T-R-I-A-G-E

originates from the French word ´trierµ,

which means to sort out or choose

a universal term applied to methods of

allocating treatment prioritizations for
casualties from disasters or in warfare
helps a medical team to treat urgently
casualties to defer those whose treatment is
less urgent and to provide care and
comfort for those with fatal injuries.

determined who should be transferred to

medical facilities and who were critically
injured with little chance of survival.


tosort out casualties on the battlefields for the primary
purpose of providing quick treatment to soldiers who
could return to battle

Military Classification of Triage:

Minimal care: little or no treatment is required; minor injuries

Immediate care: immediate life or limb-saving measures are

required; receives highest priority

Delayed care: treatment is required but the injury is not life or

limb-threatening; treatment can wait for a short period of time

Expectant care: major injuries requiring extensive time and

supplies; these victims would most likely expire even with
immediate treatment.
A. Emergent I

ë requires immediate medical interventions;

potentially life or limb threatening
ë Airway compromise
ë Cardiac arrest
ë Severe shock
ë Cervical spine injury
ë Multisystem trauma
ë Altered LOC
ë Eclampsia
˜. Urgent II
ë patient with stable condition but
requires medical intervention within a
few hours; no immediate threat to life or
limb of these patients
ë Fever
ë Minor burns
ë Minor musculoskeletal injuries
ë Dizziness
ë Lacerations
C. Non-emergent III

ë patients with chronic or minor injuries; no danger

to life or limb by having these patients wait to
be seen; no obvious signs of distress noted
ë Chronic low back pain
ë Routine medical refills
ë Dental problems
ë Missed menses
ëNonprofessional determination of priority of care ²
assessment and prioritization are carried out by the registration
clerk according to how sick the patient appears.

ë˜asic triage ² a quick assessment is done by an RN, LPN, or

physician to ensure that the most seriously ill or injured patients are
treated first; a chief complaint is determined with little or no
collection of other data; little to no documentation is done.

ëComprehensive triage ² assessment and prioritization are

done by an educated, experienced ED RN; standards are
developed and followed for assessment, prioritization, and plan of
care, immediate nursing action, and documentations. This type
utilizes established triage categories.
Experienced in emergency nursing: minimum
of 6 months
Emergency nursing clinical knowledge and
assessment skills; demonstrated clinical
competence
Ability to prioritize appropriately
Leadership skills
Assertiveness
Ability to solve problems
Ability to make quick decisions using good
judgment
Good verbal communications skills
Common sense
Ability to empathize with patients, family, and
colleagues
Ability to act as a patient advocate and
public relations representative
Ability to document accurately and concisely
Organizational skills
High tolerance of stress
˜e aware of arriving patients
Maintain contact with patients in the waiting room
Have a warm and caring manner of all patients
˜e in ongoing communication with the charged nurse
Assigned patient to treatment rooms or notify the
charged nurse of patients who need emergent or
urgent treatment
Demonstrate understanding of patient and family
requests and concerns
Determine priorities of care
Determine how non-emergent patients are brought in
or called into the ED proper for treatment
the triage function must be an important part
of the ED orientation process

a new ED RN should spend at least four shifts

in triage with an experienced RN before being
allowed to triage alone

the nursing staff who will be assigned to the

triage function should attend educational
classes to prepare them for the role
the purpose of triage, rapid assessment and
prioritization of presenting patient problems
according to established standards and
categories or levels of patient acuity, required
documentation, policies, resources, and a
specific triage procedure

should have the authority to decide what

patient is to be brought directly in for treatment
her decision should not be challenged by
peers, because the triage nurse is the initial
assessor of the patient and is the only person
aware of the patient·s degree of illness

must empathize with co-workers and only

bring those patients who require immediate
attention directly into the treatment area
during time of high activity and ED overload
a triage manual should be developed and kept in the
triage area, so that it can be referred to by the triage
nurses at any time

established triage procedure for the individual

hospital
supplies and equipment to be maintained in the
triage area
definitions of category terms
an index of patient complaints or problems with
specific levels of priority; the index makes up most of
the manual.
The patient is greeted by a professional, which helps
establish immediate communication, rapport, and an
appearance of sensitivity to the patient and family
needs. It also enhances the public relations image of
the hospital.

When a nurse has immediate contact with the

patient, patient stress is alleviated.

Initial communication with hospital (or ED) does not

concern insurance or ability to pay.
Treatment of patients requiring immediate care is
expedited by se of an acuity category system.

Immediate assessment and documentation of

patient problems are provided for.

Certain diagnostic procedures and/or treatments

can be initiated without delay.

It
provides for continuous reassessment of patients
waiting in the waiting room.

It provides for continued communication with family

in the waiting room.
Desk
One chair for the triage nurse and one chair
for the patient
Telephone
Intercom to the nurse station
Oral and rectal thermometers
Sphygmomanometer with three cuff sizes:
adult, extra large, child
Ice packs
Splints
˜andages, dressings, tape
˜asins
Irrigating water: a sink if possible
Specimen containers
Phlebotomy supplies
Supplies and fluids for emergency IV infusion
Airways, Ambu bag
Wheelchair
˜ulletin board
Triage forms
ED nursing documentation form
Referral forms
Referral services and agencies
Catchment area lists
˜eeper list
Hospital telephone directory
Triage manual
Computer terminal in EDs with computerized
registration
to ensure prompt evaluation of all patients within
2-3 minutes of their arrival at the ED
all patients are to be assessed within 15 minutes
of arrival
when the number of patients waiting to be
triaged at one time is more than one triage nurse
can manage, an additional nurse to assist
temporarily should be requested
EDs with patient visits over 200 often have more
than one nurse assigned to triage at all times
a list of established hospital or public health
clinics and services should always be available
the triage nurse introduces her- or
himself to the patient

asks about the name, the problem, a

brief history of the presenting problem,
and if he has a private physician
name and sex; race, birth date, and age
assessment: subjective and objective (with
vital signs)
allergies
level of acuity: emergent, urgent or non-
urgent
plan: send directly to the treatment area or
waiting room or what medical service he will
be assigned to
nursing interventions: ice packs, splint,
elevation, cleaning and dressing of a wound;
neuro check; patient teaching; referral
re-evaluation of patient waiting
]˜uschiazzo, L. (1987). The Handbook of
Emergency Nursing Management. Maryland:
Aspen Publisher, Inc.
]Lippincott, J.˜. The Lippincott Manual of Nursing
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Publishers
]˜lack, J.M. & Hawks, J.H. (2004). Medical-
Surgical Nursing: Clinical Management for
Positive Outcomes. 7th Ed., Vol 2. Singapore:
Elsevier Pte. Ltd.
]Macpherson, G. (2002). ˜lack·s Medical
Dictionary. 40th Ed. London: A&C ˜lack Publisher
Limited