without rib pain / resp distress
Difficulty swallowing – nil resp distress
Minor HI – no loss of consciousness
Moderate pain
Eye inflammation / FB – normal vision
Minor limb trauma – sprain, ?#, uncomplicated laceration –
normal VS’s / minor – mod pain
Non specific abdo pain
Behavioural / psych
Semi urgent mental health prob
Under obs & no risk to self / others
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ATS 5
Response
Description
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Assessment &
treatment within
120 mins
Less urgent
Chronic or minor –
outcome not affected if
treatment delayed 2 hours
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Clinico-administrative
results review, med certs,
prescriptions
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What are some clinical descriptors
for triage category 5 ?
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Clinical descriptors
Minimal pain – no high risk features
Low risk Hx, asymptomatic
Minor symptoms existing stable illness
Minor symptoms of low risk conditions
Minor wounds – not requiring sutures
Scheduled visit eg wound review
Immunisation
Behavioural / psych
Known with chronic symptoms
Social crisis, clinically well
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See ACEM - Infocentre, Policies and Guidelines
Policy document ATS; Guidelines for implementation of
the ATS
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Case scenarios
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• 22 yr female, abdo pain 2 hours, R) lower
quadrant, constant, LMP ? 6/52 (unsure as often
irregular), HR 110, a bit pallid
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• What triage cat do you give her?
• Why?
• What factors may make her triage category higher
or lower?
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•
•
•
•
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42 yr old female
Brought in by partner
Following ingestion of 45 paracetamol tabs 35 mins ago
alert and orientated
Regretful of taking tabs, and does not want to cause you
any more work ..v apologetic
• What are your considerations in making the triage
decision?
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• 77 year old male, presents with a 2 cm lac to
forehead, states he slipped on the stairs
• Nil other questions were asked but in order to
triage this man …..
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• What other information do you need?
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•
•
•
•
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His GCS is 15
He was KO’d
He does not have c spine pain
He also has some tenderness in his left wrist, nil other
pain noted
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• On further questioning it is not clear if he did fall - he
may have collapsed
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• What triage category will you allocate?
• What factors might make you allocate a higher or lower
triage category?
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• 22 yr old female
• Presents with neck pain
• states turned to use telephone and became aware of v
acute neck pain
• Now complaining of severe neck pain, headache
• Feeling very unwell
• What other info do you require to triage this woman
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•
•
•
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•
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Woman
Febrile … temp 38.3
Hot and miserable
Headache is v severe
doesn’t like bright light
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• Now how would you triage her??
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• 44 yr old male, recent RTI
• C/O chest pain, left sided, localised, describes
the pain as “cutting”, worse on coughing &
movement
• On examination P 96, RR 18, to touch warm
but not hot
• What triage category will you allocate?
• What factors might make you allocate a
higher or lower category?
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• 10 year old male, has fallen from his
skateboard
• OE obvious dinner fork deformity right wrist
• Not KO’d
• Nil other injuries
• States it is very sore when he moves it
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• What triage category will you allocate?
• What factors might result in a higher or lower
category?
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What factors would impact on the ability of your work
setting to have a formal triage system?
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(Include telephone triage)
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What could be some possible solutions?
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