Triage: a literature review 1985-1993

Validity of the Paediatric Canadian Triage Acuity Scale in a Tertiary Hospital: An Analysis of Severity Markers' Variability

With the increasing influx of patients and frequent overcrowding, the adoption of a valid triage system, capable of distinguishing patients who need urgent care, from those who can wait safely is paramount. Hence, the aim of this study is to evaluate the validity of the Paediatric Canadian Triage and Acuity Scale (PaedCTAS) in a Portuguese tertiary hospital. Furthermore, we aim to study the performance and appropriateness of the different surrogate severity markers to validate triage. This is a retrospective study considering all visits to the hospital's Paediatric Emergency Department (PED) between 2014 and 2019. This study considers cut-offs on all triage levels for dichotomization in order to calculate validity measures e.g. sensitivity, specificity and likelihood ratios, ROC curves; using hospital admission, admission to intensive care and the use of resources as outcomes/markers of severity. Over the study period there were 0.2% visits triaged as Level 1, 5.7% as Level 2, 39.4% as Level 3, 50.5% as Level 4, 4.2% as Level 5, from a total of 452,815 PED visits. The area under ROC curve was 0.96, 0.71, 0.76, 0.78, 0.59 for the surrogate markers: "Admitted to intensive care"; "Admitted to intermediate care"; "Admitted to hospital"; "Investigations performed in the PED" and "Uses PED resources", respectively. The association found between triage levels and the surrogate markers of severity suggests that the PedCTAS is highly valid. Different surrogate outcome markers convey different degrees of severity, hence different degrees of urgency. Therefore, the cut-offs to calculate validation measures and the thresholds of such measures should be chosen accordingly.

Ethical prioritization of patients during disaster triage: A systematic review of current evidence

INTRODUCTION

Triage is a dynamic and complex decision-making process in order to determine priority of access to medical care in a disaster situation. The elements which should govern an ethical decision-making in prioritizing of victims have been debated for a long time. This paper aims to identify ethical principles guiding patient prioritization during disaster triage.

METHOD

Electronic databases were searched via structured search strategy from 1990 until July 2017. The studies investigating patients' prioritization in disaster situation were eligible for inclusion. All types of articles and guidelines were included.

RESULT

Of 7167 titles identified in the search, 35 studies were included. The important factors identified in patient prioritization were grouped into two categories: medical measures (medical need, likelihood of benefit and survivability) and Nonmedical measures (saving the most lives, youngest first, preserving function of society, protecting vulnerable groups, required resources and unbiased selection). Demographic characteristics, health status of patients, social value of patient, and unbiased selection are discriminatory factors in disaster triage.

CONCLUSION

Various factors have been introduced to consider ethical patient prioritization in disaster triage. Providers' engagement, public education, and ongoing training are required to reach a fair decision.

Qualitative Analysis of Surveyed Emergency Responders and the Identified Factors That Affect First Stage of Primary Triage Decision-Making of Mass Casualty Incidents

Introduction: After all large-scale disasters multiple papers are published describing the shortcomings of the triage methods utilized. This paper uses medical provider input to help describe attributes and patient characteristics that impact triage decisions.

Methods: A survey distributed electronically to medical providers with and without disaster experience. Questions asked included what disaster experiences they had, and to rank six attributes in order of importance regarding triage.

Results: 403 unique completed surveys were analyzed. 92% practiced a structural triage approach with the rest reporting they used “gestalt”.(gut feeling) Twelve per cent were identified as having placed patients in an expectant category during triage. Respiratory status, ability to speak, perfusion/pulse were all ranked in the top three. Gut feeling regardless of statistical analysis was fourth. Supplies were ranked in the top four when analyzed for those who had placed patients in the expectant category.

Conclusion: Primary triage decisions in a mass casualty scenario are multifactorial and encompass patient mobility, life saving interventions, situational instincts, and logistics.

Safety of a modification of the triage level for febrile children 6 to 36 months old using the Paediatric Canadian Triage and Acuity Scale

Objective:

The Paediatric Canadian Triage and Acuity Scale (PaedCTAS) stipulates that febrile patients who are 3 to 36 months old should be triaged to the PaedCTAS 3 “urgent” category. To optimize resource use, we implemented a protocol enabling these children to be down-triaged to the PaedCTAS 4 “less urgent” category if there was no sign of toxicity. Our objective was to evaluate the safety of this triage protocol modification.

Methods:

This retrospective cohort study evaluated all patients triaged in an urban tertiary pediatric hospital during a 6-month period between November 22, 2005, and May 22, 2006. Data were retrieved from the emergency department (ED) database and rates of hospitalization and intensive care unit (ICU) admission were compared for 4 groups: all patients triaged as urgent (level 3), all febrile patients from 3 to 36 months old triaged as urgent (level 3), all patients triaged as less urgent (level 4) and all febrile patients aged 3 to 36 months old who were down-triaged to less urgent (level 4).

