FIVE-TIER TRIAGE MODEL

LECTURER:
Y.SURAHAYA MOHD YUSOF
BSc(Hons) Nursing Practice
Development New Castle UK.
k
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TRIAGE
Triage Level I Resuscitation
• Condition requiring immediate nursing and
physician assessment. Any delay in treatment is
potentially life or limb threatening.
• Condition includes:
- Airway compromise.
- Cardiac arrest.
- Severe shock cervical injury.
- Multisystem trauma.
- LOC
- Eclampsia.
-
Triage level II- emergent
• Require nursing assessment and physician assessment within 15 minutes of arrival.
• Conditions includes;
- Head injury.
- Severe trauma.
- Lethargic or agitation.
- Conscious over doses.
- Severe allergic reaction.
- Chemical exposure.
- Chest pain.
- Back pain
- GI bleed with unstable signs.
- Stroke
- Severe asthma.
- Abdominal pain in patients older than age 50. vomiting & diarrhoea with dehydration.
- Fever in infants less than 3 month

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Triage II
- Ac. Psychotic
- Severe headache.
- Any pain greater then 7 on a scale of 10
- Any sexual assault
- Any neonate age 7 day/ younger
-
Triage level III-Urgent
• Requiring nursing and physician assessment
within 30 minute of arrival.
• Condition;
- Alert head injury with vomiting.
- Mild to moderate asthma.
- Moderate trauma
- Abuse and neglect
- GI bleed with stable vital signs
- History of seizure alert on arrival.
Triage level IV- less urgent
• Requiring nursing and physician assessment
within one hour( within 1h)
• Condition include:
- Alert head injury without vomiting.
- Minor trauma
- Vomiting and diarrhoea in patient older without
evidence of dehydration.
- Minor allergic reaction and chronic back pain.
Triage level V- Non Urgent
• Requiring nursing and physician assessment
within 2 hours.
• Conditions include:
• Minor trauma not acute.
• Sore throat.
Reassessment of intervention is
important to give:
• Client feel that they will not be forgotten if have a
place and staff.
• Supporting or caring give them comfort.
Triage System
• Start from lobby at main entrance of A&E
department, where the triage nurse can see
and observe client and family.
• Give a chance to see professional staff.
• The family also feel that they can easily get any
information regarding their family.
Triage History
• The nurse need to analyse client complain.
• Which is the symptom can get through PQRST
• P: Provokes
 - What provokes the symptom? ( make a
better or worse).
• Q: Quality.
 - What does it feel like? Patient own
description word
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
Triage history
• S: severe:
severe
 - rate it on scale 1-10
• T: Time.
Time
 - How long have you had this?
 - Has it ever happened before?
• T: treatment.
 - treatment prior to arrival( including home
remedies).
 - what has worked before?
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references
• Trauma centre. UIA ( University Islam
Antarabangsa).
• Emergency and disaster nursing. Ampang Putri
specialist hospital.