From the French word trier, literally means: to sort. The aim is to bring the greatest good to the greatest number of people this is achieved through prioritizing limited resources to achieve the greatest possible benefit. Is a method of ranking sick or injured people according to the severity of their sickness or injury in order to ensure that medical and nursing staff facilities are used most efficiently

Patients are sorted with a scientific triage scale in order of urgency - the end result is that the patient with the greatest need is helped first.

Common Types of Triage

ED Triage: Used daily to prioritize patient assessment and treatment in the emergency department during routine functioning. Priority is given to those most in need. Resources are not rationed.

Inpatient Triage: Applied day-to-day in a variety of medical settings, such as the ICU, medical imaging, surgery, and outpatient areas, to allocate scarce resources. Priority is given to those most in need based upon medical criteria. Resources are rarely rationed.

Incident Triage: Used in multiple casualty incidents such as bus accidents, fires, or airline accidents to prioritize the evacuation and treatment of patients. These events place significant stress on local resources but do not overwhelm them. Resources are rarely rationed, and most patients receive maximal treatment.

Military Triage: Used on the battlefield, modern military triage protocols most reflect the original concept of triage and include many of the same principles. Resources are rationed when their supply is threatened.

Disaster Triage: Used in mass casualty incidents that overwhelms local and regional healthcare systems. Disaster triage protocols both prioritize salvageable patients for treatment and ration resources to ensure the greatest good for the greatest number.

  • Patient to triage: when a patient appears relatively stable and is able to mobilize him/herself to the designated triage area. This will be the type of triage used in most of the cases.
  • Triage to patient: here the patient is usually unstable. The patient is unable to mobilize him/herself to the designated triage area and should be transfered directly to the resuscitation room. Triage should be performed at the bedside and documented in retrospect. This type of triage will be used less often.

Benefits of Triage

The aim of an efficient triage system is

a. To expedite the delivery of time-critical treatment for patients with life-threatening conditions,
b. To ensure that all people requiring emergency care are appropriately categorized according to their clinical condition,
c. To improve patient flow
d. To improve patient satisfaction
e. To decrease the patient's overall length of stay
f. To facilitate streaming of less urgent patients
g. To be user-friendly for all levels of health care professionals.

Triage Nurse

The Triage Nurse works in the hospital setting, most often in the Emergency Room. It is the responsibility of these men and women to quickly and accurately assess a patient's condition and determine that patient's priority for treatment. Strong evaluation ability, quick and decisive judgment, and the ability to keep a cool head are all necessary skills needed to be a successful Triage Nurse.

Triage is the first point of clinical contact for all people presenting to the Emergency Department and the point at which care begins.

Triage is a brief clinical assessment that determines the clinical urgency of the patient's presenting problem and culminates with the allocation of an emergency category, which determines the time and sequence in which they are going to be seen.

Minimum Standards for the Triage Practice and the Triage Environment

Standard 1: Triage Clinical Practice

The Role of the Triage Nurse is to:

  1. Undertake patient assessment and allocate the Triage Score category based on;

a. Findings of the primary survey
b. Risk assessment

  1. Initiate appropriate nursing interventions and organizational guidelines (e.g.

    • First aid and emergency interventions to improve patient outcomes and
    • Secure the safety of patients and staff of the department;

  1. Ensure continuous reassessment and management of patients who remain in the waiting room appropriate with their condition and time frames
  2. Provide patient and public education where appropriate to facilitate

A. Health promotion and education
B. Injury prevention
C. Community information resource and

  1. Act as the liaison for members of the public and other health care


Standard 3: Equipment and Environment

The triage environment must provide safety for the public, the triage nurse, staff and patients of the Emergency Department and the hospital. The environment:

a. Must be immediately accessible and well sign posted
b. Must have access to an area for patient examination and primary treatment
c. Must be designed to maximize the safety of the triage nurse, staff and patients (e.g. threat alarms, access to security personnel)
d. Must be equipped with emergency equipment (air way equipment, Gloves, face masks & other barrier protective devices, mercury Thermometer, Electronic/ manual blood pressure & pulse analyze Pulse oximetry, ECG, Dry dressings/ bandages, Finger prick Glucotest & finger prick hemoglobin, Urine dipsticks & urine Pregnancy tests )
e. Must enable care to be provided with due regard to standard and additional Precautions for infection control and prevention
f. Should enable and facilitate patient privacy

Triage scale(TS) or Emergent Severity Index (ESI)

ESI 1- (RED) Immediately life threatening ----Resuscitation

EG. Patients with ABC instability, Respiratory, facial, neck, chest injuries, severe hemorrhage, neck injuries, unstable vital signs (shock), coma with airway obstruction, severe respiratory distress, convulsions, chest pain with unstable VS, Severe GI bleeding

ESI 2 - (orange) Emergent imminently/potentially life threatening if care is not given within 15-30min ( pending respiratory failure, altered consciousness without airway obstruction, moderate trauma with stable vital signs, such patients require frequent re-triage until they are seen by the physician and they are the second priority following the red and if any deterioration appears they may be re-categorized accordingly

ESI 3 (Yellow)- less urgent potentially serious, could be delayed up to 1hr. Eg. Injuries to the Lower genitourinary tract, peripheral nerves and vessels, splinted fractures, soft tissue lesions, they also require re- triaging until they are assessed by the physician and if any deterioration appears they might be re-categorized accordingly

ESI 4 (Green) non urgent, can be send to nearby health institution, regular OPDs, after counseling or 1st aid

ESI 5 (BLACK/Blue) Dead

Organization and Sequence of Patient Evaluation (Triage)

  1. The triage nurse should be available at the triage area at all times
  2. The triage nurse should organize her/his working area with necessary supplies before the start of her/his shift
  3. The triage nurse needs to be attentive to pick up the critical patient on arrival
  4. All unconscious patients should be evaluated for ABCD before any history and vital signs taken
  5. Critical patients can be transferred immediately to the resuscitation area while the triage nurses can do their triage documentation at bed side
  6. Whenever >5 patients are coming to the ER the coordinator should assign more than one triage personnel
  7. Whenever critical patient or injured patient is evaluated complete undressing is important to minimize pitfall
  8. During assessment/triage of critical patients conduct primary assessment which includes: ABCD, vital signs, short history about the course of illness or mechanism of injury (see primary assessment)

Last modified: Monday, 21 November 2016, 8:14 AM