One-two-triage: a novel system for austere environments

Triage is the process of determining treatment priority based on the severity of a patient’s condition. The term triage is derived from the French word trier which means “to sort.” The concept of triage was first applied to medicine by French military surgeon Baron Dominique-Jean Larrey, a chief surgeon of Napoleon’s Imperial Guard. Larrey recognized the need to categorize the wounded during battle to treat and evacuate those requiring the most urgent medical attention (Iserson et al.). While medical technologies advance and the time-sensitive nature of emergencies stay the same, it is important to continually revise triage systems to fit local needs and resources.

Currently, the most common emergency department (ED) triage system in the United States is the Emergency Severity Index (ESI). The ESI is a five-level tool for experienced ED personnel to rate patient acuity which takes into consideration both clinical and operational decisions such as resource allocation. In a recent study by Khan et al., a new triage system is proposed that better matches the needs of austere environments. In her podcast with Urgent Matters, Dr. Khan described the many reasons why traditional triage systems are not as useful where there are fewer experienced emergency providers and a scarcity of resources, such as in low- and middle-income countries. Low- and middle-income countries can’t afford to have experienced providers conduct triage assessments because they are needed for patient care, and the resource-based triage in the ESI is not as relevant when there are fewer resources available. For example, providers in austere settings may not have the ability to order certain radiography or laboratory tests.

Khan and her team proposed the one-two-triage (OTT) system. OTT is a two-triage system that can be reliably applied after only eight hours of training. Instead of relying on experience in making subjective clinical decisions, Stage 1 is designed to quickly separate out patients categorized as critical (red) and emergent (orange) from a simple assessment of the patient’s airway, breathing, circulation, and disability. Patients are greeted and pulse oximetry is assessed. If the patient does not qualify as critical or emergent, they are sent to registration. Stage 2 separates patients into urgent (yellow) or non-urgent (green) based on their chief complaint and vital signs, taking the person who is conducting triage – who may have little medical training – through a series of protocols related to each chief complaint to determine how emergent a specific condition might be. This allows less experienced providers to assess severity of illness based on medically sound algorithms. The complete OTT process can be found here.

OTT is currently being used as an alternative to ESI in 22 Cambodian hospitals (with 21 additional EDs coming on board soon), a healthcare population where there is a relative paucity of experienced healthcare professionals. As Dr. Khan discussed in her podcast, crowd-sourcing information about triage needs in specific settings can catalyze the process of customizing systems in various environments. For more information, you can reach out to her here. 


Ameer Khalek is a MPH Candidate of the GWU Milken Institute School of Public Health