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584 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

TABLE 22.2 Australasian triage scale (ATS) category characteristics 5,11

ATS code Typical description
1 Immediately Life-Threatening (or imminent risk of deterioration)
Patients are critically ill, and require immediate transfer to a resuscitation area for initial resuscitation, with no delay at
triage. 3,5,11,12 The majority will arrive by ambulance, and will be suffering:
l multi-trauma
l shock
l unconsciousness
l convulsions
l extreme dyspnoea
l cardiorespiratory arrest.
2 Imminently Life-Threatening
Patients ‘at high risk’ of critical deterioration or have very severe pain from any cause. Assessment and treatment needs
to commence within 10 minutes for: 3,5,11,12
l chest pain or other symptoms suggestive of myocardial ischaemia, pulmonary embolism or aortic dissection
l important time-critical treatment (e.g. thrombolysis, antidote)
l severe abdominal pain or other symptoms suggestive of ruptured aortic aneurysm
l severe dyspnoea from any cause
l altered levels of consciousness
l acute hemiparesis / dysphasia
l fever, rash, headache, suggestive of sepsis or meningitis
l severe skeletal trauma such as femoral fractures or limb dislocations
l very severe pain from any cause (practice mandates the relief of pain or distress within 10 minutes)
3 Potentially Life-Threatening or Situational Urgency
Patients have significant illness or injury and should have assessment and treatment commenced within 30 minutes of
presentation. Typical patients include those with: 3,5,11,12
l moderately severe pain from any cause (e.g. abdominal pain, acute headache, renal colic), but not suggestive of critical
illness; practice mandates relief of severe discomfort or distress within 30 minutes
l symptoms of significant infections (e.g. lung, renal)
l moderate injury (e.g. Colles’ fracture, severe laceration without active haemorrhage)
l head injury, with transient loss of consciousness
l persistent vomiting / dehydration.
4 Potentially Serious
The patient’s condition may deteriorate, or adverse outcome may result, if assessment and treatment is not commenced
within 1 hour of arrival. Patients have moderate symptoms, symptoms of prolonged duration, or acute symptoms of
low-risk preexisting conditions, including: 3,5,11,12
l minor acute trauma (e.g. sprained ankle)
l minor head injury, no loss of consciousness
l mild haemorrhage
l earache or other mildly painful conditions
l practice mandates relief of discomfort or distress within one hour
l there is a potential for adverse outcome if time-critical treatment is not commenced within one hour
l likely to require complex work-up and consultation and/or inpatient management.
5 Less Urgent
The patient’s condition is minor or chronic; acute symptoms of minor illness, symptoms of chronic disease or with a
duration of greater than 1 week. Symptoms or clinical outcome will not be significantly affected if assessment and
treatment are delayed up to 2 hours from arrival. Examples include: 3,5,11,12
l chronic lower back pain with mild symptoms
l minor wounds: small abrasion/minor lacerations
l most skin conditions
l clinical administrative presentations (e.g. results review, medical certificates, repeat prescriptions).

equipment used includes a thermometer, stethoscope,
oxygen saturation monitor and sphygmomanometer, in Practice tip
combination with clinical skills. This examination is
not comprehensive but focuses on the presenting com- The triage physical assessment should be quick, accurate and
plaint while avoiding tunnel vision and wrong con- concise, focusing on the presenting complaint.
clusions. 3,12 Remember that the patient may not be able
to lie down or be exposed for an examination in
the triage area, and may be distressed. The triage process Approaches to Triage Assessment
should reflect a system of rapid assessment that A range of approaches to nursing assessment is applicable
8
is reproducible and adaptable to a variety of to triage assessments (see Table 22.3). Body systems
presentations. approach enables systematic examination of each body