The following table provides the criteria for adult physiological predictors.
Within 10 minutes
within 30 minutes
Within 60 minutes
Within 120 minutes
|Breathing||Severe respiratory distress/ absent respiration/ hypoventilation||Moderate respiratory distress||No respiratory distress||No respiratory distress||No respiratory distress|
|Circulation||Severe haemodynamic compromise/ absent circulation |
|Moderate haemodynamic compromise||No haemodynamic compromise||No haemodynamic compromise||No haemodynamic compromise|
|Disability||GSC <9||GCS 9-12||Normal GCS||Normal GCS||Normal GCS|
Risk factors for serious illness or injury
These should be considered in the light of history of events and physiological data.
Multiple risk factors = increased risk of serious injury.
The presence of one or more risk factors may result in allocation of triage category of higher acuity.
Developed by a project team for the 'Consistency in Triage Project' (2001).
Contributors: Emergency Nurses' Association, Triage Working Party and Royal Children's Hospital emergency nursing staff.