Five-Level Triage: A Report from the ACEP/ENA Five-Level Triage Task Force

Pediatric Triage Education for the General Emergency Nurse: A Randomized Crossover Trial Comparing Simulation With Paper-Case Studies

INTRODUCTION

The majority of pediatric emergency patients are seen in mixed-age emergency departments and triaged by general emergency nurses. Educational methods for teaching pediatric triage education to general emergency nurses have not been well studied, and previous studies of the use of the Emergency Severity Index in children have been performed primarily in centers that are high volume for pediatrics.

METHODS

A repeated-measures, randomized crossover study comparing 2 different methods of pediatric triage education was conducted. Participants were general emergency nurses recruited from a general emergency department that is classified as low volume for pediatrics. Each participant was exposed in a random order to both educational methods: paper-based cases and high-fidelity simulation.

RESULTS

All participants had substantial improvement in pediatric triage accuracy as measured by a standardized set of pediatric triage cases. The previously reported trend toward undertriage of the pediatric patient was observed despite a mean triage agreement rate of 73% at the end of the study period. No differences were observed between groups; the order of the educational intervention did not result in statistically significant differences in triage accuracy.

CONCLUSION

A combined approach of paper-based cases and high-fidelity simulation was effective at improving pediatric triage accuracy among a group of general ED nurses with limited exposure to pediatric patients. The results from this study suggest that combining both methods of education may be a viable means of providing general emergency nurses with additional knowledge in pediatric triage; however, persistent trends in undertriage should be studied further.

Triage Systems in Mass Casualty Incidents and Disasters: A Review Study with A Worldwide Approach

BACKGROUND:

Injuries caused by emergencies and accidents are increasing in the world. To prioritise patients to provide them with proper services and to optimally use the resources and facilities of the medical centres during accidents, the use of triage systems, which are one of the key principles of accident management, seems essential.

AIM:

This study is an attempt to identify available triage systems and compare the differences and similarities of the standards of these systems during emergencies and disasters through a review study.

METHODS:

This study was conducted through a review of the triage systems used in emergencies and disasters throughout the world. Accordingly, all articles published between 1990 and 2018 in both English and Persian journals were searched based on several keywords including Triage, Disaster, Mass Casualty Incidents, in the Medlib, Scopus, Web of Science, PubMed, Cochrane Library, Science Direct, Google scholar, Irandoc, Magiran, Iranmedex, and SID databases in isolation and in combination using both and/ or conjunctions.

RESULTS:

Based on the search done in these databases, twenty different systems were identified in the primary adult triage field including START, Homebush triage Standard, Sieve, CareFlight, STM, Military, CESIRA Protocol, MASS, Revers, CBRN Triage, Burn Triage, META Triage, Mass Gathering Triage, SwiFT Triage, MPTT, TEWS Triage, Medical Triage, SALT, mSTART and ASAV. There were two primary triage systems including Jump START and PTT for children, and also two secondary triage systems encompassing SAVE and Sort identified in this respect. ESI and CRAMS were two other cases distinguished for hospital triage systems.

CONCLUSION:

There are divergent triage systems in the world, but there is no general and universal agreement on how patients and injured people should be triaged. Accordingly, these systems may be designed based on such criteria as vital signs, patient’s major problems, or the resources and facilities needed to respond to patients’ needs. To date, no triage system has been known as superior, specifically about the patients’ clinical outcomes, improvement of the scene management or allocation of the resources compared to other systems. Thus, it is recommended that different countries such as Iran design their triage model for emergencies and disasters by their native conditions, resources and relief forces.

Reliability of triage systems for paediatric emergency care: a systematic review

OBJECTIVE

To present a systematic review on the reliability of triage systems for paediatric emergency care.

METHODS

A search of MEDLINE, Cochrane Library, Latin American and Caribbean Health Sciences Literature, Scientific Electronic Library Online, Nursing Database Index and Spanish Health Sciences Bibliographic Index for articles in English, French, Portuguese or Spanish was conducted to identify reliability studies of five-level triage systems for patients aged 0-18 years published up to April 2018. Two reviewers performed study selection, data extraction and quality assessment as recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

RESULTS

Twenty studies on nine triage systems were selected: the National Triage System (n=1); the Australasian Triage Scale (n=3); the paediatric Canadian Triage and Acuity Scale (PedCTAS) (n=5); the Manchester Triage System (MTS) (n=1); the Emergency Severity Index (ESI) (n=5); an adaptation of the South African Triage Scale for the Princess Marina Hospital in Botswana (n=1); the Soterion Rapid Triage System (n=1); the Rapid Emergency Triage and Treatment System-paediatric version (n=2); the Paediatric Risk Classification Protocol (n=1). Ten studies were performed with actual patients, while the others used hypothetical scenarios. The studies were rated low (n=14) or moderate (n=6) quality. Kappa was the most used statistic, although many studies did not specify the weighting. PedCTAS, MTS and ESI V.4 exhibited substantial to almost perfect agreement in moderate quality studies.

CONCLUSIONS

There is some evidence on the reliability of the PedCTAS, MTS and ESI V.4, but most studies are limited to the countries where they were developed. Efforts are needed to improve the quality of the studies, and cross-cultural adaptation of those tools is recommended in countries with different professional qualification and sociocultural contexts.

Machine Learning-Based Prediction of Clinical Outcomes for Children During Emergency Department Triage

IMPORTANCE

While machine learning approaches may enhance prediction ability, little is known about their utility in emergency department (ED) triage.

OBJECTIVES

To examine the performance of machine learning approaches to predict clinical outcomes and disposition in children in the ED and to compare their performance with conventional triage approaches.

DESIGN, SETTING, AND PARTICIPANTS

Prognostic study of ED data from the National Hospital Ambulatory Medical Care Survey from January 1, 2007, through December 31, 2015. A nationally representative sample of 52 037 children aged 18 years or younger who presented to the ED were included. Data analysis was performed in August 2018.

MAIN OUTCOMES AND MEASURES

The outcomes were critical care (admission to an intensive care unit and/or in-hospital death) and hospitalization (direct hospital admission or transfer). In the training set (70% random sample), using routinely available triage data as predictors (eg, demographic characteristics and vital signs), we derived 4 machine learning-based models: lasso regression, random forest, gradient-boosted decision tree, and deep neural network. In the test set (the remaining 30% of the sample), we measured the models' prediction performance by computing C statistics, prospective prediction results, and decision curves. These machine learning models were built for each outcome and compared with the reference model using the conventional triage classification information.

