Triage

Introduction

Provision of high-availability quality medical care is expensive and has been traditionally limited to the very wealthy or to situations of great demand, such as the military in battle. Even today, well-organized emergency medical systems are concentrated in societies sufficiently affluent to spend 5% or more of Gross Domestic Product (GDP) on health. Some form of rationing is required whenever an expensive resource is coupled with fluctuating demand. Price, queuing and denial are all used in different areas of medicine. Simple application of any of these methods in emergency medicine would not be efficient nor equitable, so the majority of emergency medical systems use a triage process to sort patients into a number of queues.

Triage, the sorting of patients on the basis of urgency, is an ongoing process that nevertheless requires formal structures at different points within the continuum of care. In the emergency department (ED) setting there is considerable evidence that urgency can be assigned reliably and distinctly on a five-level scale and that this categorization is applicable and useful beyond the concept of ‘urgency’ into other aspects of hospital care.

Origins of triage

The word ‘triage’, arising from the French ‘trier’ meaning ‘to sort’ has its origins in Latin. It has entered English at least three times: from the 18th century wood industry, the 19th century coffee industry and from 20th century emergency medicine. The process understood today as triage was first described by Baron Dominique Jean-Larrey (1766–1842), the surgeon to Napoleon, who also developed the ambulance volante, the first field ambulance. This delivered large numbers of injured but salvageable cases to medical units, mandating a more efficient system than treatment in order of military rank. Jean-Larrey’s ‘order of dressing and arrangement’ by urgency was also in keeping with the egalitarian spirit of the French revolution, although there is no evidence that he actually used the word triage. His concept was embraced and refined by military surgeons over the next 150 years, usually with the primary intent of returning soldiers to battle in the most efficient manner.

Civilian triage developments

There was certainly some sorting of patients from the moment ‘casual wards’ opened in 19th century hospitals, but the first systematic description in civilian medicine was in Baltimore in 1966. Since that time, there has been a huge growth in emergency medicine as a specialty and a number of workers have undertaken formal investigation of triage, particularly in Australasia. The Australasian experience formed the basis of ED triage development in Canada and the UK, while some other jurisdictions have developed systems independently.