Results:

There were 36 285 total ED visits during the study period, including 3477 febrile children who were 3 to 36 months old. Nurses down-triaged 1869 febrile children (54%) to the level-4 (less urgent) category and left 1322 (38%) in the level-3 (urgent) category. Hospitalization rate for down-triaged febrile patients was similar to that seen for all PaedCTAS 4 patients (2.4% v. 2.8%, 95% confidence interval for difference –0.3% to 1.1%). Down-triaged patients had significantly lower admission rates than those remaining in the level-3 (urgent) category (absolute risk reduction 10.7% standard deviation 1.9%, p < 0.001). No down-triaged patient died or required ICU admission.

Conclusion:

Febrile children aged 6 to 36 months who have no signs of toxicity can safely be down-triaged, based on triage nurse clinical judgement, to the less urgent PaedCTAS 4 category. This modification would affect the triage level of approximately 5% of all pediatric ED visits.

Validity of the Canadian Paediatric Triage and Acuity Scale in a tertiary care hospital

Objective:

We evaluated the validity of the Canadian Paediatric Triage and Acuity Scale (Paed-CTAS) for children visiting a pediatric emergency department (ED).

Methods:

This was a retrospective study evaluating all children who presented to a pediatric university-affiliated ED during a 1-year period. Data were retrieved from the ED database. Information regarding triage and disposition was registered in an ED database by a clerk following patient management. In the absence of a gold standard for triage, admission to hospital, admission to pediatric intensive care unit (PICU) and length of stay (LOS) in the ED were used as surrogate markers of severity. The primary outcome measure was the correlation between triage level (from 1 to 5) and admission to hospital. The correlation between triage level and dichotomous outcomes was evaluated by aχ2test and an analysis of variance (ANOVA) was used to evaluate the association between triage level and ED LOS.

Results:

Over the 1-year period, 58 529 patients were triaged in the ED. The proportion admitted to hospital was 63% for resuscitation (level 1), 37% for emergent (level 2), 14% for urgent (level 3), 2% for semiurgent (level 4) and 1% for nonurgent (level 5) (p< 0.001). There was also a good correlation between triage levels and LOS and admission to PICU (bothp< 0.001).

Conclusion:

This computerized version of PaedCTAS demonstrates a strong association with admission to hospital, admission to PICU and LOS in the ED. These results suggest that PaedCTAS is a valid tool for triage of children in a pediatric ED.

Emergency physician workload modeling

Background:

A variety of models are used by hospitals, provincial governments, and departments of emergency medicine to “predict” the number of physician hours of coverage necessary to staff emergency departments. These models have arisen to meet specific requirements—some for the purpose of determining hourly rates of compensation, others to determine the amount of funding that will be provided to “purchase” physician coverage, and others to determine the number of hours of coverage necessary to maintain patient waits within “acceptable” limits. All such models have their strengths and weaknesses and have been criticized as not reflecting the “real” needs of any given department.

Objective:

In the article that follows, a review of existing models is presented, annotating their strengths and weaknesses to derive the characteristics of an “ideal” workload model.

Conclusion:

None of the models currently used to measure emergency department workload can be relied on to accurately predict the number of staffed hours necessary. Models that may achieve this objective are suggested.

Reliability of a computerized version of the Pediatric Canadian Triage and Acuity Scale

BACKGROUND

The use of a standardized triage tool allows better comparison of the patients; a computerized version could theoretically improve its reliability.

OBJECTIVES

To compare the interrater agreement of the Pediatric Canadian Triage and Acuity Scale (PedCTAS) and a computerized version (Staturg).

METHODS

A two-phase experimental study was conducted to compare the interrater agreement between nurses assigning triage level to written case scenarios using either traditional PedCTAS or Staturg. Participants were nurses with at least one year of experience in pediatric emergency medicine and trained at triage. Each of the 54 scenarios was evaluated first by all nurses using either one of the strategies. Four weeks later, they evaluated the same scenarios using the other tool. The primary outcome was the interrater agreement measured using kappa score.

RESULTS

Eighteen of the 29 eligible nurses participated in the study. The computerized triage tool showed a better interrater agreement, with a Staturg kappa score of 0.55 (95% confidence interval = 0.53 to 0.57) versus a PedCTAS kappa score of 0.51 (95% confidence interval = 0.49 to 0.53). The computerized version was also associated with higher agreements for scenarios describing patients with the highest severity of triage (kappa score of 0.72 vs. 0.55 for level 1; kappa score of 0.70 vs. 0.51 for level 2).

CONCLUSIONS

A computerized version of the PedCTAS showed a statistically significant improvement in the interrater agreement for nurses evaluating the triage level of 54 clinical scenarios, but this difference has probably small clinical significance.

