ARTICULO ORIGINAL

REVISTA DE LA FACULTAD DE MEDICINA HUMANA 2019 - Universidad Ricardo Palma DOI 10.25176/RFMH.v19.n1.1797

THE HOSPITAL TRIAGE IN EMERGENCY SERVICES

EL TRIAGE HOSPITALARIO EN LOS SERVICIOS DE EMERGENCIA

Rolando Vásquez-Alva^1,3,a,b, Consuelo Luna-Muñoz2,4,^2,4,c , Cleto M. Ramos-Garay^1,a

¹ Departamento de Emergencia, Servicio de Emergencia Hospital E. Rebagliati Martins - EsSalud, Lima, Perú.
² Departamento de Emergencia, Servicio de Emergencia Pediátrica Hospital E. Rebagliati Martins - EsSalud, Lima, Perú.
³ Facultad de Medicina Universidad Nacional Mayor de San Marcos, Lima, Perú.
⁴ Facultad de Medicina Universidad Ricardo Palma, Lima, Perú.
^a Médico internista- Emergenciólogo.
^b Magister en docencia e investigación en salud.
^c Médico pediatra.

ABSTRACT:
Hospital triage is a fundamental part of clinical management in emergency, when the demand exceeds the availability of human and technical resources. The Emergency Triage is a system that offers a method to assign clinical priority in emergency situations. It is not designed to judge whether patients are adequately diagnosed in the emergency, but to ensure that those who need urgent care receive it properly and in a timely manner.

Through the implementation of triage in emergencies, there has been an improvement in the quality of care, since it is attended in an appropriate manner and in the time necessary to those pathological situations that require rapid assistance.

Triage in emergency services has been evaluated in many research projects where they conclude that it is necessary to create, develop and change it according to the demands of better care and increased demand in emergency.

This last aspect has been the most important determinant worldwide in the development and creation of different triage scales to deal with emergencies adequately and in the necessary time. In Peru in general and in Lima in particular, there is no systematic development of concepts and uniform implementation of triage in hospital emergency services. It is therefore necessary to know the concepts surrounding the triage of hospital emergency services and in accordance with this, establish the regulations, by the governing bodies in health, necessary to improve initial care and emergency quality.

Key words:Triage; Hospital triage; Emergency. (source: MeSH NLM)

RESUMEN:
El Triage hospitalario, es una parte fundamental de la gestión clínica en emergencia cuando la demanda excede la disponibilidad de recursos humanos y técnicos.
El Triage de emergencia es un sistema que ofrece un método para asignar prioridad clínica en situaciones de emergencia. No está diseñado para juzgar si los pacientes están adecuadamente diagnosticados en el marco de la emergencia, sino para asegurarse de que aquellos que necesitan atención urgente la reciban adecuada y oportunamente.

Mediante la implementación del triage en las emergencias se ha producido una mejora en la calidad asistencial, ya que se atiende de una manera adecuada y en el tiempo necesario a aquellas situaciones patológicas que hacen necesaria una asistencia rápida.

El Triage en los servicios de emergencia ha sido evaluado en muchos trabajos de investigación donde concluyen que es una necesidad su creación, desarrollo y cambio según las exigencias de una mejor atención e incremento de la demanda en emergencia.

Este último aspecto ha sido el determinante más importante a nivel mundial en el desarrollo y creación de diferentes escalas de triage para atender las emergencias de manera adecuada y en el tiempo necesario. En el Perú en general y en Lima en particular, no existe un desarrollo sistemático de los conceptos y de la implementación uniforme del triage en los servicios de emergencia hospitalarios.

Es necesario conocer los conceptos que rodean al triage de los servicios de emergencia hospitalarios y en función a ello establecer las normativas, por los entes rectores en salud, necesarias para mejorar la atención inicial y de calidad en emergencia.

