The word ‘triage’ is the French word for ‘to sort’ (Breton, 2011). It became vital during the First World War for injured soldiers to be organised according to severity of injury on the battlefield. Since then it has become vitally important in the emergency room setting to organise the patients that need to be seen immediately from the patients that can wait, by assessing the three major body systems: respiratory, cardiovascular and neurological. Triage in emergency practice occurs over the phone, in the waiting room, and also in hospitalised patients. The aim of triage is to provide a rapid assessment of the patient based on their physical parameters, to guarantee the life threatening signs are identified early, to ensure the best treatment and outcome.
Human hospitals use different triage scoring systems to sort patients according to how rapidly they need to be seen. These are five point scales, the Manchester Triage Scale (MTS) being the most widely used in Europe. Ruys et al (2012) developed a Veterinary Triage List (VTL) (see Table 1) using the MTS, and adjusted the different discriminators, e.g. cardiac pain, to be more applicable to veterinary patients. The triage system was divided by body system: respiratory, circulatory, neurological, obstetrical, gastrointestinal, urogenital and generalised, with different grades of severity requiring different waiting times (Breton, 2011). Their findings were that a standardised triage system, with the use of physical examination, improved patient waiting times when compared with nurse triage using intuition.
| Colour | Urgency | Target waiting time |
|---|---|---|
| Red | Immediate | O mins |
| Orange | Very urgent | 15 mins |
| Yellow | Urgent | 30–60 mins |
| Green | Standard | 120 mins |
| Blue | Non urgent | 240 mins |
Another veterinary triage system is the animal trauma triage system (ATT) (Table 2) which is divided into six body systems: respiratory, cardiac, perfusion, neurological, eye/muscle/integument and skeletal, with a grade from 0–3 being alocated to the patient, and the scores added to make a total score out of 18. Olsen et al (2014) found the use of the ATT for gunshot injuries was a good predictor of 7 day survival, with a one point increase making survival 2.3 times less likely, and a higher score predicting a longer overall hospital stay.
| Grade | Perfusion | Cardiac | Respiratory | Eye/muscle/integument | Skeletal | Neurological |
|---|---|---|---|---|---|---|
| 0 | Mucous membranes (MM) pink and moist, capillary refill time (CRT) 2 s | Heart rate (HR) 60–140 beats per minute (bpm) (dog), 180–200 bpm (cat) | Regular rate. |
Abrasion/laceration: none/partial thickness. |
Weight bearing on 3–4 limbs. No palpable fracture or joint laxity | Central: conscious, alert to slightly dull, interested in surroundings. Peripheral: normal spinal reflexes, movement, nociception |
| 1 | MM hyperaemic/pale pink, tacky MM, CRT 0–2 s, rectal temp >37.8°C | HR 140–180 bpm (D) 200–280 (C). |
Mildly increased RR and effort +/- abdominal effort Mildly increased upper airway sounds | Abrasion/lacerationfull thickness with no deep tissue involvement. |
Closed limb/rib/mandibular fracture. Joint laxity or luxation. Pelvic fracture with intact sacroiliac joint, single limb open or closed fracture at or below carpus/tarsus | Central: dull, depressed, and withdrawn. Peripheral: abnormal spinal reflexes, and purposeful movement and nociception in all 4 limbs |
| 2 | MM very pale pink and tacky. |
HR (dog) >180 bpm HR (cat) >260 bpm. Consistent arrhythmia | Moderate increased respiratory effort with abdominal component, elbow abduction, moderate increased upper air-way sounds | Abrasion/laceration: full thickness, deep tissue involvement and intact arteries, nerves and muscle. |
Multiple conditions from above, single long bone open fracture above carpus or tarsus with cortical bone preserved | Central: unconscious and responsive to noxious stimuli. Peripheral: absent purposeful movement, intact nociception in 2 or more limbs or nociception absent in only 1 limb. Reduced anal/tail tone |
| 3 | MM grey/blue/white CRT >3 s, rectal temp <37.8°C, no femoral pulses | HR (dog): <60 bpm, HR (cat) <120 bpm. Erratic arrhythmia | Marked respiratory effort, gaping or agonal respiration or irregularly timed effort, or little/no air passage | Penetration into thoracic or abdominal cavity. Abrasion or laceration, full thickness and deep tissue involvement. Arterial, nervous and muscle compromise | Vertebral body fracture or luxation (except coccygeal), multiple long bone open fractures above tarsus and carpus, single long bone open fracture above carpus with cortical bone compromise | Central: non-responsive to all stimuli, refractory seizures. Peripheral: absent nociception in 2 or more limbs. Absent tail or peripheral nociception |
Other illness scoring systems that have been used are the survival prediction index and acute patient physiological and lab evaluation (APPLE), however, these scores require the use of lab parameters such as creatinine, albumin, lactate, base excess and ionised calcium (Chan, 2013), which may make triage too lengthy a process to be of practical value. The use of a shock index score is quick and simple — this uses the patient's heart rate divided by the blood pressure, and can pick up on patients in compensatory shock that have a seemingly normal heart rate and blood pressure (Chan, 2013).
