From Battlefield to Bedside: The Evolution of Triage and the Nurse’s Role Today

Triage is the process of prioritizing patient care based on the severity of illness or injury, and it is one of the most fundamental practices in modern healthcare. For nurses, triage is not just a system; it is a mindset rooted in critical thinking, rapid decision-making, and compassionate care. Understanding its evolution helps you appreciate how far healthcare has come and how triage continues to shape patient outcomes today.

The Origins of Triage

• The word triage comes from the French verb trier, meaning “to sort.” It was first used to describe the sorting of agricultural products. 

• Two French surgeons were instrumental in the development of the triage system: Pierre-François Percy (1754–1825) and Dominique Jean Larrey (1766 -1842).

• The concept of triage was first developed during the Napoleonic Wars in the late 18th and early 19th centuries. It was a time when military surgeons faced overwhelming numbers of casualties on the battlefield, leading to the need for a system that could prioritize care effectively. 

• Percy was the first to use the term triage in his diary in 1808 when discussing the care of wounded soldiers. 

• Larrey refined the concept of triage in 1812 by sorting soldiers who were quickly transported back to field hospitals and then categorizing them based on the urgency of their injuries, rather than their rank. His system ensured that those who could benefit most from immediate care were treated first, a revolutionary shift in thinking that saved many lives.

 (Iserson & Moskop, 2007; Nakao et al., 2017)

In 1793, the first ambulance, called the flying ambulance, was created by Larrey. 

Triage in the 20th Century

As military battles continued to occur around the world, each country worked on how to care for its injured soldiers. From the Napoleonic Wars to the Crimean War, and the American Civil War, significant advances occurred in battles until the 20th Century. 

• Napoleonic Wars - British military medicine employed sorting of the wounded, aid stations, field hospitals, and general hospitals.

• Mid-1850s Crimean War - The French and British had medical units and some system for transporting wounded, but no real triage of patients was documented.

• Nikolai Pirogov, a Russian surgeon, traveled to Crimea and developed a triage system, although it was not yet formally named, which categorized the wounded into four categories to prioritize care. He also set up hospitals.

• During the American Civil War, some surgeons employed a classification system for the wounded based on how they arrived at the field hospital and who should receive immediate care.  

(Slawson, 2017)

• The principles of triage carried forward into both World Wars, with the emphasis shifting to helping the greatest number of soldiers.

• Nurses and medics were utilized to help apply structured approaches to prioritize battlefield injuries. 

• These wartime experiences influenced civilian healthcare, particularly emergency medicine. 

• By the mid-20th century, hospitals began adapting triage systems for civilian emergency departments (EDs) as patient volumes grew. Nurses often became the first point of contact, quickly assessing symptoms and directing patients to appropriate levels of care. 

(Razzak & Kellermann, 2002)

Modern Triage Systems

Today, triage has expanded far beyond the battlefield and emergency rooms. Various standardized systems have been developed worldwide to promote accuracy and consistency:

• In the United States, the Emergency Severity Index (ESI) is widely used. This five-level system (Level 1 most urgent to Level 5 least urgent) helps nurses assess both adult and pediatric patient acuity and predict resource needs (ENA, 2023). 

  • Four Conceptual Decision Points in the ESI Algorithm

    • Is this patient unstable and in need of immediate lifesaving intervention?

    • Is this a high-risk situation?

    • How many resources will this patient need?

    • Do the patient’s vital signs warrant a reassessment of the acuity level? 

(ENA, 2023, Chapter 2)

• In other countries, the Canadian Triage and Acuity Scale (CTAS) and the Manchester Triage System (MTS) are commonly used to ensure patients are assessed quickly and placed in priority categories. 

  • Canadian Triage and Acuity Scale (CTAS)

    • Based on the National Triage Scale of Australia

    • 5-Level triage system (Level 1 most severe)

    • Based on the severity of illness and the time before medical intervention is needed

    • Categorizes symptoms (e.g., cardiovascular) and uses modifiers (e.g., VS, mechanism of injury) to refine triage

  • Manchester Triage System (MTS)

    • One of the most widely used tirage systems in Europe

    • Based on 52 flowcharts linked to patients’ presenting complaints and specific discriminators (signs & symptoms)

    • Based on the above bullet point, the patient is placed in an urgency category that is tied to a maximum wait time

      • 5 Urgency Categories range from Immediate: 0 minutes to non-urgent: 240 minutes

(Mackway-Jones et al., 2014; Yancey & O’Rourke, 2023). 