Palabras clave:Triage; Triage hospitalario; Emergencia. (fuente: DeCS BIREME)

INTRODUCTION
The concepts about the situations that currently we know as individual emergencies or collectives have a development time relatively short, both on the world stage and local. In the past 40 years, the speed of development focus on emergencies first is gone increasing, to become dizzying later. Emergency Medicine is a young specialty, well established and mature, but only in a number a relatively small number of countries¹.

However, emergencies and disasters are so ancient like humans himself and make their appearance since man has existed, either with injuries or acute illnesses needing care in immediate form, especially those that threaten life or the integrity of the human being².

The current situation of the health systems of our country and the world has undergone changes. The transition demographic and epidemiological translate the increase in life expectancy, but also chronic diseases and multiple pathologies. Already from the 1993 Census, the pyramid by age presented a relative reduction in younger ages and a slight increase in intermediate ages. Age Median population increased from 19 to 22 years during the intercensal period 1981 - 1993, and to 2017 the transformation of the population pyramid of a wide base and narrow vertex to one with a base reduced and a progressive widening in the centers reflects a smaller number of births and largest working-age population, a figure that tends to be rectangular, which shows that Peru is in a stage of transition towards aging demographic and a notable increase in demand emergency services³.

Various studies mention the impact of aging on the casuistry of a hospital and its different services for which the need to adapt hospital resources to requirements of the geriatric population, with the history and diagnoses that most frequently present and their treatment in particular^4,5,6. In most of the cities of our country, health facilities are saturated, even more so in emergency and emergency services, probably due to the uneven growth of the population that has access to these and the portfolio of health services provided, problematic that apparently has not been anticipated or faced weather. Populations in urban areas grow exponentially, the high rates of violence, crime, and the generalization of youth gangs translate into high numbers of victims with serious injuries, enhancing with chaotic growth vehicle and the emergence of modes of transport how are motorcycle taxis⁷.

Overcrowding in emergency services translates to the problems of the various systems of health. Today, the main problems that afflict the population over 60 years of age are related to chronic degenerative pathologies, where cardiovascular disease is in the first order, leading to higher utilization of health services, in particular emergencies, higher cost of care, and higher capacity resolution of health establishments^8,9.

The aforementioned creates a need for health that must offer quality, opportunity, and efficiency in the care of the critical emergency patient in accordance with the new conceptions of health care.

One of the most important aspects both at the level hospital as well as the emergency service itself due to the perception of the quality of care of patients is the first contact made by the same with the hospital. The constant increase in the number of visits to emergency services or hospital emergencies determines the need for have a system to classify patients who go to these services, depending on their severity probable, to give priority to those who more deserves it, this process is the Triage and the place where the first contact of the users is made of the emergency services with the personnel of health are the Triage areas that can be organized to a greater or lesser extent in the emergency services.

Triage means the classification of patients according to their health condition. Triage is a valuation process initial clinic that classifies patients before diagnostic and therapeutic medical evaluation, based on your degree of urgency, without necessarily taking take into account the order of arrival, determining that the most urgent patients are evaluated first while the remainder must be controlled and reevaluated until full medical evaluation¹⁰.

HISTORY OF TRIAGE
The development of Triage is born from the experiences of war and military medicine, in ancient times the armies made little or no effort to care for their wounded by the level of their knowledge, the few attentions provided were little or totally ineffective¹¹.

French military surgeon Baron Dominique-Jean Larrey, chief surgeon of the Imperial Guard of Napoleon is considered by most authors as the first to conceive and implement an official triage system on the battlefield via the rapid evaluation and classification of soldiers injured^11,12.

As Iserson¹² points out, he prioritized treatment and evacuation of casualties requiring medical care urgent instead of waiting hours and even days or let the battle end. In this way, Larrey realized hundreds of amputations on the battlefield while the battle raged, and also designed light cars, which he called "ambulances flying "to quickly transport the casualty. It said "those who are dangerously injured should receive first care, regardless of rank or distinction, those who are injured to a lesser degree They can wait until their brothers in arms that are very mutilated, have been operated and dresses, otherwise they will not survive for many hours, rarely, until the next day "what was reflected in his memoirs on the campaign from Russia^18-12.

