Editing Triage (section)

== Concepts in triage ==
=== Simple triage ===
Simple triage is usually used in a scene of an accident or "[[mass-casualty incident]]" (MCI), in order to sort patients into those who need critical attention and immediate transport to a secondary or tertiary care facility to survive, those who require low-intensity care to survive, those who are uninjured, and those who are deceased or will be so imminently.<ref>{{cite book | vauthors = Hanfling D, Lang CR | chapter = Chapter 166 - Aircraft Crash Preparedness and Response |date=2006-01-01| title = Disaster Medicine |pages=829–833 | veditors = Ciottone GR, Anderson PD, Der Heide EA, Darling RG  |place=Philadelphia |publisher=Mosby |language=en |isbn=978-0-323-03253-7 }}</ref> In the United States, this most commonly takes the form of the [[Simple triage and rapid treatment|START]] triage model, in Canada, the CTAS model, and in Australia the ATS model.<ref name="Yancey_2023">{{cite book | vauthors = Yancey CC, O'Rourke M | chapter = Emergency Department Triage |date=2023 | chapter-url=http://www.ncbi.nlm.nih.gov/books/NBK557583/ | title = StatPearls |access-date=2023-05-06 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=32491515 }}</ref> Assessment often begins with asking anyone who can walk to walk to a designated area, labeling them the lowest priority, and assessing other patients from there.<ref name="Yancey_2023" /> Upon completion of the initial assessment by the care provider, which is based on the so-called [[ABC (medicine)|ABCDE approach]],<ref name="World Health Organization_2008" /><ref name="Thim_2012">{{cite journal | vauthors = Thim T, Krarup NH, Grove EL, Rohde CV, Løfgren B | title = Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach | journal = International Journal of General Medicine | volume = 5 | pages = 117–121 | date = January 2012 | pmid = 22319249 | pmc = 3273374 | doi = 10.2147/IJGM.S28478 | doi-access = free }}</ref> patients are generally labelled with their available information, including "patient’s name, gender, injuries, interventions, care-provider IDs, casualty triage score, and an easily visible overall triage category".<ref>{{cite book | vauthors = Foley E, Reisner AT | chapter = Chapter 54 - Triage | veditors = Ciottone GR |title=Ciottone's Disaster Medicine | year = 2016 | doi = 10.1016/B978-0-323-28665-7.00054-6 |publisher = Elsevier Inc. |language=en | isbn = 978-0-323-28665-7 | pages = 339–340 }}</ref>

==== ABCDE Assessment ====
{{Main|ABC (medicine)}}

An ABCDE assessment (other variations include ABC,<ref>{{Cite web | vauthors = Schimelpfenig T |title=ABCs of Wilderness Medicine: The Initial Assessment |url=http://blog.nols.edu/2019/07/30/wilderness-medicine-abcs |access-date=2023-05-12 | location = Lander, WY | publisher = National Outdoor Leadership School (NOLS ) | work = blog.nols.edu |language=en-us}}</ref> ABCD,<ref>{{cite journal | vauthors = Livingston EH, Passaro EP | title = Resuscitation. Revival should be the first priority | journal = Postgraduate Medicine | volume = 89 | issue = 1 | pages = 117–20, 122 | date = January 1991 | pmid = 1985304 | doi = 10.1080/00325481.1991.11700789 }}</ref> ABCDEF,<ref>{{Cite book |title=UK Ambulance Services Clinical Practice Guidelines 2013 |publisher=[[National Health Service]] |year=2013 |isbn=9781859593639}}</ref> and many others, including those localized to non-English) is rapid patient assessment designed to check bodily function in order of importance.<ref name="Thim_2012" />
{| class="wikitable"
|+ABCDE Assessment Example<ref name="Thim_2012" />
!Letter
!Term
!Meaning
|-
|A
|Airway
|Checking for airway obstruction
|-
|B
|Breathing
|Checking if the patient is breathing and if the breathing is normal
|-
|C
|Circulation
|Checking to see if the heart rate and capillary refill time is normal
|-
|D
|Disability
|Checking the patient’s alertness, awareness, and response to painful stimuli
|-
|E
|Exposure
|Checking the patient for trauma, bleeding, temperature, and other skin signs
|}

==== Tags ====
{{Main|Triage tag}}
[[File:Triage 041105 big.jpg|thumb|Many triage systems use triage tags with specific formats]]
[[File:ET Light Picture 352 X 240.jpg|thumb|Emergency Triage (E/T) Lights – particularly useful at night or under adverse conditions]]

A [[triage tag]] is a premade label placed on each patient that serves to accomplish several objectives:
* identify the patient.
* bear record of assessment findings.
* identify the priority of the patient's need for medical treatment and transport from the emergency scene.
* track the patients' progress through the triage process.
* identify additional hazards such as contamination.

