Journal of Veterinary Emergency and Critical Care 23(5) 2013, pp 487488
Editorial
Triage 2.0: Re-Evaluation of Early Patient
Assessment
The concept of rapidly assessing patients to predict their
requirement for immediate medical attention and divert-
ing resources to aid in their stabilization is not new and
has been used since World War I.1 The main premise for
triage being that early identification of life-threatening
conditions (eg, shock) will prompt early intervention
and thus improve patient outcome. Many re-iterations
of formalized triage systems have been developed and
are commonly employed in different parts of the world.
These systems share many similarities but also place
different emphasis on various physiological parameters.
Despite the universal agreement that triage is a vital com-
ponent to emergency medicine, there are inherent prob-
lems relating to almost every triage system in use.2 One
issue is the somewhat subjective nature of various as-
sessments. As highlighted by a recent veterinary attempt
to develop a triage system based on a human five-point
triage system,3 such assessments still rely on trained per-
sonnel making subjective judgments such as assessing
moderate respiratory distress, or exsanguinating hem-
orrhage. Refining triage systems often center on balanc-
ing under- and over-triaging so that patients that truly
require emergency care are not missed and patients that
do not require immediate attention do not put undue
strains on already stretched emergency services. The
work by Ruys et al3 is not the first devised system in
veterinary medicine for triaging but did focus on the
feasibility of rapidly assessing patients to a set standard
and compared the performance of the proposed system
with assessments made by veterinary nurses and vet-
erinary students to the assessment made by the main
investigator.
Earlier veterinary systems which are still used to date,
such as the Animal Trauma Triage (ATT) scoring system,4
rely on grading 6 body systems on a scale from 03,
for a possible total score of 18 (indicative of improbable
survival). Interestingly, the authors of the ATT system
suggested that their devised system should serve as a
prototype for severity of injury scoring system. Yet to
date, there has not been a revision of an injury scoring
system focusing on trauma in veterinary patients. Sub-
sequent illness severity scoring systems, such as the Sur-
vival Prediction Index,5 and Acute Patient Physiological
and Laboratory Evaluation (APPLE) score,6 have been
devised to be applied more globally to critically ill veteri-
nary patients and rely on laboratory parameters such as
creatinine and albumin concentrations. Indeed, there has
been a shift to evaluate the predictive value of various

C Veterinary Emergency and Critical Care Society 2013
doi: 10.1111/vec.12104
surrogate markers such as plasma lactate,6 base excess,7
and even ionized calcium,8 in early patient assessments.
Another interesting development in triaging veteri-
nary patients has been the interest to incorporate diag-
nostic imaging in these early patient assessments within
the emergency room.911 In light of these developments,
veterinary triage systems may be evolving into rather
complex systems and perhaps we are losing sight that
they must remain rapid, reliable, and must not make pa-
tient assessment cumbersome, nor place undue stress on
overstretched emergency services. So it is refreshing that
in the current issue of the Journal, there are 2 investiga-
tions evaluating a relatively simple scoring system the
Shock Index, in veterinary patients.12, 13 The shock index,
which is calculated by dividing the patients heart rate by
the systolic blood pressure, was developed to address the
shortcomings of evaluating heart rate and blood pressure
alone for assessment of shock. It has been recognized that
alterations in heart rate and blood pressure may be too
insensitive in the early stages of shock,14 and therefore
the shock index was developed to allow discrimination
of patients in shock despite relative normal physiological
parameters. Although the shock index was first devel-
oped in the early 1990s,15, 16 the performance in various
patient populations and variations to this simple index
are still being evaluated in people.1719 The performance
of the shock index as a predictor of patient outcome and
as a triage tool has yield mixed results, emphasizing the
need for further refinement.1519 However, the appeal of
the shock index lies not only in its simplicity, but also in
its ability to reflect changes in cardiac index, stroke vol-
ume, mean arterial pressure, oxygen delivery and mixed
venous oxygen saturation.15
In this issue of the Journal, Porter et al12 aimed to de-
termine the normal range for the shock index in healthy
dogs evaluated in a setting mimicking presentation to an
emergency room and comparing these values to those
determined in clinical patients deemed to be in shock
(based on a plasma lactate exceeding 5 mmol/L) as well
as other emergency cases not deemed to be in shock.12 As
a discriminator for shock, the index performed relatively
well and receiver operator characteristic curve analysis
suggested an optimal cut-off value of 1.0 for the popula-
tion evaluated.12 This value is similar to the commonly
cited cut-off value of 0.9 in human trials.16, 18 Echoing
these results, Peterson et al13 retrospectively re-analyzed
data from 2 previous studies20, 21 assessing tissue oxy-
gen saturation in healthy dogs and dogs with confirmed
487
Editorial
hemorrhagic shock and evaluated the performance of
the shock index in discriminating these populations. In-
terestingly, the median shock index for dogs with con-
firmed hemorrhagic shock was exactly the same (1.37) as
reported by Porter et al.12 The studies did differ slightly
in the median shock index for healthy dogs; however,
this is unlikely important as the purpose of the shock in-
dex is to simply discriminate between patient with and
without shock, which both studies effectively demon-
strated.
What these studies offer is the opportunity to re-
evaluate our approach to early patient assessment and
a return perhaps to simpler, more objective systems for
patient evaluation. It is perhaps befitting that these inves-
tigations were carried out by 2 of the 9 inaugural Level
I Veterinary Trauma Centers announced recently.22 As
these centers have been charged with developing col-
laborative efforts for the production of evidence-based
protocols, it is with great hope that the performance and
refinement of simple measures such as the shock index
can be further evaluated by this initiative and lead to
improvement in veterinary emergency patient care.
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Daniel L. Chan, DVM, DACVECC, DACVN,
MRCVS
Department of Clinical Science and Services,
The Royal Veterinary College, University of
London, United Kingdom,
The author declares no conflict of interest.

C Veterinary Emergency and Critical Care Society 2013, doi: 10.1111/vec.12104