How is triage carried out in the emergency department? The START and CESIRA methods
Triage is a system used in Accident and Emergency Departments (EDAs) to select those involved in accidents according to increasing classes of urgency/emergency, based on the severity of the injuries sustained and their clinical picture
How to carry out triage?
The process of assessing users must involve gathering information, identifying signs and symptoms, recording parameters and processing the data collected.
In order to carry out this complex process of care, the triage nurse makes use of his or her professional competence, the knowledge and skills acquired during education and training in triage and his or her own experience, as well as other professionals with whom he or she cooperates and interacts.
Triage is developed in three main phases:
- visual” assessment of the patient: this is a practically visual assessment based on how the patient presents him/herself before having assessed him/her and identified the reason for access. This phase makes it possible to identify from the moment the patient enters the emergency department an emergency situation requiring prompt and immediate treatment: a patient who arrives at the emergency department unconscious, with an amputated limb and copious bleeding, for example, does not need much more evaluation to be considered a code red;
- subjective and objective assessment: once emergency situations have been ruled out, we proceed to the data collection phase. The first consideration is the patient’s age: if the subject is less than 16 years old, paediatric triage is performed. If the patient is over 16 years old, adult triage is performed. The subjective assessment involves the nurse investigating the main symptom, the present event, pain, associated symptoms and past medical history, all of which should be done through targeted anamnestic questions as quickly as possible. Once the reason for access and anamnestic data have been identified, an objective examination is conducted (mainly by observing the patient), vital signs are measured and specific information is sought, which may be derived from an examination of the body district affected by the main symptom;
- Triage decision: At this point, the triagist should have all the necessary information to describe the patient with a colour code. The decision of such a code is however a very complex process, which relies on quick decisions and experience.
The triagist’s decision is often based on actual flow charts, such as the one shown at the top of the article.
One of these diagrams represents the “S.T.A.R.T. method”.
Triage by S.T.A.R.T. method
The acronym S.T.A.R.T. is an acronym formed by:
To apply this protocol, the triagist must ask four simple questions and perform only two manoeuvres if necessary, airway disobstruction and stopping massive external haemorrhage.
The four questions form a flow chart and are:
- is the patient walking? YES= code green; if NOT walking I ask the next question;
- is the patient breathing? NO= airway disobstruction; if they cannot be disobstructed = code black (unsalvageable patient); if they are breathing I assess the respiratory rate: if it is >30 respiratory acts/minute or <10/minute = code red
- if the respiratory rate is between 10 and 30 breaths, I move on to the next question:
- is the radial pulse present? NO= code red; if pulse is present, go to the next question:
- is the patient conscious? if he carries out simple orders = code yellow
- if not carrying out simple orders = code red.
Let us now look at the four questions of the S.T.A.R.T. method individually:
1 CAN THE PATIENT WALK?
If the patient is walking, he should be considered green, i.e. with low priority for rescue, and move on to the next injured person.
If he is not walking, move on to the second question.
2 IS THE PATIENT BREATHING? WHAT IS HIS RESPIRATORY RATE?
If there is no breathing, attempt airway clearance and placement of an oropharyngeal cannula.
If there is still no breathing, disobstruction is attempted and if this fails the patient is considered unrescetable (code black). If, on the other hand, breathing resumes after a temporary absence of breath, it is considered code red.
If the rate is greater than 30 breaths/minute, it is considered code red.
If it is less than 10 breaths/minute, it is considered code red.
If the rate is between 30 and 10 breaths, I proceed to the next question.
3 IS RADIAL PULSE PRESENT?
The absence of a pulse means hypotension due to various factors, with cardiovascular decompensation, therefore the patient is considered red, is positioned in antishock respecting the alignment of the spine.
If radial pulse is absent and does not reappear, it is considered code red. If the pulse reappears it is still considered red.
If a radial pulse is present, a systolic pressure of at least 80mmHg can be attributed to the patient, so I move on to the next question.
4 IS THE PATIENT CONSCIOUS?
If the patient responds to simple requests such as: open your eyes or stick out your tongue, the brain function is sufficiently present and is considered yellow.
If the patient does not respond to requests, he is categorised as red and placed in a safe lateral position respecting the alignment of the spine.
The C.E.S.I.R.A. method is an alternative method to the S.T.A.R.T. method.
We will elaborate on it in a separate article.