ERTRIAGE category

Response

Description of category

Clinical descriptors (indicative only)

1

Immediate simultaneous assessment and treatment

Immediately life‑threatening

Conditions that are threERTRIAGE to life (or imminent risk of deterioration) and require immediate aggressive intervention

■   Cardiac arrest

■   Respiratory arrest

■   Immediate risk to airway – impending arrest

■   Respiratory rate <10/min

■   Extreme respiratory distress

■   BP <80 (adult) or severely shocked child/infant

■   Unresponsive or responds to pain only (GCS <9)

■   Ongoing/prolonged seizure

■   IV overdose and unresponsive or hypoventilation

■   Severe behavioural disorder with immediate threat of dangerous violence

ERTRIAGE category

Response

Description of category

Clinical descriptors (indicative only)

2

Assessment and treatment within

10 minutes

(assessment and treatment often simultaneous)

Imminently life‑threatening

The patient’s condition is serious enough or deteriorating so rapidly that there is the potential of threat to life, or organ system failure, if not treated within 10 minutes

of arrival

■   Airway risk – severe stridor or drooling with distress

■   Severe respiratory distress

■   Circulatory compromise:

− Clammy or mottled skin, poor perfusion

− HR <50 or >150 (adult)

− Hypotension with haemodynamic effects

− Severe blood loss

■   Chest pain of likely cardiac nature

■   Very severe pain – any cause

■   Suspected sepsis (physiologically unstable)

■   Febrile neutropenia

■   Fever with signs of lethargy (any age)

■   BSL* <3 mmol/L

■   Drowsy, decreased responsiveness any cause (GCS <13)

■   Acute stroke

■   Acid or alkali splash to eye – requiring irrigation

■   Suspected endophthalmitis post‑eye procedure (post‑cataract, post‑intravitreal injection), sudden onset pain, blurred vision and red eye

■   Major multi trauma (requiring rapid organised team response)

■   Severe localised trauma – major fracture, amputation

■   Suspected testicular torsion

■   High‑risk history:

− Significant sedative or other toxic ingestion

− Significant/dangerous envenomation

− Significant pain or other feature suggesting PE, aortic dissection/AAA or ectopic pregnancy

■   Behavioural/psychiatric:

− Violent or aggressive

− Immediate threat to self or others

− Requires or has required restraint

− Severe agitation or aggression

OR

Important time‑critical treatment

The potential for time‑critical treatment (e.g. thrombolysis, antidote) to make a significant effect on clinical outcome depends on treatment commencing within a few minutes of the patient’s arrival in the ED

OR

Very severe pain

Humane practice mandates the relief of very severe pain or distress within 10 minutes

ERTRIAGE category

Response

Description of category

Clinical descriptors (indicative only)

3

Assessment and treatment start within 30 minutes

Potentially life‑threatening

The patient’s condition may progress to life or limb threatening, or may lead

to significant morbidity, if assessment and treatment are not commenced within 30 minutes of arrival

■   Severe hypertension

■   Moderately severe blood loss – any cause

■   Moderate shortness of breath

■   Seizure (now alert)

■   Persistent vomiting

■   Dehydration

■   Head injury with short LOC – now alert

■   Suspected sepsis (physiologically stable)

■   Moderately severe pain – any cause – requiring analgesia

■   Chest pain likely non‑cardiac and moderate severity

■   Abdominal pain without high‑risk features – moderately severe or patient age >65 years

■   Moderate limb injury – deformity, severe laceration, crush

■   Limb – altered sensation, acutely absent pulse

■   Trauma – high‑risk history with no other high‑risk features

■   Stable neonate

■   Child at risk of abuse/suspected non‑accidental injury

■   Behavioural/psychiatric:

− Very distressed, risk of self‑harm

− Acutely psychotic or thought disordered

− Situational crisis, deliberate self‑harm

− Agitated/withdrawn

− Potentially aggressive

OR

Situational urgency

There is potential for adverse outcome if time‑critical treatment is not commenced within 30 minutes

OR

Humane practice mandates the relief of severe discomfort or distress within 30 minutes

ERTRIAGE category

Response

Description of category

Clinical descriptors (indicative only)

4

Assessment and treatment start within 60 minutes

Potentially serious

The patient’s condition may deteriorate, or adverse outcome may result, if assessment and treatment is not commenced within one hour of arrival in ED. Symptoms moderate or prolonged

■   Mild haemorrhage

■   Foreign body aspiration, no respiratory distress

■   Chest injury without rib pain or respiratory distress

■   Difficulty swallowing, no respiratory distress

■   Minor head injury, no loss of consciousness

■   Moderate pain, some risk features

■   Vomiting or diarrhoea without dehydration

■   Eye inflammation or foreign body – normal vision

■   Minor limb trauma – sprained ankle, possible fracture, uncomplicated laceration requiring investigation or intervention – normal vital signs, low/moderate pain

■   Tight cast, no neurovascular impairment

■   Swollen ‘hot’ joint

■   Non‑specific abdominal pain

■   Behavioural/psychiatric:

− Semi‑urgent mental health problem

−  Under observation and/or no immediate risk to self or others

OR

Situational urgency

There is potential for adverse outcome if time‑critical treatment is not commenced within hour

OR

Significant complexity or severity

Likely to require complex work‑up and consultation and/ or inpatient management

OR

Humane practice mandates the relief of discomfort or distress within one hour

ERTRIAGE category

Response

Description of category

Clinical descriptors (indicative only)

5

Assessment and treatment start within 120 minutes

Less urgent

The patient’s condition is chronic or minor enough that symptoms or clinical outcome will not be significantly affected if assessment and treatment are delayed up to two hours from arrival

OR

Clinico‑administrative problems

Results review, medical certificates, prescriptions only

■   Minimal pain with no high‑risk features

■   Low‑risk history and now asymptomatic

■   Minor symptoms of existing stable illness

■   Minor symptoms of low‑risk conditions

■   Minor wounds – small abrasions, minor lacerations (not requiring sutures)

■   Scheduled revisit (e.g. wound review, complex dressings)

■   Immunisation only

■   Behavioural/psychiatric:

− Known patient with chronic symptoms

− Social crisis, clinically well patient