British naval surgeon John Wilson argued that surgeons should focus on those patients who needed immediate treatment with a further probability of success; patients with fewer injuries serious and those whose injuries were probably fatal treatment was extended. During the Civil War of the United States (USA), with the formal establishment of a military field ambulance and aid stations direct through the efforts of two surgeons of the Union Army, Charles Tripler, and Jonathan Letterman consolidated what was indicated by Larrey¹¹.

However, in the early days of the Civil War in The US did not have a uniform classification method of those wounded in combat determining high mortality which resulted in the implementation of selection procedures on the front line and ambulance services reducing mortality. With the advent of the first world war, a number of high-lethality weapons were developed with a large number of victims not seen before, that needing treatment they had to enter a system of triage. As Iserson¹² refers, Keen in his book"Treatment of war wounds" mentions that "A hospital with 300 or 400 beds can suddenly be overwhelmed by 1000 or more cases. Often times, Therefore, it is materially impossible to give a treatment fast and complete to all. A single case, even if urgently requires attention and whether to absorb a long time, you might have to wait, as in that same time a dozen others, almost as demanding, but requiring less time, could be cared for. The greatest good for the greatest number it must be the rule ”.

This approach explicitly recognizes that when resources are limited, some patients who could save can wait while saving the elder number. Other triage planners in the first war offer a very different approach to the triage of the battlefield, which poses delaying treatment of the least seriously injured, as they suggested give priority to this group, as they can be treated quickly and return to combat.

In World War II, new weapons, including upgraded tanks and support air, and new treatments, including plasma and penicillin. Military physicians developed protocols new and more detailed tests for the evaluation and triage of patients.

Similarly, German military doctors, during the Russian campaign of 1941, used the principle of maximizing combat strength by treatment of those who could more quickly return to action with the least expenditure of time and resources. Another example of this approach to military triage is can be found in a 1958 NATO manual (North Atlantic Treaty Organization) that describes three categories of triage: 1. Those who are slightly injured and may return to duty, 2. Those who are more seriously injured and in need of immediate resuscitation or surgery, and the "hopelessly wounded "or dead on arrival.

The rapid evacuation of the wounded began with the basic aeromedical transport (without medical attention in the air) in the Korean War and advanced to transport sophisticated multi-causal helicopter with treatment air in Vietnam. The mean time between injury and definitive treatment was reduced from 12 to 18 hours in World War II, 2 to 4 hours in Korea, and less than 2 hours in Vietnam. In the 2 conflicts of Iraq, mobile field hospitals, ideally within 10 miles of the battlefield, he remained relatively short evacuation times.

The use of nuclear weapons in WWII World and the continuing threat of nuclear weapons, chemical and biological mass destruction pose special challenges for classification and planning triage. In a limited attack with weapons of mass destruction, planning triage for major catastrophes can help providers to distribute limited resources among the injured survivors. After the widespread use of such weapons or a disaster natural magnitude, the number of victims, the destruction of available resources, and order social care can be so great that medical care cash, including triage, becomes impossible. It is often mentioned that military systems triage have been adapted for triage in contexts civil, including disasters. Based on a comprehensive review of state disasters States, Auf der Heide reported that, despite the existence of triage systems, most of the disaster victims outside the hospital, find and are transported directly to hospitals by passersby¹³.

The first description of the civilian use of triage in the Emergency Departments (DE) for the first time was at Yale-New Haven Hospital in 1963, with a focus on the civilian population and was published by Weinerman in 1964¹⁴. His classification included three categories:

a) Emergent (conditions requiring attention to an immediate medical condition, as they are life-threatening).
b) Urgent (conditions that require attention within a few hours per be considered an acute condition, but not necessarily serious).
c) Non-urgent (a condition that does not warrant the use of Emergency Department resources).