Triage tags take a variety of forms.  Some countries use a nationally standardized triage tag,<ref>{{cite journal |vauthors=Idoguchi K, Mizobata Y, etal |title=Usefulness of Our Proposed Format of Triage Tag |journal=Journal of Japanese Association for Acute Medicine |volume=17 |issue=5 |pages=183–91 |year=2006 |doi=10.3893/jjaam.17.183 |doi-access=free }}</ref> while in other countries commercially available triage tags are used, which vary by jurisdictional choice.<ref>{{cite journal | vauthors = Nocera A, Garner A | title = Australian disaster triage: a colour maze in the Tower of Babel | journal = The Australian and New Zealand Journal of Surgery | volume = 69 | issue = 8 | pages = 598–602 | date = August 1999 | pmid = 10472919 | doi = 10.1046/j.1440-1622.1999.01643.x | url = http://www.ema.gov.au/www/emaweb/rwpattach.nsf/VAP/(084A3429FD57AC0744737F8EA134BACB)~Australian_disaster_triage.pdf/$file/Australian_disaster_triage.pdf | access-date = 2010-04-12 | url-status = dead | archive-url = https://web.archive.org/web/20110314034438/http://www.ema.gov.au/www/emaweb/rwpattach.nsf/VAP/(084A3429FD57AC0744737F8EA134BACB)~Australian_disaster_triage.pdf/$file/Australian_disaster_triage.pdf | archive-date = 2011-03-14 }}</ref> In some cases, international organizations also have standardized tags, as is the case with [[NATO]].<ref name="United States Marine Corps" /> The most commonly used commercial systems include the METTAG,<ref>{{cite web|url=http://www.mettag.com/|title=METTAG Corporate website|access-date=2008-12-05|archive-date=2019-03-28|archive-url=https://web.archive.org/web/20190328180133/https://www.mettag.com/|url-status=dead}}</ref> the SMARTTAG,<ref>{{cite web|url=http://www.tsgassociates.co.uk/English/Civilian/products/smart_tag.htm|title=Smart Triage Tag | work = TSG Associates Corporate website |access-date=2008-12-05 |url-status=dead |archive-url= https://web.archive.org/web/20081120030204/http://www.tsgassociates.co.uk/English/Civilian/products/smart_tag.htm |archive-date=2008-11-20}}</ref> E/T LIGHT<ref>{{cite web|url = http://www.nationaldefensemagazine.org/archive/2010/December/Pages/MilitaryMedics,FirstRespondersGuidedBySimpleLight.aspx|title = Military Medics, First Responders Guided By Simple Light|date = December 2010| vauthors = Beidel E | work = National Defense |publisher = National Defense Industrial Association | location = Arlington, VA |access-date = 2011-02-03|archive-url = https://web.archive.org/web/20110131074100/http://www.nationaldefensemagazine.org/archive/2010/December/Pages/MilitaryMedics,FirstRespondersGuidedBySimpleLight.aspx|archive-date = 2011-01-31|url-status = dead}}</ref> and the CRUCIFORM systems.<ref>{{cite book | vauthors = Lakha R, Moore T |title=Tolley's handbook of disaster and emergency management |publisher=Elsevier |location=Amsterdam |year=2006 |isbn=978-0-7506-6990-0 }}</ref>  More advanced tagging systems incorporate special markers to indicate whether or not patients have been contaminated by hazardous materials, and also tear off strips for tracking the movement of patients through the process.<ref>{{Cite web |title=Mass Casualty START Triage and the SMART Tag System {{!}} Technical Resources |url=https://asprtracie.hhs.gov/technical-resources/resource/4082/mass-casualty-start-triage-and-the-smart-tag-system |access-date=2023-05-06 | work =  Administration for Strategic Preparedness and Response (ASPR) | publisher = U.S. Department of Health and Human Services }}</ref>

=== Advanced triage ===
{{Hatnote|For classifications, see the specific section for that topic}}

In advanced triage, those with advanced training, such as doctors, nurses and paramedics make further care determinations based on more in-depth assessments, and may make use of advanced diagnostics like [[CT scan]]s.<ref>{{Cite journal | vauthors = Masoumi G |title=Simple and advanced triage in occurrence of natural disasters and examine the role of volunteers |url=https://www.academia.edu/28749033 |journal=International Journal of Current Life Sciences}}</ref> This can also be a form of secondary triage, where the evaluation occurs at a secondary location like a hospital,<ref>{{cite book | vauthors = Haller HL, Wurzer P, Peterlik C, Gabriel C, Cancio LC | chapter = 5 - Burn Management in Disasters and Humanitarian Crises |date=2018-01-01 | title = Total Burn Care | edition = Fifth  |pages=36–49.e2 | veditors = Herndon DN  |publisher=Elsevier |language=en |isbn=978-0-323-47661-4 }}</ref> or after the arrival of more qualified care providers.

