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TRIAGE

Lee WallisSenior Lecturer

Division of Emergency Medicine, UCT/SU

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Triage

Background

Cape Triage Group

Cape Triage Score Development

The CTS

Validation South African Triage Score

EWS in children

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Triage

French verb trier

To sieve / to sort

Medically: The process of applying medical priority topatients to do the most for the most

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History of triage

Baron Dominique Jean Larr

Napoleons surgeon

Changed the treatment of injured soldiers

Least injured first, return to war

Little improvement until Vietnam

Military now use standard civilian priorities

Triage common to EDs in West for 20+years

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Triage tools

Discriminators: Demographics

Old or young triaged out

Mechanism of injury Only for trauma

Anatomy Dependent upon examinationtime consuming

Physiology Most reliable

Intended use:

Hospital vs Pre-hospital Day-to-day vs MCI

Trauma vs Other

Adult vs Child

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MCI Pre-hospital triage

Do the most for the most Try to pick out sickest first

Theoretical evidence for leaving these

Easy to learn & use Close to daily practice

Physiologic most common Triage sieve, Triage sort, START, Careflight etc

Paediatric Triage Tape

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MCI Hospital triage

Triage Sort RR 0-4

SBP 0-4

GCS 0-4 Total 0-12

P312

P211

P1 - other

+ Basic Anatomical information

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Daily Pre-hospital triage

Often not done

When done - trauma only

TS, RTS, TRTS, PHI, CRAMS, ACS TTC, etc

ChildrenPTS, adult tools Physiologically incorrect

Most used to identify need for Trauma Centrecare (USA)

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Hospital triage - subjective

Senior doctor or nurse

Front door of unit

Eyeball Gut-feel

Accuracy as low as 35%

Poorly reproducible

24 / 7 coverage

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Hospital triage - objective

MCItriage sort or similar

Day-to-day

Manchester triage, CTS, ATAS, ESI, PTS

Complicated, time consuming, training

implications, senior staff

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Cape Triage Group

Convened Jan 2004

Joint division of Emergency medicine, UCT / SU Jan 2004

32 registrars, 5 waiting posts Dip PEC, MPhil, MSC, MMed / FCEM

Private & Public

Pre-hospital & hospital

Doctors, nurses, paramedics

1 speech therapist.

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CTG: objectives

Saw the need for triage in W Cape (SA)

setting

Develop a tool for hospital EU use

Pre-hospital triage

Not a MCI tool

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CTS: staffing considerations

