Content
Background
The presence of a physiological abnormality, failure to recognise and treat it, and age greater than 65 years are known risk factors for poor outcomes. Timely responses to abnormal clinical findings have been shown to reduce morbidity and mortality in critically ill patients.
The ATS clinical descriptors are informed by research into predictors of outcome in critical illness / injury and clinically relevant assessment criteria. The correct application of this information is also critical to the timely recognition and treatment of patients who have deteriorated and thus warrant re-triage.
The primary survey approach is recommended to identify and correct life-threatening conditions at triage. Table 4.1 provides a summary of adult physiological discriminators for the ATS, using the primary survey format.
Table 4.1: Summary of adult physiological predictors for the ATS
Category 1 Immediate
Airway Obstructed / partially obstructed
Breathing
Severe respiratory distress / absent respiration / hypoventilation
Category 2 10 minutes
Category 3 30 minutes
Category 4 60 minutes
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Moderate respiratory distress
Mild respiratory distress
No respiratory distress
Category 5 120 minutes
No respiratory distress
19
Circulation
Severe haemodynamic compromise / absent circulation
Uncontrolled haemorrhage
Moderate haemodynamic compromise
Mild haemodynamic compromise
No haemodynamic compromise
No haemodynamic compromise
Disability GCS < 9 GCS 9 – 12 GCS > 12 Normal GCS Normal GCS
Risk factors for serious illness / injury – age, high risk history, high risk mechanism of injury, cardiac risk factors, effects of drugs or alcohol, rash and alterations in body temperature – should be considered in the light of history of events and physiological data. Multiple risk factors = increased risk of serious injury / illness. Presence of one or more risk factors may result in allocation to a triage category of higher acuity.
The collection of physiological parameters at triage requires the clinician to make the best use of their senses to detect abnormalities( i. e. look, listen, feel and smell).
Triage Nurses must ensure that patients with physiological abnormalities are not delayed by the triage process and are allocated to a clinical area that is equipped to provide ongoing assessment and treatment of their condition.
Diagram 4.1 illustrates the recommended triage method.
Department of Health and Ageing – Emergency Triage Education Kit