RESULTS

Of 52 037 eligible ED visits by children (median [interquartile range] age, 6 [2-14] years; 24 929 [48.0%] female), 163 (0.3%) had the critical care outcome and 2352 (4.5%) had the hospitalization outcome. For the critical care prediction, all machine learning approaches had higher discriminative ability compared with the reference model, although the difference was not statistically significant (eg, C statistics of 0.85 [95% CI, 0.78-0.92] for the deep neural network vs 0.78 [95% CI, 0.71-0.85] for the reference; P = .16), and lower number of undertriaged critically ill children in the conventional triage levels 3 to 5 (urgent to nonurgent). For the hospitalization prediction, all machine learning approaches had significantly higher discrimination ability (eg, C statistic, 0.80 [95% CI, 0.78-0.81] for the deep neural network vs 0.73 [95% CI, 0.71-0.75] for the reference; P < .001) and fewer overtriaged children who did not require inpatient management in the conventional triage levels 1 to 3 (immediate to urgent). The decision curve analysis demonstrated a greater net benefit of machine learning models over ranges of clinical thresholds.

CONCLUSIONS AND RELEVANCE

Machine learning-based triage had better discrimination ability to predict clinical outcomes and disposition, with reduction in undertriaging critically ill children and overtriaging children who are less ill.

Reliability of the revised Swiss Emergency Triage Scale: a computer simulation study

Background

The Swiss Emergency Triage Scale (SETS) is a four-level emergency scale that previously showed moderate reliability and high rates of undertriage due to a lack of standardization. It was revised to better standardize the measurement and interpretation of vital signs during the triage process.

Objective

The aim of this study was to explore the inter-rater and test–retest reliability, and the rate of correct triage of the revised SETS.

Patients and methods

Thirty clinical scenarios were evaluated twice at a 3-month interval using an interactive computerized triage simulator by 58 triage nurses at an urban teaching emergency department admitting 60 000 patients a year. Inter-rater and test–retest reliabilities were determined using κ statistics. Triage decisions were compared with a gold standard attributed by an expert panel. Rates of correct triage, undertriage, and overtriage were computed. A logistic regression model was used to identify the predictors of correct triage.

Results

A total of 3387 triage situations were analyzed. Inter-rater reliability showed substantial agreement [mean κ: 0.68; 95% confidence interval (CI): 0.60–0.78] and test–retest almost perfect agreement (mean κ: 0.86; 95% CI: 0.84–0.88). The rate of correct triage was 84.1%, and rates of undertriage and overtriage were 7.2 and 8.7%, respectively. Vital sign measurement was an independent predictor of correct triage (odds ratios for correct triage: 1.29 for each additional vital sign measured, 95% CI: 1.20–1.39).

Conclusion

The revised SETS incorporating standardized vital sign measurement and interpretation during the triage process resulted in high reliability and low rates of mistriage.

Comparison of scenario based triage education by lecture and role playing on knowledge and practice of nursing students

INTRODUCTION

Quick and accurate triage of patients in the emergency department is a key factor for successful management of the emergency situations and ensuring the quality of care. Moreover, triage skills education is one of the important aspects of preparedness of nurses for different emergency situations. The objective of this study was to compare the effect of educating emergency severity index (ESI) triage using lecture and role-playing on the knowledge and practice of nursing students.

METHODS

This experimental study was conducted in the School of Nursing and Midwifery, Tabriz, Iran, in 2016. In this study, 56 nursing students were selected by convenience sampling method and were randomly divided into two groups. Triage scenarios were taught and presented in two ways by using lecture or role-playing method. One month later, the post-test was taken. Data were collected using a questionnaire assessing the knowledge and practice of ESI and were analysed using SPSS (version 21).

RESULTS

The mean knowledge and practice scores in both groups improved significantly (p < 0.05). The post-test score showed a significant difference between the two groups, and the mean score was higher in the role-playing group compared with that of the lecture group (p < 0.05).

DISCUSSION

The results showed the effectiveness of both educational methods on students' learning. However, the role-playing method was more effective than the lecture method and is recommended for triage education. In addition, according to the importance of triage, developing the theoretical and practical education courses for nursing students is recommended.

Initial assessment, level of care and outcome among children who were seen by emergency medical services: a prospective observational study

Background

The assessment of children in the Emergency Medical Service (EMS) is infrequent representing 5.4% of the patients in an urban area in the western part of Sweden. In Sweden, patients are assessed on scene by an EMS nurse whom independently decides on interventions and level of care. To aid the EMS nurse in the assessment a triage instrument, Rapid Emergency Triage and Treatment System-paediatrics (RETTS-p) developed for Emergency Department (ED) purpose has been in use the last 5 years. The aim of this study was to evaluate the EMS nurse assessment, management, the utilisation of RETTS-p and patient outcome.

Methods

A prospective, observational study was performed on 651 children aged < 16 years from January to December 2016. Statistical tests used in the study were Mann-Whitney U test, Fisher’s exact test and Spearman’s rank statistics.

Results

The dispatch centre indexed life-threatening priority in 69% of the missions but, of all children, only 6.1% were given a life threatening RETTS-p red colour by the EMS nurse. A total of 69.7% of the children were transported to the ED and, of these, 31.7% were discharged without any interventions. Among the non-conveyed patients, 16 of 197 (8.1%) visited the ED within 72 h but only two were hospitalised. Full triage, including five out of five vital signs measurements and an emergency severity index, was conducted in 37.6% of all children. A triage colour was not present in 146 children (22.4%), of which the majority were non-conveyed. The overall 30-day mortality rate was 0.8% (n = 5) in children 0–15 years.

Conclusions

Despite the incomplete use of all vital signs according to the RETTS-p, the EMS nurse assessment of children appears to be adapted to the clinical situation in most cases and the patients appear to be assessed to the appropriate level of care but indicating an over triage. It seems that the RETTS-p with full triage is used selectively in the pre-hospital assessment of children with a risk of death during the first 30 days of less than 1%.

Validation of a Modified Triage Scale in a Norwegian Pediatric Emergency Department

Objective

Triage is a tool developed to identify patients who need immediate care and those who can safely wait. The aim of this study was to assess the validity and interrater reliability of a modified version of the pediatric South African triage scale (pSATS) in a single-center tertiary pediatric emergency department in Norway.

Methods

This prospective, observational study included all patients with medical conditions, referred to the pediatric emergency department of a tertiary hospital in Norway from September 1, 2015, to November 17, 2015. Their assigned triage priority was compared with rate of hospitalization and resource utilization. Validity parameters were sensitivity, specificity, positive and negative predictive value, and percentage of over- and undertriage. Interrater agreement and accuracy of the triage ratings were calculated from triage performed by nurses on written case scenarios.

Results

During the study period, 1171 patients arrived at the hospital for emergency assessment. A total of 790 patients (67 %) were triaged and included in the study. The percentage of hospital admission increased with increasing level of urgency, from 30 % of the patients triaged to priority green to 81 % of those triaged to priority red. The sensitivity was 74 %, the specificity was 48 %, the positive predictive value was 52 %, and the negative predictive value was 70 % for predicting hospitalization. The level of over- and undertriage was 52 % and 26 %, respectively. Resource utilization correlated with higher triage priority. The interrater agreement had an intraclass correlation coefficient of 0.99 by Cronbach's alpha, and the accuracy was 92 %.

