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TRIAGE. Lee Wallis Senior Lecturer Division of Emergency Medicine, UCT/SU. Triage. Background Cape Triage Group Cape Triage Score Development The CTS Validation South African Triage Score EWS in children. Triage. French verb trier To sieve / to sort Medically:

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triage

TRIAGE

Lee Wallis

Senior Lecturer

Division of Emergency Medicine, UCT/SU

triage2
Triage
  • Background
  • Cape Triage Group
  • Cape Triage Score
    • Development
    • The CTS
    • Validation
  • South African Triage Score
  • EWS in children
triage3
Triage
  • French verb trier
    • To sieve / to sort
  • Medically:
    • The process of applying medical priority to patients to do the most for the most
history of triage
History of triage
  • Baron Dominique Jean Larré
    • Napoleon’s surgeon
    • Changed the treatment of injured soldiers
      • Least injured first, return to war
  • Little improvement until Vietnam
  • Military now use standard civilian priorities
  • Triage common to EDs in West for 20+ years
triage tools
Triage tools
  • Discriminators:
    • Demographics
      • Old or young triaged out
    • Mechanism of injury
      • Only for trauma
    • Anatomy
      • Dependent upon examination – time consuming
    • Physiology
      • Most reliable
  • Intended use:
    • Hospital vs Pre-hospital
    • Day-to-day vs MCI
    • Trauma vs Other
    • Adult vs Child
mci pre hospital triage
MCI Pre-hospital triage
  • Do the most for the most
    • Try to pick out sickest first
        • Theoretical evidence for leaving these
  • Easy to learn & use
    • Close to daily practice
  • Physiologic most common
    • Triage sieve, Triage sort, START, Careflight etc
    • Paediatric Triage Tape
mci hospital triage
MCI Hospital triage
  • Triage Sort
      • RR 0-4
      • SBP 0-4
      • GCS 0-4
      • Total 0-12
      • P3 – 12
      • P2 – 11
      • P1 - other
  • + Basic Anatomical information
daily pre hospital triage
Daily Pre-hospital triage
  • Often not done
  • When done - trauma only
    • TS, RTS, TRTS, PHI, CRAMS, ACS TTC, etc
  • Children – PTS, adult tools
    • Physiologically incorrect
  • Most used to identify need for Trauma Centre care (USA)
hospital triage subjective
Hospital triage - subjective
  • Senior doctor or nurse
  • Front door of unit
    • Eyeball
    • Gut-feel
  • Accuracy as low as 35%
  • Poorly reproducible
  • 24 / 7 coverage
hospital triage objective
Hospital triage - objective
  • MCI – triage sort or similar
  • Day-to-day
    • Manchester triage, CTS, ATAS, ESI, PTS
    • Complicated, time consuming, training implications, senior staff
cape triage group
Cape Triage Group
  • Convened Jan 2004
  • Joint division of Emergency medicine, UCT / SU
      • Jan 2004
      • 32 registrars, 5 waiting posts
      • Dip PEC, MPhil, MSC, MMed / FCEM
  • Private & Public
  • Pre-hospital & hospital
  • Doctors, nurses, paramedics
    • 1 speech therapist….
ctg objectives
CTG: objectives
  • Saw the need for triage in W Cape (SA) setting
  • Develop a tool for hospital EU use
  • Pre-hospital triage
  • Not a MCI tool
cts staffing considerations
CTS: staffing considerations

Doctors and nurses per 100,000 population per annum for selected countries

cts development
CTS: development
  • Look at other countries’ tools
  • Look at other options
    • EWS
  • Derivation phase
  • Validation phase
cts priorities
CTS: Priorities
  • 5 colours
  • Red Immediate
  • Orange 10 mins
  • Yellow 60 mins
  • Green 4 hours
  • Blue Dead
cts the basics
CTS: the basics
  • 2 part tool
    • TEWS
    • Discriminators
  • 3 versions
    • Adult, Child, Infant
  • 5 colours
cts tews
CTS: TEWS
  • Triage Early Warning Score
  • From MEWS – UK ICU outreach program
  • MEWS reduced ICU admission and mortality / LoS
  • Minor modifications to adult version = TEWS
cts adult
CTS: adult
  • TEWS Derivation: from MEWS
  • Discriminators: committee consensus
  • Validation
    • 1500 GF Jooste, 2000 Mediclinic, 12,000 CHC EUs
    • 2 MPhils
cts child infant
CTS: child & infant
  • TEWS Derivation:
    • 1500 healthy school children
    • 4000 injured children RXH TU
  • Discriminators: committee consensus
  • Validation
    • 8000 children at CHC EUs
  • Age, height, weight related vital signs
  • Logistic regression vs neural nets
  • PhD
slide27

Step 1

Measure vital signs and document the findings

Step 3

Calculate the TEWS and document the total value

Step 4

Match the score to the list and observe the discriminator list for issues not picked up by the TEWS

Step 5

Document the triage code and act accordingly

CTS: step by step

Step 2

Take a brief history directed at the main complaint and document this

example
Example
  • 10 year old, electrical burn
    • Walking (0) RR 24 (1) HR 110 (1) SBP 115 (0) Temp 37 (0) alert (0) trauma (1)
  • TEWS total = 3
    • YELLOW
slide29

Discriminators: Adult

  • Final Triage
    • ORANGE
cts management aids
CTS: management aids
  • Series of management pointers
    • Including:
      • Diabetes – test glucose
      • Low temp – blankets
      • Chest pain – ECG
  • Aimed at ENA
cts benefits
CTS: benefits
  • GF Jooste, 4 CHCs:
  • Reduced waiting times
    • 590 mins mean, to 30 mins red, 60 orange, 400 green
  • Decreased EU length of stay
  • Improved patient flow, decreased overcrowding in EU
  • Reduction in mortality 2% to 0.7%
    • Morbidity?
  • Improved patient and health provider satisfaction
slide32

CTS: validity

  • Overtriage, undertriage
  • What should a triage tool identify?
    • Injury severity
    • Resource usage
    • Death / High care / Admission
    • Urgency of Intervention
cts implementation
CTS: Implementation
  • 1 Jan roll out W Cape
  • All EUs
    • Primary Care
    • Secondary & tertiary care
  • DoH funded and supported
  • Intensive training program
  • Educational materials
  • Posters, keycards, patient leaflets
future developments cts
Future developments: CTS
  • 1 year M&E manager
    • Audits
    • QA
    • Performance indicator thresholds
  • CTS living tool
    • Modify as needed
    • Keep same format
future developments sats
Future developments: SATS
  • CTS taken on by 4 provinces so far
  • Call for SA Triage Group
    • First meet June 2006, Durban
    • Represent all provinces
  • Develop a SATS
    • Based on CTS
future developments ews
Future developments: EWS
  • MEWS part of TEWS for in-patient monitoring
    • Mortality and morbidity benefit, LoS reduction
  • Validate child & infant versions
  • Funding for age – group specific EWS from UK