Emergency care is one of the most sensitive areas of health care. This sensitivity is commonly based on a combination of factors such as urgency and crowding [1
]. Urgency of care results from a combination of physical and psychological distress, which appears in all emergency situations in which a sudden, unexpected, agonizing and at times life threatening condition leads a patient to the emergency department (ED).
The Australasian College for Emergency Medicine (ACEM) defines ED overcrowding as the situation where ED function is impeded primarily because the number of patients waiting to be seen, undergoing assessment and treatment, or waiting to leave exceeds the physical and/or staffing capacity of the ED [2
]. ED overcrowding is a common scenario across the globe [1
] and resources like staff, space and equipment are limited. Patients often have to wait for a long time before being seen by a doctor and even longer before being transferred to a hospital bed [3
]. The result is not merely inconvenience but a degradation of the entire care experience - quality of care is compromised, the patient's safety may be endangered, staff morale is impaired and the cost of care increases.
The inappropriate use and/or misuse of ED services is one of the common problems leading to overcrowding [4
]. Sociodemographic characteristics are predictors of nonurgent use of emergency department [5
]. Public orientation [4
], strengthening and expanding primary care services can be a solution to the problem [6
When existing needs cannot be met by the available resources a system is needed to cope with the situation and many hospitals use a triage system in order to do this [8
]. The aim of triage is to improve the quality of emergency care and prioritize cases according to the right terms [9
The term "triage" is derived from the French word trier
(to sort) which was originally used to describe sorting of the agricultural products. Today, "triage" is almost exclusively used in specific health care contexts [9
Iserson and Moskop [9
] describe the requirement of three conditions for triage in emergency practice:
1. At least modest scarcity of resources exists.
2. A health care worker (often called a "triage officer") assesses each patient's medical needs based on a brief examination.
3. The triage officer uses an established system or plan, usually based on an algorithm or a set of criteria to determine a specific treatment or treatment priority for each patient.
From the perspective of ethical theories
, triage is commonly seen as a classic example of distributive justice, which addresses the question of how benefits and burdens should be distributed within a population [10
]. It is traditionally used within the ethical literature as an example of a pressing ethical conflict between the utilitarian principle to do the greatest good for the greatest number, [11
] the principle of equal respect for all, the principle of nonmaleficence, and the principle of non-abandonment [12
The fundamental point of triage is the following: not everyone who needs a particular form of health care, such as medicine, therapy, surgery, transplantation, intensive care bed, can gain immediate access to it. Triage systems are designed to assist allocation decisions in this regard. These decisions are more difficult when a condition is life-threatening and the scarce resource potentially life-saving. In life threatening conditions, the question can become: "Who shall live when not everyone can live?" The crux of the matter is the seeming inappropriateness of abstract allocation principles at the level of face-to-face relationships. The general utilitarian concerns of the system, which in the context of scarcity comes down to calculating and choosing between patients on the basis of abstract reasoning (focused on "statistical lives", realizing the best results out of an abstract cost-benefit analysis applied to patients as abstract cases), seems to collide with the Hippocratic duty of doing as much as you can for the patients who need care (focused on "identifiable lives", that is, on the patients as particular persons with whom one stands in a face-to-face care relationship) [12
Ethical issues are hardly considered in emergency department setting. A study by Anderson-Shaw et al has suggested that patients hospitalized through ED often present with ethical dilemmas significantly impacting their inpatient care and overall health outcomes [13
]. There is need of more research regarding the proactive use of ethics consultation in ED.
Within existing medical literature
, the controversies relating to the ethics of triage in medical practices predominantly date back to the early eighties [14
]. Recent studies focus on the contemporary concept of triage [9
], underlying values and preferences [10
], evolution of systems [15
] and their variation according to traditions, cultures, social context and religious beliefs [16
], update on guidelines [17
] and position statements [18
Currently, the existing literature on triage is deficient in two ways. Either there is a predominant focus, from a medical perspective, on the practical elements of triage and on clinical-based guidelines. Or there is a focus, from an ethical perspective, on the domain of distributive justice, with its conflicting principles, as such remaining on the abstract level of reasoning. The aim of this paper is to bring the two strands together.
The central question is the following: how can triage systems in emergency care be ethically assessed, so as to realize optimal use of scarce resources in an ethically just way without remaining on the abstract level, that is by taking the effect of triage on the individual patients and caregivers into account?
In order to do this, we will focus on ED triage. We aim at complementing existing literature on ED triage with an ethical framework that can help ED management teams in planning and executing triage for the care of emergency patients in the daily practice.
