Those less severely injured could wait for treatment or go to the hospital line if they had transport. The concept of triage was refined during subsequent wars and demonstrated that early assessment, prompt resuscitation and early patient transfer reduced mortality Kennedy et al, More than a century after the publication of his memoirs in , and following many great world wars, civilian healthcare providers realised that such a system of sorting patients could be applied to the non-combat setting.
During the late s and early s, emergency centres ECs began to develop and implement their own versions of a triage system Fry and Burr, Medical staff constructed contextually-based aims and expectations to improve patient flow and safety through innovative triage coding systems using numbers, colours, ribbons, balloons or the alphabet to indicate patient urgency Kennedy et al, In the early days of EC triage, it was performed by a variety of acute care personnel with varying degrees of experience and education George et al, The United States was the first to assign the responsibility of triaging patients to nurses back in the s Fry and Burr, This resulted in the formalisation of emergency triage, which became a sub-specialty within nursing.
By the s, Britain had assigned a dedicated triage nurse to most of its ECs George et al, Australia implemented the role in the late s but restricted the position to business hours with clerical staff performing the role after hours Fry and Burr, During this time, there were no national guidelines for allocating triage codes and nurses learned the role by adopting their departments' norms and expectations Johnson, Since the review of triage literature by Fry and Burr in , there has been a substantial rise in the design, development, and validation of triage systems in the 21 st century.
Current triage systems are mostly based on consensus opinions from expert groups in clinical emergency medicine Moll, Most current triage systems follow a categorically measured acuity scale consisting of three, four or five levels depending on their requirements Parenti et al, Although no universal standard for triage exists, various modern triage systems have evolved to favour the five-level acuity scales. Originally, the concept of three levels was used in warfare situations where casualties could be sorted into either immediate, urgent or non-urgent categories based on how long they could wait to be treated Robertson-Steel, This was the basic principle of how four-and five-level triage systems came into existence.
Civilian EC patient populations can be like in-the-field wartime patient populations in that they also see major trauma. However, civilian EC patient populations also deal with non-traumatic conditions and medical illnesses on a more frequent basis than military populations, depending on the specific environment Kennedy et al, ; Fry and Burr ; Robertson-Steel, This led to the current belief that patient acuity and the urgency by which these patients are attended to are best suited to modern five-level triage systems.
This extended delineation of the original three-level system was purely based on the requirements of ECs to sort patients and assign specific resources. However, which five-level triage system to implement is very dependent on the patient population, setting and overall needs of the EC in managing its patients.
Many modern triage systems include the use of vital sign parameters e. This is accompanied by clinical descriptors; words or expressions used to describe a physiological condition or illness.
These two methods are the most predominant techniques used in modern triage systems. Each system has its own application and weighted distribution techniques to determine acuity. A brief overview of triage system development over the years and across various countries is presented in Table 1.
Australia adopted a five-level triage system called the National Triage Scale NTS with the aim of promoting a standardised approach to triage in Australian ECs between and Fry and Burr, The NTS used clinical algorithms, rather than diagnoses, to aid urgency in decision making Fry and Burr This approach to triage was thought to be capable of allocating the same triage category each time to any patient presenting to any triage nurse, in any EC, at any time of the day, with a specific problem Wollaston et al, However, there was concern regarding the applicability of the system in rural areas and unaccredited ECs Fry and Burr, McClellan may well have been receptive to this idea because he had been one of the official observes the Army had sent to the Crimean War, and would have seen the problems caused by the lack of coordinated care.
It would be re-instituted in September when the entire Army of the Potomac was returned to the command of McClellan, on the way to the battles of South Mountain and Antietam.
Many of the units in the new army had never been trained in the system, so it was only partially effective in these battles. In October , Letterman, with approval from the Surgeon General and the army commander, re-organized medical care, thus creating a medical evacuation system.
