Triage in a Modern Landscape

Author: Karolina Künnapuu

Triage is a system through which provision of medical treatment is allocated to maximise the number of survivors in a situation where demand for treatment is higher than the hospital is able to provide (1). In practice, this means that patients are treated according to the severity and urgency of their injury or illness as opposed to a first come, first served-based system. Triage initially began as a method of maximising survivors of battlefield injuries, and as such is historically a largely trauma-based system. Changing healthcare landscapes and demands have prompted triage to evolve into an integrated multi-stage system in which all kinds of injuries and illnesses must be accommodated and sorted to allow urgent cases to be treated as quickly as possible (2).

Currently, triage takes place both before the patient arrives at the emergency department (pre-hospital triage) and on arrival (hospital triage). Pre-hospital triage can involve the allocation of ambulances and first-response resources as well as assessment of the severity and urgency or injuries or illness at the scene of an emergency. Hospital triage then takes place once a patient has arrived at the emergency room, where the patient’s condition and symptoms can be assessed and a medical history collected. In many countries, hospital triage is implemented by assigning colours to patients to indicate the severity of their ailments and chance of survival (see table 1) (1). Various triage systems and assessment scales are in place throughout the world, differing from country to country or even hospital to hospital in accordance with local needs (3). An example of a triage system is the Manchester Triage System, which is widely used in the UK and Europe (4).

Table 1: Emergency triage in accordance with the Manchester Triage System (adapted from reference 6)

Triage is an ever-changing process and not all patients undergo all stages of triage, meaning that hospitals must employ multiple triage systems to accommodate for different entry points into the triage pathway and have the capability to adapt patient prioritisation quickly and continuously according to incoming information (2). One triage method that has become widespread in recent years is digital triage, in which patients can submit their symptoms and medical history through an online platform prior to visiting a healthcare practice or receive online consultations (see figure 1) (5). Online reporting and consultation systems have been especially useful during the COVID-19 pandemic to reduce the number of people physically visiting GP practices, minimising chances of infection (7). An issue with online triage, however, is difficulty in tending to patients without the ability to use the internet. While help can be provided by carers or administrative staff, still not all individuals will be able to make use of digital triage systems and as such alternatives must continue to exist and be integrated with online options.

Figure 1: Total digital triage outlined by the NHS (from reference 7)

Another development in speeding up the triage process is point of care testing (POCT). Analytical tests that can be performed without having to be analysed by a central lab save time and resources and are helpful in both pre-hospital and hospital triage. They can be used, for example, by paramedics at the site of an emergency to assess need for hospitalisation through biomarkers as opposed to visible symptoms. Studies of POCT test kits used by paramedics showed that using POCT tests affected patient management decisions in 31% of cases and considered to add value in 97% of cases in which they were used (8). POCT tests are also in development for triaging patients with suspected tuberculosis (9). POCT tests allow medical professionals to make more accurate care decisions using portable diagnostic devices and without the time and logistics associated with laboratory-based analytics.

Triage is a system used by emergency rooms and other medical practices to allocate treatment to maximise the number of survivors. Originally used to treat battlefield injuries, triage is now commonly used in accident and emergency rooms and even GP practices around the world. Changing healthcare environments require the development of integrated and quickly adaptable triage systems that are appropriate for a wide range of patients and emergencies. The spread of the COVID-19 pandemic sped up the adoption of digital triage systems where patient evaluation is completed through online symptom reporting and consultation, reducing physical visits to GP practices and preventing the spread of infection. A possible future direction in triage is the use of POCT in pre-hospital and hospital triage to increase the speed and accuracy of patient management decisions.

References:

1. Torrey, T. (2022, February 20). What Medical Triage Is and How It Is Used to Priortize Treatment. Verywell Health. https://www.verywellhealth.com/medical-triage-and-how-it-works-2615132 (Accessed 5th May, 2022)

2. Robertson‐Steel, I. (2006). Evolution of triage systems. Emergency Medicine Journal : EMJ, 23(2), 154–155. https://doi.org/10.1136/emj.2005.030270

3. Lidal, I. B., Holte, H. H., & Vist, G. E. (2013). Triage systems for pre-hospital emergency medical services—A systematic review. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 21(1), 28. https://doi.org/10.1186/1757-7241-21-28

4. Zachariasse, J. M., Seiger, N., Rood, P. P. M., Alves, C. F., Freitas, P., Smit, F. J., Roukema, G. R., & Moll, H. A. (2017). Validity of the Manchester Triage System in emergency care: A prospective observational study. PLoS ONE, 12(2), e0170811. https://doi.org/10.1371/journal.pone.0170811

5. Roberts, J. (2020, October 15). What is triage and why is it important? | NHS GP practices | eConsult blog. EConsult. https://econsult.net/blog/what-is-triage/ (Accessed 5th May, 2022)

6. Mackway‐Jones, K., Marsden, J., & Windle, J. (Eds.). (2013). Introduction. In Emergency Triage (1st ed., pp. 1–5). https://doi.org/10.1002/9781118299029.ch1

7. National Health Service (2020). Coronavirus » Advice on how to establish a remote ‘total triage’ model in general practice using online consultations. https://www.england.nhs.uk/coronavirus/documents/advice-on-how-to-establish-a-remote-total-triage-model-in-general-practice-using-online-consultations/ (Accessed 5th May, 2022)

8. Heany, K. (2020) Point-of-care testing by paramedics using a portable laboratory: An evaluation. Journal Of Paramedic Practice. https://www.paramedicpractice.com/features/article/point-of-care-testing-by-paramedics-using-a-portable-laboratory-an-evaluation

9. Field evaluation of a point-of-care triage test for active tuberculosis—ERA-LEARN. (n.d.). https://www.era-learn.eu/network-information/networks/edctp-ii/diagnostic-tools-for-poverty-related-diseases-1/field-evaluation-of-a-point-of-care-triage-test-for-active-tuberculosis (Accessed 12 May 2022)