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Emergency Medicine: The South African Triage Scale: a tool for emergency nurses

The South African Triage Scale:


a tool for emergency nurses

Augustyn JE, MA(Health Studies), BCur, Dipl Nursing Education,


Nurse Educator (Emergency Nursing), Medi-Clinic Learning Centre, Western Cape
Correspondence to: Jean Augustyn, e-mail: jean.augustyn@mediclinic.co.za
Keywords: Triage Scale, emergency nursing, South Africa

Abstract

Triage is considered as one method of enhancing the business of an operationally healthy emergency centre.
Emergency nurses should all be able to identify life-threatening conditions quickly and prioritise patients to provide
safe emergency care. This article describes the South African Triage Scale, a tool researched and validated in South
Africa, and demonstrates the simplicity of the instrument with practical examples. Further advantages of triage are
described and the concept of triage aids is also illustrated.

Introduction

(ATLS) manual refer to triage criteria in enhancing


decision-making for the transfer of seriously injured.3
Major incident management also refers to surgical triage
which attempts to assist in determining priority in surgical
intervention.4

Any emergency (including trauma and medical


emergencies) requires competent early assessment by
health care providers. Early prioritisation of patients is
an essential competency that every nurse dealing with
emergencies should possess. Emergency centres are
notoriously unpredictable in terms of patient load, with
overcrowding and patient flow problems contributing
to potentially unsafe situations. Accurate statistics are
sketchy, but in 2000, injuries alone caused 12% of deaths
in South Africa. In the same year, an estimated 3.5 million
persons sought help as a result of trauma.1 It is thus of
great importance to be able to identify the critically ill/
injured quickly on their arrival, as well as categorise
patients in order of urgency so as to provide safe and
efficient emergency care. This is achieved through, among
other things, triage.

There are various forms of triage used throughout the


world, but this article will focus on the system used by
South African nurses. Nurse triage in the United Kingdom
is classified into two categories, direct and indirect triage.
Indirect triage refers to telephone triage whereas direct
triage is referred to as face-to-face triage. Direct triage
may be further classified into three categories:3
Non-professional triage (where a receptionist may
identify a problem at registration)
Basic triage (which this article is concerned with )
Advanced triage (where the nurse assesses the patient
and may initiate certain investigations, such as X-rays
and blood investigations).

Triage is derived from the French word trier and


is defined as putting the patient in the right place at
the right time to receive the right level of care the
allocation of appropriate resources to meet the patients
medical needs.2 Rendering the most appropriate type of
care within the shortest time possible is one of the most
important aspects in the prevention of death and disability
in an emergency centre.3

This article focuses on a basic triage technique, the South


African Triage Scale (SATS) and will demonstrate the
simplicity of the instrument with practical examples.
Triage aids are discussed, and further advantages of triage
are described.
Background
Until recently, South African Emergency Centres did
not have a uniform means of triaging patients. Some
Emergency Centres allocated triage colours or priorities
subjectively, whereas others used internationally designed
triage instruments. Through research, an objective

Triage not only refers to the classification of patients on


arrival at the Emergency Centre or in the pre-hospital
arena, but also has other connotations within emergency
medicine. The Committee on Trauma of the American
College of Surgeons in the Advanced Trauma Life Support

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Emergency Medicine: The South African Triage Scale: a tool for emergency nurses

ADULT TRIAGE SCORE


Over 12 years/taller than 150cm
3

Mobility
RR

With help

Stretcher/
immobile

9-14

15-20

21-29

> 29

101-110

111-129

> 129

<9

HR
SBP

0
Walking

< 71

< 41

41-51

51-100

71-80

81-100

101-199

< 199
Feels hot
OR
> 38.4

Temp

Feels cold
OR
< 35

Feels normal
OR
35-38.4

AVPU

Confused

Alert

Reacts to
Voice

No

Yes

Trauma
Colour
TEWS
Taget time to treat
Mechanism of
injury

Presentation

Pain

Red
7
Immediate

Orange
Yellow
5-6
3-4
< 10 minutes
< 60 minutes
High-energy
transfer
Shortness of breath:
acute
Coughing blood
Chest pains
Haemorrhage:
Haemorrhage:
uncontrolled
controlled
Seizure: current
Seizure: postictal
Focal neurology:
acute
Level of
consciousness:
reduced
Psychosis/
aggression
Threatened limb
Dislocation:
Dislocation:
other joint
finger or toe
Fracture:
Fracture:
compound
closed
Burn > 20%
Burn: electrical
Burn:
Burn: other
Burn:
face/inhalation
circumferential
Burn: chemical
Poisoning/overdose
Abdominal pain
Hypoglycaemia:
Diabetic:
Diabetic:
glucose < 3 mmol/l glucose < 11 mmol/l glucose > 17 mmol/l
and ketonuria
and no ketonuria
Vomiting:
Vomiting:
fresh blood
persistent
Pregnancy and
Pregnancy and
abdominal trauma
trauma
or pain
Pregnancy and PV
bleed
Severe
Moderate
Senior healthcare professionals discretion