This article will look at practical approaches to triage for use in practice.
Telephone triage
The first triage will usually be done over the phone to assess how quickly the animal needs to be seen. It is of vital importance that receptionists or nurses answering the phone are well trained in triage, and ask clear, concise questions where possible. The owners concern should not be dismissed, and there should always be an offer to be seen. The call should be logged, and owner details, patient signs and advice given recorded. An approximate estimated time of arrival (ETA) should be made and the owner should be given directions if they have not attended the practice before. The owner should be advised how to transport the patient safely, e.g. if trauma, potential fracture sites should be immobilised and the patient should be moved carefully into the car (Macintire et al, 2012); any small species that can fit comfortably in a carrier should be put into a carrier so they can be accessed easily (Breton, 2011). The owner should be made aware that if the patient is painful or has behavioural changes it can become aggressive and may require muzzling, so advise the owner to tie tights/string around the muzzle when moving. Treatment advice should be given if deemed appropriate, e.g. cooling a potential hyperthermic patient before going in a hot car (Macintire et al, 2012); however this should delay the veterinary treatment as little as possible. A suggested list of patients that should be asked to come in immediately are:
If the following are not stated when the owner is describing the presenting complaint, the following questions should be asked to determine if the pet needs urgent treatment:
From this information the patient can be deemed an emergency requiring urgent medical attention, or non-urgent requiring a routine appointment, and advised to come into the hospital accordingly. The hospital can use one of the triage systems described previously or devise their own. Staff members should be made aware of any emergencies that are coming in, so equipment can be set up and a nurse can be in reception ready to triage (Macintire et al, 2012).
Triage on arrival
Triage can take place in the car, in reception or in a consult room. The patient needs to have the three major body systems assessed on arrival at the practice. These are the respiratory, circulatory and neurological systems. From assessing these systems, it is possible to identify if it is a life threatening emergency that requires immediate further diagnostics and treatment, or if the patient can wait in reception for a veterinary surgeon to become available.
Airway
Anaesthesia and intubation is immediately required if the airway is obstructed, a urinary catheter can be passed if the airway is too narrow (Haskins and Macintire, 2012).
Breathing: assessment of respiratory rate and effort
If there is any concern over a patient having respiratory compromise, oxygen therapy should be started and suitable treatment should be given (Figure 1), e.g. thoracocentesis if suspected pleural effusion.
Cardiovascular: assessment of pulse rate, peripheral pulse quality, mucous membrane (MM) colour, capillary refill time (CRT) and auscultation
If there is a concern about poor pulse quality, arrhythmias, tachycardia, bradycardia the patient should be admitted immediately for further monitoring, diagnostics and treatment.
Neurological: mentation
If the patient has abnormal mentation it should be admitted immediately for further monitoring and diagnostics.
A patient with an abnormal gait or unable to walk is not necessarily a life threatening emergency that requires immediate attention, but will need prioritising over more routine cases, as they may require interventions to preserve spinal cord function.
Pain
A very painful animal should receive analgesia quickly on arrival, under veterinary direction. The analgesia chosen should ideally be short acting, but potent enough to relieve the patient's pain; fentanyl is often a good choice for this. This allows the site of the pain to be identified when the analgesia wears off after a short time. The analgesia that is most suitable will vary from case to case, and it will be down to the veterinary surgeon in charge to decide what is most suitable.
Assessing all of these parameters will help to determine if the patient needs urgent medical treatment and stabilisation immediately. Following the major body assessment a more thorough clinical examination is required to detect other conditions that may require intervention quickly, i.e. thorough examination is required in less than half an hour, but no need to rush through for urgent diagnostics and treatment.
