Triage overview

Definition

Triage is the process of determining the priority of patients for medical care based on the acuity (severity) of their condition and the capacity of the health system to provide appropriate care. The goal of triage is to optimize patient outcomes by ensuring timely assessment and treatment.

Importance of triage

Triage enables rapid identification of patients who require immediate medical attention, helping to reduce delays in treatment and improve patient outcomes.

It also assists in:

• Organizing patient flow

• Monitoring patient status

• Prioritizing care

• Allocating available resources appropriately

• Determining the level of care required

Triage system

The triage system is based on Emergency Medicine experts' basic principles of triage and classifies patients into three levels of acuity.

Emergency (Red)

This category includes patients with immediate life-threatening or limb-threatening conditions who are potentially salvageable but are likely to deteriorate without immediate intervention.

Management

• Move immediately to the resuscitation or high-acuity area.

• Immediate assessment and treatment are required.

Priority (Yellow)

This category includes patients with serious illness or injury who are at risk of deterioration if treatment is delayed.

Management

• Move to the clinical or treatment area.

• The patient should be assessed within 1 hour.

Queue (Green)

This category includes ambulatory patients or those with minor illness or injury who are unlikely to deteriorate while waiting.

Patients should continue to be monitored because their condition may change and require re-triage.

Management

• Move to the low-acuity or waiting area.

• Assess when the next healthcare provider is available.

• Reassess periodically and upgrade the triage category if the patient's condition deteriorates.

High-risk vital signs

Patients with the following abnormal vital signs should be considered for Priority (Yellow) triage if they do not already meet Emergency criteria:

• Heart rate <60 beats/minute or >130 beats/minute

• Respiratory rate <12 breaths/minute or >30 breaths/minute

Emergency criteria (Red)

Assign the patient to the Emergency (Red) category if any of the following are present:

Airway and breathing

• Unresponsive

• Stridor

• SpO₂ <90%

• Respiratory distress

• Cyanosis

Circulation

• Weak pulse

• Capillary refill time >3 seconds

• Heart rate <50 beats/minute or >150 beats/minute

• Heavy bleeding

Neurological emergencies

• Active convulsions

• Hypoglycaemia

Trauma and toxicological emergencies

• High-risk trauma

• Poisoning or dangerous chemical exposure

• Threatened limb

• Snake bite

Behavioural emergencies

• Violent or aggressive patient

Pregnancy-related emergencies

• Heavy vaginal bleeding

• Severe abdominal pain

• Seizures

• Severe headache

• Visual disturbances

• Systolic blood pressure ≥160 mmHg

• Diastolic blood pressure ≥110 mmHg

• Active labour

• Trauma during pregnancy

Paediatric emergencies

• Child younger than 2 years with temperature <36°C or >39°C

• Child younger than 14 years with severe dehydration

Other emergencies

• Adult with signs of meningitis

• Acute chest pain or acute abdominal pain in adults older than 50 years

• ECG showing acute ischaemia

• Other emergency condition (specify)

Priority criteria (Yellow)

Assign the patient to the Priority (Yellow) category if any of the following are present and Emergency (Red) criteria are absent.

Gastrointestinal

• Vomits everything

• Ongoing diarrhoea (adult)

• Unable to feed or drink

General medical conditions

• Severe pallor

• Ongoing bleeding without Emergency criteria

• Recent fainting

• Altered mental status without Emergency criteria

• Acute generalized weakness

• Acute focal neurological deficit

• Acute visual disturbance

• New rash that is worsening over hours or peeling, without Emergency criteria

• Severe pain without Emergency criteria

Musculoskeletal and trauma

• Visible acute limb deformity

• Open fracture

• Suspected dislocation

• Other trauma or burns without Emergency criteria

Genitourinary

• Acute testicular or scrotal pain

• Priapism

• Unable to pass urine

Respiratory

• Wheezing without Emergency criteria

Infectious exposure

• Exposure requiring time-sensitive prophylaxis, for example:

  • Animal bite

  • Needle-stick injury

Paediatric conditions

• Any infant aged 8 days to 2 months

• Child younger than 14 years with malnutrition

• Child younger than 14 years with dehydration

• Child younger than 14 years with ongoing diarrhoea

Other

• Referral patient without Emergency criteria

• Sexual assault

• Other Priority condition (specify)

Queue criteria (Green)

Assign the patient to the Queue (Green) category if:

• No Emergency (Red) criteria are present.

• No Priority (Yellow) criteria are present.

These patients may safely wait for assessment but should be reassessed periodically while waiting, as deterioration may require re-triage.