Conclusions

The modified pSATS had a moderate sensitivity and specificity but showed good correlation with resource utilization. The nurses demonstrated excellent interrater agreement and accuracy when triaging written case scenarios.

Outcome-Based Validity and Reliability Assessment of Raters Regarding the Admission Triage Level in the Emergency Department: a Cross-Sectional Study

INTRODUCTION

Emergency department (ED) is usually the first line of healthcare supply to patients in non-urgent to critical situations and, if necessary, provides hospital admission. A dynamic system to evaluate patients and allocate priorities is necessary. Such a structure that facilitates patients' flow in the ED is termed triage.

OBJECTIVE

This study was conducted to investigate the validity and reliability of implementation of Emergency Severity Index (ESI) system version 4 by triage nurses in an overcrowded referral hospital with more than 80000 patient admissions per year and an average emergency department occupancy rate of more than 80%.

METHOD

This prospective cross-sectional study was conducted in a tertiary care teaching hospital and trauma center with an emergency medicine residency program. Seven participating expert nurses were asked to assess the ESI level of patients in 30 written scenarios twice within a three-week interval to evaluate the inter-rater and intra-rater reliability. Patients were randomly selected to participate in the study, and the triage level assigned by the nurses was compared with that by the emergency physicians. Finally, based on the patients' charts, an expert panel evaluated the validity of the triage level.

RESULTS

During the study period, 527 patients with mean age of 54 ± 7 years, including 253 (48%) women and 274 (52%) men, were assessed by seven trained triage nurses. The degree of retrograde agreement between the collaborated expert panel's evaluation and the actual triage scales by the nurses and physicians for all 5 levels was excellent, with the Cohen's weighted kappa being 0.966 (CI 0.985-0.946, p < 0.001) and 0.813 (CI 0.856-0.769, p<0.001), respectively. The intra-rater reliability was 0.94 (p < 0.0001), and the inter-rater reliability for all the nurses was in perfect agreement with the test result (Cohen's weighted kappa were as follows: 0.919, 0.956, 0.911, 0.955, 0.860, 0.956, and 0.868; p < 0.001).

CONCLUSION

The study findings showed that there was perfect reliability and, overall, almost perfect validity for the triage performed by the studied nurses.

Barriers and Facilitators to Implementing the HEADS-ED: A Rapid Screening Tool for Pediatric Patients in Emergency Departments

OBJECTIVES

This study sought to identify barriers and facilitators to the implementation of the HEADS-ED, a screening tool appropriate for use in the emergency department (ED) that facilitates standardized assessments, discharge planning, charting, and linking pediatric mental health patients to appropriate community resources.

METHODS

A qualitative theory-based design was used to identify barriers and facilitators to implementing the HEADS-ED tool. Focus groups were conducted with participants recruited from 6 different ED settings across 2 provinces (Ontario and Nova Scotia). The Theoretical Domains Framework was used as a conceptual framework to guide data collection and to identify themes from focus group discussions.

RESULTS

The following themes spanning 12 domains were identified as reflective of participants' beliefs about the barriers and facilitators to implementing the HEADS-ED tool: knowledge, skills, beliefs about capabilities, social professional role and identity, optimism, beliefs about consequences, reinforcement, environmental context and resources, social influences, emotion, behavioral regulation and memory, and attention and decision process.

CONCLUSIONS

The HEADS-ED has the potential to address the need for better discharge planning, complete charting, and standardized assessments for the increasing population of pediatric mental health patients who present to EDs. This study has identified potential barriers and facilitators, which should be considered when developing an implementation plan for adopting the HEADS-ED tool into practice within EDs.

Artificial Intelligence-Based Triage for Patients with Acute Abdominal Pain in Emergency Department; a Diagnostic Accuracy Study

Introduction:

Artificial intelligence (AI) is the development of computer systems which are capable of doing human intelligence tasks such as decision making and problem solving. AI-based tools have been used for predicting various factors in medicine including risk stratification, diagnosis and choice of treatment. AI can also be of considerable help in emergency departments, especially patients’ triage.

Objective:

This study was undertaken to evaluate the application of AI in patients presenting with acute abdominal pain to estimate emergency severity index version 4 (ESI-4) score without the estimate of the required resources.

Methods:

A mixed-model approach was used for predicting the ESI-4 score. Seventy percent of the patient cases were used for training the models and the remaining 30% for testing the accuracy of the models. During the training phase, patients were randomly selected and were given to systems for analysis. The output, which was the level of triage, was compared with the gold standard (emergency medicine physician). During the test phase of the study, another group of randomly selected patients were evaluated by the systems and the results were then compared with the gold standard.

Results:

Totally, 215 patients who were triaged by the emergency medicine specialist were enrolled in the study. Triage Levels 1 and 5 were omitted due to low number of cases. In triage Level 2, all systems showed fair level of prediction with Neural Network being the highest. In Level 3, all systems again showed fair level of prediction. However, in triage Level 4, decision tree was the only system with fair prediction.

Conclusion:

The application of AI in triage of patients with acute abdominal pain resulted in a model with acceptable level of accuracy. The model works with optimized number of input variables for quick assessment.

The Singapore Paediatric Triage Scale Validation Study

INTRODUCTION

This study aimed to determine the usefulness and validity of the triaging scale used in our emergency department (ED) by analysing its association with surrogate clinical outcome measures of severity consisting of hospitalisation rate, intensive care unit (ICU) admission, length of ED stay, predictive value for admission and length of hospitalisation.

METHODS

A retrospective observational study was conducted of the performance markers of the Singapore Paediatric Triage Scale (SPTS) to identify children who needed immediate and greater care. All children triaged and attended to at the paediatric ED at KK Women's and Children's Hospital, Singapore, from 1 January 2014 to 31 December 2014 were included. Data was retrieved from the Online Paediatric Emergency Care system, which is used for patients' care from initial triaging to final disposition.

RESULTS

Among 172,933 ED attendances, acuity levels 1, 2 plus, 2 and 3 were seen in 2.3%, 26.4%, 13.5% and 57.8% of patients, respectively. For admissions, triage acuity level 1 had a strong positive predictive value (79.5%), while triage acuity level 3 had a strong negative predictive value (93.7%). Fewer patients with triage acuity level 3 (6.3%) were admitted as compared to those with triage acuity level 1 (79.5%) (p < 0.001). There was a correlation between triage level and length of ED stay.

CONCLUSION

The SPTS is a valid tool for use in the paediatric emergency setting. This was supported by strong performance in important patient outcomes, such as admission to hospital, ICU admissions and length of ED stay.

Validity of triage systems for paediatric emergency care: a systematic review

AIM

To present a systematic review on the validity of triage systems for paediatric emergency care.

METHODS

Search in MEDLINE, Cochrane Library, Latin American and Caribbean Health Sciences Literature (LILACS), Scientific Electronic Library Online (SciELO), Nursing Database Index (BDENF) and Spanish Health Sciences Bibliographic Index (IBECS) for articles in English, French, Portuguese or Spanish with no time limit. Validity studies of five-level triage systems for patients 0-18 years old were included. Two reviewers performed data extraction and quality assessment as recommended by PRISMA statement.