Figure 1: The Adult Triage Scale9 (reproduced with permission)

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Reacts to
Pain

Mobility
RR
HR
SBP
Temp

Unreponsive AVPU
Trauma

Green
0-2
< 240 minutes

All other patients

Mild

Blue

Dead

Emergency Medicine: The South African Triage Scale: a tool for emergency nurses

Child tool (age three to 12 years or length 96150cm)


Infant tool (age under three years or length under
95cm)

triage tool was developed and validated by the Cape


Triage Group from 2005 and later expanded when the
SATS was introduced into South African Emergency
Centres from 2007 (personal e-mail communication
from Wallis LA, 2011 Jan 19). The researchers found
that the implementation of the then Cape Triage Score
dramatically reduced patients waiting times.5 Another
feature of the implemented Scale was its simplicity,
allowing even the most junior of nursing personnel, i.e.
enrolled nurse auxiliaries, to triage patients.6

Figure 1 demonstrates the adult triage tool. Each tool


consists of a Triage Early Warning Score (TEWS) and a
discriminator list.
The TEWS assesses the patients:
Mobility
Respiratory rate
Heart rate
Systolic blood pressure
Temperature
Level of consciousness using the AVPU (alert, responds
to voice, responds to pain, unresponsive) scale
History of trauma

The use of triage is recommended for several reasons,


including:3,6
Emergency treatment delivery is accelerated for
patients with life-threatening conditions or injuries.
All patients requiring emergency care are categorised
according to their clinical status.
Patient flow through emergency centres improves (thus
decreasing overcrowding).
Patient satisfaction increases (and aggression may be
prevented).
Patients length of stay decreases.
Allowance is made for streaming of less urgent patients.
Improved infection control (e.g. through management
of blood spills, as well as patients with potential
infectious diseases)
Improved personnel satisfaction (reduction of stress,
particularly in frontline reception personnel)
Prediction of potential hospital admissions

The Triage Early Warning System was specifically


designed and researched for the South African
emergency care context. It is derived from the British
Modified Early Warning System which was designed as
an in-patient early warning system for medical patients.
This concept acts as an early warning system for
deteriorating patients and assists health care providers
to intervene earlier in the patients care. The TEWS,

Triage logistics
The South African Triage Group (SATG) offers
recommendations on location and equipment6 which
sometimes leads practitioners to believe that triage
should be performed by a dedicated triage nurse in a
dedicated triage area. Where a constant influx of patients
is present and nursing personnel are inundated, a
dedicated triage nurse is recommended. Triage practices
should therefore be flexible to suit the existing situation.
Should the emergency centre be quieter and nurses able
to receive patients in the treatment area immediately,
patients should be assessed immediately in the treatment
area and triaged concurrently. This is also recommended
in cases where an obvious (life-threatening) emergency
presents.
The triage should be performed by competent personnel.
The SATG states that any category of nurse may perform
triage,6 with the proviso that adequate training has been
given in the use of the SATS.

The South African Triage Scale


The SATS consists of three age-specific tools that are
used to assist the health care provider during the triage
process:68
Adult tool (age over 12 years or length over 150cm)

Prof Nurs Today

Figure 2: A stepwise process to determine a patients


triage colour6
a = Triage Early Warning Score

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Emergency Medicine: The South African Triage Scale: a tool for emergency nurses

Step 3: Calculate the Triage Early Warning Score

however, has also been amended so as to consider the


trauma patient.6,7

Score the findings in Step 2 against the TEWS scoring


sheet (Figure 1).
The range in which the patients vitals fall is matched to
the score and a total TEWS score is calculated.
The presence of trauma is also considered in the TEWS
calculation.

The discriminator list below the TEWS table consists of:


TEWS colour classification
Target time to treat
Symptom list
Pain classification
Provision for the senior health care professionals
(HCP) discretion

Mrs Mpendus TEWS is calculated:

A step-by-step approach

Mobility: mobile

Respiratory rate: 16 breaths/minute

Triage should be short and succinct, and the steps


illustrated in Figure 2 are designed to guide the nurse
through the process quickly so as to reach a conclusion.68
A specific case study follows so as to illustrate the triage
process practically.

Heart rate: 105 beats/minute

Systolic blood pressure: 145 mmHg

Temperature: 36.2C

AVPU: alert

Trauma: no

Step 1: Obtain a brief history

Total TEWS

Step 4: Match TEWS score to discriminator list and


search for any other relevant discriminators

A brief history should be obtained regarding the main


complaint.
The nurse should try to get to the essence of the
emergency as soon as possible by asking What is
your emergency?6 or, Why are you here today?

