Abstract:- an ethical analysis of “routine” emergency department triage.

Abstract:- The severity
of the injury may be such that ongoing care of the individual patient is
futile, and this can lead to disagreement with the family or friends of the
patient with regard to further treatment. Patient
capacity or ability to participate in the informed consent process may be
compromised and the patient is therefore managed by the clinical team on the
basis of the best interest’s principle, with clinicians relying on proxy
consent or substituted judgment.      

These sections of the
hospital have their own ethical and medico-legal issues for the trauma patient
and the treating clinician.  

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Key words

Trauma, Medico-legal, management time



Emergency departments ED} across the globe follow a triage
system in order to cope with overcrowding. The intention behind triage is to
improve the emergency care and to prioritize cases in terms of clinical urgency.
In ED triage, medical care might lead to adverse consequences like delay in a
providing care, bcompromise in privacy cconfidentiality d poor physician-patient
communication and ultimately failing to provide the necessary care altogether,
or even having to decide whose life to save when not everyone can be saved. These
consequences challenge the ethical quality of emergency care. This article
provides an ethical analysis of “routine” emergency department
triage. The four principles of biomedical ethics – viz. a respect for autonomy
c beneficence dno maleficence and d justice provide the starting point and
help us to identify the ethical challenges of emergency department triage.
However, they do not offer a comprehensive ethical
view. To address the ethical issues of ED triage from a more comprehensive
ethical view, the care ethics perspective offers additional insights.                                                                          
Emergency care is a  sensitive
issue which requires  urgency due to
overcrowding 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 1,3 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 3The 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 term “triage” is derived from the French word trier (to
sort) is now specifically used in specific health care contexts                                                                     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.

.in short the triage is all about in life threatening
conditions, the question can become: “Who shall live when not everyone can

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 There is need of more
research regarding the proactive use of ethics consultation outcomes 13 in

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.

Triage in Health Care- is
divided in three steps a First, pre-hospital triage in order to
dispatch ambulance and pre-hospital care resources in the Government of
Karnataka we have services of 108 ambulance and Second, triage at the scene by
the first clinician attending the patient.

most cases are shifted  of
road traffic cases and trauma cases are shifted ,m  Second, triage at the scene by the first
clinician attending the patient Third, triage on arrival at the hospital ED.

Guidelines for Emergency Department Triage

Table 1


Triage Scale (ATS)


1 – Resuscitation

Level 1 – 0 minutes


New Zealand

2 – Emergency

Level 2 – 10 minutes



3 – Urgent

Level 3 – 30 minutes



4 – Semi-urgent

Level 4 – 60 minutes



5 – Noncurrent

Level 5 – 120 minutes



1 – Immediate (red)

Level 1 – 0 minutes



2 – Very urgent (orange)

Level 2 – 10 minutes



3 – Urgent (yellow)

Level 3 – 60 minutes



4 – Standard (green)

Level 4 – 120 minutes



5 – Non urgent (blue)

Level 5 – 240 minutes

The most commonly used guidelines for ED triage on the
international literature are The Manchester Triage Score 17, 28, 29, The
Canadian Triage and Acuity Scale 28, 29, 30, 31, The
Australasian Triage Scale 28, 32
and Emergency severity Index 27, 29. In
ESI, there are five-levels of these triage score (see Figure 1). In
addition national and institutional guidelines are also developed and used in
practice 15, 33.

There are six general discriminators for
triage:1 life threat,2 hemorrhage3, pain, 4conscious level, 5temperature
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.

We follow our own flow chart and as guidelines. As followers:-




The inappropriate use and/or misuse of ED services is one of the
common problems leading to overcrowding 4.
Socio demographic characteristics are predictors of non-urgent use of emergency
department 5.
Public orientation 4,
strengthening and expanding primary care services can be a solution to the
problem 6, 7.

 In summary, a case study was
presented regarding a middle-aged recalcitrant homeless man who experienced
severe trauma and survived despite his lack of cooperation with the medical
regimen. Lessons learned are a culmination of ideas gleamed from multiple
discussions with caregivers and research into similar situations. It is important
to realize that disruptive patients do have rights and just because they
interfere with the health care teams usual, routine does not permit team
members to ignore the patient.

Trauma patients are typically evaluated in the emergency department {ED}
and the physicians have an excellent opportunity to assess and document the
patient’s decision-making capacity. This simple evaluation is usually not
documented, but should be in every history and physical examination. Just
writing, “awake, alert, and oriented to time, place, and person” is not
adequate to assess decision-making capacity. The question is, “Does this
patient understand the severity of his or her condition?” The caring team needs
this information up front to actively engage the patient in his or her own
treatment plan. If the patient is incapacitated, a spokesperson should be
immediately identified either in the hospital or through local government

New members of a nursing unit or treating team should during orientation,
demonstrate their skills in evaluating capacity by using and documenting the
components of decision-making capacity and informed consent process. This
specific education would make a valuable in-service topic for quality
improvement purposes. 

As soon as the treating team identifies a complex patient, the
multidisciplinary team needs to be mobilized and become knowledgeable about the
care plan. Then as problems arise, they can be reconvened to assist in
analyzing the problems. Personal distress elicited by the extremes of behavior
from such complex patients would, thus be mitigated or prevented. The group
process would allow for debriefing of stressful events and circumstances and
therefore be a more ethical outlet for anxiety rather than inappropriate humor.

It has been the authors’ intent to convey the ethical dilemmas of Mr. D’s
experience within a thoughtful and retrospective framework. We recognize the
difficulties of delivering care to a person in the midst of confusion and
overwhelming concern for saving a life. The overall impact on the healthcare
team was analyzed. The impact of caring for this man has left a lasting
impression on those who remember him. 

Ideally, it would be helpful under similar circumstances to embrace and
integrate these concepts and practices into daily clinical practice and then
measure their effectiveness prospectively






A Total of 106 patients were involved in the study,















of Trauma patients involves very meticulous work which can be achieved only
with proper team-work and planning protocol, and the more important aspects
towards the management involves the documentation and proper communication with
patient attendants and responsible persons.


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