JOHN PAUL N.

TOGADO BSN4 NIGHTINGALE NCM118LME

1. DEFINITION AND EXPLANATION OF TRIAGE IN

EMERGENCY ROOM
The term "triage" originated from the French word "trier" which means "to sort, select, choose". It
has been in use in English since 1727 and it refers to the action of sorting things based on their
quality. In medical settings, triage is the process of sorting patients according to the urgency of
their need for medical attention and the likelihood of benefiting from such care. During mass
casualty events, triage is used to prioritize medical treatment based on the severity of injuries.

The main goals of triage in an emergency room are to prioritize patients based on their medical
urgency, provide prompt and appropriate treatment, assign them to the most suitable care areas to
avoid crowding, continuously evaluate their condition, inform patients and their families about
services, care plans, and wait times, and collect data to help determine the department's overall
acuity and resource requirements.

2. CRITERIA USED FOR TRIAGE

In triage, healthcare professionals prioritize patients based on three crucial criteria: respiration,
circulation, and mental status.

1. Respiration:
Respiration refers to a patient's ability to exchange oxygen and carbon dioxide, which is assessed
by observing their breathing rate, rhythm, and effort.
• Breathing Rate: The number of breaths a patient takes per minute is closely monitored.
Rapid or labored breathing could indicate the patient is experiencing respiratory distress.
• Rhythm: Healthcare professionals assess whether the patient's breathing is regular or
irregular. Regular breathing is consistent and predictable, while irregular breathing is
erratic and unpredictable.
• Effort: Healthcare professionals observe how easy or difficult it is for the patient to
breathe. Struggling to breathe, using accessory muscles, or having retractions (visible
sinking of the chest or ribcage during inhalation) could be a sign of respiratory distress.
Patients with severe respiratory issues, such as acute respiratory failure, severe asthma attacks, or
compromised airways, are considered high priority during triage due to their immediate threat to
oxygenation.

2. Perfusion:
Perfusion refers to the circulation of blood through the body's tissues, delivering oxygen and
nutrients. In triage, perfusion is assessed by evaluating cardiovascular function and circulation.
• Pulse: The strength and regularity of the patient's pulse are examined. Weak or absent
pulses can indicate poor perfusion.
• Skin Color and Temperature: The patient's skin color (pale, cyanotic, or mottled) and
the temperature of the extremities can provide insights into circulation.
• Capillary Refill: This test involves pressing on a nailbed and observing how fast the color
returns after release. Slow capillary refill may suggest impaired perfusion.

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JOHN PAUL N. TOGADO BSN4 NIGHTINGALE NCM118LME

Impaired perfusion is a critical sign of conditions such as shock, bleeding, or cardiac arrest.
Patients with compromised perfusion require immediate triage.

3. Mental Status:
Mental status assessment evaluates a patient's cognitive function and level of consciousness to
determine their alertness, orientation, and ability to respond appropriately.
o Alertness: Assessing if the patient is awake, responsive, and aware of their
surroundings.
o Orientation: Checking whether the patient is oriented to person, place, time, and
situation.
o Glasgow Coma Scale (GCS): A standardized tool used to assess and quantify a
patient's level of consciousness based on eye-opening, verbal response, and motor
responses.
Changes in mental status, such as confusion, disorientation, or a decreased GCS score, may
indicate neurological or other serious medical conditions. Patients with altered mental status often
require prompt evaluation and care.

3. ROLES OF A TRIAGE NURSE:

• Performing a physical examination or conducting an interview on patients admitted to the
emergency department
• Prior to treatment, reviewing a patient's medical history, identifying the patient's symptoms
and degree of disease or injury, and monitoring vital signs
• Patients are prioritized and routed to obtain proper medical care or treatment
• Directing patients to the appropriate location in the health care institution for treatment or
care
• Patients who are awaiting medical attention are being reassessed
• Performing patient evaluations in accordance with standard protocols
• Treating the patient before other health care professionals arrive if their condition is fatal.
• Managing patients who are on the waiting list and notifying doctors and other
healthcare personnel about the status of patients
• Creating queues in order to minimize patient wait times and speed up healthcare service
delivery
• Organizing and arranging patient care services through collaboration with other
departments or healthcare institutions, including transportation services
• Keeping track of patient conditions, treatments, and drugs
• Communicating the plan of action to patients, families, or caregivers

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JOHN PAUL N. TOGADO BSN4 NIGHTINGALE NCM118LME

4. COMMON TRIAGE CATEGORIES

A. PRIMARY TRIAGE
Simple Triage and Rapid Treatment (START Triage)
• Done in the field by a rescue personnel using a quick assessment of respirations, perfusion
and mental status
• Utilizes the standard four triage categories

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Jump START Pediatric MCI Triage

• Jump START provides a rapid triage system specifically designed for children, taking into
consideration their unique physiology

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JOHN PAUL N. TOGADO BSN4 NIGHTINGALE NCM118LME

B. SECONDARY TRIAGE
ENA 5-Level Triage Protocol - used in the hospital setting (emergency department)
LEVEL 1 - RESUSCITATION •This category is critical and the patient’s
condition is life-threatening if not
managed immediately.
• Patients need immediate medical
attention, simultaneous assessment and
interventions.
• Patients’ condition could quickly
deteriorate and will require multiple staff
at the bedside, mobilization of the
resuscitation team, and many resources.
EXAMPLES:
• Severe respiratory distress
• Cardiopulmonary arrest
• Major trauma
• Seizure
• Shock
• Status asthmaticus
LEVEL 2 - EMERGENT • This category is high risk for a patient
waiting for treatment. The patient’s
condition could deteriorate rapidly if
treatment is delayed.
• Patients need quick assessment and rapid
treatment or interventions within 10
minutes. It is unsafe for the patient to wait
longer.
• Patients will require multiple diagnostic
studies or procedures, frequent
consultation with the physician, and
continuous monitoring.
EXAMPLES:
• Cerebrovascular accident
• Chest pain
• Asthma attacks
• Head injuries without other
complications
• Severe abdominal pain
• Decreased level of consciousness
LEVEL 3 - URGENT • This category is moderate risk for a
patient waiting to be seen. The patient’s
condition is stable, but treatment should
be provided as soon as possible to relieve
distress and pain.