The calculated TEWS score is matched to the colour


allocation in the discriminator list (Figure 1) and the
patient is allocated a triage colour.
Once the initial colour has been identified based
on the TEWS score, a nurse should assess for any
discriminator which is applicable to the patients
situation.
The discriminators which should be assessed should lie
to the left of the colour selected. These discriminators
may also act as prompting questions for the nurse in
assessing the patient accurately.
It should be noted that the TEWS will categorise a
patient accordingly if the patient displays abnormal
physiology. However, there are specific situations (listed
in the discriminator list) where the TEWS may not
identify such situations safely and so the discriminator
list acts as a safety net.6

Case history:
Mrs Mpendu visits the emergency centre. She walks into the
department, complaining of central chest pain, stabbing and
severe in nature. The pain started an hour ago while she was
shopping and is unrelieved by nitrates. The pain radiates to
her left shoulder.

Step 2: Measure vital signs


Assess the patients vital signs including heart rate,
respiratory rate, temperature and blood pressure.
Determine the patients level of consciousness by using
the AVPU scale. The patients best response should be
noted. AVPU is determined by observing the patient,
speaking to him/her or providing a painful stimulus.
The patient is then noted to be alert (A), responsive
to verbal stimulus (V), responsive to pain (P) or
unconscious (U).
Document the patients mobility as being either
walking, on a stretcher or requires assistance (with
help).

It is beyond the scope of this article to define each


discriminator. However, two definitions that require
mention are as follows, according to the SATG:6
High energy transfer: Excessive accelerationdeceleration injuries. Examples include fall from
a height (over 2 m) and high speed motor vehicle
collisions (over 50 km/h).
Threatened limb: An acute insult to a limb characterised
by pallor, pulselessness and coldness, which includes
sensory and or motor deprivation.

Mrs Mpendus vitals are obtained:


Respiratory rate: 16 breaths/minute
Heart rate: 105 beats/minute
Blood pressure: 145/90 mmHg
Temperature: 36.2C
AVPU: Alert

Patients may only be up-triaged (from the initial colour


selected) and never down-triaged as a rule. Only senior
health care providers may amend the triage colour.6

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Emergency Medicine: The South African Triage Scale: a tool for emergency nurses

Step 5: Determine actual triage colour according to


the discriminator list

latter should be instituted time permitting.


These aids enhance management at triage (e.g. through
administration of oxygen) and may also assist in
further assessment of the patient (e.g. by performing
an electrocardiogram or pulse oximetry).

The final triage colour is selected if any discriminators


are applicable to the situation. If none are applicable,
the original colour is allocated.
Pain severity should also be considered.
Senior health care professionals, who have more
experience, may finally amend the triage colour. Any
such amendments should always be documented.

Triage aids are considered:


The doctor is called immediately and the nurse obtains an
electrocardiogram so that a complete cardiac assessment may
be performed.

Mrs Mpendus final triage colour is determined:


Mrs Mpendus TEWS totals 2. The TEWS is matched to a
triage colour and green is selected. However, the remainder
of the discriminators are assessed, and chest pain as well as
severe pain is noted under orange. No further applicable
discriminators fall to the left of orange. The final triage colour
is therefore orange.

Finally, the management recommended by the SATG is


as follows:6
Red patients should be referred to the resuscitation
room/bay for emergency immediate management.
Orange patients should be referred to the treatment
area for urgent management.
Yellow patients should be referred to the treatment area
for medical management within one hour at most.
Green patients may be streamed (depending on the
facilitys policy).
Blue patients require certification by the attending
doctor.

Step 6: Utilise triage aids if required and document


findings
Once triaged, the patient should be managed accordingly:
The SATG recommend certain triage aids (examples
in Table I) which may be instituted at triage as per the
policy of the specific emergency centre.
There are compulsory and optional interventions. The

Streaming refers to the use of a dedicated health care


practitioner (such as a doctor or nurse) for the specific
group of patients who will then manage them in a
dedicated room.6

Table I: Interventions to be carried out at triage (excerpt


reproduced with permission)10

Emergency nursing requires adaptability and so common


sense should prevail at all times. Any obvious lifethreatening situation should be managed immediately
and the triage process should never deter the nurse from
instituting basic life support. Any obvious red patient
should be managed immediately as per resuscitation
protocols. Such situations include, for example,
cardiopulmonary resuscitation (CPR) in an apnoeic/
asystolic patient and active seizures.

