Journal of Emergencies, Trauma, and Shock
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Year : 2020  |  Volume : 13  |  Issue : 2  |  Page : 107-109
All india institute of medical sciences triage protocol (ATP): ATP of a busy emergency department


1 Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Department of Emergency Medicine, University of South Florida, Tampa, FL, USA

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Date of Submission16-Oct-2019
Date of Decision06-Sep-2019
Date of Acceptance22-Oct-2019
Date of Web Publication10-Jun-2020
 

How to cite this article:
Sahu AK, Bhoi S, Galwankar S, Aggarwal P, Murmu L, Nayer J, Sinha TP, Mishra PR, Ekka M, Kumar A. All india institute of medical sciences triage protocol (ATP): ATP of a busy emergency department. J Emerg Trauma Shock 2020;13:107-9

How to cite this URL:
Sahu AK, Bhoi S, Galwankar S, Aggarwal P, Murmu L, Nayer J, Sinha TP, Mishra PR, Ekka M, Kumar A. All india institute of medical sciences triage protocol (ATP): ATP of a busy emergency department. J Emerg Trauma Shock [serial online] 2020 [cited 2020 Sep 26];13:107-9. Available from: http://www.onlinejets.org/text.asp?2020/13/2/107/286227




Emergency department (ED), the specialty of undifferentiated resuscitation and care, caters all patients irrespective of their age, gender, social status, or disease condition. In doing so, the demand almost always outstrips the supply. To handle this demand-supply mismatch, ED triage is one of the measures. It is a carefully structured process in which patients are categorized to subsequent groups according to the severity of their presenting condition.[1]

Variety of triage systems are applied in different hospitals to best suit the given resource availability, economic situation, and patient capacity of each ED.[2] The more popular variants of the triage system with good reported reliability rates are Emergency Severity Index (ESI), Canadian Triage and Acuity Scale (CTAS), Manchester Triage System (MTS), and Australasian Triage Scale (ATS).[3] These are five-level triage systems with decreasing order of severity.

ESI used in EDs of USA, categorizes treatment priority on the basis of disease severity and the expected resource needs. The triage algorithm consists of four decision points.[4] CTAS widely used in EDs of Canada, has an extensive list of presenting clinical symptoms (i.e., the Canadian ED Information Systems complaint list) to determine the triage level.[5] MTS is used in EDs in Europe, has a different approach. The patient's presenting complaints are allocated to 1 of the 53 flowchart diagrams, followed by the use of key discriminators to determine the priority.[6] The ATS has been used in Australian EDs which has five categories defined by a time limit within first contact with emergency medicine (EM) physician should be done.[7]

India, with the second largest population of world, is one of the countries with highest burden of emergencies.[8] However, the history of EM in India is just few years old.[9] Currently, there is no evidence-based ED triage system available in the country. Here, we at, All India Institute of Medical Sciences (AIIMS), New Delhi, one of the premier medical institutes in the country; has been using an innovative ED triage protocol since 2010. Yearly, we receive approximately 1.5 lakh patients in our ED (trauma and nontrauma patients). Before 2010, patients in our ED were managed without any formal triage. It was difficult to use any of these internationally accepted five-tier complex algorithm-based triage systems because of huge daily burden of patients, limited trained emergency physicians, unavailability of trained personnel for triage, and hospital support staffs those who facilitate patient flow are mostly uneducated. Even some of the acceptable triage systems create confusion for untrained hospital staffs due to different numbers, colors, and severity. Hence, we developed in-hospital AIIMS Triage Protocol (ATP) from the color pattern-based simple triage and rapid treatment protocol used in disaster situations.[10] In a pilot study at AIIMS, we found that this protocol can reduce overtriage and undertriage rates.[11]

We are going to discuss the ATP in terms of its evolution, components, relevance to the community, adoption in different parts of country, comparison with international systems, and future prospects.

Patients in the ED triage area are triaged into traffic-color coded “Red,” “Yellow,” and “Green” categories, by a triage nurse in the triage area. Patients who need immediate care are categorized as “Red;” defined by the presence of any altered physiological parameters, any time-sensitive conditions or conditions with increased urgency [Details in Supplementary Material]. Yellow-triaged patients are those who have no “Red” criteria but have semi-urgent conditions needing admission for monitoring, evaluation, and treatment. Green-triaged patients are given minor treatment and discharged.

For harmonization of initial triage decision with care delivery, our ED is divided into respective Red, Yellow, and Green areas. This color concept is so easy that support staffs such as hospital attendants and patients' relatives do not find difficult to comprehend the severity and timeliness of condition. From triage area, color-coded floor-signages for specific zones are there to shift the patients easily. All “Red” and “Yellow” triaged patients are tagged with respective color bands for easy identification. In the respective areas, all necessary equipment, medication, and workforce are available round the clock. Telephonic consultations to different specialties and laboratory investigations including imaging are always done with a mention of triage category to fast-track “Red” patient's care. Emergency physicians may sometimes do retriage to decongest the zones.

