TRIAGE

Implementation of the Australian Triage Scale

dr. Aidyl Fitrisyah, SpAn

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 TRIAGE
An essential function in Emergency Departments
(EDs), where many patients may present
simultaneously.
Function:
Ensure that patients are treated in the order of their
clinical urgency which refers to the need for time-
critical intervention.
Allows for the allocation of the patient to the most
appropriate assessment and treatment area, and
contributes information that helps to describe the
departmental case-mix.

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 Triage Assessment

The first point of public contact with the ED

Assessment < 2-5 minutes with a balanced aim of

speed and thoroughness being the essence.

Involves a combination of the presenting problem

and general appearance of the patient, and may be
combined with pertinent physiological observations.

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 Triage Assessment

Vital signs should only be measured at triage if

required to estimate urgency, or if time permits.

Any patient identified as ATS Category 1 or 2

should be taken immediately into an appropriate
assessment and treatment area.

Not intended to make a diagnosis.

The initiation of investigations or referrals from

triage is not precluded if time permits.

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 Time to Treatment

The time to treatment described for each ATS

Category refers to the maximum time a patient in
that category should wait for assessment and
treatment

In the more urgent categories, assessment and

treatment should occur simultaneously.

Ideally, patients should be seen well within the

recommended maximum times.

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 Re-Triage

If a patients condition changes while one is waiting

for the treatment, or if additional relevant
information becomes available that impacts on the
patients urgency, the patient should be re-triaged.

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 Triage Colours

Red (Category 1)

Orange (Category 2),

Green (Category 3),

Blue (Category 4) and

White (Category 5),

are commonly utilised by EDs in order to identify each

ATS Category, and are recommended to be the
standard colours.
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 Category 1
ATS Response Description of Clinical Descriptors
Category Category

Category I Immediate Immediately Life- -Cardiac arrest

simultaneous Threatening -Respiratory arrest
RED assessment -Immediate risk to airway
and Conditions that impending arrest
treatment are threats to life -Respiratory rate <10/min
(or imminent risk -Extreme respiratory distress
of deterioration) -BP< 80 (adult) or severely shocked
and require child/infant
immediate -Unresponsive or responds to pain
aggressive only (GCS < 9)
intervention. -Ongoing/prolonged seizure
-IV overdose and unresponsive or
hypoventilation
-Severe behavioural disorder with
immediate threat of dangerous
8 violence
 Category 2
ATS Response Description of Clinical Descriptors
Category Category

Category 2 Assessment Imminently life- Airway risk severe stridor or

and treatment threatening drooling with distress
ORANGE within 10 Severe respiratory distress
minutes Important time- Circulatory compromise
(assessment critical treatment Chest pain of likely cardiac nature
and treatment Very severe pain - any cause
often Very severe pain Suspected sepsis (physiologically
simultaneous) unstable) Febrile neutropenia
BSL < 3 mmol/l
Drowsy, decreased responsiveness
any cause (GCS< 13)
Acute stroke
Fever with signs of lethargy (any age)
Acid or alkali splash to eye
requiring irrigation Suspected
9 endophthalmitis post-eye procedure
 Category 3
ATS Response Description of Clinical Descriptors
Category Category

Category 3 Assessment Potentially Life- Severe hypertension

and Threatening Moderately severe blood loss
GREEN treatment Moderate shortness of breath
start within Situational Seizure (now alert)
30 mins Urgency Persistent vomiting
Dehydration
Head injury with short LOC- now
alert Suspected sepsis
(physiologically stable)
Moderately severe pain
Chest pain
Abdominal pain
Moderate limb injury

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 Category 4
ATS Response Description of Clinical Descriptors
Category Category

Category 4 Assessment Potentially serious Mild haemorrhage

and Foreign body aspiration
BLUE treatment Situational Chest injury without rib pain
start within Urgency Difficulty swallowing
60 mins Minor head injury, no loss of
Significant consciousness
complexity or Moderate pain, some risk features
Severity Vomiting or diarrhoea without
dehydration
Eye inflammation or foreign body
normal vision
Minor limb trauma
Non-specific abdominal pain

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 Category 5
ATS Response Description of Clinical Descriptors
Category Category

Category 5 Assessment Less Urgent Minimal pain with no high risk

and features
WHITE treatment Clinico- Low-risk history and now
start within administrative asymptomatic
120 minutes problems Minor symptoms of existing stable
illness
Minor symptoms of low-risk
conditions
Minor wounds - small abrasions,
minor lacerations
Scheduled revisit e.g. wound review,
complex dressings

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Documentation Standards
Date and time of Initial triage category
assessment allocated

Name of triage officer Re-triage category with

time and reason
Chief presenting
problem(s) Assessment and treatment
are aallocated
Limited, relevant history
Any diagnostic, first aid or
Relevant assessment treatment measures
findings initiated

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