Based on the needs of patients and the health personnel who first receive the patients who come to the Emergency, said classification was modified with experience and the various research works developed, so that in Currently, a triage with a scale of five is proposed levels based on prioritization based on severity filed¹⁵.
• Level I: absolute priority with immediate attention and without delay.
• Level II: very urgent life-threatening situations, instability, or very severe pain Delay of medical assistance for up to 10 minutes.
• Level III: urgent but hemodynamically stable, potentially life-threatening that probably requires diagnostic and/or therapeutic tests. Delay of 60-minute attention.
• Level IV: minor urgency, potentially without risk vital to the patient. A maximum delay of 120 minutes.
• Level V: No urgency. Little complexity of the pathology or administrative issues, appointments, etc.

Delay of up to 240 minutes. Based on the five priority system before mentioned, there are currently five models hospital triage for universal use16, existing various local attempts to implement their own models^17,18,19.

HOSPITAL TRIAGE MODELS

a) Australian triage scale, NTS 1993 and ATS 2000
b) Triage of the Canadian Emergency Department 1995 CTAS
c) 1996 Manchester MTS Triage System,
d) Emergency Severity Index ESI of 1999 and
e) Andorran triage system or Spanish system of Triage MAT-SET 2003

The classification model must be standardized, normalized and have a high level of concordance interobserver, valid when classifying the patient according to your actual level of urgency. The primary objective of the classification will optimize the time span from that the patient arrives in the emergency room and is assessed by the doctor who will treat the patient. The priority assigned will depend on the reason consultation, clinical assessment, signs objective and subjective patient, this process is continuous until starting medical attention on the topic respective.

During the triage process it is revealed the principle of charity, that is, getting the best for the patient with rational use of existing resources, as well as the principle of justice with allocation of said resources to those who have greater chances of survival.

The background to the five-priority system is originate in Australia. As FitzGerald20 points out, in Australia developing a classification system was based on the observations of nurses in classification of patients. This observation identified several consistent and distinct actions after evaluation those that were determined by the urgency of the patient and included:

1. Seek immediate medical attention and get started resuscitation.
2. Assign the patient to the next available physician.
3.Place the patient's emergency history at the front of the waiting list.
4.Place the patient's emergency history in order on the waiting list.
5.Encourage the patient to seek help elsewhere or in another moment.

The central decision underlying these observations was the "urgency" of the patient and the evaluation of the nurse at the time of the medical evaluation. This led to the development of The Ipswich Triage Scale (ITS), which was based largely measured on a categorical scale of 5 levels in operation at Box Hill Hospital in Victoria.

However, the ITS included an urgency descriptor based on the general determination of the nurse of the patient's emergency.

In the STI the patient must be seen under circumstances reasonable by a physician within 1. Seconds, 2. Minutes, 3. One hour, 4. Hours and 5. Days. The category of "days" did not imply that patients should wait days, but they could do it without adverse clinical conditions.

Following this, a detailed usage analysis was performed on the scale for 12 months at Ipswich Hospital. These studies showed a relatively high-level concordance in ranking assessments among nurses, a direct relationship between rating evaluation and a variety of others severity measures (e.g., Trauma Score, injury severity, and Asthma severity score), and a direct association with outcomes such as mortality, time in a hospital, time in UCI and the use of resources.

