Healthcare EMS Triage Protocol

HEALTHCARE EMS TRIAGE PROTOCOL

Agency Information

Purpose and Authority

This EMS Triage Protocol establishes standardized field triage criteria and required actions for prehospital personnel operating under the medical oversight of the Medical Director. This protocol authorizes appropriately trained emergency medical personnel to perform primary triage, initiate indicated life‑saving interventions, and make scene‑to‑facility transport decisions in accordance with the medical authority delegated by the Medical Director. Deviation from this protocol is permitted only with direct consultation and documented authorization from online medical control.

Scope

Applies to adult and pediatric patients encountered by agency personnel on scene, multiple‑casualty incidents, and single‑patient transports when triage assessment is required. Personnel performing triage must be trained and validated per agency education standards. Special population criteria (pediatric, geriatric, pregnant) are included to modify category assignment when clinically indicated.

Patient Identification

Incident Information

Primary Triage Assessment

Assess and document airway, breathing, circulation, disability (neurologic status), and exposure. Initiate immediate life‑saving interventions as indicated. Reassess at intervals consistent with patient condition and agency protocol.

Triage Categories (Select one)

Use clinical criteria and patient presentation to assign a single triage category. Document the primary reason for category selection in the rationale field.

Triage Criteria Checklist

Check all applicable findings used to determine triage category. If none apply, document clinical judgment below.

Airway compromise (stridor, severe facial trauma)

Respiratory distress or RR <10 or >29 (<12 for infants)

Absent radial pulse / systolic hypotension

Uncontrolled external hemorrhage

Altered mental status (GCS <13)

Severe burns (partial/full thickness >10% or airway burn)

Multi‑system trauma / penetrating chest/abdominal trauma

Age extremes (infant <1 year or elderly >65) influencing triage

Pregnancy >20 weeks with traumatic mechanism

Immediate Interventions Allowed Under This Protocol

Authorized prehospital interventions include airway maneuvers, basic and advanced airway management per scope of practice, hemorrhage control including tourniquet use, needle thoracostomy for suspected tension pneumothorax, intravenous/IO access, bolus fluid administration for hypotension consistent with medical direction, controlled analgesia per standing orders, and pediatric dosing per weight. All interventions must be documented and reported.

Transport Decision and Destination

Destination selection should balance patient acuity, required specialty care, and transport time. When higher level care is required notify receiving facility and document time and receiving clinician.

Documentation, Medical Control, and Reporting

All triage decisions, findings, treatments, and communications must be documented contemporaneously on the patient care record. Any deviation from this protocol requires documentation of the clinical reason and notification of on‑line medical control unless impracticable. Reportable incidents and protocol variances shall be submitted to the agency quality assurance office within 72 hours.

Training and Competency

Personnel must complete agency‑approved triage training and competency validation prior to independent application of this protocol. Training records and last competency date must be maintained in personnel files.

Administrative Authorization and Limitations

This protocol is issued under the authority of the agency Medical Director. The Medical Director retains the authority to modify the protocol based on clinical evidence and regulatory requirements. Use of this protocol does not waive applicable legal requirements or replace local regulations. Providers shall comply with state scope of practice limits and report any adverse outcomes as required by agency policy.

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