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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
Any emergency (including trauma and medical Major incident management also refers to surgical triage
emergencies) requires competent early assessment by which attempts to assist in determining priority in surgical
health care providers. Early prioritisation of patients is intervention.4
an essential competency that every nurse dealing with
emergencies should possess. Emergency centres are There are various forms of triage used throughout the
notoriously unpredictable in terms of patient load, with world, but this article will focus on the system used by
overcrowding and patient flow problems contributing South African nurses. Nurse triage in the United Kingdom
to potentially unsafe situations. Accurate statistics are is classified into two categories, direct and indirect triage.
sketchy, but in 2000, injuries alone caused 12% of deaths Indirect triage refers to telephone triage whereas direct
in South Africa. In the same year, an estimated 3.5 million triage is referred to as face-to-face triage. Direct triage
persons sought help as a result of trauma.1 It is thus of may be further classified into three categories:3
great importance to be able to identify the critically ill/ • Non-professional triage (where a receptionist may
injured quickly on their arrival, as well as categorise identify a problem at registration)
patients in order of urgency so as to provide safe and • Basic triage (which this article is concerned with )
efficient emergency care. This is achieved through, among • Advanced triage (where the nurse assesses the patient
other things, triage. 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 This article focuses on a basic triage technique, the South
the right time to receive the right level of care … the African Triage Scale (SATS) and will demonstrate the
allocation of appropriate resources to meet the patient’s simplicity of the instrument with practical examples.
medical needs.”2 Rendering the most appropriate type of Triage aids are discussed, and further advantages of triage
care within the shortest time possible is one of the most are described.
important aspects in the prevention of death and disability
in an emergency centre.3 Background

Triage not only refers to the classification of patients on Until recently, South African Emergency Centres did
arrival at the Emergency Centre or in the pre-hospital not have a uniform means of triaging patients. Some
arena, but also has other connotations within emergency Emergency Centres allocated triage colours or priorities
medicine. The Committee on Trauma of the American subjectively, whereas others used internationally designed
College of Surgeons in the Advanced Trauma Life Support triage instruments. Through research, an objective

Prof Nurs Today 24 2011;15(6)


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

ADULT TRIAGE SCORE


Over 12 years/taller than 150cm
3 2 1 0 1 2 3
Mobility Walking With help Stretcher/ Mobility
immobile
RR <9 9-14 15-20 21-29 > 29 RR
HR < 41 41-51 51-100 101-110 111-129 > 129 HR
SBP < 71 71-80 81-100 101-199 < 199 SBP
Temp Feels cold Feels normal Feels hot Temp
OR OR OR
< 35 35-38.4 > 38.4
AVPU Confused Alert Reacts to Reacts to Unreponsive AVPU
Voice Pain
Trauma No Yes Trauma

Colour Red Orange Yellow Green Blue


TEWS ≥7 5-6 3-4 0-2
Taget time to treat Immediate < 10 minutes < 60 minutes < 240 minutes
Mechanism of High-energy
injury 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 Dead
Presentation Fracture: Fracture: All other patients
compound closed
Burn > 20%
Burn: electrical
Burn: Burn: other
face/inhalation Burn:
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
Pain Severe Moderate Mild
Senior healthcare professional’s discretion

Figure 1: The Adult Triage Scale 9 (reproduced with permission)

Prof Nurs Today 25 2011;15(6)


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