How Triage Works

Triage differs based on the scenario you're in (battlefield, mass casualty incident, regular emergency room), but most of the time it's pretty predictable. Upon arrival in the emergency room (ER) or other urgent care setting, patients are directed to the triage nurse, who greets them and does a quick visual assessment, which is a huge part of the process. If the patient appears really ill, struggles to breathe or is unresponsive he or she will be seen more quickly by a doctor than those who are uncomfortable, but otherwise all right. Triage is also the time for the nurse to obtain necessary patient information, such as the general complaint, medical history, allergies and current medications. Basic vitals also will be collected, including temperature and blood pressure [source: Sacred Heart Healthcare System].

After all of these details are gathered, which generally takes only a few minutes, the nurse will assign a score or code to the patient. The method for this differs between hospitals, but is often a color or number-based system; Dr. Batchelor's team at Children's uses both (see sidebar). The coding system isn't necessarily static, however. A patient's level can change as they go through the process, depending on how their symptoms progress.

It's important to understand that other factors can influence how a patient is sorted. Very young children and people with a history of chronic illness, cancer and other serious issues are at greater risk for complications, so they're often put at the head of the acute care line. That's not to say that people with less urgent issues are absolutely doomed to wait hours upon hours for care. Many urgent care settings feature two "tracks" for patients – one for those who are in severe distress and another for people who can be quickly and efficiently treated, such as those dealing with minor cuts, injuries or treatable illnesses [source: Sacred Heart Healthcare System]. So even though your injury or illness isn't terribly severe, you still have the potential to be seen just as quickly as those who are in bad shape, just by a different team.

Once the triage assessment is made and the code is assigned, the emergency department uses the information to send patients back to the doctors for diagnosis, treatment and possible code change. "It's not the nurse's job to diagnose, but to see, assess and sort," says Batchelor.

Most of us will only experience standard doctor's office or emergency room triage, but the process does adapt to suit a range of other scenarios. As you already know, triage was originally developed for use on battlefields. Tactical Combat Casualty Care methodology uses two major indicators (pulse and mental status determined by a score on the Glasgow Coma Scale) to assign a field triage score (FTS) to help physicians decide which soldiers to treat, and when. Basically, a weak or absent pulse and greatly altered mental state are both predictive of whether or not a person can survive injury, whether they receive immediate care, or not. It might sound harsh, but a 2010 study found that these basic assessments are effective at estimating casualties and helping to assign limited resources to people who can benefit from treatment [source: Eastridge, BJ et al.]. This military-inspired methodology also is used in other emergency triage situations, particularly disasters or other mass casualty events.

Triage in the event of an explosion, major accident or other disaster situation is greatly abbreviated from what patients experience in the doctor's office, and is done by any medical professional working the site. "You have to get them done quickly," says Dr. Batchelor. "Look at the patient, assess them briefly and determine if something needs to be done up front, or can wait a bit." This rapid-fire process is usually accompanied by the use of colored tags and numbers written on the patient to make them easier to spot and assist accordingly.

Trauma triage occurs in a disaster scenario or at the site of a smaller accident, and is typically done several times to keep tabs on the patients' evolving state (when help arrives, before transport to the hospital and upon arrival at the hospital). Several major body functions and other factors are evaluated quickly to assess and classify each patient according to severity. For instance, let's say the doctor examines the patient. Is he breathing? (If the answer is "no," he might be dead, which means no further treatment – important to determine when resources are limited.) If the answer is "yes," what is the respiratory rate? And then, what is the pulse rate? Depending on the answers, the patient might be assigned for immediate treatment; for intervention between the next two to four hours; or perhaps for delayed care [source: Tidy].

The concept of triage is definitely a worthwhile one – help the people who need it the most, while also managing the flow of patients in and out of the emergency department or other triage situation. "From the provider standpoint it gives us a way to see the sicker kids first," says Dr. Batchelor of Children's Healthcare of Atlanta at Scottish Rite. "They need more attention, more time, more tests and more intervention."

By the same token, though, triage can inadvertently upset less critical patients. "Some parents don't understand the process, so they see a kid come in after theirs and get taken back sooner, not realizing that the kid is much sicker," Batchelor explains. "Parents get upset about that." Sometimes, patients in an overcrowded setting who are classified as "less urgent" wind up with lengthy wait times, causing them to become disenchanted and even leave without being seen. Other critics of triage find it unethical to delay treating patients, pointing to the possibility for rapid and unforeseen deterioration.

Many health systems address these concerns by constantly tweaking the process to reduce wait times, especially those with exceptionally high patient volumes. A study conducted at Kaiser Permanent South Sacramento Medical Center employed Lean thinking principles, a Japanese business methodology, to reduce waste and improve efficiency. For instance, under the old system, after the initial triage, the less-sick patients were sent to a separate waiting room where they waited again to be seen by a doctor. Under the new system, for minor injuries, a doctor does the examination in the waiting area or in a small room close by, rather than waiting for an open bed in the main patient area (though patients still have that option to wait for, if they wish.) Researchers found that the LWBS ("left without being seen") rate fell from 4.5 percent to 1.5 percent, and the time to be seen by a physician fell almost in half [source: Murrell et al.].

Although the core practice remains the same, the way triage is done has changed since the days of Napoleon, thanks to improvements in technology, medicine and efficiency. This trend is poised to continue because of the near-constant contributions being made by research and technology. "Telemedicine is coming out, smart phone apps and devices that take vitals will all make an impact," says Batchelor. Napoleon and his chief surgeon may have been visionaries in their own ways, but I doubt either of them could have ever seen that coming!