Tessa Quinn
Triage is a system of sorting patients, especially in emergency rooms, according to the urgency of their need for care. The goal of triage is to prioritize patients with the most severe conditions to maximize the number of survivors. During the COVID-19 pandemic, India experienced a surge in cases, which overwhelmed the healthcare system and posed challenges in triaging patients in hospital settings. To address this, the Government of Tamil Nadu introduced a new triage protocol, including standalone triage centers and a home-based triage system. Outside of the pandemic context, there is limited data on airway management in trauma patients from developing countries, including India. However, observational studies have been conducted in India to assess tracheal intubation practices and their associated complications in trauma triage settings.
| Characteristics | Values |
|---|---|
| Purpose | To help health practitioners identify which emergency cases to prioritize in order to save the greatest number of lives |
| Criteria | The urgency of the patient's need for care, based on a system of priorities |
| Example | During the COVID-19 pandemic, patients triaged at home or in standalone centers with mild symptoms and SpO2 >94% were advised to self-isolate |
| Implementation | Triage protocols can be implemented in hospitals, as well as outside hospital settings, such as in the community or at patients' homes |
| Benefits | Triage strategies can enable early referral of high-risk patients and ensure evidence-informed treatment |
| Challenges | A sudden surge of cases, such as during the COVID-19 pandemic in India, can overwhelm the health system and pose challenges to triaging patients effectively |
| Specialties Involved | Emergency medicine, trauma care, airway management, and public health |
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What You'll Learn
Triage in mass casualty situations
Triage systems are essential in mass casualty situations to effectively prioritise patient care and optimise the use of medical resources. The primary objective of triage in such scenarios is to maximise the number of survivors by allocating medical attention based on the urgency of each patient's needs. This involves sorting patients into categories reflecting the severity of their condition, ensuring that those with the most critical injuries receive immediate treatment.
There are various triage systems employed worldwide in mass casualty incidents and disasters. A review of literature between 1990 and 2018 identified twenty different adult triage systems, including well-known methods such as START, Homebush Triage Standard, Sieve, and Military Triage. These systems differ in their specific protocols and criteria, but they all share the common goal of efficiently managing patient care during emergencies.
The specific triage system implemented in a mass casualty situation may depend on various factors, including the nature of the incident, the available resources, and the medical infrastructure. For example, the SALT triage system is specifically designed for mass casualty incidents involving chemical, biological, radiological, or nuclear agents. It focuses on sorting patients based on their exposure levels and potential for decontamination.
In mass casualty situations, triage plays a crucial role in coordinating the response of healthcare professionals. It helps ensure that patients are directed to the appropriate clinical setting, whether it's a trauma centre, emergency department, or primary care facility, to receive the necessary level of healthcare. This coordination is vital in maximising the survival rates of victims and preventing further injuries or complications.
Additionally, triage systems in mass casualty situations should be adaptable and flexible to accommodate the dynamic nature of emergencies. They should also consider the availability of resources, including medical personnel, equipment, and facilities, to make the best use of them. Effective triage requires continuous reassessment of patients' conditions and the situation as a whole, allowing for the adjustment of priorities and the efficient allocation of resources.
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Tracheal intubation practices
Triage systems are used in healthcare to categorise patients based on the severity of their injuries and the urgency with which they require care. The concept of triage originated in the military, with the first recorded instance of a triage system being described in the 17th-century BCE Egyptian document, the Edwin Smith Papyrus. The modern triage system was developed in the 18th century by French military surgeon Baron Dominique Jean Larrey, who served as the chief surgeon in Napoleon Bonaparte's imperial guard. Triage was first implemented in hospitals in 1964.
In India, the All India Institute of Medical Sciences (AIIMS) in New Delhi has been using an innovative ED triage protocol since 2010. This protocol involves categorising patients into "Red", "Yellow", and "Green" categories, with "Red" denoting the highest level of urgency. Some other medical centres in India, such as AIIMS Bhubaneswar, CMC Vellore, and GTB Delhi, have also adopted and modified their own triage protocols.