=== Reverse triage ===
There are a three primary concepts referred to as reverse triage. The first is concerned with the discharge of patients from hospital often to prepare for an incoming mass casualty.<ref name="Pollaris_2016" /> The second concept of Reverse Triage is utilized for certain conditions such as lightning injuries, where those appearing to be dead may be treated ahead of other patients, as they can typically be resuscitated successfully.<ref name="van Ruler_2022">{{cite journal | vauthors = van Ruler R, Eikendal T, Kooij FO, Tan EC | title = A shocking injury: A clinical review of lightning injuries highlighting pitfalls and a treatment protocol | journal = Injury | volume = 53 | issue = 10 | pages = 3070–3077 | date = October 2022 | pmid = 36038387 | doi = 10.1016/j.injury.2022.08.024 | s2cid = 251661429 | doi-access = free | hdl = 2066/288478 | hdl-access = free }}</ref> The third is the concept of treating the least injured, often to return them to functional capability. This approach originated in the military, where returning combatants to the theatre of war may lead to overall victory (and survivability).<ref name="Pollaris_2016">{{cite journal | vauthors = Pollaris G, Sabbe M | title = Reverse triage: more than just another method | journal = European Journal of Emergency Medicine | volume = 23 | issue = 4 | pages = 240–247 | date = August 2016 | pmid = 26479736 | doi = 10.1097/MEJ.0000000000000339 | s2cid = 23551247 | url = https://lirias.kuleuven.be/handle/123456789/519402 | url-access = subscription }}</ref>

=== Undertriage and overtriage ===
'''Undertriage''' is underestimating the severity of an illness or injury.  An example of this would be categorizing a Priority 1 (Immediate) patient as a Priority 2 (Delayed) or Priority 3 (Minimal). The rate of undertriage generally varies by the location of the triage, with a 2014 review of triage practices in emergency rooms finding that in-hospital undertriaging occurred 34% of the time in the United States,<ref name="Xiang-2014">{{cite journal | vauthors = Xiang H, Wheeler KK, Groner JI, Shi J, Haley KJ | title = Undertriage of major trauma patients in the US emergency departments | journal = The American Journal of Emergency Medicine | volume = 32 | issue = 9 | pages = 997–1004 | date = September 2014 | pmid = 24993680 | doi = 10.1016/j.ajem.2014.05.038 }}</ref> while reviews of pre-hospital triage finding undertriage rates of 14%.<ref>{{cite journal | vauthors = Lokerman RD, Waalwijk JF, van der Sluijs R, Houwert RM, Leenen LP, van Heijl M | title = Evaluating pre-hospital triage and decision-making in patients who died within 30 days post-trauma: A multi-site, multi-center, cohort study | journal = Injury | volume = 53 | issue = 5 | pages = 1699–1706 | date = May 2022 | pmid = 35317915 | doi = 10.1016/j.injury.2022.02.047 | s2cid = 247240059 | doi-access = free }}</ref>

'''Overtriage''' is the overestimating of the severity of an illness or injury.  An example of this would be categorizing a Priority 3 (Minimal) patient as a Priority 2 (Delayed) or Priority 1 (Immediate). Acceptable overtriage rates have been typically up to 50% in an effort to avoid undertriage.  Some studies suggest that overtriage is less likely to occur when triaging is performed by hospital medical teams, rather than paramedics or EMTs.<ref name="Turégano-Fuentes-2008">{{cite journal | vauthors = Turégano-Fuentes F, Pérez-Díaz D, Sanz-Sánchez M, Ortiz Alonso J | title = Overall Asessment of the Response to Terrorist Bombings in Trains, Madrid, 11 March 2004 | journal = European Journal of Trauma and Emergency Surgery | volume = 34 | issue = 5 | pages = 433–441 | date = October 2008 | pmid = 26815987 | doi = 10.1007/s00068-008-8805-2 | s2cid = 13657747 }}</ref>

=== Telephone triage ===
In telephone triage, care providers like [[nurses]] assess symptoms and medical history, and make a care recommendation over the [[phone]].<ref>{{cite journal | vauthors = Wheeler SQ, Greenberg ME, Mahlmeister L, Wolfe N | title = Safety of clinical and non-clinical decision makers in telephone triage: a narrative review | journal = Journal of Telemedicine and Telecare | volume = 21 | issue = 6 | pages = 305–322 | date = September 2015 | pmid = 25761468 | doi = 10.1177/1357633x15571650 | s2cid = 23049229 }}</ref> A review of available literature found that these services provide accurate and safe information about 90% of the time.<ref>{{cite journal | vauthors = Huibers L, Smits M, Renaud V, Giesen P, Wensing M | title = Safety of telephone triage in out-of-hours care: a systematic review | journal = Scandinavian Journal of Primary Health Care | volume = 29 | issue = 4 | pages = 198–209 | date = December 2011 | pmid = 22126218 | pmc = 3308461 | doi = 10.3109/02813432.2011.629150 }}</ref>

