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
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Emergency Medicine: The South African Triage Scale: a tool for emergency nurses
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
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Reacts to
Pain
Mobility
RR
HR
SBP
Temp
Unreponsive AVPU
Trauma
Green
0-2
< 240 minutes
Mild
Blue
Dead
Emergency Medicine: The South African Triage Scale: a tool for emergency nurses
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.
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Emergency Medicine: The South African Triage Scale: a tool for emergency nurses
A step-by-step approach
Mobility: mobile
Temperature: 36.2C
AVPU: alert
Trauma: no
Total TEWS
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.
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Emergency Medicine: The South African Triage Scale: a tool for emergency nurses
Intervention
Temperature 38.5
Temperature 35
Blankets
Altered level of
consciousness
(AVPU score other than A)
Chest pain
Active bleeding
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
References
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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