This paper presents a research proposal investigating the feasibility and applicability of a universal triage system in emergency nursing and clinical care. It traces the origins of triage from its military roots to modern civilian emergency departments, reviews the major international triage models — including the Australian, Canadian, Manchester, and French SAMU systems — and identifies key limitations of current approaches. The proposal argues that globalization and the increasing frequency of cross-border mass casualty events create an urgent need for a standardized, universally applicable triage framework. The paper outlines research hypotheses, a proposed methodology using observational and interview-based fieldwork, and the ethical considerations relevant to such a study.
The word "triage" has its origins in the French word trier, meaning to sort, classify, or choose (Williams, 1992). The triage system of prioritizing care delivery to large numbers of patients was adapted from its earlier military origins to fit a civilian context, and it now serves as the very first step in the process of handling medical and clinical emergencies. Triage in the emergency department (ED) is considered a formal process that must be performed in order to immediately assess all patients who are in need of emergency clinical care (Mallett & Woolwich, 1990). The findings obtained from the triage assessment are then used to prioritize or classify patients based on their level of illness or severity of injury. This information is subsequently used to plan for the appropriate medical and nursing response (ACEM, 1993a).
The aim of an effective triage system is to ensure that patients in the ED "receive appropriate attention, in a suitable location, with the requisite degree of urgency" (George, Read, Westlake, Williams, Pritty & Fraser Moodie, 1993). The primary purpose of a universal triage system is therefore to promote a clinical environment that safeguards the safety of all patients in any emergency department. This ensures proper timing in the rate at which care is delivered and appropriate allocation of available resources. Resource allocation is carried out in accordance with the degree or severity of illness or injury (ACEM, 1993b). It is worth noting that decisions involved in any triage system are complex clinical judgments made under conditions best described as uncertain — with limited information and minimal time — yet with the highest possible requirement for accuracy and low rates of error.
It is therefore critically important for triage nurses to possess the knowledge necessary to effectively evaluate every emergency situation and to generate the appropriate information needed for successful triage operations. This means the nurse performing the triage bears responsibility for the rapid identification of and response to any threat to a patient's life.
The aim of this study is to determine the applicability of a single universal triage system in emergency nursing.
The core objective is to develop an appropriate framework and set of conditions that can support the implementation of a universal triage system. The drive to meet these objectives is fuelled by globalization and the unification of healthcare systems worldwide, with the potential to reduce time, reduce costs, and improve efficiency — outcomes that, in the healthcare sector, translate directly into saving more lives.
The requirement for a triage system in the emergency department of most hospitals makes it a necessary component of every health facility. There is a growing desire for a universal health system aimed at harmonizing standards across different regions of the world. The result would be increased efficiency in service delivery, a reduction in the cost of running hospitals, and a lower overall cost of healthcare. The primary application of a universal triage system is, however, contingent on its ability to deliver rapid results in tackling mass casualty events of universal impact — such as floods, hurricanes, earthquakes, and terrorism. These types of disasters routinely require assistance from multiple nations, and it would therefore be highly beneficial for all workers and volunteers involved to share a common knowledge base for handling clinical emergencies. This would facilitate the easy integration of diverse volunteers and workers when responding to a specific incident.
Triage is the process of evaluating and determining which patients require priority treatment based on the severity of their medical condition. The triage system is broadly divided into three categories: pre-hospital triage, which identifies where to direct hospital resources based on priority; triage at the scene of a medical emergency by the arriving clinician or paramedic; and triage on arrival at a health facility or emergency department. Various countries have adopted different triage models, including the Manchester Triage System, the Australian Triage Score, the French SAMU triage system, the Cape Triage System, and the Canadian Triage and Acuity Scale.
One of the major shortcomings of early triage systems is that they were trauma-based, designed primarily for battlefield situations, mass accidents, or natural disasters. There is a need for a triage system that handles the full spectrum of disease — from very minor clinical conditions to more advanced medical cases. Pre-hospital triage systems have a wide application across different countries; however, they have been shown to lack sensitivity and to be inadequate within hospital settings during emergencies, because different clinical parameters must be measured. For patients identified as requiring only routine care, the challenge lies in directing them to the correct care channel.
Several bodies of literature have been dedicated to the context of triage, addressing a variety of aspects of triage systems.
The literature consistently highlights that the triage system requires nurses to make time-sensitive decisions about the urgency needed for each patient in the ED in order to allocate appropriate care, interventions, and space (Purnell, 1991). The triage system must be straightforward, as unnecessary complexity creates significant problems. It is therefore necessary to ensure that an extensive knowledge base informs the modeling of triage systems. This must be coupled with unique clinical presentations and a large volume of care practices designed to ensure timely investigation and referrals for every patient (VanBoxel, 1995).
Regarding the origins of triage practice, the 1970s saw nurses in the United States begin practicing triage in hospital facilities (Estrada, 1979), a move adopted in response to the growing use of emergency triage techniques, which necessitated that the process be undertaken by a qualified professional (George, 1995). During this period, the triage system was regarded as a subspecialty of emergency nursing (Shields, 1976).
Literature reveals that the triage system was implemented in Britain during the 1980s. A dedicated triage nursing system, along with appropriate emergency departments, was established in 1989 (George et al., 1993). The movement toward a universal triage system began when several countries started to formally acknowledge the role of triage in resolving patient emergency challenges, initially grounding their efforts in the National Triage Scale (NTS) guidelines (Jelinek and Little, 1996).
There are various problems that affect the different types of triage systems. Pure NTS-based systems, while popular in many regions, were limited in their application to certain patient subgroups, notably pediatric and mental health patients. This limitation prompted many healthcare practitioners to adopt modified versions. A notable example is the Canadian system, which addresses various deficiencies through the inclusion of a larger number of patient subgroups (Canadian Association of Emergency Physicians, 1999). Another modified system is the Manchester Triage System, developed on the basis of the NTS but with entirely different guidelines. The Manchester system was developed using a clinical algorithm rather than a diagnostic algorithm, in an effort to support rapid decision-making (Manchester Triage Group, 1997). It is worth noting that the validity and reliability of the Manchester guidelines have yet to be fully ascertained (Robertson, 1997). Among existing systems, only New Zealand and Canada are considered to have robust triage frameworks (Standen et al., 1997).
Much of the literature has been devoted to testing the reliability and validity of triage systems. This study, however, focuses on assessing the applicability of a universal triage system in emergency clinical work. Current triage systems are somewhat "one-size-fits-all" in their design (Veenema, 2007). Veenema points out that the main problem with existing triage methodologies is that they are not tailored for all situations — such as those involving weapons victims — but instead reflect standard pediatric scenarios. This means that some components of various triage systems are likely to fail under certain circumstances due to disparities in the physiological baselines used in their development. Veenema consequently raises the question of whether the solution to these dilemmas lies in the development and adoption of a universal triage system.
The following research questions serve as the basis for the study's hypotheses:
Hypothesis 1: Does the use of a universal triage system lead to a general improvement in casualty handling during unprecedented cross-border clinical emergencies?
Hypothesis 2: Does the universal triage system lead to better universal healthcare outcomes?
The proposed timetable for the research is as follows: the proposal is to be completed by the end of week two; the literature review by the end of week three; fieldwork by the end of week five; data analysis by the end of week six; presentation by the end of week seven; and the final report by the end of week eight.
"Two hypotheses guiding the proposed study"
"Observational and interview-based research design"
"Confidentiality, constraints, and research boundaries"
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