Surgical Triage

Definition
Purpose
Demographic
Description
Who Performs the Triage Procedure
Triage Systems
Surgical Triage after Trauma
Triage Coding in Disasters
Ethical Considerations of Triage

Definition

Triage (from the French verb trier “to sort”) is the assessment of medical condition performed by health care providers to screen for the most critically ill patients out of a group of people. Surgical triage focuses on establishing priority with respect to which surgeries are most critical in a time-sensitive manner. Triage is a necessary process when health care resources are limited and not every patient can be treated at once.

Purpose

Triage is performed to prioritize medical treatment so that the most endangered patients are treated first, while the number of lives saved is maximized. Triage is especially important in emergency situations where the amount of resources are limited and so have to be distributed in a selective manner. For example, a patient with a chest wound requiring immediate surgery to maintain life will take priority over a patient who needs surgery for a benign tumor.

Demographic

Surgical triage is performed on any patient presenting with a condition that may be amenable to surgical repair. Surgical triage is performed, when medically necessary, regardless of age, gender, or race.

Description

Triage is a system of screening, evaluating, and classifying the sick or wounded. It may be done during war, disaster situations, or in the emergency room of a hospital. Regardless of where it is performed, triage for any medical treatment is dependent on available medical resources. Medical resources include medications, operating room space, hospital space, bandages or other materials, as well as a physician’s time. Medical resources are all limiting factors to the medical treatment available for patients. Surgical triage takes both the acuity (severity) of the patient’s medical condition, as well as available medical resources into account.

Emergency Surgical Triage

There are multiple grading systems or standards for triaging patients in an emergency setting. In emergency situations, each patient is evaluated (including obtaining a brief history when possible) and given a rapid physical exam specifically geared toward vital signs and areas of critical injury or illness. The components of the initial triage history include a specific set of information that is important: allergies to specific medications; current medications need to be established in case new medications are indicated; when the patient last ate is pertinent due to the risk of vomiting and breathing in the vomit during general anesthesia and the surgical procedure. Establishing an airway and taking basic life support measures is a priority. Other priority items include stopping any arterial bleeding before the patient goes into shock. Emergency surgery procedures apply the general principles of emergency triage in addition to information about the specific medical condition involved in order to determine which surgeries need to be performed first.

Emergency surgical procedures may be necessary due to trauma (with the patient being critically injured) or a critical phase of a disease state (such as immediately life-threatening heart failure that is caused by a condition amenable to surgical repair). It is essential that triage be performed rapidly and accurately, because in emergency situations a single minute could make the difference between survival and death. The rationale of surgical triage is to first treat patients that are in the most critical need of care in order to preserve life. Topics that factor into the order in which patients are triaged includes vital signs, clinical history, mechanism of injury or pre-hospital course of disease, age, co-morbid conditions, and whether they have open airways through which to breathe. A patient may be given priority if their vital signs are unstable, they have a clinical history of cardiac or pulmonary disease, have serious injuries, closed airways, are very young or very old, have lost consciousness, or are showing signs of neurological injuries.

An initial assessment of the patient involves running a primary survey, during which the airway, breathing, circulation/hemorrhage, and mental disability are evaluated. The purpose of the primary survey is for the initial management of life-threatening conditions. If the airway is obstructed, the patient may immediately go into an emergency surgery procedure to remove the obstruction. Next the patient’s ability to breathe independently is evaluated. If the patient cannot breathe due to a surgically amenable condition such as internal bleeding into the chest cavity they may be triaged into emergency surgery. If the patient has obstructed circulation, such as in cardiac tamponade where the heart sac is filled with blood and the heart cannot pump properly, emergency surgery would be required. Mental disability in the context of a primary survey refers to the current mental status of the patient. If the patient has serious neurological disability due to a head or spinal cord injury, neurosurgery may be necessary.

If the patient has not been triaged in the primary survey as having an immediately life-threatening condition, a secondary survey is performed. The secondary survey is a more thorough physical examination covering the entire body of the patient. Blood tests may be run to check the basic functioning of the patient’s bodily systems. At this point, triage is performed and the patients are prioritized for surgery.