Further body system triage
Temperature
A patient with a temperature <37°C and >41°C should be admitted immediately. Active cooling should be started immediately on a patient >41°C by pouring cold (not freezing) water over the patient. Active warming should only be started on patients that are cardiovascularly stable with a temperature <37°C, however, the patients that are not cardiovascularly stable should be insulated from losing more heat.
Reproductive
When was the last season?
Patients need rapid treatment if:
From this patients can be admitted for blood tests to check electrolytes, especially glucose and calcium, and to have further imaging to determine the presence of any fetuses in the birth canal and their viability. The decision can then be made to assist with the birth using oxytocin/other methods or to do a Caesarian.
Ocular
These patients need to be admitted and require eye treatment to avoid further damage or loss of the eye. Proptosed eyes should have saline soaked swabs placed over them to prevent drying (Breton, 2011).
Urinary
Patients that are suspected of having a blocked bladder should be admitted quickly for catheterisation and/or cystocentesis, as well as assessment of their electrolytes.
Abdomen
A distended abdomen could indicate significant ascites, or gastric dilatation with or without gastric torsion. A good way to check if fluid is present is by carrying out a fluid wave test; feeling one side of the abdomen and tapping the other side. If fluid is present the tap will be felt on the opposite side. The presence of fluid can then be confirmed using ultrasound.
Fractures and wounds
Open fractures/wounds should be covered with a moist sterile dressing to reduce infection risk while the patient has a full assessment and treatment for more life threatening symptoms. Following this patients can have a full wound and fracture assessment under sedation/general anaesthetic.
Neonates
Neonates can rapidly deteriorate, and become hypothermic, dehydrated and hypoglycaemic very quickly if they have diarrhoea and/or vomiting or are inappetant. These patients should be admitted as soon as possible to be kept warm and to avoid their condition worsening (Fortney, 2004).
Wildlife
Wildlife will often arrive in a critical state because catching them can be difficult. They need rapid assessment and a decision on whether rehabilitation and release will be possible (Breton, 2011). These patients require minimal handling to prevent stress worsening their condition and they should be kept in a quiet and dark place during assessment.
Exotics
Exotic patients will often mask signs until a later stage of the disease, therefore these patients will need quicker diagnosis and treatment than a dog and cat with the same signs. Rabbits especially are at risk of gut stasis with any illness or stress. Minimal and gentle handling are important, and an assessment within the carrier is best to start off with.
The following can be assessed within the carrier (Fordham, 2007):
It is important to ask the owner about the husbandry they are providing to ensure it is appropriate.
Triage interview
A quick basic history should be taken provided the patient is not a category 1 emergency. A category 1 emergency is cardiac arrest, active seizures, active bleeding, collapse, unconsciousness and anaphylaxis. On arrival at the practice every owner should be greeted with your name and qualification (e.g. veterinary nurse or veterinary surgeon), and a very quick explanation of why treatment is needed and what is required to ensure their consent (Breton, 2011). The owner should be made aware of the cost of an out of hours (OOH) consultation prior to arrival, and an approximate estimate should be given once the patient has been assessed and a diagnostics and/or treatment plan has been made. A resuscitation code should be discussed as soon as possible to determine if the owner consents for their pet to have cardiopulmonary resuscitation (CPR) and if this can be open in a large/deep chested dog breed.
Provided the patient is not category 1, the following questions would be useful to ask during the brief examination:
Post triage
After triage, the patient should either be admitted and undergo emergency diagnostics and treatment, or should remain in reception if the triage examination finds them to be stable.
Once the triage examination has been completed, further assessment and monitoring can be carried out such as blood pressure, electrocardiogram (ECG) and pulse oximetry if thought necessary (Figure 5). An IV catheter can also be placed to give fluids/other medications as necessary. Analgesia and/or sedation may also be required as this point. Patients with upper or lower respiratory tract compromise may benefit from sedation. Further diagnostics can include blood tests, especially blood gas analysis (if available), electrolytes, packed cell volume (PCV)/total solids (TS) and glucose. Further imaging such as AFAST, TFAST and x-rays.
Conclusion
It is of paramount importance that everyone in the practice is trained in how to triage patients effectively. Receptionists will be the first to speak to the owner so they need to be aware of the questions to ask to determine how urgently the patient needs to be seen. The practice should be well equipped to deal with any emergency, with a well equipped and maintained crash trolley a necessity. All veterinary surgeons and veterinary nurses should be trained in how to assess the three major body systems to determine if a patient has a life threatening condition, to ensure all patients receive the best treatment as quickly as possible.