Now, for tracheal intubation practices in India:
Tracheal intubation (TI) is a common procedure in intensive care units (ICUs) and can often be life-saving. The All India Difficult Airway Association (AIDAA) has developed guidelines for managing unanticipated difficulties during tracheal intubation in adults and children. These guidelines provide a step-by-step approach to dealing with challenges that may arise during the procedure. The guidelines were formulated based on available evidence and, in cases where evidence was lacking, through consensus among airway experts.
The AIDAA guidelines emphasise the importance of optimum pre-oxygenation and recommend nasal insufflation of 15 litres per minute of oxygen during apnea for all patients. It is also suggested that transnasal humidified rapid insufflations of oxygen at 70 litres per minute be used when available. During intubation, the presence of at least two people is required, one of whom should be experienced in airway management. Preoxygenation should be performed using non-invasive ventilation with a pressure support ventilation level between 5 and 15 cm H2O. In cases where intubation fails, two more attempts may be made if the SpO2 level is at or above 95%. If subsequent attempts are necessary, they should be carried out by a more experienced operator, and changes should be made to improve the chances of success, such as altering the position or using different tools.
Additionally, the AIDAA guidelines address specific situations, such as difficult intubation in obstetrics and ICU patients, and provide strategies for extubation. They also offer recommendations for the equipment required in a difficult airway cart (DAC) and propose a standard format for reporting challenging airway cases.
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Airway management in trauma patients
Airway management is the first priority in trauma patients, and multiple factors can cause airway compromise. It is perhaps the most vital component in the treatment of traumatized patients. Complications related to airway management in such patients are common and can be life-threatening within a very short time. Therefore, establishing a definitive airway in a trauma patient is a primary essential of early management. Any flaw in airway management may lead to grave morbidity or mortality.
Trauma patients can present the most complex airway management problems, especially in the prehospital setting. The evaluation of injuries is usually incomplete at the time airway management is undertaken. If the airway is injured, attempts to secure the airway by performing endotracheal intubation or inserting other devices may cause further injury. Direct airway trauma may involve actual damage to the airway or any injury to nearby structures that distort the airway anatomy. Indirect or associated airway trauma affecting airway management is considered to be those injuries that limit or influence the techniques available for airway management.
Injuries that may cause direct and indirect airway trauma include small mouth, inability to open the mouth, temporomandibular joint abnormalities, and contusions of the lung, which are usually associated with multiple rib fractures, with or without flail chest. A comprehensive physical examination of the dental system and airway should be performed in traumatized patients before every nonemergency endotracheal intubation. Approximately 2% to 3% of patients have anatomic features that make tracheal intubation difficult.
The most important technique to open the airway is anterior displacement of the mandible, which elevates the epiglottis and base of the tongue from the posterior pharyngeal wall. This can be accomplished by lifting the mentum of the mandible with the fingers. The techniques to be used should be decided upon in advance, and all equipment should be thoroughly checked before the patient's arrival in the emergency department or operating room. In addition to informing the patient of the potential problems, the anesthesiologist should notify the surgeon and nurses that difficulty may be encountered and indicate whether special equipment is required.
Triage is a French word that means "to sort" or "to select." It is a process used in healthcare to categorize patients based on the severity of their injuries and the order in which they require care and monitoring. The concept of triage originated in the military, with the earliest records dating back to the 18th century, where field surgeons would quickly assess soldiers to determine their course of treatment. Modern triage practices were further developed during World War I and World War II, with the increased availability of airplanes allowing for rapid evacuation to hospitals outside of war zones.
In India, the All India Institute of Medical Sciences (AIIMS) has developed and implemented a colour-coded triage protocol known as the AIIMS Triage Protocol (ATP) since 2010. This protocol categorizes patients into ""Red," "Yellow," and "Green" categories based on the urgency of their condition. The ATP has been adopted by several medical centres in India, including AIIMS Bhubaneswar, CMC Vellore, and GTB Delhi, and has been found to reduce overtriage and undertriage rates.