Other studies by Jelinek²¹ confirmed the repeatability and validity of the system. This work formed the basis for the adoption of the ITS in 1994 by the Australasian College for Emergency Medicine (ACEM) and the National Triage Scale (NTS). McMahon notes that the ATS requires that personnel trained health practitioners evaluate all patients at their arrival, determining classification category when completing the sentence: "This patient must wait to receive a medical evaluation and treatment no more than ___ minutes. "Each category of the classification has a recommended maximum time for the treatment. The assessment takes two to five minutes; Nurses obtain vital signs and other data only when needed. A wide development of this scale can be obtained from https: // acem.org.au/Content-Sources/Advancing-EmergencyMedicine/Better-Outcomes-for Patients/Triage. Subsequently, the NTS became the Australasian Triage Scale - ATS in 2000 and has been widely validated by research experience and operational, the ATS is also one of the bases of the Canadian Triage and Acuity Scale CTAS in Canada and the Manchester Triage System MTS of the United Kingdom. McMahon22, notes that the Canadian scale of classification and acuity (CTAS) is similar to ATS but it has slight differences in time to doctor's evaluation. Also includes scales of pain and a separate acuity scale for pediatric patients, and allows the determination of the severity of conditions (such as asthma) in more than one category, and has a "summary view Quick "of the sorting categories broken down by body system. Also, describe the frame time for a reassessment of patients in the waiting area and allows you to change the category of classification when the patient has been waiting for a long time (for example, a patient-rated "5" may change to "4" after waiting two hours). It also has an indicator of quality that measures whether the department meets its own response time standards. It can get widely developed at https://caep.ca/ resources/cats / implementation-guidelines / The Manchester Triage System, developed by the Triage Task Force from Manchester, England, directs professional triage health staff to assign levels by identifying signs and symptoms and the assessment of six factors: a threat for life, pain, bleeding, level of consciousness, temperature and acuity. (Specifically, avoid diagnosis during triage). They have been developed fifty-two algorithms for use during This process. Its development can be seen at https: //www.triagenet.net/classroom/ or at http: // www.triagemanchester.com/web/presentacion_es_66.php

The Emergency Severity Index (ESI), developed by a team of emergency doctors and nurses led by Wuerz, now deceased, at Brigham and Women's Hospital in Massachusetts and by Eitel in York Hospital in Pennsylvania. The ESI is based on a conceptual model that not only raises the question “When should this patient be seen? " but also “What does this patient need? " Thus, the algorithm first incorporates the acuity and then the expected resource consumption to determine the priority of treatment. Components include airway stability, cardiac function, level of consciousness, the intensity of pain, number of interventions required, and the level of risk. I know has proven its high degree of reliability among raters in the classification category. A strong correlation was observed between the category of classification and the probability of hospitalization. Version 4 with examples can be obtained from https://www.ahrq.gov/professionals/systems/hospital/esi/index.html The Spanish Triage System - Andorran Model of Triage (SET-MAT), arises in the year 2000, with the CTAS as a reference, moving from a scale based on symptoms and sentinel diagnoses on a scale based on symptom categories. It is a set of symptoms or syndromes that the professional recognizes based on the reason for consultation and allows it to be classified into asymptomatic category¹⁰.

In 2001, the computer program Triage aid and the Spanish Society of Medicine of Urgencies and Emergencies (SEMES) adopts it as a triage model for the Spanish state in 2003, with the name of Spanish Triage System (SET). The set has 32 symptomatic categories and 14 subcategories that group 578 different reasons for consultation.

The SET-MAT uses a 5-level priority scale and has a specific version for pediatrics with more specific symptomatic categories according to the employed population. This version has been validated, although it does not show such a close correlation between consumption of health transport resources or index income according to the level of urgency, as in the adult population.

Triage principles According to PAHO in its Manual for the implementation of a triage system for emergency rooms²³, the fundamental principles that characterize a structured and modern triage system are:

• Triage system with 5 levels of prioritization, standardized and equipped with a computer program triage management, which allows the registration of classification, control of all patients in and out of service, and time control performance (Timelines).
Integrating the model is one of the most relevant aspects of the current 5 category triage models, to which it has to contribute aspects of review and adaptation to the health environment where it is applied.

• Quality model, with operational objectives, proposed as quality indicators of triage, reliable, valid, useful, relevant, and applicable.
• Medical and nursing triage system no exclusive, integrated into a service dynamic where the urgency of the patient is prioritized, over any other structural approach or professional, within a specialization model emergency.
• Model equipped with a computer program of help clinical decision in triage evaluated and validated, with ongoing help and registration triage anamnestic.