Country Doctors Nurses Nurse ratio

South Africa 56.3 471.2 1 : 8.0

Canada 229 897 1 : 4.0

UK 164 479 1 : 3.0

Israel 385 613 1 : 1.6

Australia 240 830 1 : 3.4

Doctors and nurses per 100,000 populationper annum for selected countries

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CTS: development

Look at other countries tools

Look at other options

EWS

Derivation phase

Validation phase

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CTS: Priorities

5colours

Red Immediate Orange 10 mins

Yellow 60 mins

Green 4 hours Blue Dead

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CTS: the basics

2 part tool

TEWS

Discriminators

3versions

Adult, Child, Infant

5colours

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CTS: TEWS

Triage Early Warning Score

From MEWSUK ICU outreach program

MEWS reduced ICU admission andmortality / LoS

Minor modifications to adult version =

TEWS

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CTS: adult

TEWS Derivation: from MEWS

Discriminators: committee consensus

Validation

1500 GF Jooste, 2000 Mediclinic, 12,000CHC EUs

2 MPhils

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CTS: child & infant

TEWS Derivation: 1500 healthy school children

4000 injured children RXH TU

Discriminators: committee consensus

Validation 8000 children at CHC EUs

Age, height, weight related vital signs Logistic regression vs neural nets

PhD

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v1.1

MODIFIED EARLY WARNING SCOREScore 3 2 1 0 1 2 3

Pulse 40 41-50 51-100 101-110

111-129

>130

RR 8 9-14 15-20 21-29 >30

Temp 35.0 35.1-37.2

37.3-37.9

38

CNS Confused

Alert Respond tovoice

Respond topain

Unresponsiv

eSysto

BP70 71-80 81-100 101-

199200

RED YELLOW GREEN

MEWS 6 or MEWS 3 5 or MEWS 0 - 2 or

CHEST PAIN or HB < 8 or HB 10Vx 16 or PV bleeding or

HYPOGLYCAEMIA (Vx

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TEWS: Adult

3 2 1 0 1 2 3

Mobility Walking With HelpStretcher/

Immobile

RR less than 9 9-14 15-20 21-29 more than 29

HR less than 41 41-50 51-100 101-110 111-129more than

129

SBP less than 71 7180 81-100 101-199 more than 199

Temp less than 35 35-38.4 38.5 or more

AVPU AlertReacts to

VoiceReacts to Pain

Unresponsiv

e

Trauma No Yes

over 12 years / taller than 150cm

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TEWS: Child

3 2 1 0 1 2 3

Mobility Walking With HelpStretcher/

Immobile

RR less than 15 15-16 17-21 22-26 27 or more

HR less than 60 60-79 80-99 100-129 130 or more

SBP less than 70 70-79 80-130 131-149 150 or more

Temp less than35 35-38.4 38.5 or more

AVPU AlertReacts to

VoiceReacts to Pain

Unresponsiv

e

Trauma No Yes

3 to 12 years old / 96 to 150 cm tall

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TEWS: Infant

3 2 1 0 1 2 3

MobilityNormal for

age

Stretcher/

Immobile

RR less than 20 20-25 26-39 40-49 50 or more

HR less than 70 70-79 80-130 131-159 160 or more

SBP less than 60 60-69 70-110 111 or more

Temp less than 35 35-38.4 38.5 or more

AVPU AlertReacts to

VoiceReacts to Pain

Unresponsiv

e

Trauma No Yes

younger than 3 years / smaller than 95cm

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CTS: step by stepStep 1

Measure vital signs

and document the

findings

Step 2

Take a brief history directed at the main

complaint and document this

Step 3

Calculate the TEWS

and document the

total value

Step 4

Match the score to the list and observe the discriminator list for

issues not picked up by the TEWS

Step 5Document the

triage code

and act

accordingly

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Example

10 year old, electrical burn

Walking (0) RR 24 (1) HR 110 (1) SBP 115

(0) Temp 37 (0) alert (0) trauma (1)

TEWS total = 3

YELLOW

Colour RED ORANGE YELLOW GREEN BLUE

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Discriminators: Adult

TEWS 7 or more 5-6 3-4 0-2 DEAD

Target time to

treatImmediate less than 10 mins less than 60 mins less than 240 mins

Mechanism of

injuryHigh energy transfer

Presentation

Shortness of breath - acute

Coughing blood

Chest pain

Haemorrhage - uncontrolled Haemorrhage - controlled

Seizurecurrent Seizure - post ictal

Focal neurology - acute

Level of consciousness

reduced

Psychosis / Aggression

Threatened limb

Dislocation - other jointDislocation - finger or

toeALL

Fracture - compound Fracture - closed OTHER DEAD

Burn

face / inhalation

Burn over 20%

Burn - other

PATIENTS

Burn - electrical

Burn - circumferential

Burn - chemical

Poisoning / Overdose Abdominal pain

Hypoglycaemia -

glucose less than 3

Diabetic - glucose over

11 & ketonuria

Diabetic - glucose

over 17 (no

ketonuria)

Vomiting - fresh blood Vomiting - persistent

Pregnancy & abdominal

trauma or pain

Pregnancy & trauma

Pregnancy & PV bleed

Pain Severe Moderate Mild

Senior Healthcare Professionals Discretion

Final Triage

ORANGE

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CTS: management aids

Series of management pointers

Including:

Diabetestest glucose

Low tempblankets

Chest painECG

Aimed at ENA

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CTS: benefits

GF Jooste, 4 CHCs:

Reduced waiting times 590 mins mean, to 30 mins red, 60 orange, 400 green

Decreased EU length of stay

Improved patient flow, decreased overcrowding in EU

Reduction in mortality 2% to 0.7% Morbidity?

Improved patient and health provider satisfaction

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CTS: validity

0%

20%

40%

60%

80%

100%

R O Y G B MD

Adult CTS vs disposal

DNW/MD

Home

Referred

Died

0%

20%

40%

60%

80%

100%

R O Y G B MD

Children CTS vs disposal

0%

20%

40%

60%

80%

100%

R O Y G B MD

Infants CTS vs disposal

Overtriage, undertriage

What should a triage toolidentify?

Injury severity

Resource usage

Death / High care / Admission

Urgency of Intervention

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CTS: Implementation

1 Jan roll out W Cape

All EUs

Primary Care

Secondary & tertiary care

DoH funded and supported

Intensive training program Educational materials

Posters, keycards, patient leaflets

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Future developments: CTS

1 year M&E manager

Audits

QA

Performance indicator thresholds

CTS living tool

Modify as needed

Keep same format

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Future developments: SATS

CTS taken on by 4 provinces so far

Call for SA Triage Group

First meet June 2006, Durban

Represent all provinces

Develop a SATS

Based on CTS

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Future developments: EWS

MEWS part of TEWS for in-patient

monitoring

Mortality and morbidity benefit, LoS reduction

Validate child & infant versions

Funding for agegroup specific EWS

from UK