• With the rise of telehealth, telephone and virtual triage now allow nurses to assess patients remotely, guiding them toward urgent care, primary care, or safe self-care when appropriate (HRSA, 2025).

Beyond the Emergency Department

Triage principles are now applied across healthcare settings. In urgent care, disaster response, pandemics, and even primary care clinics, nurses use triage to allocate limited resources effectively. The COVID-19 pandemic highlighted this reality, where triage decisions often extended beyond individual patient care to include population-level priorities and ethical considerations (Kobeissi & Ruppert, 2022; Zhu et al., 2022).

The Nurse’s Role in Triage Today

For nurses, triage is both science and art. It requires rapid assessment, knowledge of evidence-based protocols, and strong communication skills. Equally important is empathy, understanding that behind every set of symptoms is a person who is anxious, vulnerable, and in need of reassurance.

Nurses also play a vital role in continually improving triage systems. By documenting outcomes, participating in quality improvement initiatives, and advocating for safe staffing levels, nurses help ensure triage remains effective and equitable. 

Looking Ahead

As healthcare evolves, so will triage. Artificial intelligence, predictive analytics, and advanced telehealth platforms are now supporting clinical decision-making. However, technology cannot replace the nurse’s critical thinking and compassionate presence. The heart of triage remains a human one.

Final Thoughts

From its origins on the battlefield to its central role in modern emergency departments and beyond, triage has always been about one thing: saving lives through smart, timely decisions. For nurses, understanding this evolution reinforces our essential role as the first line of care, advocates for patients, and leaders in healthcare innovation.

PICTURE FROM DRIVE

This upcoming Emergency Nurses Week, let’s honor the incredible work of emergency nurses who embody the very essence of triage:

• Calm in chaos

• Clarity in uncertainty

• Compassion in crisis

Please take a moment to reflect on your own triage experiences, share them with colleagues, and celebrate the profound impact nurses make every day. Together, we can continue to advance our profession and strengthen the care we provide to every patient, in every moment of need.

References

Emergency Nurses Association. (2023). Emergency severity index (ESI) handbook (5th ed.). Emergency Nurses Association (ENA). https://media.emscimprovement.center/documents/Emergency_Severity_Index_Handbook.pdf

Health Resources and Services Administration (HRSA). (2025). Tele-Triage. HRSA. https://telehealth.hhs.gov/providers/best-practice-guides/telehealth-for-emergency-departments/tele-triage#:~:text=Tele%2Dtriage%20is%20like%20traditional,condition%20and%20the%20care%20needed.

Iserson, K. V., & Moskop, J. C. (2007). Triage in medicine, Part I: Concept, history, and types. Annals of Emergency Medicine, 49(3), 275–281. https://doi.org/10.1016/j.annemergmed.2006.05.019

Kobeissi, M. M., & Ruppert, S. D. (2022). Remote patient triage: Shifting toward safer telehealth practice. Journal of the American Association of Nurse Practitioners, 34(3), 444-451. doi: 10.1097/JXX.0000000000000655 

Mackway-Jones, K., Marsden, J., & Windle, J. (2014). Emergency triage: Manchester Triage Group (3rd ed.). Wiley-Blackwell.

Nakao, H., Ukai, I., & Kotani, J. (2017). A review of the history of the origin of triage from a disaster medicine perspective. Acute medicine & surgery, 4(4), 379–384. https://doi.org/10.1002/ams2.293

Razzak, J. A., & Kellermann, A. L. (2002). Emergency medical care in developing countries: Is it worthwhile? Bulletin of the World Health Organization, 80(11), 900–905. https://apps.who.int/iris/handle/10665/268707

Slawson, R. (2017). The development of triage. National Museum of Civil War Medicine. Retrieved from: https://www.civilwarmed.org/surgeons-call/triage/

Yancey, C.C., & O'Rourke, M.C. Emergency Department Triage. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557583/

Zhu, J., Brenna, C.T.A., McCoy, L.G., Atkings, C.G.K., & Das, S. (2022). An ethical analysis of clinical triage protocols and decision-making frameworks: What do the principles of justice, freedom, and a disability rights approach demand of us?. BMC Med Ethics 23, 11. https://doi.org/10.1186/s12910-022-00749-0