• Integrated system in a continuous improvement model of quality, with monitoring of indicators quality of triage, which defines a standard of reasons for consulting the emergency room and allowing others, evaluate the casuistry of the service.
• Be able to integrate into a global model of history electronic clinic, integrating activity medical and nursing, standardized and following quality standards, allowing total control of the clinical and administrative management of the emergencies.
• Propose structural adaptations and staff in the emergency room, consistent with the quality needs of the triage system and specific training for triage personnel.
• Holistic structured triage system, application both in the field of urgency hospital and out-of-hospital, applicable both children as well as adults, and regardless of the type of hospital, device, or assistance center.

TRIAGE GOALS

The objectives of the triage system in Emergency¹⁵ point towards timely, rapid identification of life-threatening patients, try decrease patient congestion by ensuring granting the appropriate priority by assigning it to the most suitable area to treat the case. As I know has indicated it is not the intention to establish diagnoses but to grant the priority of attention. An important aspect is to aim for the information to patients and their families about the general condition of the patient and the probable time Standby.

ADVANTAGES OF TRIAGE

Triage provides the patient with information about your state of health and approximate waiting time prioritizing your attention according to its severity clinic. It also guides patient flows in function to its gravity allowing the rearrangement of emergency resources based on demand.

TRIAGE FUNCTIONS

Determine the life-threatening situation of the patient, through a system of care priorities, determining the most suitable area to treat the patient informing patients and relatives of the first actions to take according to your priority of attention and likely waiting time.

TRIAGE QUALITY INDICATORS

The classification of a structured triage allows have quality indices. Some of them are the waiting time to be attended in the triage which it should generally be less than 10 minutes. It is also measurable index the proportion of patients who leave the hospital without being treated by a doctor and that, in Generally, it should be less than 2%. 10-24 quality indicators have been proposed for the hospital triage which would be:

1. The rate of patients lost without being visited by the which would be a Quality Index of satisfaction, risk, and adequacy. The established standard is in 2% of all patients attending the emergency room, they subdivide it into:

a. Index of patients lost without being classified which is the percentage of patients who decide to leave the emergency department after being registered administratively and before being classified, on the total number of registered patients.
b. Index of patients classified and lost without be visited by the doctor, which is the percentage of classified patients who decide to leave the service of emergencies before being visited by the doctor, on the total classified patients.

2. The time since the patient's arrival at the service emergency until the moment the classification. It is recommended that this time be 10 minutes, this index does not have an established standard, it is difficult to calculate unless there is an electronic system and automatic check-in.

3. The duration of the classification (time of triage duration), it is recommended that it be 5 minutes.

4. The waiting time to be visited is established that at least 90% of patients have to be visited by the medical team within 2 hours of their classification and 100% in 4 hours.

The various types of triage models must have high reliability and reproducibility. Reliability is a statistical term that evaluates the degree of inter-rater and intra-rater uniformity. Either that two different people or the same person carry out triage would obtain the same result25. At the present time a correct triage is performed through the computerization of the same because despite the reliability and scientific validity of the 5-level triage scales, the experience of your usage has shown problems translated into jobs of research as the reliability of results in clinical practice (concordance problems interprofessional and interhospital when applied on patients in triage), attributed to different causes: 1.- heterogeneity in the formation of professionals; 2.- the tendency to undertriage in quarters of oversaturated emergencies; 3.- the tendency to undertriage in common acute situations; 4.- the tendency to over-triage to justify long delays; 5.- the tendency to over-triage in paid services by casuistry. All of which would diminish with computerization of the triage that would constitute critical support for triage staff and it also allows a more reliable audit 23.

The implementation in the emergency services of the triage area has determined in part, satisfaction by emergency personnel, since the pathology he faces has been selected and qualified before your attention, decreasing that which is the one that should not attend and but that if it should receive medical care at other levels of care. Community health education is produced, making the patient with a banal pathology, who does not require studies or complementary tests hospitals and what do you think that by going to the services of hospital emergencies will perform these auxiliary examinations, you meet a necessary triage that discriminates against that situation. Likewise, it has achieved an improvement in the quality of care given that is taken care of properly and in the time necessary those pathologies that make it necessary prompt assistance increases satisfaction internal and external users and streamlines consumption of resources collaborating in the improvement of the overall quality of the service and providing an order just in the attendance, based on the gravity, of the patients, emergency / urgency^26,27.

