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Here is a thorough overview of Triage drawn from Rosen's Emergency Medicine and Tintinalli's Emergency Medicine textbooks, supplemented with current guidelines.
Triage
Definition & Origin
The word triage comes from the French verb trier, meaning "to sort." The concept dates to Napoleon's era, when priorities for treating battlefield wounded had to be set under scarce resources. Today, triage is a rapid evaluation process that assigns patients a priority for care based on the severity of their condition and the urgency for treatment.
- Rosen's Emergency Medicine, p. 3684
- Tintinalli's Emergency Medicine, p. 66
Goals of Triage
| Setting | Goal |
|---|---|
| Routine ED | Identify most seriously ill patients with time-dependent conditions; ensure rapid care |
| Mass casualty / Disaster | Do the most good for the most people - shift from individual focus to population focus |
A key tradeoff exists in all triage:
- Undertriage (assigning too low a priority) - greater potential for patient harm
- Overtriage (assigning too high a priority) - wastes resources and can delay care for others
Types of Triage
1. ED Triage - Emergency Severity Index (ESI)
The most widely used system in US emergency departments. It has 5 levels based on risk and required resources:
| ESI Level | Criteria | Examples |
|---|---|---|
| 1 | Requires immediate life-saving intervention | Cardiac arrest, respiratory failure |
| 2 | High-risk situation; lethargic; severe distress; dangerous vital signs | Chest pain, stroke, sepsis |
| 3 | Multiple resources required, but stable vitals | Abdominal pain needing labs + imaging |
| 4 | One resource required | Simple laceration, UTI needing UA |
| 5 | No resources required | Prescription refill, minor complaint |
The first ESI question a triage nurse asks: "Is the patient dying?" - checking airway, breathing, and pulse. ESI has shown variability across countries but remains the best available option and is broadly used in the US.
- Rosen's Emergency Medicine, p. 3684 (Table e8.2)
2. Mass Casualty / Disaster Triage - START System
START = Simple Triage And Rapid Treatment
Uses a quick mnemonic: RPM - Respirations, Perfusion, Mental status
Process:
- Ask all walking patients to move away - these become GREEN (walking wounded)
- Remaining patients are assessed in seconds for RPM
- The only interventions at this stage: open obstructed airway + direct pressure on hemorrhage
Color Categories:
| Color | Priority | Criteria |
|---|---|---|
| 🔴 Red | Immediate (1st) | Life-threatening shock or hypoxia present or imminent; salvageable with immediate care |
| 🟡 Yellow | Delayed (2nd) | Systemic implications but not yet in life-threatening shock; can wait 45-60 minutes |
| 🟢 Green | Non-urgent (3rd) | Localized injuries without systemic implications; "walking wounded" |
| ⚫ Black | Dead / Expectant | No spontaneous ventilation or circulation; or catastrophically injured with slim survival chance |
Under true disaster conditions, CPR is not performed (resources are directed to salvageable patients).
- Tintinalli's Emergency Medicine, p. 66 (Table 5-8)
- Rosen's Emergency Medicine, p. 3688
3. Pediatric Triage
Special pediatric adaptations exist because adult criteria do not apply to children:
- JumpSTART - a modification of START that adds 5 rescue ventilations for apneic children, and adjusts respiratory rate and mental status criteria
- Pediatric Triage Tape (PTT) - uses size-based criteria (e.g., 50-80 cm length band)
- CareFlight - performed best overall in database evaluations; JumpSTART best for children under 8 years
No pediatric system has proven clear superiority; choice should be left to individual jurisdictions. Training quality may matter more than system choice.
Triage Phases
Triage occurs at three distinct phases:
- Prehospital triage - by paramedics/first responders at the scene
- Triage at the scene of an event - field triage during mass casualty incidents
- Triage upon ED arrival - even if field triage was done, re-triage is performed at the hospital
Patients arrive with color-coded triage tags that document prior triage and guide ED reassessment.
Triage Errors
Triage is an inherently imperfect, abbreviated decision process. Key error mechanisms:
- Limited information available at initial assessment
- Cognitive bias - an incorrect triage to a treatment area can bias the treating team's thinking
- Varied presentations of illness and injury
- ESI inter-rater reliability is poor across countries, though broadly used in the US
Special Notes
- The ACEP/ENA joint policy (January 2025) recommends implementing a standardized, validated 5-level triage scale in all EDs
- START was evaluated in the 2002 Placentia Linda train crash: 100% sensitivity for red category, 90% specificity for green, with acceptable undertriage
- Rosen's recommends START over SALT triage for mass casualty events until more comparative evidence emerges
Key Takeaway: Triage is never completely safe because of time pressure and limited information - it always involves a tradeoff between sensitivity and specificity. The goal shifts from "best care for one patient" to "best outcomes for the most patients" in disaster settings.
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