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JOHN PAUL N. TOGADO BSN4 NIGHTINGALE NCM118LME

• Patients may wait for up to 30 minutes for

treatment.
• Patients may need multiple diagnostic
studies or procedures and should be
monitored for changes in condition while
waiting.
EXAMPLES:
• Infections
• Moderate pain
• Mild respiratory distress
• Fractures
LEVEL 4 – LESS URGENT • This category is low risk for deterioration
while the patient is waiting. Symptoms
are less severe and the patient can safely
wait for treatment.
• Patients may wait for up to 1 hour for
treatment.
• Patients may need a simple diagnostic
study or procedure.
• The nurse should reassess the waiting
patient, per facility protocol, and provide
comfort measures.
EXAMPLES:
• Chronic back pain
• Ear ache
• Mild headache
• Coughs and colds
• Abscesses
• Sprains
LEVEL 5 – NON-URGENT • This category is a lower risk for further
deterioration while the patient is waiting.
Generally, this category of patient could
be seen in a lower acuity treatment area,
and can safely wait.
• Patients may wait up to 2 hours or longer
for treatment
• Patients’ may need only a simple exam.
• The nurse should reassess the waiting
patient, per facility protocol, and offer
comfort measures.
EXAMPLES:
• Menstrual discomfort
• Non-infectious sore throat
• Tooth ache

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JOHN PAUL N. TOGADO BSN4 NIGHTINGALE NCM118LME

RESOURCES: NOT RESOURCES:

• Laboratory tests: blood, urine • History and physical exam including
• ECG pelvic exam
• X-ray, MRI, CT scan, ultrasound • Heparin lock
• IV fluids (Hydration) • PO medications
• IV, IM or nebulized medications • Tetanus immunizations
• Procedures: catheterization, NGT • Simple wound care
• Crutches, splints or slings

5–TIER TRIAGE

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JOHN PAUL N. TOGADO BSN4 NIGHTINGALE NCM118LME

5. CHALLENGES FACED DURING TRIAGE

1. Rapid and precise assessments are crucial in the high-pressure and often hectic
environment of an emergency department. Triage nurses and doctors must make prompt
assessments to determine the priority of care for patients. This requires a high level of
expertise and composure to make important decisions in fast-paced and unpredictable
conditions. Time is of the essence in emergencies as triage nurses and doctors need to
assess patients promptly.

2. Allocating resources during triage, such as beds, medical staff, and specialized equipment,
is a complex and crucial task. Ensuring that critically ill patients receive prompt medical
attention while preventing overcrowding in the emergency department is of utmost
importance. The responsibility of triage nurses is to make informed and thoughtful
decisions about how to allocate resources, which involves determining where to direct
patients with varying degrees of acuity. This requires a delicate balancing act to ensure that
patients in urgent need of immediate care can receive attention, even when resources are
limited.

3. When patients arrive at a healthcare facility, they may present with a variety of medical
conditions. These conditions may not be immediately apparent, which can complicate the
triage process. The complexity is further exacerbated by the fact that some medical
conditions, such as internal injuries or early-stage illnesses, may not have readily
discernible symptoms, making it difficult to accurately assess and prioritize patients.

4. When healthcare providers and nurses are faced with a scarcity of resources, they are forced
to make difficult decisions about which patients to prioritize. These triage choices can pose
ethical dilemmas and require healthcare professionals to make complex moral judgments.
They must determine who has the highest likelihood of survival or the most urgent need
for care, all while grappling with the profound ethical implications of their choices.

5. In situations where triage nurses and doctors have to make decisions that can change lives,
they often find themselves in situations that are emotionally draining. They are responsible
for prioritizing patients based on their medical needs, rather than when they arrived, which
can be difficult. Healthcare providers must make tough choices that can directly impact
patients' lives while still showing empathy and compassion towards them.

6. Effective communication is crucial in managing patient expectations about the urgency of

their care. Patients and their families may have different perceptions of the severity of a
condition than the triage assessment suggests. This can lead to misunderstandings and
tensions. Triage professionals must approach these situations delicately to ensure that
patients and their families are informed and that expectations are appropriately managed.

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JOHN PAUL N. TOGADO BSN4 NIGHTINGALE NCM118LME

References:
• Balka, Ellen. (2006). Sorting, Sending and Allocating: Indicators as a Secondary Ordering
System in Hospital Triage Work.
• Sapra A, Malik A, Bhandari P. Vital Sign Assessment. [Updated 2023 May 1]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available
from: https://www.ncbi.nlm.nih.gov/books/NBK553213/#
• https://slideplayer.com/slide/8202442/
• https://www.azdhs.gov/documents/preparedness/emergency-
preparedness/conferences/2013/workgroups/clinical/annals-of-emergency-med-june-13-
head-to-head.pdf

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