Trauma patients being triaged for surgery may need diagnostic tests such as a Computed Tomography (CT) scan to help diagnose what is wrong with them and initiate appropriate surgery. However, if a patient has initially been brought to a smaller hospital without an appropriate surgeon present, this aspect of surgical triage may be temporarily put aside. Diagnostic tools such as CT scans take time and may delay the transfer of the patient to an appropriate trauma facility.

Non-emergency Surgical Triage

Triage also takes place in non-emergency department situations when scheduling operations in the hospital. While non-emergent procedures are generally scheduled on a first-come first-serve basis, if a patient is identified who medically requires a procedure in a time-sensitive manner, it may take precedence over a previously scheduled surgery. For example, if a current patient is identified during a routine examination with an aggressive tumor that requires surgery, a non-emergent procedure may be rescheduled to make room for the tumor patient. Hence, initial triage decisions may take place outside of the emergency department of the hospital.

Who Performs the Triage Procedure

An initial triage officer is a health care professional who performs triage on a patient arriving at the hospital. In the emergency department, the initial triage officer is often a triage nurse, who identifies the critically ill and sends them for further evaluation by a physician. Sometimes the triage officer is a resident, a full medical doctor who is in training for their specialty. For surgical triage, it is often a surgical resident that first determines whether a new patient requires surgery immediately.

Once a patient has undergone a surgical procedure, the triage process continues in the Surgical Intensive Care Unit (SICU). The SICU is a special hospital unit dedicated to patients undergoing surgery until they are deemed well enough to be transferred to other parts of the hospital or discharged. The surgical specialties of each hospital support the SICU, and may include the specialties of trauma surgery, neurosurgery, cardiothoracic surgery, transplant surgery, orthopedic surgery, ear nose and throat surgery, plastic surgery, vascular surgery, general surgery, and obstetrics and gynecological surgery. While the SICU is run by numerous types of health care providers, some systems utilize a Surgical Intensivist to triage which patients need to stay in the SICU and which may leave. A Surgical Intensivist is an MD who is both a general surgeon and has special training in intensive care practices.

In addition to the triage needs of each individual patient, the Surgical Intensivist must also manage a balance between the supply and demand of factors such as operating room time, post-anesthesia care unit availability, and bed space. It is a challenge for the Surgical Intensivist to properly assess which patients require SICU admission and which ones can be either denied admission or discharged safely for home. Patients who are inappropriately judged ready for discharge have been associated with a higher level or mortality, so triage on this level has a critical impact on healthcare. The Surgical Intensivist’s triage decisions may be supported by the surgeons on the patient’s primary surgical care team.

Triage Systems

Triage systems of classification may have from two to five categories into which to place patients. Many hospitals in the U.S. use three level systems with the categories of Emergency, Urgent, and Non-Urgent. However, studies have shown that five level systems are the most effective. Five level systems include the categories of Resuscitation (when breathing or pulse is not detected), Emergent, Urgent, Non-urgent, and Referred (minimal medical resources are required). One well-known five level triage system that is employed by emergency departments of the United States is the Emergency Severity Index (ESI). The ESI categorizes patients presenting to the emergency department by both health threat acuity and the resources available. The ESI scale ranges from one to five, with a lower number indicating greater severity. A triage nurse is usually the one who initiates the ESI when a patient presents to the emergency department. The acuity of a patient’s medical condition is determined by the stability of the patient’s vital signs and the potential for threat to life, limbs, or organs. If the patient meets high acuity level criteria (level 1 or 2), they need immediate treatment possibly including surgery. If the patient does not meet high acuity level criteria, the triage nurse then proceeds to evaluate the expected resources needed for treatment to help determine a triage level (level 3, 4, or 5). The ESI is a method for emergency departments to triage patients in a validated manner. It is one of the only triage systems that specifically categorizes based on resources available. A general triage system such as the ESI is only one factor in the process of surgical triage. Patients with high acuity levels and conditions amenable to surgery are then given over to more specific surgical done by the appropriate surgical specialty.

