Triage and Nursing

The presentation is based on the following outlines:-









The main objective of triage is to ensure a prompt and orderly assessment of all patients coming to the emergency services, identifying those that require immediate attention.


Triage is the process of determining priority of the patients’ treatments based on the severity of their conditions. Triage can also be define ad the principle or practice of sorting casualties in battle or disaster into categories of priority for treatment. Triage is the process of quickly examining sick or injured people, for example after an accident or a battle, so that those who are in the most serious condition can be treated first.


Triage is derived from the French word TIER, “to sort/separate or select”. A process of determining the severity of patients and prioritizing them according to their medical urgency, initially used to sort agricultural products, during disaster, in the battle field and even on telephonic advice, however presently it is exclusively used in specific health care context like hospital EDs (emergency department), and in ambulatory medical services.

Dominique Jean Larrey, was the first to own most of the triage ideas during the Napoleonic Wars. Triage was then formalized during World War I to treat the injured solders in battlefields. Historically, there has been a broad range of attempts to triage patients, and differing approaches and patient tagging systems were used in different countries. Since the last century, triage is modified with scientific and modern approaches and more logically dependent on physiological needs and assessment findings of patients. Assess, Categorization/transport are the bases of all triage.

Triage refers to the evaluation and categorization of the sick or wounded when there are insufficient resources for medical care of everyone at once. Historically, triage is believed to have arisen from systems developed for categorization and transport of wounded soldiers on the battlefield. Triage is used in a number of situations in modern medicine, including:

In mass casualty situations, triage is used to decide who is most urgently in need of transportation to a hospital for care (generally, those who have a chance of survival but who would die without immediate treatment) and whose injuries are less severe and must wait for medical care.


In a disaster or mass casualty situation, different systems/types for triage have been developed, viz:

1:- Simple Triage and Rapid Treatment (START). In START, victims are grouped into four categories, depending on the urgency of their need for evacuation. If necessary, START can be implemented by persons without a high level of training.

The categories in START are:

  • a:- The deceased, who are beyond help
  • b:- The injured who could be helped by immediate transportation
  • c:- The injured with less severe injuries whose transport can be delayed
  • d:- Those with minor injuries not requiring urgent care.

2:- Another type that has been used in mass casualty situations is an example of advanced triage implemented by nurses or other skilled personnel. This advanced triage system involves a color-coding scheme using red, yellow, green, white, and black tags:

  • Red tags – (immediate) are used to label those who cannot survive without immediate treatment but who have a chance of survival.
  • Yellow tags – (observation) for those who require observation (and possible later re-triage). Their condition is stable for the moment and, they are not in immediate danger of death. These victims will still need hospital care and would be treated immediately under normal circumstances.
  • Green tags – (wait) are reserved for the ” walking wounded” who will need medical care at some point, after more critical injuries have been treated.
  • White tags – (dismiss) are given to those with minor injuries for whom a doctor’s care is not required.
  • Black tags – (expectant) are used for the deceased and for those whose injuries are so extensive that they will not be able to survive given the care that is available.

3:- MASS ( Move, Asses, Sort, Send):- This type of triage divides patients into categories based on their ability to move

  • Move: “every one who can hear me and needs medical attention please move to designated area now”.
  • Assess:- non ambulating, every one who can raise an arm or leg.
  • Sort:- Proceed to the remaining victims.

Pic Source: Journal of Pakistan Medical Association

The following will also help you in categorizing the patients

  • Triage I: The patient requires immediate attention. The patient’s condition is life-threatening and needs resuscitation because of a ventilatory, neurological, respiratory or hemodynamic compromise, loss of limb or organ or other conditions requiring immediate care, by law.
  • Triage II: The patient’s clinical condition can evolve rapidly to deterioration or death, or increase the risk for the loss of a limb or organ, therefore requiring care not to exceed thirty (30) minutes. Extreme pain identified according to the classification system used must be considered as a criterion in this category.
  • Triage III: The patient’s clinical condition requires diagnostic and therapeutic measures in emergency. These are patients who need further examination or rapid treatment, considering they are stable from a physiological point of view, but their situation may worsen if nothing is done.
  • Triage IV: The patient has medical conditions that neither compromise the overall state nor represent an obvious risk to life or loss of limb or organ. However, there are risks of complications or consequences of the illness or injury if the patient does not receive appropriate care.
  • Triage V: The patient has a medical condition related to acute or chronic problems without evidence of weakening that could compromise the general condition of the patient and does not represent an obvious risk to life, or limb or organ functionality.


A Triage Nurse is a registered nurse positioned in an emergency room (ER) or facility; responsible for assessing patients and determining their level of need for medical assistance. The criteria used to evaluate a patient include the type of injury or illness, its severity, symptoms, patient explanation of emergency, and vital signs. A Triage Nurse is typically the first point of clinical contact for patients visiting an ER.

  • a) Perform patient assessment
  • (b) Reassess patients who are waiting
  • (c) Initiate emergency treatment if necessary
  • (d) Manage and communicate with patients in waiting room
  • (e) Provide education to patients and families when necessary
  • (f) Sort patients into priority groups according to guidelines
  • (g) Transport patients to appropriate treatment areas
  • (h) Communicate status of patients to doctors and nurses
  • (i) In situations when a patient’s condition is life-threatening, Triage Nurses are tasked with providing immediate medical treatment. In some facilities they answer patient phone calls and offer medical assistance.


  • (I) You do not decide who lives or dies.
  • (II) The sooner you start the triage, the sooner the medical care starts.
  • (III) Triage is an ongoing process that can be repeated many times.


(1) Journal of Pakistan medical association Emaduddin Siddiqui (August, 2012)

(2) Webster’s New world college dictionary, 4th edition, 2010, Huoghton Mifflin Harcourt

(3) Minsalud Republica de Colombia(


(5) triage

(6) COBUILD Advanced English Dictionary

credit 👉👉 Nursing World Nigeria

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