Agreement among pediatric health care professionals with the pediatric Canadian triage and acuity scale guidelines

OBJECTIVES

To compare triage level assignment, using case scenarios, in a pediatric emergency department between registered nurses (RNs) and pediatric emergency physicians (PEPs) based on the Pediatric Canadian Triage and Acuity Scale (P-CTAS) guidelines. To compare triage level assignment of the RNs and PEPs to that done by a panel of experts using the same P-CTAS guidelines.

METHODS

A cross-sectional questionnaire survey (55 case scenarios) was sent to all RNs and PEPs working in the emergency department after the P-CTAS was implemented. Participants were instructed to assign a triage level for each case. A priori, all cases were assigned a triage level by a panel of experts using the P-CTAS guidelines. Kappa statistics and the mean number (+/-1SD) of correct responses were calculated.

RESULTS

A response rate of 85% was achieved (29 RNs, 15 PEPs). The kappa level of agreement (95% CI) among RNs was 0.51 (0.50-0.52) and was 0.39 (0.38-0.41) among PEPs (P < 0.001). The mean number of correct responses (+/-1SD) for RNs was 64% +/- 27% and for PEPs 60% +/- 22% (P = 0.31). Levels of agreement did not vary according to experience or type of shift work done or work status of RNs and PEPs.

CONCLUSIONS

With the introduction of the P-CTAS, the level of agreement and accuracy of triage categorization remained moderate for both RNs and PEPs. The reliability of the P-CTAS needs to be further assessed and the requirements for revisions considered prior to its widespread use.

Characteristics, insights, decision making, and preparation of ED triage nurses

INTRODUCTION

The purpose of this study was to describe characteristics, insights, and decision making of expert emergency nurses practicing in a triage environment.

METHODS

A qualitative, descriptive study design was used. A purposive sample of 10 expert nurses from 2 midwestern emergency departments was recruited for 2 separate focus groups. After transcribing from audiotapes, the data were collapsed to reflect the responses of participants from each focus group to each of the 6 questions asked.

RESULTS

A variety of themes emerged from the data to describe the decision-making characteristics of triage nurses from the perspective of the expert emergency nurse.

DISCUSSION

Expert triage nurses discussed the characteristics that they deemed important in themselves and in those they worked with, such as intuition, assessment abilities, good communication, and critical thinking. The participants strongly verbalized the need for more formal education and emergency nursing experience for new triage nurses. Positive reinforcement from management for timely and accurate decision making was also an important topic.

Telephone triage: an Irish view

This paper examines the issue of telephone triage for an Irish Emergency Department and includes definitions of triage and telephone triage. At St. James Hospital, Dublin the first attempt at formal telephone triage failed. In hindsight this was attributed to inadequate research into the topic and lack of staff motivation. This paper forms part of a larger literature review undertaken by the author following the first failed attempt. An overview of the international literature addresses both the positive and negative sides of a telephone helpline. The body of literature reviewed suggests telephone triage can be successful but advises the use of formal protocols, training of staff and accurate documentation. The purpose of this paper is therefore to investigate the benefits and recommended practices of implementing telephone triage with a view to successfully changing policy and practice in a busy Emergency Department.

Clinical decisions using the National Triage Scale: how important is postgraduate education?

Triage is the formal nursing assessment of all patients who present to an Emergency Department (ED). The National Triage Scale (NTS) is used in most Australian EDs. Triage decision making involves the allocation of every patients presenting to an ED to one of the five NTS categories. The NTS directly relates a triage category to illness or injury severity and need for emergency care. Triage nurses' decisions not only have the potential to impact on the health outcomes of ED patients, they are also used, in part, to evaluate ED performance and allocate components of ED funding. This study was a correlational study that used survey methods. Triage decisions were classified as 'expected triage', 'overtriage' or 'undertriage' decisions. Participant's qualifications were allocated to five categories: 'nil'; 'emergency nursing'; 'critical care nursing'; 'midwifery'; and 'tertiary' qualifications. There was no correlation between triage decisions and length of experience in emergency nursing or triage. 'Expected triage' decisions were more common when the predicted triage category was Category 3 (P < 0.001) and 'overtriage' decisions were less common when the predicted triage category was Category 2 (P < 0.0010). The frequency of 'undertriage' decisions decreased significantly when the predicted triage category was Category 3 (P < 0.001) or Category 4 (P < 0.001). There was no correlation between triage decisions and qualifications in the 'nil', 'emergency nursing' or 'critical care nursing' categories. A midwifery qualification demonstrated a positive correlation with 'expected triage' decisions (P = 0.048) and a negative correlation with 'undertriage' decisions (P = 0.012). There was also a positive correlation between a tertiary qualification and 'expected triage' decisions (P = 0.012).