RESULTS

We found 25 studies on seven triage systems: Manchester Triage System (MTS); paediatric version of Canadian Triage and Acuity Scale (PedCTAS) and its adaptation for Taiwan (paediatric version of the Taiwan Triage and Acuity System); Emergency Severity Index version 4 (ESI v.4); Soterion Rapid Triage System and South African Triage Scale and its adaptation for Bostwana (Princess Marina Triage Scale). Only studies on the MTS used a reference standard for urgency, while all systems were evaluated using a proxy outcome for urgency such as admission. Over half of all studies were low quality. The MTS, PedCTAS and ESI v.4 presented the largest number of moderate and high quality studies. The three tools performed better in their countries or near them, showing a consistent association with hospitalisation and resource utilisation. Studies of all three tools found that patients at the lowest urgency levels were hospitalised, reflecting undertriage.

CONCLUSIONS

There is some evidence to corroborate the validity of the MTS, PedCTAS and ESI v.4 for paediatric emergency care in their own countries or near them. Efforts to improve the sensitivity and to minimise the undertriage rates should continue. Cross-cultural adaptation is necessary when adopting these triage systems in other countries.

Five-level emergency triage systems: variation in assessment of validity

INTRODUCTION

Triage systems are scales developed to rate the degree of urgency among patients who arrive at EDs. A number of different scales are in use; however, the way in which they have been validated is inconsistent. Also, it is difficult to define a surrogate that accurately predicts urgency. This systematic review described reference standards and measures used in previous validation studies of five-level triage systems.

METHODS

We searched PubMed, EMBASE and CINAHL to identify studies that had assessed the validity of five-level triage systems and described the reference standards and measures applied in these studies. Studies were divided into those using criterion validity (reference standards developed by expert panels or triage systems already in use) and those using construct validity (prognosis, costs and resource use).

RESULTS

A total of 57 studies examined criterion and construct validity of 14 five-level triage systems. Criterion validity was examined by evaluating (1) agreement between the assigned degree of urgency with objective standard criteria (12 studies), (2) overtriage and undertriage (9 studies) and (3) sensitivity and specificity of triage systems (7 studies). Construct validity was examined by looking at (4) the associations between the assigned degree of urgency and measures gauged in EDs (48 studies) and (5) the associations between the assigned degree of urgency and measures gauged after hospitalisation (13 studies). Particularly, among 46 validation studies of the most commonly used triages (Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System), 13 and 39 studies examined criterion and construct validity, respectively.

CONCLUSION

Previous studies applied various reference standards and measures to validate five-level triage systems. They either created their own reference standard or used a combination of severity/resource measures.

Comparison of prehospital triage and five-level triage system at the emergency department

OBJECTIVE

There is lack of scientific evidence regarding the effectiveness of prehospital triage systems. This study compared the two-level Taiwan Prehospital Triage System (TPTS) with the five-level Taiwan Triage and Acuity Scale (TTAS) at ED arrival regarding the prediction of patient outcomes and the utilisation of medical resources.

DESIGN

This was a retrospective cohort study. Adult patients transported via the emergency medical service (EMS), who arrived at the ED of a medical centre in northern Taiwan during the study period were enrolled. TTAS acuity levels 1-2 were considered comparable to the designation of 'emergent' by the prehospital TPTS system. The outcomes were analysed by comparing TPTS and TTAS by acuity levels.

RESULTS

Among 4430 enrolled patients, 25.2% and 74.8% were classified as emergent and non-emergent by TPTS; 44.1% and 55.9% were classified as levels 1-2 and levels 3-5 by TTAS. Of the TPTS emergent patients, 15.2% were classified as TTAS levels 3-5, whereas 30.4% of TPTS non-emergent transports were classified as TTAS levels 1-2 at the ED. TTAS levels 1-2 showed better predictability than TPTS emergent level for hospitalisation rate with a sensitivity of 70.3% (95% CI 68.3% to 72.2%) versus 41.1% (95% CI 39.0% to 43.2%), and a negative predictive value of 74.8% (95% CI 73.4% to 76.0%) versus 62.6% (95% CI 61.7% to 63.5%).

CONCLUSION

The current prehospital triage system is insufficient and inappropriate in classifying patients transported to the ED. The present study offers supporting evidence for the introduction of a five-level triage system to prehospital EMS systems.

Can an emergency department clinical "triggers" program based on abnormal vital signs improve patient outcomes?

BACKGROUND

Because abnormal vital signs indicate the potential for clinical deterioration, it is logical to make emergency physicians immediately aware of those patients who present with abnormal vital signs.

OBJECTIVES

To determine if a clinical triggers program in the emergency department (ED) setting that utilized predetermined abnormal vital signs to activate a rapid assessment by an emergency physician-led multidisciplinary team had a measurable effect on inpatient hospital metrics.

METHODS

The study design was a retrospective pre and post intervention study. The intervention was the implementation of an ED clinical "triggers" program. Abnormal vital sign criteria that warranted a trigger response included: heart rate 130 beats/minutes, respiratory rate 30 breaths/minute, systolic blood pressure <90 mm Hg, or oxygen saturation <90% on room air. The primary outcome investigated was the median days admitted with secondary outcomes of median days in special care unit, in-hospital 30-day mortality and proportion of patients who required an upgrade in inpatient care level.

RESULTS

There was no difference in median days admitted for inpatient care (3.8 v. 4.0 days, p=0.21) or median days spent in a special care unit (5.0 v. 5.6 days, p=0.42) between the groups. There was no difference in the percentage of in-hospital patient deaths (6.0% v. 5.6%, p=0.66) or frequency of upgrade in level of care within 24 hours (4.9% v. 4.0%, p=0.52).

CONCLUSIONS

In our study, the implementation of an ED clinical triggers program did not result in a significant change in measured inpatient outcomes.

A Queue-Based Monte Carlo Analysis to Support Decision Making for Implementation of an Emergency Department Fast Track

Emergency departments (EDs) are seeking ways to utilize existing resources more efficiently as they face rising numbers of patient visits. This study explored the impact on patient wait times and nursing resource demand from the addition of a fast track, or separate unit for low-acuity patients, in the ED using a queue-based Monte Carlo simulation in MATLAB. The model integrated principles of queueing theory and expanded the discrete event simulation to account for time-based arrival rates. Additionally, the ED occupancy and nursing resource demand were modeled and analyzed using the Emergency Severity Index (ESI) levels of patients, rather than the number of beds in the department. Simulation results indicated that the addition of a separate fast track with an additional nurse reduced overall median wait times by 35.8 ± 2.2 percent and reduced average nursing resource demand in the main ED during hours of operation. This novel modeling approach may be easily disseminated and informs hospital decision-makers of the impact of implementing a fast track or similar system on both patient wait times and acuity-based nursing resource demand.