Interventions to be carried out at triage


Problem

Intervention

Respiratory rate scores


1 point

Pulse oximetry (saturation)


Finger prick glucotest if
patient is diabetic
Refer to anteroom and give
oxygen

Temperature 38.5

Paracetamol 1g orally stat


(document in notes )
Children - discuss with sister
or doctor

Temperature 35

Blankets

Altered level of
consciousness
(AVPU score other than A)

Refer to anteroom and hand


patient over to a senior
health care professional
Finger prick glucotest

Unable to sit up/needs to lie


down

Refer to anteroom and hand


patient over to a senior
health care professional
Finger prick glucotest

Chest pain

Immediate ECG and present


to a senior health care
professional

Active bleeding

Apply pressure to site of


trauma with a dry dressing
ant take to anteroom
Hb to obtain baseline

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The SATG has identified one vulnerable population,


neonates (infants under one month of age), who are
always to be triaged red and therefore should be seen by a
senior nurse or doctor immediately.6

Target time to treat


The discriminator list contains one line which describes
the ideal time within which the patient should receive
assistance.6 These times should be seen as the maximum
time-to-treat and ideally the patient should be assisted
much faster than that listed.

Doctor triage
Triage is not restricted to nurses. Doctor (physician)
triage is a relatively new concept in South Africa and
aims to bring the doctor closer to the patient on arrival,

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Emergency Medicine: The South African Triage Scale: a tool for emergency nurses

thereby reducing length of stay in the emergency centre.


This strategy is particularly helpful during busy periods
or when all treatment beds are occupied.11 This still needs
further investigation and with the resource constraints
that South Africa is faced with, in general, appears not to
be a common phenomenon locally.

South African Triage Scale [document online]. 2010.


Available from: http://emssa.org.za/documents/
em014.pdf
3. Wallis L, Smith W. Disaster medicine. Claremont: Juta
and Company, Ltd; 2011.

References

Major incident triage

1. Van Niekerk A, Suffla S, Seedat M. Crime, violence and injury


prevention in South Africa: data to action. Cape Town: South
African Medical Research Council and University of South Africa;
2008.
2. Gilboy N. Triage. In: Howard PK, Steinmann RA, editors. Sheeys
emergency nursing: principles and practice. 6th ed. St Louis: Mosby
Elsevier, 2010; p. 59.
3. Augustyn JE. An investigation into the implementation of an
emergency unit triage system in a selected private hospital [MA Cur
dissertation]. Pretoria: University of South Africa; 2006.
4. Wallis LA, Smith W. Disaster medicine. Claremont: Juta and
Company, Ltd; 2011.
5. Bruijns SR, Wallis LA, Burch VC. Effect of introduction of nurse
triage on waiting times in a South African emergency department.
Emerg Med J. 2008;25:395397.
6. The South African Triage Group. South African triage scale
hospital provider manual. 2nd ed. South African Triage Group
Subgroup on Training; 2008.
7. Bruijns SR, Wallis LA, Burch VC. A prospective evaluation of the
Cape triage score in the emergency department of an urban public
hospital in South Africa. Emerg Med J. 2008; 25:398402.
8. Emergency Medicine Society of South Africa. EMSSA Practice
Guideline EM014: implementation of the South African Triage Scale
[document online]. 2010 [cited 2011 Jan 10]. Available from: http://
emssa.org.za/documents/em014.pdf
9. South African triage scale: Adult triage score. The South African
Triage Group [homepage on the Internet]. 2011. [cited 2011 Sept
23]. Available from: http://emssa.org.za/documents/sats/ADULT_
A4.pdf
10. South African triage scale: flowchart. The South African Triage
Group [homepage on the Internet]. 2011. [cited 2011 Sept 23].
Available from: http://emssa.org.za/documents/sats/FLOWCHART.
pdf
11. Pimental L. The healthy emergency department. In: Crosskerry
P, Cosby KS, Schenkel SM, Wears RL, editors. Patient safety in
emergency medicine. Philadelphia: Lippincott, Williams & Wilkins,
2009; p. 43.

It is important to note that the SATS is not recommended


for use in major incidents where globally a simpler
triage scale is used. The triage strategy taken on by many
emergency centres in South Africa, in times of major
incidents (or disasters as some may know them),
differs. In these cases, the South African Triage Scale
is impractical and so the Triage Sieve and Triage Sort
methods are recommended (see under Recommended
Reading).4

Conclusion
An operationally healthy emergency department places
emphasis on early physical evaluation of all patients.11
Triage seeks to address this essential operational
requirement by ensuring that the nurse assesses and
prioritises patients in need of emergency care as quickly
as possible. There is no absolute magic bullet (i.e. triage
system) which will solve all patient-flow problems, but the
effective use of triage will only enhance the care delivered
by an operationally healthy emergency centre.

Recommended reading
1. South African Triage Scale resources [homepage on
the Internet]. No date. Available from: http://emssa.
org.za/sats/
2. Emergency Medicine Society of South Africa. EMSSA
Practice Guideline EM014: implementation of the

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