South African Triage Group

Current pdf. versions of the South African Triage Scale
Adult South African Triage Scale
Child South African Triage Scalre
Infant South African Triage Scale
Generic Flowchart
Generic Interventions chart

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Contents of page (select topic for easy page navigation)

  1. The physiological scoring system
  2. Discriminator list
  3. Application of the triage system
  4. Frequently asked questions (pdf)

The physiological scoring system

Physiological assessment was chosen as a major component of the system as it is a core element of triage. The Medical Early Warning Score (MEWS) utilises systolic blood pressure, heart rate, temperature, respiratory rate and AVPU (a measure of level of consciousness, viz. Alert/Verbal/Pain/Unresponsive) as parameters. MEWS has been used to successfully identify physiological deterioration of medical inpatients, where MEWS scores of five or more were associated with increased risk of death, ICU and high dependency unit admission. The MEWS score identifies patients who need medical intervention.

The UK-based Intensive Care Outreach Services (ICORS) found that summarising abnormal physiology into the MEWS was a particularly useful tool in identifying medical patients in need of ICU admission. Using the MEWS as a referral tool reduced ICU admissions and length of hospitalisation.

However, the MEWS has limitations with regard to triage in that it is medically biased. Trauma patients (who were often previously healthy and therefore have greater physiological reserve) may have severe injuries and yet have a low MEWS if they have unchanged physiology. The addition of both a mobility parameter and a trauma factor increases the severity score for trauma patients, as well as for medical patients who are physiologically normal but have time-critical conditions, e.g. ischaemic stroke. These parameters have therefore been added to the MEWS score by the SATG in order to improve its triage capabilities, and the resulting system has been renamed the Triage Early Warning Score (TEWS). Figure 1 below shows the adult version of the TEWS; similar scores have been developed by the SATG for children and infants.

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Adult TEWS physiological score
Figure 1. Triage Early Warning Score (TEWS) for adults

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TEWS has the following advantages:

  1. It enables early, accurate assessment of the emergency patient
  2. It translates measurable parameters into a number
  3. Minimal equipment is required (a blood pressure cuff and a low-reading thermometer)
  4. It encompasses both trauma and medical emergencies
  5. It facilitates uniform assessment, as well as communication between medical staff enabling appropriate patient disposition
  6. It is user-friendly in both the pre-hospital and EU settings

Discriminator list

Triage systems use discriminators as a core component of the decision-making process. Once again, the SATS comprises an adult, child and infant version with slightly different discriminators. The SATG has used the following discriminators:

  1. Mechanism of injury:
    Mechanism of injury has been limited to high energy transfer. Mechanism of injury scores have been shown to be highly sensitive at identifying patients with severe trauma; however, they have also been shown to have high rates of overtriage (the tool incorrectly identifies minor injury or illness as being more serious)
  2. Presentation:
    This includes symptoms such as chest pain and abdominal pain; it also includes ‘eyeball diagnoses’ such as seizures and dislocations, which are clear at triage
  3. Pain:
    As with many triage scores, pain is regarded as an important indicator of priority. It is recorded as severe, moderate, or mild
  4. Senior health care professional’s discretion:
    Experienced health care professionals can improve the triage process by adding their opinion to other parameters. In the SATG protocol, a senior health care professional may alter the triage coding, either up- or downgrading the triage status

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Application of the triage system

The TEWS score is calculated by first measuring the physiological parameters. The discriminators are then assessed, and a triage colour category is allocated. Patients are triaged as follows:

  1. Vital signs: measure, and score each against the TEWS scoring sheet, to produce a total TEWS. This score corresponds with a triage category (0 - 2 green, 3 - 4 yellow, 5 - 6 orange, > 6 red)
  2. Mechanism of injury: determine if relevant
  3. Presentation: consider any relevant symptoms or eyeball diagnoses
  4. Pain: consider the patient’s pain
  5. Senior health care professional’s discretion: consider

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The triage category is selected from a five-colour coding sheet (Figure 2).

Adult discriminator list
Figure 2. Adult discriminator list

If the discriminators (mechanism of injury, presentation, pain) categorise a patient in a higher triage category than the TEWS score, then this higher category is regarded as the correct category. The discriminators are used as a safety net for patients who have normal vital signs, but potentially significant pathology.

This triage system is not intended for mass casualty situations. It is standard practice throughout much of the world to use a simpler triage system for mass casualty situations and a more complex system for ‘everyday’ use.

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