Criteria for Screening and Triaging to Appropriate aLternative care, (CriSTAL) was news in The Telegraph. “It is a checklist of 29 assessments that help to identify which of the elderly are closest to death so costly treatments are not wasted on them. Medical professionals in Australia say the 29-point assessment will prompt honest discussions with family members about end of life care and stop futile treatments. The proposals, printed in the British Medical Journal, assess the most likely predictors of death in the short term – 30 days – to medium term – 12 weeks – and provide definitions for the dying patients. The authors write: ‘Delaying unavoidable death contributes to unsustainable and escalating healthcare costs, despite aggressive and expensive interventions. These interventions may not influence patient outcome, often do not improve the patient’s quality of life, may compromise bereavement outcomes for families and cause frustration for health professionals.'” A death test which predicts if people will die within 30 days could allow them to go home and say goodbye to family members.
What are the criteria that guide our medical people in triage decisions?
The components that would make up the CriSTAL risk of death analysis are —
1 Decreased LOC (Level Of Consciousness): Glasgow Coma Score change greater than 2 or the quick AVPU = P or U (Alert, Voice, Pain, Unresponsive) tests.
2 Systolic blood pressure less than 90 mm Hg
3 Respiratory rate less than 5 or greater than 30
4 Pulse rate less than 40 or greater than 140
5 Need for oxygen therapy or known oxygen saturation less than 90%
6 Hypoglycaemia: (BGL – glucose-binding lectin) low blood sugar
7 Repeat or prolonged seizures
8 Low urinary output (less than 15 mL/h or less than 0.5 mL/kg/h) or MEW (Modified Early Warning)
Other risk factors/predictors of short-medium term death
Personal history of active disease with at least 1 of these —
Chronic kidney disease
Chronic heart failure,
Chronic obstructive pulmonary disease
New cerebrovascular disease
Moderate/severe liver disease
Evidence of cognitive impairment (eg, long-term mental disorders, dementia, behavioral alterations or disability from stroke)
Length of stay before this RRT call (greater than 5 days predicts 1-year mortality)
Previous hospitalization in past year10 repeat ICU admission at this or previous hospitalization (associated with a fourfold increase in mortality)
Evidence of frailty: 2 or more of these —
Unintentional or unexplained weight loss (10 lbs in past year)
Self-reported exhaustion (felt that everything was an effort or felt could not get going at least 3 days in the past week)
Weakness (low grip strength for writing or handling small objects, difficulty or inability to lift heavy objects =4.5 kg)
Slow walking speed (walks 4.5 meters in more than 7 seconds)
Inability for physical activity or new inability to stand
Nursing home resident/in supported accommodation
Proteinuria on a spot urine sample: positive marker for chronic kidney disease & predictor of mortality: >30 mg albumin/g creatinine
Abnormal ECG (Atrial fibrillation, tachycardia, any other abnormal rhythm or =5 ectopics/min, Changes to Q or ST waves
Age = 65 + and admitted via emergency room procedures for a current hospitalization (associated with 25% mortality within 1 year)
Glasgow Coma Score
This Glasgow Coma Score is a measure of consciousness created by adding the number scores in each of the following three categories – eye opening, motor response, and verbal response. The poor score is 3/15 for a person totally unconscious, and a most favorable score would be 15/15 for totally conscious.
4 Opens eyes spontaneously
3 Opens eyes in response to speech
2 Opens eyes in response to painful stimulation – fingernail pinch
1 Does not open eyes in response to any stimulation
6 Follows commands
5 Makes localized movement in response to painful stimulation
4 Makes non-purposeful movement in response to noxious stimulation
3 Flexes upper extremities / extends lower extremities in response to pain
2 Extends all extremities in response to pain
1 Makes no response to noxious stimuli
5 Is oriented to person, place, and time
4 Converses, may be confused
3 Replies with inappropriate words
2 Makes incomprehensible sounds
1 Makes no response
Revised Trauma Score
Revised Trauma Score (RTS) combines the tables 1 & 2 and gives a quick numerical triage score to victims, by combining measured systolic Blood Pressure (BP) and Respiratory rate, with this Glasgow Coma Scale listed directly above.
First responders use START (Simple Triage And Rapid Treatment) to evaluate victims and assign them to one of the following four categories:
Walking wounded/minor (green)
The colors correspond to triage tags, which are used by some agencies to indicate each victim’s status, although physical tags are not necessary if patients can be physically sorted into different areas.
Responders arriving to the scene of a mass casualty incident may first ask that any victim who is able to walk relocate to a certain area, thereby identifying the ambulatory, or walking wounded, patients. Non-ambulatory patients are then assessed. The only medical intervention used prior to declaring a patient deceased is an attempt to open the airway. Any patient who is not breathing after this attempt is classified as deceased and given a black tag. No further interventions or therapies are attempted on deceased patients until all other patients have been treated. Patients who are breathing and have any of the following conditions are classified as immediate:
Respiratory rate greater than 30 per minute.
Unresponsive (unable to follow commands)
All other patients are classified as delayed.
Treatment and Evacuation
After all patients have been evaluated, responders use the START classifications to determine priorities for treatment or evacuation to a hospital. The most basic way to use the START classifications is to transport victims in a fixed priority manner: immediate victims, followed by delayed victims, followed by the walking wounded.
This post pulls together data from different triage and hospital settings, and is intended to illustrate what you might encounter when you enter a life-threatening medical situation. For clarity I bolded and underlined acronyms created from first letters of titles attached to the various methods for measuring trauma. The suggestions above are not mine, but are compiled from the quoted sources.