What are the triage guidelines for patients in urgent, nonurgent, and emergency situations?

Triage Guidelines for Urgent, Nonurgent, and Emergency Situations

Triage systems should be structured according to five levels of priority, where urgency is distinguished from severity—what is urgent is not always serious, and what is serious is not always urgent. 1

Standard Triage Categories (Normal Operations)

Under normal circumstances, patients should be classified into five acuity levels based on physiological abnormalities and clinical presentation 2:

1. Resuscitation (Immediate/Life-Threatening)

• Patients requiring immediate intervention to prevent death 2
• Examples include:
  • Cardiac arrest 2
  • Cardiorespiratory failure 2
  • Decompensated shock 2
  • Deep coma 2
  • Severe stridor 2
  • Glasgow Coma Scale <14 3
  • Systolic blood pressure <90 mmHg 3
  • Respiratory rate <10 or >29 breaths per minute 3

2. Emergent Care (Emergency)

• Patients with potentially life-threatening conditions requiring rapid assessment and intervention 2
• Should be seen within minutes 1
• Includes patients meeting physiologic criteria with high risk of deterioration 3

3. Urgent Care

• Patients with serious conditions requiring timely evaluation but not immediately life-threatening 2
• Should be reassessed regularly while awaiting definitive care 1
• Examples include stable patients with significant anatomic injuries 3

4. Less Urgent (Semi-Urgent)

• Patients with conditions that can tolerate longer waiting times without significant risk 2
• Require medical attention but not time-critical 1

5. Nonurgent

• Patients with minor conditions that could be managed in outpatient settings 2
• Lowest priority for emergency department resources 1

Primary Assessment Process

The initial triage evaluation should be completed using the Pediatric Assessment Triangle (PAT) approach, which involves immediate visual and auditory assessment of appearance, breathing, and circulation, categorizing patients as either stable or unstable. 2

Systematic Assessment Steps:

1. Airway (A): Assess patency and risk of obstruction 2
2. Breathing (B): Evaluate respiratory effort, rate, and oxygen saturation 2
3. Circulation (C): Check perfusion, blood pressure, and heart rate 2
4. Disability/Neurologic (D): Assess level of consciousness and focal deficits 2
5. Exposure (E): Perform head-to-toe examination 2

This primary assessment takes 1-3 minutes and determines the appropriate triage category 2.

Commonly Used Standardized Systems

The Emergency Severity Index (ESI) and Manchester Triage System (MTS) are the most frequently implemented structured triage tools, with scientific evidence supporting their accuracy and reliability. 4

• Both systems are multidisciplinary and based on presenting complaints and urgency rather than diagnoses 1
• Can be performed by nursing staff with medical support when required 1
• Include quality monitoring capabilities for the emergency service 1

Emergency Operations (Mass Casualty Events)

During emergency operations with resource shortfalls, critical care triage protocols should only be triggered when it is evident that resource shortages will occur across a broad geographic area despite all reasonable efforts to extend or obtain additional resources. 3

Activation Criteria for Crisis Triage:

• Declared state of emergency 3
• Surge capacity fully employed within healthcare facilities 3
• Maximum conservation, reutilization, adaptation, and substitution efforts exhausted 3
• Identification of critically limited resources (ventilators, medications) 3
• Regional and federal resource requests made without resolution 3

Triage Flow in Mass Casualty Events:

1. Primary triage: Occurs in pre-hospital settings (field, physician offices, community assessment centers) 3
2. Secondary triage: Performed in emergency departments 3
3. Tertiary triage: For ICU admission decisions by designated triage officers 3

ICU Triage Exclusion Criteria (Crisis Standards):

Patients should be excluded from ICU admission during resource scarcity if they have 3:

• Severe trauma with predicted mortality >80% (TRISS score) 3
• Severe burns with age >60 years, >40% body surface area, and inhalation injury 3
• Unwitnessed cardiac arrest or recurrent arrest 3
• Severe baseline cognitive impairment requiring institutionalization 3
• Metastatic malignant disease 3
• End-stage organ failure (NYHA Class III/IV heart failure, severe COPD with FEV1 <25%, Child-Pugh score ≥7) 3

Prioritization Tool:

The Sequential Organ Failure Assessment (SOFA) score can be used for prioritization, with reassessment at 48 hours to predict outcomes, though it has limitations including need for laboratory tests and variability in interpretation. 3

Critical Pitfalls to Avoid

• Never implement crisis triage protocols during normal or irregular operations—these are reserved exclusively for declared emergencies with documented resource exhaustion 3
• Avoid using primary assessment systems alone to refer patients to downstream structures without thorough medical examination 4
• Do not confuse urgency with severity—patients may be urgent without being severely ill, or severely ill without requiring immediate intervention 1
• Ensure bidirectional communication between triage officers and incident command structure to maintain situational awareness 3

Documentation Requirements

During emergency mass critical care scenarios, medical records must document 3:

• Declaration of emergency and activation of facility response system 3
• Exhaustion of all existing resources and surge capacity 3
• Institution of mass triage strategy resulting in care rationing 3
• Triage officer/team assessment and approval by regional incident commander 3
• Continuation of all supportive care and measures for alleviating suffering 3