Medical care would start with an assistant surgeon and attendant at the edge of the battle who provided the first level of care. Those lightly wounded were sent back to battle and those who could benefit from medical care were sent to the field hospitals located beyond cannon range where urgent care would be given.
Most amputations took place in these field hospitals. Patients would then be sent to brigade hospitals, then on to general hospitals for recuperation and further care. Even though most armies had developed similar evacuation systems, these did not become official until February In World War I, the approach to handling casualties changed again, with the emphasis on helping the largest number of people. It was stated that a single case, even if it urgently required attention, should wait if it would absorb a good deal of time.
In the same time frame a dozen others might be treated. The greatest good for the greatest number of people was the rule. Many supported giving treatment to the less severely injured so that more soldiers could return to duty.
The term should only be used when true mass casualties occur, where the number of casualties is expected to exceed the care facilities available in the area.
This is much more likely to occur in a military situation, although several recent weather-related catastrophes have shown the need for such a system as care facilities are damaged and reduced. Medical triage is not needed when there is no shortage of medical care facilities or when no medical care facilities existed at the start.
The sorting of casualties according to a predetermined scheme, applied throughout all echelons of the system, is essential to its successful operation. The triage officer uses an established plan with specific criteria. Triage planning has already decided the conditions to use based on resources available and such planning, of necessity, involves a certain degree of health care rationing. Adams G.
Barnes J. Bernard C. New York, NY: Bailliere; Bollet A. Civil War Medicine: Challenges and Triumphs. Brinton J. Personal Memoirs of John H. Brinton, Civil War Surgeon, Chisolm J. Crumpler M. Men of Steel: Surgery in the Napoleonic Wars. Shrewsbury, UK: Quillen Press; Cunningham H. Field Medical Services at the Battles of Manassas.
Duncan L. Fromento Jr. Notes and Observations on Army Surgery. New Orleans, LA: L. Marchand; Gillett M. The Army Medical Department Greenleaf C. Philadelphia, PA: Lippincott; Hamilton F.
A Practical Treatise on Fractures and Dislocations. Philadelphia, PA; Iserson K. V, Moskop J. Triage in Medicine. Part I: Concept, History, and Types. Ann Emerg Med ;49 3 Jacquette H. Letterman J. Medical Recollections of the Army of the Potomac. Angetter: Yes. It follows globally uniform standard guidelines, which are also supported by the WHO.
People are judged as critical, stable, or uninjured. Patients who are triaged are given a triage tag, on which the initial diagnosis, therapy and measures are briefly noted. Decisions such as whether to administer infusions or medication to stabilize the circulation must be made very quickly. You have a maximum of one minute per patient —triage should not take longer. If there is a disparity between the availability of emergency services and the number of injured people, the aim is to save as many as possible.
Angetter: With triage, a decision is made based on the severity of the injury. For example, if the ambulance service arrives at the scene of a traffic accident with seven people injured, including an adult with a badly bleeding wound and a child requiring resuscitation, then the adult will be saved first because they have a better chance of survival than the child requiring resuscitation.
Understandably, this causes consternation in the population. But if there is a disparity between the availability of emergency services and the number of injured people, the aim is to save as many as possible. And in this case the needs of the individual have to take a back seat. In times of scarce resources in the corona pandemic, triage comes up when asking who gets the ventilators Angetter: And the intensive care beds. Regardless of the pandemic, intensive care beds are needed. Intensive means that hour monitoring is required.
The patient is attached to devices that immediately emit a tone if, for example, the heart rate drops, or the oxygen saturation is no longer normal. And here the fear is understandably very great, if the new corona infections remain so high, not only that the capacity of the intensive care beds will be exhausted, but also that the nursing staff and doctors will no longer be able to cope with the number of patients. Daniela Angetter is a historian and literary scholar.
Angetter, what is the concept of triage? How did triage come about? The term triage originally comes from military medicine. The historical photo shows the wounded arriving at a triage station in France during the First World War.
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