Triage in Health Care
Common contexts of triage in contemporary health care practices are pre-hospital care [19
], emergency care, intensive care (who to admit), waiting lists (e.g. for lifesaving treatments such as organ transplants) and battlefield situations [20
]. In case of emergencies and disasters, three stages of triage have emerged in modern healthcare systems [15
1. First, pre-hospital triage in order to dispatch ambulance and pre-hospital care resources.
2. Second, triage at the scene by the first clinician attending the patient.
3. Third, triage on arrival at the hospital ED.
During the last decade, the issue of pandemic triage has entered the discussion of triage [21
]. The emerging infectious disease like Severe Acute Respiratory Syndrome (SARS) and Pandemic Influenza have alerted emergency departments to the need for contingency plans. This applies to triage for intensive care services as well. In such public health emergencies, the managerial emphasis shifts from the individual to the population, from "individual" to "statistical" lives, trying to realize a maximal outcome out of the available resources [24
]. Nevertheless, emergency staff continues to be confronted, on a face-to-face level, with the care for individual patients in need, whom they might not be able to help.
Emergency Department Triage
Triage is a system of clinical risk management employed in emergency departments worldwide to manage patient flow safely when clinical needs exceed capacity. It promulgates a system that delivers a teachable, auditable method of assigning clinical priority in emergency settings [17
In contemporary emergency care, triage is regarded as an essential function not only during massive influx of patients as in disasters, epidemics and pandemics but also in regular emergency care departments. The burden in emergency care is increasing and so are the expectations of patients [1
]. In hospitals that apply triage for regular emergency care, triage is the first point of contact with the ED. Assessment by the triage officers involves a combination of the chief complaint of the patient, general appearance and at times, recording of vital signs [25
Guidelines for Emergency Department Triage
Triage guidelines score emergency patients into several categories and relate it to the maximum waiting time based on specific criteria of clinical urgency. Initial versions of triage guidelines had three levels of categorization mostly termed as emergent, urgent and non-urgent [25
]. Studies have revealed that five-level triage systems are more effective, valid and reliable [25
]. In contemporary emergency care, most triage systems sort out patients into five categories or levels (Table ) including the time within which the patient should be seen by the emergency care provider [27
The most commonly used guidelines for ED triage on the international literature are The Manchester Triage Score
], The Canadian Triage and Acuity Scale
], The Australasian Triage Scale
] and Emergency severity Index
]. In ESI, there are five-levels of these triage score (see Figure ). In addition national and institutional guidelines are also developed and used in practice [15
Emergency Severity Index (ESI) Triage Algorithm, v. 4 (Five Levels).
When reflecting on the question whether these triage systems say anything about how
to sort a patient among one of the five levels, we can apply The Manchester Triage Score
] as an example. This triage system selects patients with the highest priority first and works without making any assumptions about diagnosis. In this method the actual priority is determined by using flow charts which utilizes 'discriminators' at each level of priority. Discriminators are factors (general or specific) that discriminate between patients to be allocated to one of the five clinical priorities. There are six general
discriminators for triage: life threat, haemorrhage, pain, conscious level, temperature and acuteness. These have to be practiced at each level of priority and it is essential for the triage officer to understand the triage method. For example: Pain can be severe pain, moderate pain and recent pain. Specific
discriminators are applicable to individual presentations or to small groups of presentations, which tend to relate to key features of particular conditions. For example: cardiac pain
or pleuritic pain
. Thus, the specific criteria of triage are based on clinical urgency.
Though terminology of categorization differs slightly between the various guidelines, their practical meaning is more or less the same. Triage is a brief encounter between triage officer and patient, which takes two to four minutes [34
]. Subsequently, the patient is labeled with a colored tag. Depending on this tag, the patients are sent to specified areas where they will be consulted by the physicians. While undergoing treatment, the patient may improve or worsen and so may need to be re-triaged and shifted to appropriate area for further treatment. Thus, triage is a continuous process in which clinical characteristics need to be checked regularly to ensure that the priority remains correct.
The Canadian Triage and Acuity Scale (CTAS) consist of separate guidelines for adult [30
] and child [31
] patients. In The Manchester Triage Score [17
], the level of consciousness in adult and children is considered separately. A guideline, entitled SALT (sort, assess, life-saving interventions, treatment and/or transport) triage, was developed in 2008; which incorporates aspects from all of the existing triage systems (see Figure ) to create a single overarching guide for unifying the mass casualty triage process across the United States [35
]. START triage utilises the use of colours green, yellow, red and black to categorise the patients (see Figure ). More importantly, separate guidelines have been developed for potential pandemics like influenza [22
] and special situations like the use of weapons of mass destruction and bioterrorism [36
]. During sudden emergence of '2009 H1N1 influenza', web-based self-triage named Strategy for Off-Site Rapid Triage (SORT) was disseminated by H1N1 Response Centre to reduce a potential surge of health system utilization without denying needed care [37
SALT triage scheme. LSI = Life Saving Interventions.
The Sacco Triage Method (initially known as resource-constrained triage method) is an evidence based outcome driven triage which considers the resources to maximize the expected survivors. Triage decisions are based on a simple age adjusted physiological score (i.e. respiratory rate, pulse rate and best motor response) that is computed routinely on every trauma patient and are correlated to survival probability [38