Comparing ATP with other international triage systems, we found that ESI – 1 and 2; CTAS – I, II, and III; MTS – 1 and 2; and ATS – 1, 2, and 3 partially matches with “Red” category. ATP “yellow” cadre is somewhat similar to ESI – 3 and 4; CTAS – IV; MTS – 3; and ATS – 4. ATP “Green” category matches with MTS – 4 and category – 5 of all systems [Table 1] and [Table 2].
Table 1: Comparison of three-tier All India Institute of Medical Science Triage Protocol with Internationally available five-tier triage systems, i.e., Emergency Severity Index, Canadian Triage and Acuity Scale, Manchester Triage System, and Australasian Triage Scale - Detailed comparison

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Table 2: Comparison of three-tier All India Institute of Medical Science Triage Protocol with Internationally available five-tier triage systems, i.e., Emergency Severity Index, Canadian Triage and Acuity Scale, Manchester Triage System and Australasian Triage Scale

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Some centers in India, like AIIMS Bhubaneswar, CMC Vellore, and GTB Delhi, have adopted and modified ATP for their ED. Even the Directorate of Health Services in state of Kerala has adopted similar protocol for use in medical colleges and community hospitals like district hospitals and community health centers.[12]

Now, we are conducting a prospective study for validation of ATP in AIIMS ED with a sample size of 10,000 and utilization of it in predicting mortality at 24 h, at 7 days and proportion of intensive care unit admission.

Although well-reliable, internationally available triage systems are applicable to Western countries, the applicability of these in ED with high volume of patients but with less trained-personnel is a concern. We propose that ATP can be used in these locations and act as an energy for the ED patient management (hence compared to ATP – adenosine triphosphate, energy currency of cellular metabolism).


   Supplementary Material Top



   Description Of All India Institute Of Medical Sciences Triage Protocol Non-Trauma Settings Top


RED Triage Criteria



Yellow Triage Criteria

  • Patients with normal ABCD but requires further investigation and/or observation.


Green Triage Criteria

  • Patients with normal ABCD with minor injuries.



   Trauma Settings Top


RED Triage Criteria



Yellow Triage Criteria

  • Patients with normal ABCD but requires further investigation and/or observation.


Green Triage Criteria

  • Patients with normal ABCD with minor illness.




 
   References Top

1.
Robertson-Steel I. Evolution of triage systems. Emerg Med J 2006;23:154-5.  Back to cited text no. 1
    
2.
Saeed A, Al-Fayyadh F, Alshomar K, Zekry Z, Alamiri N, Abaalkhail A, et al. Validating the implementation of the triage system in an emergency department in a university hospital. J Health Spec 2017;5:73.  Back to cited text no. 2
  [Full text]  
3.
Christ M, Grossmann F, Winter D, Bingisser R, Platz E. Modern triage in the emergency department. Dtsch Arztebl Int 2010;107:892-8.  Back to cited text no. 3
    
4.
Gilboy N, Tanabe P, Travers D, Rosenau AM. Emergency Severity Index (ESI): A triage tool for emergency department care, version 4. Implementation Handbook 2012;2012:12-0014.  Back to cited text no. 4
    
5.
Bullard MJ, Unger B, Spence J, Grafstein E; CTAS National Working Group. Revisions to the Canadian emergency department triage and acuity scale (CTAS) adult guidelines. CJEM 2008;10:136-51.  Back to cited text no. 5
    
6.
Triage Group. Emergency Triage. 3rd ed. Manchester: Wiley Blackwell; 2013.  Back to cited text no. 6
    
7.
ACEM – Triage. Available from: https://acem.org.au/Content-Sources/Advancing-Emergency-Medicine/Better-Outcomes for-Patients/Triage. [Last accessed on 2019 Jun 14].  Back to cited text no. 7
    
8.
World Health Organization | Emergency Care in 59 Low- and Middle-Income Countries: a Systematic Review. World Health Organization. Available from: https://www.who.int/bulletin/volumes/93/8/14-148338/en/.[Last accessed on 2019 Mar 22].  Back to cited text no. 8
    
9.
Das AK, Gupta SB, Joshi SR, Aggarwal P, Murmu LR, Bhoi S, et al. White paper on academic emergency medicine in India: INDO-US joint working group (JWG). J Assoc Physicians India 2008;56:789-98.  Back to cited text no. 9
    
10.
Benson M, Koenig KL, Schultz CH. Disaster triage: START, then SAVE – A new method of dynamic triage for victims of a catastrophic earthquake. Prehosp Disaster Med 1996;11:117-24.  Back to cited text no. 10
    
11.
Kumar R, Bhoi S, Chauhan S, Sinha TP, Adhikari G, Sharma G, et al. (A264) Does the Implementation of START Triage Criteria in the Emergency Department Reduce Over-and under-Triage of Patients?. Prehosp Disaster Med 2011;26:s72-3.  Back to cited text no. 11
    
12.
Triage System Set to Revolutionise Emergency Medical Care in Kerala. The New Indian Express. Available from: http://www.newindianexpress.com/states/kerala/2018/apr/27/triage-system-set-to-revolutionise-emergency-medical-care-in kerala-1806924.html..[Last accessed on 2019 Mar 22].  Back to cited text no. 12
    

Top
Correspondence Address:
Sanjeev Bhoi
Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JETS.JETS_137_19

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