What are the latest updated triage protocols for patient assessment and prioritization?

Latest Updated Triage Protocols

The most current triage protocols prioritize rapid identification of life-threatening conditions using validated screening tools, with stroke patients requiring assessment within 10 minutes of arrival and trauma patients stratified by a four-step algorithm that includes vital signs, anatomic injury patterns, mechanism of injury, and special considerations. 1

Prehospital and Emergency Department Triage

Stroke Triage (2019 Update)

The American Heart Association's 2019 stroke systems guidelines represent the most recent comprehensive update for stroke triage:

• Use validated screening tools at first contact: FAST (Face, Arm, Speech, Time), Los Angeles Prehospital Stroke Screen, or Cincinnati Prehospital Stroke Scale for initial identification 1
• Apply stroke severity assessment tools in prehospital settings: Cincinnati Stroke Triage Assessment Tool, Rapid Arterial Occlusion Evaluation, Los Angeles Motor Scale, or Field Assessment Stroke Triage for Emergency Destination to identify large vessel occlusions 1
• Assign high-severity triage category with target of being seen within 10 minutes of ED arrival 1
• Limit bypass transport time to no more than 15 additional minutes when multiple hospitals exist, prioritizing facilities capable of endovascular thrombectomy for suspected large vessel occlusions 1
• Provide prearrival notification by EMS in all stroke cases to activate Code Stroke protocols 1
• Complete brain imaging within 25 minutes of ED arrival, with door-to-needle time under 60 minutes for thrombolytic candidates 1

Trauma Triage (2011 CDC Guidelines)

The National Expert Panel's four-step field triage algorithm remains the standard for trauma assessment:

Step 1 - Vital Signs and Level of Consciousness:

• Glasgow Coma Scale ≤13 1
• Systolic blood pressure <90 mmHg 1
• Respiratory rate <10 or >29 breaths per minute (or <20 in infants <1 year) 1

Step 2 - Anatomy of Injury:

• All penetrating injuries to head, neck, torso, and extremities proximal to elbow or knee 1, 2
• Chest wall instability or flail chest 1, 3
• Two or more proximal long-bone fractures 1, 3
• Crushed, degloved, mangled, or pulseless extremity 1, 3
• Amputation proximal to wrist or ankle 1, 3
• Pelvic fractures 1, 3
• Open or depressed skull fracture 1, 3
• Paralysis 1, 3

Step 3 - Mechanism of Injury:

• Falls: Adults >20 feet; Children >10 feet or 2-3 times height of child 1
• High-risk auto crash with intrusion >12 inches occupant site or >18 inches any site 1
• Ejection from automobile 1
• Death in same passenger compartment 1
• Auto vs. pedestrian/bicyclist with impact >20 mph 1
• Motorcycle crash >20 mph 1

Step 4 - Special Considerations:

• Age >55 years (systolic BP <110 may represent shock after age 65) 1
• Anticoagulation therapy with any trauma 1, 3
• Pregnancy >20 weeks 1, 3
• Burns with trauma mechanism 1

General Emergency Department Triage Systems

Two validated five-level triage systems are internationally recognized:

• Emergency Severity Index (ESI): Stratifies patients by acuity and estimated resource needs, with ESI-1 being highest acuity 4, 5
• Manchester Triage System (MTS): Uses presentational flow charts with specific indicators 6

Common pitfall: Studies show 34-39% of less acute patients may be seen before more acute patients in split-flow models, potentially delaying care for higher-acuity cases 7. Monitor triage-to-provider times to ensure more acute patients receive priority.

Mass Casualty Incident (MCI) Triage

Color-Coded Priority System

The CDC and American College of Surgeons recommend a four-category system for mass casualty events:

• Red (Immediate): Life-threatening but salvageable injuries requiring immediate intervention 2, 8
• Yellow (Urgent/Delayed): Serious injuries requiring treatment but can tolerate delay without significant increase in morbidity or mortality 2, 8
• Green (Minimal): Walking wounded with minor injuries 2
• Black/Blue (Expectant): Dead or injuries incompatible with survival given available resources 2, 8

Critical Care Triage During Mass Casualty Events

Activation criteria: Institute formal triage protocols only when resource shortfalls are evident or predicted across a broad geographic area despite all reasonable efforts to extend or obtain additional resources 1

Assessment tools: The Sequential Organ Failure Assessment (SOFA) score can guide ICU admission decisions, though it has limitations including need for laboratory tests and inclusion of treatment-dependent variables 1, 8

Reassessment intervals: Patients admitted to critical care should be reassessed at 48 hours and 120 hours (days 2 and 5) and re-categorized based on response to treatment 1, 8

Guiding principle: Allocate resources to maximize the number of survivors, not to provide equal care to all patients 2, 3

Critical Pitfalls in MCI Triage

• Avoid undertriage: Missing severely injured patients results in preventable deaths 2
• Avoid overtriage: Sending too many non-critical patients to critical care areas overwhelms limited resources 2
• Avoid specialty bias: Do not prioritize only your specialty cases; this creates inequitable care and fails to save the most lives 2
• Avoid equal treatment: Treating all patients with equal priority leads to inefficient resource utilization and preventable deaths 2

Implementation Considerations

Authority structure: Triage decisions should flow from a Crisis Triage Committee through regional and local incident management systems to designated triage officers 1

Triage officer qualifications: Senior clinicians should serve as triage officers, applying inclusion/exclusion criteria in a transparent fashion without direct patient care responsibilities 1, 2

Documentation: Maintain records of triage category, reassessment findings, and treatments provided for continuity of care 8

Resource optimization: Consider transferring stabilized patients to other facilities to free beds for more critical cases 1, 2