TRIAGE PROCEDURE IN EARLY HOSPITAL MANAGEMENT OF PATIENTS IN EMERGENCY CENTRES

Triage (from the French word “trier”, means: “to sort“). is the process of sorting patients into different priorities based upon their degree of illness or injury. Triage Scales are the scientifically developed tools. Triage of patients at the point of entry into the Emergency Centre (EC) allows early identification of the sickest patients. During the implementation of triage scales, the following advantages have repeatedly been observed: • Expedites the delivery of time-critical treatment for life-threatening conditions. • Ensures that all patients are appropriately categorised • Improves patient flow, and decreases overcrowding within the EC • Improves patient and health provider satisfaction • Decreases overall length of stay • Decreases waiting times


Background
Triage (from the French word "trier", means: "to sort").is the process of sorting patients into different priorities based upon their degree of illness or injury.Triage Scales are the scientifically developed tools.Triage of patients at the point of entry into the Emergency Centre (EC) allows early identification of the sickest patients.During the implementation of triage scales, the following advantages have repeatedly been observed: • Expedites the delivery of time-critical treatment for life-threatening conditions.
• Ensures that all patients are appropriately categorised

Green Within 240 minutes (4 hours) Blue
Deceased (two hours) Every emergency center (unit) has to detail the procedure to be followed in triage of emergency cases in each.
The procedure for use of any triage scale has to be detailed in three parts: triage requirements, the stepwise use of a scale and how triage fits into the patient journey.
Success of triage depends upon: • All patients are to be triaged as soon as possible after arrival at a facility • A dedicated triage staff is required at all times Only experienced professionals and EM doctors may have the discretion inherent in the triage scale using in the EC/EU.
A dedicated triage area is required.Such an area requires to be well signed, secure (in easy view of security staff), large enough to accommodate the triage staff and a patient.
The triage area is to contain triage paperwork and all other equipment necessary for vital signs measurement.
Different triage systems are used in emergency centres/units around the world to assess the severity of incoming patients' conditions and assign treatment priorities.Few five-level triage instruments are identified: the Australasian Triage Scale (ATS), the Canadian Triage and Acuity Scale (CTAS), the Manchester Triage System (MTS), and the Emergency Severity Index (ESI), the Cape Triage Scale, etc.(2)

The stepwise use of the triage scores
Adults and all children aged 13 years or older (or taller than 150 cm) are to be triaged using the adult score chart.All children are to be triaged using the paediatric chart.Older children aged between 3 and 12 years (or 96-150 cm tall) are to be triaged with the triage scores for adults, while children under 3 years of age (or smaller than 96 cm) are to be triaged with the score for a younger child.
The procedure: • Measure the vital signs and document the findings: • Calculate the total using score and document the finding using the age appropriate chart.• Match the score to the discriminator list and assign the patient to the higher triage category.• Check the triage additional investigations for further investigations that may assign the patient to a higher triage priority level.• Document the final triage category.
Registration of vital signs alone is not suitable for identification of critically ill patients in the emergency department.Therefore various systems are used internationally to determine initial treatment priorities.Five-level instruments are significantly correlated with resource utilization, rates of admission for inpatient treatment, duration of emergency treatment, and frequency of admissions, transfer to intensive care units, or mortality.(3) Five-level triage instruments: the Australasian Triage Scale (ATS), the Canadian Triage and Acuity Scale (CTAS), the Manchester Triage System (MTS), and the Emergency Severity Index (ESI), the Cape Triage Scale, etc.
• RED patients are to be taken to the resuscitation room without delay and handed over for emergency management • ORANGE patients are to be taken to the majors area and handed over for very urgent management • YELLOW patients are to be handed over for urgent management.
• GREEN patients may be referred for streaming (if this is in place at the EC) or instructed to wait in the waiting room to be seen for routine management.• BLUE patients are to be refer to doctor for certification(4.7) All patients are to be triaged!

Post Triage Care
The duty nurse in charge of the EC must ensure continuous reassessment of those patients who remain waiting and, if the clinical features change, re-triage the patient accordingly.

Quality Assurance
Benchmarks for ECs of similar role delineation will allow comparison between these units.Such benchmarks will include (but are not limited to): patterns of triage category distribution; mortality by triage category; ICU admission by triage category (for Central ECs) or referral rates (for other ECs), and waiting times by triage category.(4,5)

Responsibilities
Each facility head (manager) has to assign a task team to be responsible for the implementation and functioning of triage.This team should consist of at least one doctor and two nurses.
The facility head (manager) is responsible for developing a triage programme and provide the training.(6) The leading scores, used for five-level triage instruments are the MEWS (Medical Early Warning System) and The Triage Early Warning System (TEWS-a physiological score based on the MEWS) (7).• Trauma refers to severe trauma.

Parameters from MEWS
• A patient who has decreased consciousness should be listed as immobile on the mobility scale.

Interpretation
• minimum score: 0 • maximum score: 17 • The higher the score, the more serious the patient's condition.