Evaluation of the implementation of the South African Triage System at an academic hospital in central Haiti

BACKGROUND

Effective triage is an important part of high quality emergency care, yet is frequently lacking in resource-limited settings. The South African Triage Scale (SATS) is designed for these settings and consists of a numeric score (triage early warning score, TEWS) and a list of clinical signs (known as discriminators). Our objective was to evaluate the implementation of SATS at a new teaching hospital in Haiti.

METHODS

A random sample of emergency department charts from October 2013 were retrospectively reviewed for the completeness and accuracy of the triage form, correct calculation of the triage score, and final patient disposition. Over and under triage were calculated. Comparisons were evaluated with chi-squared analysis.

RESULTS

Of 390 charts were reviewed, 385 contained a triage form and were included in subsequent analysis. The final triage color was recorded for 68.4% of patients, clinical discriminators for 48.6%, and numeric score for 96.1%. The numeric score was calculated correctly 78.3% of the time; in 13.2% of patients a calculation error was made that would have changed triage priority. In 23% of cases, chart review identified clinical discriminators should have been circled but were not recorded. Overtriage and undertriage were 75.6% and 7.4% respectively.

CONCLUSION

This study demonstrates that with limited structured training, SATS was widely adopted, but the clinical discriminators were used less commonly than the numeric score. This should be considered in future implementations of SATS.

Validation of different pediatric triage systems in the emergency department

BACKGROUND

Triage system in children seems to be more challenging compared to adults because of their different response to physiological and psychosocial stressors. This study aimed to determine the best triage system in the pediatric emergency department.

METHODS

This was a prospective observational study. This study was divided into two phases. The first phase determined the inter-rater reliability of five triage systems: Manchester Triage System (MTS), Emergency Severity Index (ESI) version 4, Pediatric Canadian Triage and Acuity Scale (CTAS), Australasian Triage Scale (ATS), and Ramathibodi Triage System (RTS) by triage nurses and pediatric residents. In the second phase, to analyze the validity of each triage system, patients were categorized as two groups, i.e., high acuity patients (triage level 1, 2) and low acuity patients (triage level 3, 4, and 5). Then we compared the triage acuity with actual admission.

RESULTS

In phase I, RTS illustrated almost perfect inter-rater reliability with kappa of 1.0 (P<0.01). ESI and CTAS illustrated good inter-rater reliability with kappa of 0.8-0.9 (P<0.01). Meanwhile, ATS and MTS illustrated moderate to good inter-rater reliability with kappa of 0.5-0.7 (P<0.01). In phase II, we included 1 041 participants with average age of 4.7±4.2 years, of which 55% were male and 45% were female. In addition 32% of the participants had underlying diseases, and 123 (11.8%) patients were admitted. We found that ESI illustrated the most appropriate predicting ability for admission with sensitivity of 52%, specificity of 81%, and AUC 0.78 (95%CI 0.74-0.81).

CONCLUSION

RTS illustrated almost perfect inter-rater reliability. Meanwhile, ESI and CTAS illustrated good inter-rater reliability. Finally, ESI illustrated the appropriate validity for triage system.

Initial assessment and treatment of refugees in the Mediterranean Sea (a secondary data analysis concerning the initial assessment and treatment of 2656 refugees rescued from distress at sea in support of the EUNAVFOR MED relief mission of the EU)

Background

As a part of the European Union Naval Force – Mediterranean Operation Sophia (EUNAVFOR Med), the Federal Republic of Germany is contributing to avoid further loss of lives at sea by supplying two naval vessels. In the study presented here we analyse the medical requirements of such rescue missions, as well as the potential benefits of various additional monitoring devices in identifying sick/injured refugees within the primary onboard medical assessment process.

Methods

Retrospective analysis of the data collected between May – September 2015 from a German Naval Force frigate. Initial data collection focused on the primary medical assessment and treatment process of refugees rescued from distress at sea. Descriptive statistics, uni- and multivariate analysis were performed. The study has received a positive vote from the Ethics Commission of the University of Ulm, Germany (request no. 284/15) and has been registered in the German Register of Clinical Studies (no. DRKS00009535).

Results

A total of 2656 refugees had been rescued. 16.9 % of them were classified as “medical treatment required” within the initial onboard medical assessment process. In addition to the clinical assessment by an emergency physician, pulse rate (PR), core body temperature (CBT) and oxygen saturation (SpO₂) were evaluated. Sick/injured refugees displayed a statistically significant higher PR (114/min vs. 107/min; p < .001) and CBT (37.1 °C vs. 36.7 °C; p < .001). There was no statistically significant difference in SpO₂-values. The same results were found for the subgroup of patients classified as “treatment at emergency hospital required”. However, a much larger difference of the mean PR and CBT (35/min resp. 1.8 °C) was found when examining the subgroups of the corresponding refugee boats. A cut-off value of clinical importance could not be found. Predominant diagnoses have been dermatological diseases (55.4), followed by internal diseases (27.7) and trauma (12.1 %). None of the refugees classified as “healthy” within the primary medical assessment process changed to “medical treatment required” during further observation.

Conclusions

The initial medical assessment by an emergency physician has proved successful. PR, CBT and SpO₂ didn’t have any clinical impact to improve the identification of sick/injured refugees within the primary onboard assessment process.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-016-0270-z) contains supplementary material, which is available to authorized users.

Video-based Assessment of Peripheral Intravenous Catheter Insertion in the Resuscitation Area of a Pediatric Emergency Department

OBJECTIVE

The objective was to describe the frequency of and factors associated with prolonged peripheral intravenous catheter (PIV) insertion in the resuscitation area of a pediatric emergency department (PED).

METHODS

Video-based study of a consecutive sample of nontrauma patients undergoing PIV insertion in the resuscitation area of a PED. Preexisting videos were the main data source. The primary outcome was patients with prolonged duration of PIV insertion (>90 seconds from start of first attempt to successful flush/blood draw). Logistic regression identified variables independently associated with prolonged PIV insertion.

RESULTS

A total of 151 consecutive nontrauma patients underwent PIV insertion during a 2.5-month period. Sixty-nine patients (46%) had prolonged PIV insertion, including 14 for whom PED providers failed to insert PIVs. For patients with successful PIV insertion by PED providers, median duration was 48 seconds (interquartile range [IQR] = 23 to 295 seconds). Vascular access was ultimately achieved for 13 patients (93%) with initial insertion failure by the PED team (10 non-PED personnel, three intraosseous lines), with a median duration of 26.7 minutes (IQR = 19.9 to 34.2 minutes). Age ≤ 2 years (ORadj = 6.9; 95% confidence interval [CI] = 2.9 to 16.1) and musculoskeletal contractures (ORadj = 5.3; 95% CI = 1.6 to 17.2) were independently associated with prolonged PIV insertion.