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COVID-19 triage protocols
India experienced a surge in COVID-19 cases during the second wave between April and June 2021, which overwhelmed the healthcare system. In response, the Government of Tamil Nadu introduced a new triage protocol to evaluate patients at home or in community-based settings. This patient-centric strategy aimed to assess confirmed COVID-19 cases outside hospitals, utilising a workforce of paramedics and doctors. Standalone triage centres were also established outside hospitals, catering to up to 2500 patients daily.
The criteria for home isolation for patients triaged at home or standalone centres included mild symptoms, SpO2 >94%, and the availability of a separate room with an attached bathroom and a caregiver. Patients meeting these criteria were provided with a home isolation kit and monitored via telemedicine for 10 days. Those exhibiting red flag signs were transferred to hospitals by special ambulance.
To address the challenges of the pandemic, national guidelines for triaging and Infection Prevention and Control practices were accessed from the National Center for Disease Control (NCDC), the Ministry of Health and Family Welfare (MoHFW), and other sources. These guidelines were reviewed and discussed with experts, leading to changes in triage protocols during the first and second waves.
Additionally, the Karnataka government released protocols for patient management in triage centres, including categorising wards based on oxygen requirements and mandating a minimum number of doctors and interns from various specialties.
The COVID-19 pandemic overwhelmed critical care capacities, necessitating the implementation of triage protocols to determine ventilator allocation. This approach relied on triage scores to ration care and relieve clinicians from morally distressing decisions. However, it is important to prioritise autonomy, beneficence, and conversations before applying score-based triage, especially for older individuals where the benefits of critical care are uncertain.
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The triage system in emergency rooms
The triage system is a method used to sort patients, particularly in emergency rooms, according to the urgency of their need for care. The goal of triage is to maximise the number of survivors by identifying the most severe cases and directing medical attention to them first. This system is especially important in emergency departments, where quick decisions about patient care can significantly impact patient survival and resource utilisation.
The concept of triage has a long history, with early descriptions found in ancient Egyptian documents like the Edwin Smith Papyrus. However, the modern triage system has evolved significantly over time, particularly during times of war. During the reign of Emperor Maximilian I, soldiers were prioritised over civilians in hospitals, and the sickest soldiers received treatment first. In the Napoleonic era, the concept of a "flying ambulance" or rapidly moving medical transport was introduced. The tiered triage system, which categorises patients into immediate, delayed, minimal, and expectant groups, was developed during the Korean War and remains the basis for most triage systems today.
In recent times, triage has continued to play a crucial role in emergency medicine, especially in mass casualty situations. Primary triage, commonly referred to as the "triage sieve," can be performed using a validated algorithm like the Modified Physiology Triage Tool (MPTT-24). This algorithm can be effectively administered by any competent person at the scene, as it does not require a high level of medical training. While this standardised approach aims to be objective and reproducible, it may not account for individual patient trajectories. Therefore, ongoing assessment and re-triage may be necessary.
Triage systems have been implemented in various countries, including India, where a novel triage system called the AIIMS Triage Protocol was developed and validated in a tertiary care hospital in New Delhi. This system has shown promise in recognising sick patients presenting to the emergency department and could serve as a valuable tool for public hospitals in low- and middle-income countries (LMICs). However, it is important to note that further research and improvements in emergency care may lead to the evolution of triage protocols over time.
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Frequently asked questions
Triage is the sorting of patients according to the urgency of their need for care based on a system of priorities designed to maximise the number of survivors.
Yes, India has a triage system in hospitals. There is also research into improving the triage system, particularly in the context of the COVID-19 pandemic.
The triage system in India is used to assess and manage trauma patients, particularly those with tracheal intubation and those with head injuries. During the COVID-19 pandemic, triage centres were set up outside hospitals to evaluate patients with the disease.
The triage system in India involves evaluating patients according to the urgency of their need for care. Patients with mild symptoms and oxygen saturation above 94% were advised to self-isolate at home. Those with more severe symptoms were transferred to hospitals.
The triage system helps to identify more severe cases, allowing medical staff to direct their attention effectively and save as many lives as possible. It also helps individuals understand what is deemed an emergency, so they can seek the right medical treatment for their recovery.