Surgical Triage after Trauma

Triage decisions are based on many factors, and may include a patient’s trauma score. These scores are an approximate way to aid assessment of how critical a patient’s medical condition is after physical trauma. There are many different trauma-scoring systems that may assist in the process of triage. The Revised Trauma Score (RTS) is one commonly used system to aid triage decisions. The RTS is based on physiological parameters, including vital signs. Blood pressure, respiratory rate, and level of consciousness all contribute to the RTS. Each parameter is worth a certain number of points, with higher points being better. An RTS score lower than 11 requires admission of the patient to a trauma center. Other types of trauma scoring systems may be geared toward different types of injuries: The Injury Severity Score (ISS), Penetrating Abdominal Trauma Index (PATI), Systemic Inflammatory Response Syndrome (SIRS), and ICD-based Injury Severity Score (ICISS) are all examples. The Abbreviated Injury Score (AIS) is often used to assist in triage for trauma surgery. The AIS is an anatomically based system of grading injuries from one to six, with one being minor injury and six being injury. For trauma conditions that are amenable to surgery, an appropriate scoring system may greatly influence who is brought to the trauma center and surgical triage decisions.

Triage Coding in Disasters

Triage officers in mass casualty situations may utilize the Simple Triage and Rapid Treatment (START) system. The START system is a very simple four category triage system that groups medical conditions as severe, urgent, minor, and beyond medical assistance. In advanced systems, patients triaged in emergency or mass casualty situations are often given a color-coded tag to help identify their status to other health care workers. Triage tag systems vary from country to country. In general, there are five categories each assigned to a color: immediate care required with possible positive outcome anticipated, urgent care required but may be briefly delayed, care required but may be extensively delayed, and immediate care required but the patient is realistically beyond saving.

Red is the color tag used for the group of patients requiring immediate care without which they would not survive. The red triage tag indicates that the patient is in an immediate medical crisis, and may be realistically saved given the medical facilities available. Red-tagged triage patients are given top priority over other colored. In surgical triage a red-tagged patient would gener be one who requires immediate surgery to save their life. If the medical facilities are substantial enough, some types of crippling injuries that are not life threatening may be given a red triage tag. For example, amputations may be triaged as red because surgical reattachment of severed or partially severed limbs must take place within minutes of the injury, in order to be salvaged.

Yellow is the color tag used for patients who require medical care urgently but who are not in immediate danger of losing their life. Yellow triage groups may be able to wait hours for medical treatment, but not days. Yellow is the group known as delayed priority. In surgical triage, yellow-tagged patients may require surgery within a specific time frame in order to maintain life. While yellow-tagged patients may be stable for the moment, triage is a dynamic process and medical conditions may deteriorate rapidly. A patient in the yellow triage category needs to be monitored while awaiting treatment and re-triaged if necessary.

Green is the color tag used for patients for whom medical care is a minor priority, and who may wait a number of days before treatment without risking life. An example of a green triage condition is a broken bone without compound fracture, which needs to be treated but will not endanger a patient’s life. The green category is sometimes referred to as the “walking wounded”. White is the color tag used for patients who have such minor injuries that a doctor’s care is not required. These patients are dismissed and would not be placed in a surgical triage situation.

Black is the triage color category that causes the most difficult ethical dilemma. The black triage tag is given to patients who are in immediate danger of losing their lives from injury or disease, but for whom medical treatment is unlikely to be successful. This category of triage is often given lowest priority when medical resources are scarce. The purpose of triage is to maintain the health of the greatest number of people. Resources devoted to black-tagged patients are often considered resources taken away from patients who may have benefited from them. For surgical triage, black-tagged patients are patients for whom surgery is unlikely to salvage. Potential examples of black-tagged surgical triage would be patients with extremely extensive burns or crush injuries.