=== Palliative care ===
In triage, [[palliative care]] takes on a wider applicability, as some conditions which may be survivable outside of extreme circumstances become unsurvivable due to the nature of a mass casualty incident.<ref>{{cite journal | vauthors = Matzo M, Wilkinson A, Lynn J, Gatto M, Phillips S | title = Palliative care considerations in mass casualty events with scarce resources | journal = Biosecurity and Bioterrorism | volume = 7 | issue = 2 | pages = 199–210 | date = June 2009 | pmid = 19635004 | doi = 10.1089/bsp.2009.0017 }}</ref> For these patients, as well as those who are deemed to be unsavable, palliative care can mean the difference of a painful death, and a relatively peaceful one.<ref name="Arya_2020">{{cite journal | vauthors = Arya A, Buchman S, Gagnon B, Downar J | title = Pandemic palliative care: beyond ventilators and saving lives | journal = CMAJ | volume = 192 | issue = 15 | pages = E400–E404 | date = April 2020 | pmid = 32234725 | doi = 10.1503/cmaj.200465 | pmc = 7162443 }}</ref> During the [[COVID-19 pandemic]] issues of palliative care in triage became more obvious as some countries were forced to deny care to large groups of individuals due to lack of supplies and [[ventilator]]s.<ref name="Arya_2020" /><ref>{{Cite journal | vauthors = Misek R, ((The National Catholic Bioethics Center)) |date=2022 |title=The Injustice of Categorical Exclusions during Triage |url=http://www.pdcnet.org/oom/service?url_ver=Z39.88-2004&rft_val_fmt=&rft.imuse_id=ncbq_2022_0022_0003_0495_0507&svc_id=info:www.pdcnet.org/collection |journal=The National Catholic Bioethics Quarterly |volume=22 |issue=3 |pages=495–507 |doi=10.5840/ncbq202222345 |s2cid=254707340 |issn=1532-5490|url-access=subscription }}</ref>

=== Evacuation ===
In the field, [[Casualty evacuation|evacuation]] of all casualties is the ultimate goal,<ref>{{cite journal | vauthors = Xie T, Liu XR, Chen GL, Qi L, Xu ZY, Liu XD | title = Development and application of triage and medical evacuation system for casualties at sea | journal = Military Medical Research | volume = 1 | issue = 1 | pages = 12 | date = 2014-06-01 | pmid = 25722870 | pmc = 4340638 | doi = 10.1186/2054-9369-1-12 | doi-access = free }}</ref> so that the site of the incident can ultimately be cleared, if necessary investigated, and eventually rendered safe. Additional considerations must be made to avoid overwhelming local resources,<ref>{{cite journal | vauthors = Pinkert M, Lehavi O, Goren OB, Raiter Y, Shamis A, Priel Z, Schwartz D, Goldberg A, Levi Y, Bar-Dayan Y | display-authors = 6 | title = Primary triage, evacuation priorities, and rapid primary distribution between adjacent hospitals--lessons learned from a suicide bomber attack in downtown Tel-Aviv | journal = Prehospital and Disaster Medicine | volume = 23 | issue = 4 | pages = 337–341 | date = August 2008 | pmid = 18935948 | doi = 10.1017/S1049023X00005975 | s2cid = 10929982 }}</ref> and in some extreme cases, this can mean evacuating some patients to other countries.

=== Alternative care facilities ===
Alternative care facilities are places that are set up for the care of large numbers of patients, or are places that could be so set up. Examples include schools, sports stadiums, and large camps that can be prepared and used for the care, feeding, and holding of large numbers of victims of a mass casualty or other type of event.<ref>{{cite web|url=http://www.phac-aspc.gc.ca/publicat/sars-sras/naylor/8-eng.php|title=Chapter 8: Clinical and Public Health Systems Issues Arising from the Outbreak of Sars in Toronto (Public Health Agency of Canada website)|access-date=2008-12-05|date=2004-11-08|archive-url=https://web.archive.org/web/20081206185742/http://www.phac-aspc.gc.ca/publicat/sars-sras/naylor/8-eng.php|archive-date=2008-12-06|url-status=dead}}</ref>  Such improvised facilities are generally developed in cooperation with the local hospital, which sees them as a strategy for creating surge capacity.  While hospitals remain the preferred destination for all patients, during a mass casualty event such improvised facilities may be required in order to divert low-acuity patients away from hospitals in order to prevent the hospitals becoming overwhelmed.