Triage: Techniques and Applications in Decisionmaking,☆☆,

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Abstract

Correct decisionmaking may have far-reaching consequences. Triage is an area in which decisionmakers must know what they are doing, why they are doing it, and which actions to take to achieve a satisfactory outcome. Triage has its origins in military history and today is used in a variety of medical settings. In this article we focus on the role of triage in disaster situations, its application in military settings, and its use in disaster medicine. Useful concepts enabling correct decisionmaking by the triage officer include the application of computer technology and a review of methods of patient categorization. The dynamic nature of triage and the role of the triage officer as part of a team approach to disaster patient management are highlighted. We explore techniques for the successful training and education of triage officers and investigate a model of the emergency physician as the triage officer. [Kennedy K, Aghababian RV, Gans L, Lewis CP: Triage: Techniques and applications in decisionmaking. Ann Emerg Med August 1996;28:136-144.]

Section snippets

INTRODUCTION

The word "triage" describes a medical decisionmaking process that is used in several clinical settings. Its application is widespread from the description of the initial assessment by a nurse in the emergency department to the sorting of victims at a disaster scene. The term is derived from the French trier, “to sort,” and was adopted into the English language after the Napoleonic Wars. Originally triage described the first aid treatment of battle casualties in collection stations at the front

HISTORICAL PERSPECTIVE

It is well known that the ancient Greeks and Romans maintained large armies, but we know little of the manner in which they managed their sick and injured. This fact is also lamented by Pringle1, who believed that such knowledge would have contributed much to military medical history. He noted that Vegetius gives direction on how to preserve a soldier's health and speaks of physicians attending camp, but no other details are given. Wall carvings depict soldiers receiving medical attention in

THE MILITARY EXPERIENCE

In the setting of combat triage the major objective is to sort who can be returned to the front immediately, who needs treatment before returning to duty, and who will not be able to return to active duty. This sorting takes place in geographically dispersed areas by personnel with varying levels of expertise. The military experience has useful application for civilians working in mass-casualty situations. In disaster situations triage must be conducted with the purpose of doing the greatest

INJURY SCORING AS A TRIAGE TOOL

Conventional triage, accepted as the sorting of patients into those requiring urgent or emergency care, is only the first step in a dynamic decisionmaking process. In the determination of priorities for action, decisions are made that may affect the extent and quality of patient care. In a disaster or mass-casualty incident this may be difficult, and triage methods have been found to be only about 80% accurate in determining a patient's needs.11

Before the 1970s and the development of US trauma

TRIAGE IN DISASTER SITUATIONS

A disaster has been defined as a sudden massive disproportion between hostile elements of any kind and the survival resources that are available to counterbalance these in the shortest period of time.39 During such an emergency situation, shortages of personnel, equipment, and transportation vehicles may necessitate triage carried out at various levels. Triage decisions must take into account these variables. In war the priority is to return the soldier to action; after a civilian disaster such

FUTURE OF TRIAGE

Data on triage in the disaster situation are limited, but some lessons have been learned. It is usually advisable to adhere to the normal everyday routine as far as possible11 while accepting that some modifications will be necessary. The disaster situation is not the time to try out a system for the first time. One method of improving performance and keeping skills current when disaster triage is not used on a daily basis is to designate a "triage day" on which every patient is assigned to a

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    From the Department of Emergency Medicine, University of Massachusetts Medical Center, Worcester, Massachusetts.

    ☆☆

    Address for reprints: Richard V Aghababian, MD, Department of Emergency Medicine, University of Massachusetts Medical Center, 55 Lake Avenue North, Worcester, Massachusetts 01655

    Reprint no. 47/1/47867

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