CONCLUSIONS

Prolonged PIV insertion is common in a PED resuscitation area. When PED providers could not insert a PIV, time to insertion was very long. Young patients and those with contractures were at particular risk for prolonged and failed PIV placement. When emergent vascular access is required, alternative approaches should be considered early for these patients.

Reliability of the Canadian Triage and Acuity Scale: interrater and intrarater agreement from a community and an academic emergency department

OBJECTIVES

The Canadian Triage and Acuity Scale (CTAS) is a five-level triage tool that is used to help prioritize the order in which emergency department (ED) patients should be seen. The objectives of this study were to determine the interrater and intrarater agreement of the 2008 CTAS guideline revisions by triage nurses and to compare agreement between triage nurses working in a small community ED and an academic ED.

METHODS

Seventy-eight triage nurses assigned CTAS scores and free-text presenting complaints for 10 paper-based case scenarios. For five scenarios, the CTAS score should have remained unchanged from previous guidelines, whereas the other five scenarios should have been triaged differently based on the 2008 CTAS first-order modifiers. Thirty-three participants repeated the questionnaire 90 days later, and intrarater agreement was measured.

RESULTS

There was a higher level of agreement (κ  =  0.73; 95% CI 0.68-0.79) for the five case scenarios, which relied on the older 2004 guidelines compared to the scenarios where the 2008 guidelines would have suggested a different triage level (κ  =  0.50; 95% CI 0.42-0.59). For the 10 case scenarios analyzed, the free-text presenting complaints matched the Canadian Emergency Department Information System (CEDIS) list 90.1% of the time (κ  =  0.80; 95% CI 0.76-0.84).

CONCLUSION

The reliability of CTAS scoring by academic and community ED nurses was relatively good; however, the application of the 2008 CTAS revisions appears less reliable than the 2004 CTAS guidelines. These results may be useful to develop educational materials to strengthen reliability and validity for triage scoring using the 2008 CTAS guideline revisions.

Performance of the Manchester Triage System in Adult Medical Emergency Patients: A Prospective Cohort Study

BACKGROUND

Accurate initial patient triage in the emergency department (ED) is pivotal in reducing time to effective treatment by the medical team and in expediting patient flow. The Manchester Triage System (MTS) is widely implemented for this purpose. Yet the overall effectiveness of its performance remains unclear.

OBJECTIVES

We investigated the ability of MTS to accurately assess high treatment priority and to predict adverse clinical outcomes in a large unselected population of medical ED patients.

METHODS

We prospectively followed consecutive medical patients seeking ED care for 30 days. Triage nurses implemented MTS upon arrival of patients admitted to the ED. The primary endpoint was high initial treatment priority adjudicated by two independent physicians. Secondary endpoints were 30-day all-cause mortality, admission to the intensive care unit (ICU), and length of stay. We used regression models with area under the receiver operating characteristic curve (AUC) as a measure of discrimination.

RESULTS

Of the 2407 patients, 524 (21.8%) included patients (60.5 years, 55.7% males) who were classified as high treatment priority; 3.9% (n = 93) were transferred to the ICU; and 5.7% (n = 136) died. The initial MTS showed fair prognostic accuracy in predicting treatment priority (AUC 0.71) and ICU admission (AUC 0.68), but not in predicting mortality (AUC 0.55). Results were robust across most predefined subgroups, including patients diagnosed with infections, or cardiovascular or gastrointestinal diseases. In the subgroup of neurological symptoms and disorders, the MTS showed the best performance.

CONCLUSION

The MTS showed fair performance in predicting high treatment priority and adverse clinical outcomes across different medical ED patient populations. Future research should focus on further refinement of the MTS so that its performance can be improved.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT01768494.

Interrater agreement of Canadian Emergency Department Triage and Acuity Scale scores assigned by base hospital and emergency department nurses

Objective:

We sought to assess the applicability of the Canadian Emergency Department Triage and Acuity Scale (CTAS) in the prehospital setting by comparing CTAS scores assigned during ambulance transportation by base hospital (BH) nurses with CTAS scores given by emergency department (ED) nurses on patients' arrival.

Methods:

We recruited a prospective sample of consecutive patients who were transported to the ED by ambulance between December 2006 and March 2007 for whom a contact was made with the BH. Patients were triaged by the BH nurse with online communication and vital signs transmission. On arrival, patients were blindly triaged again by the ED nurse. We used the quadratic weighted κ statistic to measure the agreement between the 2 CTAS scores.

Results:

Ninety-four patients were triaged twice by 2 nursing teams (9 nurses at the BH and 39 nurses in the ED). The agreement obtained on prehospital and ED CTAS scores was moderate (κ = 0.50; 95% confidence interval 0.37–0.63).

Conclusion:

The moderate interrater agreement we obtained may be a result of the changing conditions of patients during transport or may indicate that CTAS scoring requires direct contact to produce reliable triage scores. Our study casts a serious doubt on the appropriateness of BH nurses performing triage with CTAS in the prehospital setting.

Use of quality improvement interventions and the link to performance on percutaneous intervention for acute myocardial infarction

BACKGROUND

Despite numerous calls for hospitals to employ quality improvement (QI) interventions to improve emergency department (ED) performance, their impact has not been explored in multi-site investigations.

OBJECTIVE

We investigated the association between use of QI interventions (patient flow strategies, ED electronic dashboards, and five-level triage systems) and hospital performance on receipt of percutaneous intervention (PCI) within 90 min for acute myocardial infarction patients, a publicly available quality measure.

METHODS

This was an exploratory, cross-sectional analysis of secondary data from 292 hospitals. Data were drawn from the Quality Improvement Activities Survey, the American Hospital Association's Annual Survey, and Hospital Compare. Linear regression models were used to detect differences in PCI performance scores based on whether hospitals employed one or more QI interventions.

RESULTS

Fifty-three percent of hospitals reported widespread use of patient flow strategies, 62% reported using a dashboard, and 74% reported using a five-level triage system. Time to PCI performance scores were 3.5 percentage points higher (i.e., better) for hospitals that used patient flow strategies and 6.2 percentage points higher for hospitals that used a five-level triage system. Scores were 10.4 percentage points higher at hospitals that employed two quality improvement interventions and 12.8 percentage points higher at hospitals that employed three.

CONCLUSION

Employing QI interventions was associated with better PCI scores. More research is needed to explore the direction of this relationship, but results suggest that hospitals should consider adopting patient flow strategies, electronic dashboards, and five-level triage systems to improve PCI scores.

Reliability of the Emergency Severity Index: Meta-analysis

OBJECTIVES

Although triage systems based on the Emergency Severity Index (ESI) have many advantages in terms of simplicity and clarity, previous research has questioned their reliability in practice. Therefore, the aim of this meta-analysis was to determine the reliability of ESI triage scales.

