Bengaluru: With the number of daily Covid-19 cases growing out of hand in India, resulting in a rapid resource crunch, oxygen shortage and thousands of deaths, the need of the hour is a response system where existing resources are prioritised based on patient evaluation, and appropriate care is provided to different patients at varying stages of illness without wasting crucial time.
In times of war, disasters, and other medical emergencies, injuries are treated following such a protocol, and the methodology is called a triage.
The process evaluates how to prioritise treatment based on severity of condition and the likelihood of recovery (with or without treatment). The objective is to ensure that the maximum number of lives are saved.
Broadly, the strictest of triage classification divides every incoming patient, irrespective of background, into three — those who are likely to live regardless of what care they receive; those who are unlikely to live regardless of what care they receive; and those for whom immediate care might make a positive difference.
In general practice, however, patients are sorted into categories based on priority, varying depending on the circumstances.
Typically, Priority 1 requires immediate attention and care, Priority 2 can be delayed, while Priority 3 requires minimal care. But many charts can have multiple layers of priority depending on availability of resources and personnel, and the nature of crisis.
In Covid-19 treatment today, already a medical emergency with a monumental shortage of oxygen, this is the most efficient system today to allocate resources and save time and lives. Instead of providing care to individuals one by one as they come, “altered standards” may have to be accepted, generally meaning shifting of care to saving maximum lives as opposed to focussing on saving individuals.
Simple and advanced triage
Simple triage typically occurs at sites of accidents or mass casualty incidents. In such a process, all victims are sorted into those who are critical and need immediate transport to the hospital, and those with less serious injuries who do not need a hospital visit.
However, advanced triage is practiced only by specially trained paramedics and doctors, when there are extremely limited resources. The experts identify the most critical cases that are unlikely to survive even with care, and divert resources away from them to increase the chances of survival of those with less critical injuries and a higher likelihood of survival upon care.
Advanced triage typically follows a five-colour coded system.
Black/Expectant are so severely injured or have reached such an advanced stage of disease that they will die of their injuries soon. They are provided palliative care, such as painkillers to reduce their suffering.
Red/Immediate cases require some form of immediate medical intervention, and are on the highest priority to transfer to a hospital or advanced facility. While their situation demands instant attention and they cannot wait, they are likely to survive with immediate treatment.
Yellow/Observation injuries result in a stable condition but that which require monitoring and frequent re-triaging.
Green/Wait cases would eventually require medical attention but can wait for a few hours or days.
White/Dismiss are those that have minor injuries or symptoms but a doctor’s care is not required.
Sometimes, secondary triage needs to be performed within healthcare facilities or ICUs, where nurses and doctors inside prioritise patients based on likelihood of survival.
Often, reverse triage occurs for the discharge process. In the event of a disaster or a process where there is sudden mass hospitalisation or a spike in it, reverse triage is applied to existing patients occupying hospital beds. Doctors identify those who do not need immediate care and discharge them until the surge in admissions has dissipated.
Triaging during Covid
Triage is already in place in a few parts of the country.
Covid war rooms in Mumbai have been comparatively effectively diverting patients to appropriate care and tempering confusion by triaging.
The war room staff are made up of school teachers primarily, supported by doctors and data entry operators. They gather each patient’s vitals and information required to determine if home isolation is practical.
Patients are triaged based on the information received and ambulances are dispatched to move high priority patients to hospitals in respective wards.
Tamil Nadu and Kerala have also been triaging their patients and have not yet borne witness to scenes of hundreds of patients’ loved ones frantically seeking oxygen online.
In both states, patients are being evaluated by experts — those with mild symptoms go to less resourced screening centres to get advice for treatment, while those in a critical condition are immediately moved to a hospital.
Also in place in Kerala are tele-consultation systems.
Last year, hospitals in the EU were forced to perform triage when their health systems almost buckled within the first few months of the pandemic.
Italy, one of the countries worst affected by the coronavirus in the first two months of the global pandemic, famously released guidelines to start triaging and conserving resources. They recommended prioritising treatment for younger patients who had higher chances of survival.
Spain, too, famously triaged its patients when it hit a shortage of hospital beds and ventilators. The protocol first reverse triaged existing patients from the ICU. Then it identified those requiring advanced life support, and then sorted them into a priority list of those who need immediate care.
Today, in India, the overwhelming response to the cliff of cases in the past few days has been seeking individual care, and by the individuals themselves. There are no centralised emergency instructions or directions.
A form of triage is now urgently required in all parts of the country, with centralised guidelines, in order to address the critical oxygen shortage and optimize its use.
Triage, when applied urgently to Covid patients thronging the hospitals today, can help save precious lives, as evidenced by its practice in some parts of the country already.
(Edited by Arun Prashanth)