Within the triage organization, it has been studied what professional could run it apart from the Doctor. Imperato, in a 6-month intervention study before and after implementing the presence of doctor, states that through a survey said presence had a significimant provement in patient satisfaction^26-28,29,30. Rainer, in a prospective observational study of consecutive patients who attended the station triage of an emergency department between 9 am and 5 pm, Monday through Friday, evaluated the impact of a specialist in triage in-service time. When the different triage categories were compared, a significant reduction was only observed in patients semi-urgent during the study period. However, semi-urgent patients constitute 68% of all attendances in the study group and 74% in the control group, concluding that the presence of an Emergency medicine specialist can shorten the service time of patients from category 4 and that patient triage can be performed best by a triage team with the presence of an Emergency medicine specialist and nurses instead of just a triage nurse³¹.

On the other hand, the decisions made may have a margin of error that needs to be monitored, as Grossmann publishes when reporting on a sub-triage that occurred in 117 cases out of a total of 519 patients 65 or over, the main reasons being high-risk situations and failure to interpret adequate vital signs concluding that in their study, older patients were at risk of "Subtriage". It was performed with the severity index emergency or Emergency Severity Index to which without however they found reliable and valid for triage older patients³².

A review of searches in the databases of comparative studies published from 1994 to 2014 that examine the role of the experienced physician in triage, shows that triage performed by physicians experienced can be an effective measure to improve the performance of the department of emergency³³. Concern about triage sensitivity too It was revealed in another work by Mendoza and Elguero who determined the sensitivity of clinical triage in an adult emergency department performing a prospective cross-sectional and clinical study, including patients over 18 years of age who came to request consult the emergency department and were assessed by the triage service doctor. The sample was 380 and the patients who were admitted were randomized. I know used the 3 color system, and post to your attention a color was reassigned depending on of your final diagnosis, comparing with the initial to determine diagnostic sensitivity. From 380 patients initially classified in the triage area, obtained an overall diagnostic sensitivity of 60.2 concluding that the sensitivity of clinical triage in the Adult Emergency Service of his hospital was 60.2 and that the sensitivity for patients with Real urgency is better than sensitivity for patients with medium and felt urgency³⁴. On the other hand, Beveridge reports that there was a high rate according to an interobserver agreement using the Canadian Triage and Acuity Scale and was also understood and interpreted similarly by nurses and doctors²⁵.

Over demand in emergency and change demographic that determines the attendance of the elderly from the elderly to the emergency, it is a concern of various realities as translated by Baumann in his work on Triage of geriatric patients in an emergency department and validation and survival with the severity index in an emergency where they evaluated the validity of said index and its association with survival. When used in triage for patients over 65 years of age, the ESI algorithm demonstrates validity, hospitalization, length of stay, use of resources, and survival were associated with categorization of the ESI in this cohort and was used in this group of patients as there is a great demand for the Emergency for this age group in various latitudes, including our country³⁵.

About research in Triage, the triage scales five-tier systems are superior to three-tier systems levels with respect to validity and reliability therefore that the largest number of publications refer to the five-level CTAS and ESI instruments, which have been the subject of multicenter studies and analyzes carried out in Europe. The ATS is also ok documented, but published data are scarce at the MTS. Constant training enables professionals who perform triage at an optimal level in their decisions by increasing their skills and Perceived security when doing it^36,37.

