Triage in disaster
In general, triage can be defined as
the prioritization of patient care based on severity of injury/illness,
prognosis, and availability of resources. For those responsible for the triage
of patients arriving in the emergency department, the purpose of triage is to
determine to which predesignated patient care area the patient should be sent.
The location to which patients are "triaged" establishes priorities
for care. For example, some patients may need immediate decontamination as they
arrive, regardless of their severity of injury. Those needing immediate care
(e.g., respiratory failure, shock) are taken to resuscitation areas
("crash" rooms), while the dead are moved directly to the morgue. The
severely but less critically injured are taken to the major trauma–medical area
described earlier, where they are further assessed and initial treatment
commenced. The walking injured are directed to the minor surgery–primary care
treatment area, often located in outpatient clinic areas.
Personnel
A team consisting of a physician
(preferably an emergency physician or a surgeon), an emergency department
nurse, and a medical records or admitting clerk should receive every patient.
In extraordinary situations, several triage teams may be required to handle the
casualty load. The physician performing hospital triage should be acknowledged
as being in command of the triage area, should be clearly identified by a
specially colored vest or other garment, and must understand all triage
options.
If a physician is not available, an
emergency nurse with training in the concepts of casualty triage and disaster
patient assessment can be designated as the triage officer.
Although likely triaged at the scene,
patients should undergo a second process of triage upon arrival at the
hospital, preferably at the ambulance entrance to the emergency department.
Responsibilities of members of the triage team include:
1. Assigning disaster
patients to appropriate treatment areas (e.g., resuscitation room, major
surgical, minor surgical) according to the assessment of their immediate needs
and the availability of resources.
2. Instituting the most basic
of life-support measures, such as inserting oral airways, cardiopulmonary
resuscitation, and the external control of haemorrhage.
Assessment of severity of injury should
be accomplished by conducting a rapid primary survey supplemented by obtaining
prehospital information from the patient or pre-hospital personnel. The triage
team communicates information on number of casualties, severity of injuries,
and the need for additional resources to both the emergency department and the
hospital disaster control center. If phones are tied up, this notification can
be accomplished by using runners, cellular phones, or portable radios.
Likewise, triage personnel need to be informed about the capability of the
various treatment areas (e.g., major and minor surgery) to handle additional
casualties or special problems such as eye injuries or burns. They also need to
know about the establishment and location of patient overflow areas.
The triage physician should also be
aware of the location of a family waiting and public relations area within the
institution, because family, friends, and the media will otherwise attempt to
enter the triage area.
The admitting clerk's role as part of
the triage team is to complete tags, attach them to victims, and retrieve
valuables and clothing for bagging. The admitting clerk then tags the bag and
completes the triage area casualty log.
The approach to patient evaluation and
treatment is quite different under disaster situations resulting in large
numbers of casualties.26 In mass casualty situations, one no longer has the
luxury of concentrating all resources on the management of a single critical
patient. To accomplish the most good for the most number of patients, the
triage team should evaluate all patients arriving at the ED doors and classify
their conditions with regard to severity of injury and need for treatment. Some
principles of medical care must be altered to achieve the best overall result.
There clearly is no role for resuscitation or definitive care at this stage.
Care should be limited to manually opening airways, and controlling external hemorrhage.
The most common triage classification
in the United States still involves assigning patients to one of four
color-coded categories (red, yellow, green, or black), depending on injury
severity and prognosis (Table 6-2). In addition to the nature and urgency of
the patient's systemic condition, triage decisions should be sensitive to
factors affecting prognosis, such as age, general health, and prior physical
condition of the patient, and the qualifications of the responders and
availability of key supplies and equipment.
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