What is triage?
The term triage comes from the French and means “sifting” or “sorting”. This is exactly what triage in medicine is all about: professionals (e.g. paramedics, doctors) “triage” injured or sick people and check who needs immediate help and who does not.
They also assess who is most likely to benefit from treatment and who is most likely to survive. Triage is particularly relevant and necessary when medical care options are limited. The aim is to save as many lives as possible despite the scarcity of resources.
The principle of triage was introduced by the army surgeon Dominique-Jean Larrey on the battlefields of the 18th century. Today, doctors and paramedics use it primarily in emergency medicine and in the event of a disaster. However, in view of a possible intensive care collapse in the coronavirus pandemic, the principle of triage could also become necessary in hospitals.
Triage in the corona pandemic
As the number of infections rises, the incidence of severe Covid-19 is also increasing. As a result, intensive care beds in particular are becoming scarce at times. If more patients then needed such beds than were available, doctors would have to “triage” – i.e. choose who they can and cannot treat in intensive care.
Doctors only apply triage once all options have been exhausted. To this end, the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) has compiled a recommendation specifically for the Covid-19 pandemic. The aim is to prevent deaths due to a lack of resources.
How does triage work in hospitals?
Clinical triage is primarily concerned with one thing: the chances of recovery for seriously ill patients. Ideally, comprehensive information about the individual patients is available in order to make the best possible assessment. This includes
- General condition, frailty (e.g. using the Clinical Frailty Scale)
- other existing illnesses (comorbidities) that limit the prospects of success
- Current laboratory values
- Condition of organ functions (e.g. respiratory activity, liver and kidney function, cardiovascular performance, function of the central nervous system)
- Previous course of the disease
- Response to previous therapy
Current experience and findings are also incorporated into the assessment, for example on the course of an illness in certain situations. This also means that the responsible specialists are constantly making new triage decisions. They adjust decisions that have already been made if necessary, for example if new treatment options arise.
Principle of equal treatment in triage
Self-culpability or vaccination status should not play a role either. In the current situation, this means that vaccinated patients are not given preference over unvaccinated patients. In addition, the treatment team always assesses all seriously ill patients. During the coronavirus pandemic, triage is therefore not only taking place for Covid-19 patients.
What does the Federal Constitutional Court say?
On December 28, 2021, the Federal Constitutional Court ruled that the legislator must take concrete precautions to protect people with disabilities in the event of a pandemic-related triage. Several people with disabilities and pre-existing conditions had filed a lawsuit.
Their concern was that doctors could prematurely exclude people with disabilities and underlying illnesses from intensive medical treatment because they might stereotypically assume lower chances of success for their recovery. According to the court, the current DIVI recommendations would not eliminate such a risk. Furthermore, these are not legally binding.
The required legal regulation is intended to ensure that doctors make decisions based solely on the current and short-term probability of survival – regardless of the expected long-term lifespan. Disability associations, doctors and politicians welcomed the decision. The DIVI announced that it would clarify the current recommendations.
The patient’s wishes also play a role in triage. If a patient does not want intensive medical treatment, they will not receive intensive medical care. This also applies if the patient would have a better chance of survival than others.
If the patient is no longer able to express their wishes in this regard, the doctors fall back on living wills or statements from relatives.
Discontinuation of intensive care treatment
Triage does not only take place among patients who arrive acutely at the hospital. It also includes those who are already receiving intensive care treatment. Doctors may then decide to discontinue intensive care treatment (e.g. ventilation) for a person.
Such a decision is particularly difficult from an ethical point of view; there are currently no legal requirements. The decision lies with the attending physicians. In particular, they consider the patient’s previous course and current condition.
They deal with questions such as: Are the liver and kidneys still working adequately or are their functions failing? How stable are breathing and circulation? How likely is it that the current therapy will still be successful?
Who makes the triage decision in hospital?
Triage is always based on the multiple-eye principle. According to the recommendations of the DIVI, experts from various disciplines are involved:
- If possible, an experienced representative of the nursing staff
- Other specialist representatives (e.g. clinical ethicists)
This procedure therefore takes several perspectives into account. This should ensure that the decision is fair and well-founded. It also takes the pressure off the individual decision-maker, for whom the process represents an enormous emotional and moral challenge.
Measures to avoid triage in hospitals
Hospitals take various measures in advance to relieve the pressure on intensive care units and thus avoid triage situations.
Postponing non-urgent treatments in triage
Hospitals postpone treatments that are not absolutely necessary. This is also a form of triage. The prerequisite is that the delay does not worsen the prognosis, cause irreversible damage to health or promote premature death.
In tragic cases, however, a delay could have serious consequences. For example, cancer cells could metastasize in the meantime if cancer surgery is delayed, or a bulging vessel (aneurysm) could burst unexpectedly.
Transfer of patients due to imminent triage
Such transfers affect not only Covid-19 patients, but also all other intensive care patients.
The medical staff responsible always try to bridge difficult situations as best they can. If necessary, doctors and nurses also care for seriously ill patients outside of intensive care units as far and as long as possible.
Initial assessment: What does triage mean in the emergency department?
A certain amount of “triage” is the norm in hospital emergency departments. There is usually a lot to do here, so the situation can quickly become confusing. It is then important to quickly and reliably classify those seeking help and their health problems. This initial assessment is usually carried out by experienced nursing staff.
Unlike the GP, the emergency outpatient clinic does not follow the order of arrival. Instead, the specialists there decide who needs to be treated immediately and who can wait. In the event of a serious emergency, the relevant control center informs the emergency department before the patient arrives.
Important: Triage in the emergency department is not primarily about scarce resources. These are usually sufficiently available. Rather, it is about who receives these resources first.
- Category red: Immediate treatment! All ongoing subordinate activities are interrupted. Examples: life-threatening blood loss, respiratory arrest
- Category Orange: Very urgent treatment! It should begin within 10 minutes.
- Category yellow: Urgent treatment – within 30 minutes of the patient arriving.
- Green category: Normal. The time to treatment is ideally less than 90 minutes.
- Blue category: Not urgent. In this case, treatment can easily take place elsewhere, e.g. at the GP.
In addition to the MTS, there are other triage procedures such as the Emergency Severity Index.
Triage in the event of a disaster
Triage is also used in the event of disasters and major accidents, for example after a rail accident with many victims. Here, emergency and rescue workers classify the victims according to how seriously they are injured. They check vital signs such as consciousness, breathing and pulse of the injured.
The most experienced rescuer on site, usually a specially trained emergency doctor, quickly divides the casualties into four visual categories (SC). He notes the respective category on each patient with color-coded tags:
- SK1 – life-threatening injury – red
- SK2 – seriously injured – yellow
- SC3 – slightly injured – green
- SC4 – no chance of survival – blue (used if resources are very limited, otherwise SC1)
Life-threatening injuries with a chance of survival always have priority. Rescue workers transport them first for further treatment. They are followed by the seriously injured and then the slightly injured.
The emergency services must also make decisions depending on the situation. For example, they are more likely to treat people with severe pain and little chance of survival than those with minor injuries.
What happens to patients who do not receive treatment?
Triage also means that emergency services, doctors and nurses are not always able to treat all patients in full. Nevertheless, they make every effort to continue caring for the person concerned as best they can.
Care is then aimed at alleviating symptoms as best as possible and professionally accompanying a possible dying process.
Various measures are available for this purpose:
- Oxygen administration and non-invasive ventilation alleviate respiratory distress
- Medication: opioids alleviate respiratory distress, benzodiazepines help with anxiety and panic, anticholinergics are effective for rattled breathing, antipsychotics are administered for delirium (delusions).
- Pastoral support
