Emergency department triage. Why and how?

www.smj.org.sa Saudi Med J 2014; Vol. 35 (8) T triage in medicine means sorting of patients according to priorities. It was first used to segregate coffee beans; originally the word came from the French language, from the verb “trier” meaning to sort, sift, pick over.1 It simply means selection of the most serious patients to be attended and treated first, and then to look after the less urgent or serious patients later. History. Triage was used in the battlefields to evacuate injured soldiers and treat them according to their injuries and their ability to return to duty. The initial credit of triaging the patients to civilian hospitals was earned by the trauma centers in United States of America (USA) as they applied the triage criteria to transfer injured patients to a trauma center (level: I/II) in 1986.2 This was followed by Australia,3 where the Australasian College for Emergency Physicians issued a formal triage policy in 1994 with 5 categories, setting a time frame for each level according to patient condition and needs. In 1999, Canada4 developed the Canadian Triage Acuity Scale. The United Kingdom introduced their own triage system in 1996, known as the Manchester triage system.5 In 2003, the USA adopted and designed the emergency severity index (ESI).6 All are 5 category scales. The triage categorization level procedures depend on the patients’ complaints and the vital signs as well as the expertise of the trieur (triage person: nurse/physician/others). It requires education and training. It specifies the time limit until the patients are attended by the emergency physician, but not the time until discharge from the Emergency Department (ED). It also does not allocate the site of care in the ED in relation to the patient priority or the medical responder. Why. In the last century, due to patient overcrowding and case mix, triage has been widely used in civilian hospital EDs to classify patients for management priority to manage life threatening conditions as immediate (first priority), potentially life, or limb threatening patients as emergent (second priority), followed by the less or possibly serious as urgent cases (third priority) and, lastly, the non-urgent patient (fourth priority). The ideal triage system should be simple, and should satisfy the hospital and patients’ needs. It should prove to be sensitive (reliable and valid); namely, priority I/II patients will be admitted to critical care units within the target time frame. How. Every hospital should build its triage system according to the medical services available, and the needs of the community. The following are the steps: 1. Review ED input, through-put, and output, including the average times needed for discharge or admitting the patients (Figure 1). 2. Measure the magnitude of ED load by assessment of the patient load and acuity, to classify the types of patients consuming ED services (Table 1).