METHODS

This meta-analysis was performed in March 2014. Electronic research databases were searched and articles conforming to the Guidelines for Reporting Reliability and Agreement Studies were selected. Two researchers independently examined selected abstracts. Data were extracted in the following categories: version of scale (latest/older), participants (adult/paediatric), raters (nurse, physician or expert), method of reliability (intra/inter-rater), reliability statistics (weighted/unweighted kappa) and the origin and publication year of the study. The effect size was obtained by the Z-transformation of reliability coefficients. Data were pooled with random-effects models and a meta-regression was performed based on the method of moments estimator.

RESULTS

A total of 19 studies from six countries were included in the analysis. The pooled coefficient for the ESI triage scales was substantial at 0.791 (95% confidence interval: 0.787-0.795). Agreement was higher with the latest and adult versions of the scale and among expert raters, compared to agreement with older and paediatric versions of the scales and with other groups of raters, respectively.

CONCLUSION

ESI triage scales showed an acceptable level of overall reliability. However, ESI scales require more development in order to see full agreement from all rater groups. Further studies concentrating on other aspects of reliability assessment are needed.

Effect of a triage course on quality of rating triage codes in a group of university nursing students:a before-after observational study

BACKGROUND

Most current triage tools have been tested among hospital nurses groups but there are not similar studies in university setting. In this study we analyzed if a course on a new four-level triage model, triage emergency method (TEM), could improve the quality of rating in a group of nursing students.

METHODS

This observational study was conducted with paper scenarios at the University of Parma, Italy. Fifty students were assigned a triage level to 105 paper scenarios before and after a course on triage and TEM. We used weighted kappa statistics to measure the inter-rater reliability of TEM and assessed its validity by comparing the students' predictions with the triage code rating of a reference standard (a panel of five experts in the new triage method).

RESULTS

Inter-rater reliability was K=0.42 (95%CI: 0.37-0.46) before the course on TEM, and K=0.61 (95%CI: 0.56-0.67) after. The accuracy of students' triage rating for the reference standard triage code was good: 81% (95%CI: 71-90). After the TEM course, the proportion of cases assigned to each acuity triage level was similar for the student group and the panel of experts.

CONCLUSION

Among the group of nursing students, a brief course on triage and on a new in-hospital triage method seems to improve the quality of rating codes. The new triage method shows good inter-rater reliability for rating triage acuity and good accuracy in predicting the triage code rating of the reference standard.

The German Version of the Manchester Triage System and its quality criteria--first assessment of validity and reliability

Background

The German Version of the Manchester Triage System (MTS) has found widespread use in EDs across German-speaking Europe. Studies about the quality criteria validity and reliability of the MTS currently only exist for the English-language version. Most importantly, the content of the German version differs from the English version with respect to presentation diagrams and change indicators, which have a significant impact on the category assigned. This investigation offers a preliminary assessment in terms of validity and inter-rater reliability of the German MTS.

Methods

Construct validity of assigned MTS level was assessed based on comparisons to hospitalization (general / intensive care), mortality, ED and hospital length of stay, level of prehospital care and number of invasive diagnostics. A sample of 45,469 patients was used. Inter-rater agreement between an expert and triage nurses (reliability) was calculated separately for a subset group of 167 emergency patients.

Results

For general hospital admission the area under the curve (AUC) of the receiver operating characteristic was 0.749; for admission to ICU it was 0.871. An examination of MTS-level and number of deceased patients showed that the higher the priority derived from MTS, the higher the number of deaths (p<0.0001 / χ² Test). There was a substantial difference in the 30-day survival among the 5 MTS categories (p<0.0001 / log-rank test).The AUC for the predict 30-day mortality was 0.613. Categories orange and red had the highest numbers of heart catheter and endoscopy. Category red and orange were mostly accompanied by an emergency physician, whereas categories blue and green were walk-in patients. Inter-rater agreement between expert triage nurses was almost perfect (κ = 0.954).

Conclusion

The German version of the MTS is a reliable and valid instrument for a first assessment of emergency patients in the emergency department.

A systematic review on the validity and reliability of an emergency department triage scale, the Manchester Triage System

OBJECTIVE

To conduct a systematic review to check the level of validity and reliability of the Manchester Triage System and the quality of reporting of literature on this topic.

DESIGN

This is a systematic review based on the PRISMA guideline on reporting systematic reviews.

DATA SOURCES

The systematic search of the international literature published from 1997 through 30 November 2012 in the PubMed, Embase, Cochrane Library, Cinahl, Web of Knowledge, and Scopus databases.

REVIEW METHODS

This review included quantitative and qualitative research investigating the reliability and validity of the Manchester Triage System for the broad population of adults and children visiting the emergency department. After a systematic selection process, included studies were assessed on their quality by three researchers using the STARD guidelines.

RESULTS

Twelve studies were included in the review. The studies investigated the inter- and intra-rater reliability using the "kappa" statistic; the validity was tested with many measures: validity in predicting mortality, hospital admission, under- and overtriage, used resources, and length of stay in the emergency department, as well as a reference standard rating.

CONCLUSIONS

In this review, the Manchester Triage System shows a wide inter-rater agreement range with a prevalence of good and very good agreement. Its safety was low because of the high rate of undertriage and the low sensitivity in predicting higher urgency levels. The high rate of overtriage could cause unnecessarily high use of resources in the emergency department. The quality of the reporting in studies of the reliability and validity of the Manchester Triage System is good.

Gleaning data from disaster: a hospital-based data mining method to study all-hazard triage after a chemical disaster

OBJECTIVE

To describe the methods of evaluating currently available triage models for their efficacy in appropriately triaging the surge of patients after an all-hazards disaster.

DESIGN

A method was developed for evaluating currently available triage models using extracted data from medical records of the victims from the Graniteville chlorine disaster.

SETTING

On January 6, 2005, a freight train carrying three tanker cars of liquid chlorine was inadvertently switched onto an industrial spur in central Graniteville, SC. The train then crashed into a parked locomotive and derailed. This caused one of the chlorine tankers to rupture and immediately release ~60 tons of chlorine. Chlorine gas infiltrated the town with a population of 7,000.

PARTICIPANTS

This research focuses on the victims who received emergency care in South Carolina.

RESULTS

With our data mapping and decision tree logic, the authors were successful in using the available extracted clinical data to estimate triage categories for use in our study.

CONCLUSIONS

The methodology outlined in this article shows the potential use of well-designed secondary analysis methods to improve mass casualty research. The steps are reliable and repeatable and can easily be extended or applied to other disaster datasets.

A review of the literature on the validity of mass casualty triage systems with a focus on chemical exposures

INTRODUCTION

Mass casualty incidents (MCIs) include natural (eg, earthquake) or human (eg, terrorism or technical) events. They produce an imbalance between medical needs and resources necessitating the use of triage strategies. Triage of casualties must be performed accurately and efficiently if providers are to do the greatest good for the greatest number. There is limited research on the validation of triage system efficacy in determining the priority of care for victims of MCI, particularly those involving chemicals.

OBJECTIVE

To review the literature on the validation of current triage systems to assign on-site treatment status codes to victims of mass casualties, particularly those involving chemicals, using actual patient outcomes.