Ethical Considerations of Triage

Triage systems have been developed to ensure the greatest number of people requiring medical care survive disease or injury. Unfortunately, medical resources are often limited, and not enough to give each and every patient ideal medical care. For black-tagged triage patients who are unlikely to survive despite medical care, this dilemma is especially poignant. Physicians are generally trained to see any patient under their care as one to whom the physician demonstrates fidelity by acting in the best interests of the patient over the interests of others. However in emergency triage situations it is necessary for triage officers to assign priority based on established guidelines. Any care given to black-tagged triage patients is considered care taken away from other patients who might have survived or suffered less severe disability if the resources had been used on them. In essence, physicians may greatly desire to treat any patient that requires help. However, in emergency situations they may need to put certain patients aside so as to use the available medical resources to save the lives of others. Since a physician’s time is considered a limited medical resource, especially in emergency or mass casualty situations, a patient may even be coded as black-tagged for triage if the amount of time necessary to save them is very long. With limited time to save as many as possible, a twenty-four hour procedure for one person may mean losing five others that could have been treated in the same time period. Triage is essentially designed to do the greatest good for the greatest number of patients in any given situation. However, accomplishing this goal often puts physicians in difficult ethical situations and an emotionally painful decision-making process.

KEY TERMS

Cardiac Disease— Any disease involving the heart.

Cardiac Tamponade— A condition in which the sac around the heart is filled with blood and keeps the heart from functioning properly.

Cardiothoracic Surgery— Surgery involving the chest body cavity known as the thoracic cavity.

Co-morbid Conditions— Diseases or disorders that exist simultaneously in one patient.

Computed Tomography (CT scan)— A computer uses x-rays across many different directions on a given cross section of the body, and combines all the cross sections to create one image. CT scans can be used to visualize bodily organs including the brain, blood vessels, bones, and the spinal cord. Contrast dye is sometimes administered to the patient to help visualize structures.

Hemorrhage— Excessive blood loss through blood vessel walls.

Mental Disability— The inability to mentally function due to injury, illness, or toxicity.

Neurological— Pertaining to the nervous system: peripheral nervous system, brain, and spinal cord.

Neurosurgery— Surgery involving the nervous system: peripheral nervous system, brain, and spinal cord.

Obstetrics and Gynecological Surgery— Surgery involving the reproductive organs or pregnancy.

Orthopedic Surgery— Surgery involving the musculoskeletal system, which includes muscles, tendons, joints, and bones.

Physiological— Pertaining to the normal vital life functions of a living organism.

Pulmonary Disease— Any disease involving the lungs.

Trauma Surgery— Surgery performed as a result of injury.

Vascular Surgery— Surgery involving blood vessels.

Vital Signs— The physiological aspects of body function basic to life. They are temperature, pulse, breathing rate, and blood pressure.

Resources

PERIODICALS

Dries, David J., Perry, John F. “Initial Evaluation of the Trauma Patient.” Emedicine (February 8, 2007). http://www.emedicine.com/med/topic3221.htm [accessed April 7, 2008].

Funderburke, P. “Exploring Best Practice for Triage.”Journal of Emergency Nursing 34 (2008): 180–82.

Good, L. “Ethical Decision Making in Disaster Triage.”Journal of Emergency Nursing 34 (2008): 112–15.

Iserson, K.V., Moskop, J.C. “Triage in Medicine, Part I: Concept, History, and Types.”Annals of Emergency Medicine 49, no. 3 (2007): 275–81.

Iserson, K.V., Moskop, J.C. “Triage in Medicine, Part II: Underlying Values and Principles.”Annals of Emergency Medicine 49, no. 3 (2007): 282–87.

Pohlman, Timothy H. “Trauma Scoring Systems.” Emedicine (July 16, 2007). http://www.emedicine.com/med/TOPIC3214.HTM [accessed April 7, 2008].

Stawicki, P.S., Pryor, J.P., Hyams, E.S., Gupta, R., Gracias, V.H., Schwab, C.W. “The Surgeon and the Intensivist: Reaching Consensus in Intensive Care Triage.”Journal of Surgical Education 64, no. 5 (2007): 289–93.

OTHER

Gilboy, N., Tanabe, P., Travers, D.A., Rosenau, A.M., Eitel, D.R. “Emergency Severity Index, Version 4: Implementation Handbook.” AHRQ Publication No. 05-0046-2, May 2005. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/esi/esil.htm [Accessed April 7, 2008].

Maria Basile, PhD

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