One of the aspects observed in the triage area is insufficient or excessive triage. In this regard, PAHO through the publication “development of emergency medical services: the experience of the United States of America for developing countries ”38 mentions the following: It is called insufficient triage to the situation in which the illness or injury of a patient is classified as less than that in actually has, this may result in some or all of the following situations: increased probability of death, the higher probability of permanent disability, increased costs due to lost productivity and ultimately higher costs of care as a result of delayed treatment of the illness or injury, or its resulting complications. On the contrary, the situation is called excessive triage in which a patient's illness or injury is cataloged as more serious than it actually has, the consequences are, however, paradoxically similar to the above, increased medical costs secondary to unnecessary use of medical resources (personnel, tests, and equipment). Furthermore, the fact is that while patients wrongly cataloged use the resources of Emergency Medical Service or Department Emergency, someone with a more serious picture can not do it. This will make the patient perhaps "unknown" in the system suffers the effect of consequences of the "insufficient triage" already mentioned, the aforementioned can certainly be of nature cyclical, causing a spreading effect on the emergency department. It also states that "in most systems, especially with regard to the population of trauma patients, universally accepted that a certain percentage of excessive triage against an insufficient triage is acceptable since the error aims for caution. In trauma, it is accepted in Generally, an excessive triage rate of 30% to 50% is acceptable (American College of Surgeons, 1999). It is advisable, on a moral and ethical basis, to achieve a balance between providing high-quality care to all and to do it with reasonable costs, the objective is achieve this in a way that does NOT violate quality standards regarding patients who are truly in need of immediate and urgent attention. This is the real challenge facing triage systems SEM and DE in the new millennium ”³⁸.

If it has been decided to implement a triage system, an instrument should be selected whose validity and reliability have been demonstrated, ideally in the language of the country in question, in addition, that allows the correct identification of patients requiring urgent medical attention; these instruments empower resource estimation and planning³⁹. Triage in the emergency services of Lima In Peru in general and in Lima in particular, the changes have not occurred progressively and continuous, but rather several overlapping stages as a product of epidemiological change and demographic occurred in the last 30 years and where the violence of terrorism and gangs as well like the rapid changes in the fleet and chronic degenerative diseases have determined an over-demand for the services of an emergency. The health system response has not been timely. Most emergency services for face this over demand have strengthened areas like triage, but in a messy way and without general and specific normative foundations, the aforementioned is preliminarily reflected in a study on triage in Lima hospitals; I know evaluated 20 hospital emergency services, 65% had categorization level III-1, 25% level II-2, 5% level IIE and 5% level II-1. The start time of the triage in your emergency services is on average 8.61 years old, they work on average 24 hours in 60% of health establishments, and from Monday to Sunday in 70% of them. The priority used is 4 in 61.11%, 5 priorities in 33.3%, and 3 priorities in 5.56%. The triage at 70% is in charge of the medical professional and 30% of nursing. There are 15% (3 establishments) carried out by technicians of nursing partially.

Medical programming is only total only in 30% of the establishments and partial in 30%. 8 establishments did not inform about the type of programming. fifteen% of the total of 20 establishments report that the doctor who performs triage has a specialty, they deny that have specialty 11 establishments and 6 not they report. Nursing presents 83.33% who have a specialty. In 90%, relatives or patients are informed about the health situation and 65% are informed about waiting times. 20% manage indicators of quality and 10% carry out retraining. 50% of establishments health use triage scales and 85% of the staff of the establishments that use them are aware of the same. 85% of health facilities report that have internal regulations on triage and 75% of staff would know them. 90% of establishments report that they do not research the area of triage⁴⁰.

All this presents a panorama of inadequate implementation of the triage area in services emergency of health facilities in Lima due to what in an environment of improvement of healthcare quality and in the goal of improving patient care critical governing body rules should be established in health to standardize modern concepts about triage and implementing such an important area and in many cases decisive in the primary care of the emergency patient.

CONCLUSION Triage determines the life-threatening situation of the patient provides the patient with information about your state of health and the approximate time of wait according to your clinical severity. The triage a structured triage system must be implemented and modern.

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Authorship contributions: The authors participated in the generation, information gathering, writing and final approval of the original article.
Financing: Self-financed.
Conflict of interest: The authors declare no conflict of interest in the publication of this article.
Received: November 01, 2018
Approved: December 02, 2018

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Correspondence: Rolando Vasquez Alva.
Address: Cápac Yupanqui N°2698-104, Lince. Lima, Peru
Telephone: 999952704
Email: rolandova@hotmail.com

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