METHODS

The focus of this article is a systematic review of the literature to describe the influences of MCIs, particularly those involving chemicals, on current triage systems related to the on-site assignment of treatment status codes to a victim and the validation of the assigned code using actual patient outcomes.

RESULTS

There is extensive literature published on triage systems used for MCI but only four articles used actual outcome data to validate mass casualty triage outcomes including three for chemical events. Currently, the amount and type of data collected are not consistent or standardized and definitions are not universal.

CONCLUSIONS

Current literature does not provide needed evidence on the validity of triage systems for MCI in particular those involving chemicals. Well designed studies are needed to validate the reliability, sensitivity, and specificity of triage systems used for MCI including those involving chemicals.

The Emergency Severity Index, version 4, for pediatric triage: a reliability study in Tabriz Children's Hospital, Tabriz, Iran

Background

The Emergency Severity Index (ESI) has earned reliability and validity in adult populations but has not been adequately evaluated in pediatric patients. The aim of this study was to assess the reliability of the ESI version 4 and inter-rater reliability measures to evaluate the performance of nurses in the emergency ward.

Methods

Raters were part of the same team of pediatric emergency medicine team, including pediatric emergency medicine (PEM) physicians and pediatric triage (PT) nurses. Reliability and agreement rates were measured using kappa statistics. The measurements were compared with the admission rates, readmissions to the PEM division, location of admission and death as outcomes.

Results

Initially, PT nurses rated 20 case scenarios. Further in a prospective cohort study, 1104 children were assigned ESI scores by both nurses and physicians. The ratings of case scenarios showed a kappa value of 0.84. In actual patients, ratings showed high concordance with the physicians’ ratings with the kappa value of 0.82 being in a good agreement with the nurses’ ratings. The main area of discordance was detected in level 4 where 48 cases were triaged in higher levels and 25 were triaged in lower levels. The analysis showed the likelihood of admission clearly increased as the ESI score decreased (p<0.0001). There was a significant correlation between the admission status and triage level in both PT nurses’ and PEM physicians’ ratings (Spearman coefficient=0.374, 0.407; p<0.0001).

Conclusion

ESI scores assigned to the pediatric patients are reliable in the hands of experienced PT nurses and PEM physicians. The very good agreement between PT nurses and PEM physicians, demonstrated in this study, is essential in cooperative work in crowded referral emergency departments and helpful in challenging triage cases.

Effectiveness of a five-level Paediatric Triage System: an analysis of resource utilisation in the emergency department in Taiwan

Objectives

To examine the effectiveness of a five-level Paediatric Triage and Acuity System (Ped-TTAS) by comparing the reliability of patient prioritisation and resource utilisation with the four-level Paediatric Taiwan Triage System (Ped-TTS) among non-trauma paediatric patients in the emergency department (ED).

Methods

The study design used was a retrospective longitudinal analysis based on medical chart review and a computer database. Except for a shorter list of complaints and some abnormal vital sign criteria modifications, the structure and triage process for applying Ped-TTAS was similar to that of the Paediatric Canadian Emergency Triage and Acuity Scale. Non-trauma paediatric patients presenting to the ED were triaged by well-trained triage nurses using the four-level Ped-TTS in 2008 and five-level Ped-TTAS in 2010. Hospitalisation rates and medical resource utilisation were analysed by acuity levels between the contrasting study groups.

Results

There was a significant difference in patient prioritisation between the four-level Ped-TTS and five-level Ped-TTAS. Improved differentiation was observed with the five-level Ped-TTAS in predicting hospitalisation rates and medical costs.

Conclusions

The five-level Ped-TTAS is better able to discriminate paediatric patients by triage acuity in the ED and is also more precise in predicting resource utilisation. The introduction of a more accurate acuity and triage system for use in paediatric emergency care should provide greater patient safety and more timely utilisation of appropriate ED resources.

Emergency Severity Index version 4: a valid and reliable tool in pediatric emergency department triage

OBJECTIVES

The Emergency Severity Index version 4 (ESI v.4) is the most recently implemented 5-level triage system. The validity and reliability of this triage tool in the pediatric population have not been extensively established. The goals of this study were to assess the validity of ESI v.4 in predicting hospital admission, emergency department (ED) length of stay (LOS), and number of resources utilized, as well as its reliability in a prospective cohort of pediatric patients.

METHODS

The first arm of the study was a retrospective chart review of 780 pediatric patients presenting to a pediatric ED to determine the validity of ESI v.4. Abstracted data included acuity level assigned by the triage nurse using ESI v.4 algorithm, disposition (admission vs discharge), LOS, and number of resources utilized in the ED. To analyze the validity of ESI v.4, patients were divided into 2 groups for comparison: higher-acuity patients (ESI levels 1, 2, and 3) and lower-acuity patients (ESI levels 4 and 5). Pearson χ analysis was performed for categorical variables. For continuous variables, we conducted a comparison of means based on parametric distribution of variables. The second arm was a prospective cohort study to determine the interrater reliability of ESI v.4 among and between pediatric triage (PT) nurses and pediatric emergency medicine (PEM) physicians. Three raters (2 PT nurses and 1 PEM physician) independently assigned triage scores to 100 patients; k and interclass correlation coefficient were calculated among PT nurses and between the primary PT nurses and physicians.

RESULTS

In the validity arm, the distribution of ESI score levels among the 780 cases are as follows: ESI 1: 2 (0.25%); ESI 2: 73 (9.4%); ESI 3: 289 (37%); ESI 4: 251 (32%); and ESI 5: 165 (21%). Hospital admission rates by ESI level were 1: 100%, 2: 42%, 3: 14.9%, 4: 1.2%, and 5: 0.6%. The admission rate of the higher-acuity group (76/364, 21%) was significantly greater than the lower-acuity group (4/415, 0.96%), P < 0.001. The mean ED LOS (in minutes) for the higher-acuity group was 257 (SD, 132) versus 143 (SD, 81) in the lower-acuity group, P < 0.001. The higher-acuity group also had significantly greater use of resources than the lower-acuity group, P < 0.001. The percentage of low-acuity patients receiving no resources was 54%, compared with only 26% in the higher-acuity group. Conversely, a greater percentage of higher-acuity patients utilized 2 or more resources than the lower-acuity cohorts, 43% vs 12%, respectively, P < 0.001. In the prospective reliability arm of the study, 15 PT nurses and 8 PEM attending physicians participated in the study; k among nurses was 0.92 and between the primary triage nurses and physicians was 0.78, P < 0.001. The intraclass correlation coefficient was 0.96 for PT nurses and 0.91 between the primary triage nurse and physicians, P < 0.001.

CONCLUSIONS

Emergency Severity Index v.4 is a valid predictor of hospital admission, ED LOS, and resource utilization in the pediatric ED population. It is a reliable pediatric triage instrument with high agreement among PT nurses and between PT nurses and PEM physicians.