Paying for hospital emergency care under a single-payer system

Hospital emergency services are one of the key drivers of hospital activity, yet there has been surprisingly little attention paid to appropriate funding models for single-payer systems, in which funders must be concerned with issues of access and financial viability of emergency departments. This article analyzes the dynamics of hospital emergency services in terms of the key products and cost drivers. It reviews the currently available systems for categorizing emergency activity and evaluates their applicability for funding purposes with particular emphasis on the susceptibility to gaming of both triage and disposition. It identifies and evaluates 3 models for use in single-payer health systems for funding hospital emergency services (fully variable, fully fixed, and mixed variable/fixed) in terms of the key products and cost drivers in the ED. Approaches to the setting and rebasing of fixed grants are considered. Problems of potential incentive effects and double payment for admitted patients make the setting of variable payments problematic, particularly for patients subsequently admitted as inpatients. Key characteristics of an ED funding model in single-payer systems are proposed.

Triage nurses order x-rays for patients with isolated distal limb injuries: A 12-month ED study

OBJECTIVES

To determine whether triage nurses could safely, accurately, and appropriately order x-rays for patients with distal limb injuries.

METHODS

All adult patients presenting to the emergency department of a tertiary teaching hospital for 12 months with distal limb injuries were eligible for the study. Patients with severe pain or evidence of acute neurovascular compromise were excluded. Triage nurses who had completed a training workshop offered patients the option of having an x-ray obtained before seeing a physician. Data were collected regarding the number and type of x-rays ordered, the number of positive x-ray findings on radiologic review, and violations of x-ray ordering guidelines. All ED distal limb x-rays ordered during the 12-month study period were analyzed for type, frequency, and abnormality. To determine the impact of the project on practice, all triage nurses were given the opportunity to complete a questionnaire, patient satisfaction surveys were conducted, and structured interviews were conducted with senior ED medical and radiography personnel.

RESULTS

During the 12-month study, triage nurses ordered 876 x-rays (49%), whereas physicians ordered 930 x-rays (51%). Medical staff and triage nurses ordered equal proportions of upper and lower limb x-rays. The abnormality rate in the total study group was 699 (39%). The abnormality rate for x-rays when comparing nursing and medical staff was 43% (390) and 33% (309), respectively (x(2) = 23.4; P <.0001). The triage x-ray abnormality rate for the upper limb was 51%, compared with 31% for the lower limb. Data indicated that all staff believed that this new triage practice had increased patient satisfaction and improved patient flow and waiting times.

CONCLUSION

With structured education, triage nurses at one institution safely assessed patients and ordered appropriate distal limb x-rays prior to physician assessment.

Research directions for specialist practice

Emergency nursing is a specialist area of practice that demands particular knowledge and skills. This paper reports on a study to identify the research directions necessary to advance emergency nursing as a specialist area of practice. Nurses working in nine Australian hospital emergency departments responded to questions about current research practices, and the research priorities necessary to inform the development of knowledge and practice in the evolving specialty of emergency nursing. Forty-four core topics considered relevant to the knowledge base of emergency nursing were identified by nurses who were directly involved in providing patient care. The highest ranked topics were clustered into four priority areas for further research. The key areas for further research are education needs and opportunities, specialist roles of triage, trauma and practitioner, and nurses' coping mechanisms. Discussion of these topics is framed by the increasing specialisation of nursing practice, thus this paper aims to encourage consideration and debate about the research based development of the specialty of emergency nursing.

Reliability of the Canadian emergency department triage and acuity scale: interrater agreement

STUDY OBJECTIVE

To determine the rate of interobserver reliability of the Canadian Emergency Department Triage and Acuity Scale (CTAS).

METHODS

Ten physicians and 10 nurses were randomly selected to review and assign a triage level on 50 ED case summaries containing presenting complaint, mode of arrival, vital signs, and a verbatim triage note. The rate of agreement within and between groups of raters was determined using kappa statistics. One-way, 2-way analysis of variance (ANOVA) and combined ANOVA were used to quantify reliability coefficients for intraclass and interclass correlations.

RESULTS

The overall chance-corrected agreement kappa for all observers was.80 (95% confidence interval [CI] .79 to .81), and the probability of agreement between 2 random observers on a random case was.539. For nurses alone, kappa=.84 (95% CI .83 to .85, P = .598), and for doctors alone, kappa= .83 (95% CI .81 to .85, P = .566). The 1-way, 2-way ANOVA and combined ANOVA showed that the reliability coefficients (84%) for both nurses and physicians were similar to the kappa values. A combined ANOVA showed there was a. 2-point difference with physicians assigning a higher triage level.

CONCLUSION

The high rate of interobserver agreement has important implications for case mix comparisons and suggests that this scale is understood and interpreted in a similar fashion by nurses and physicians.

The effects of technology on triage in A & E

Within the specialty of Accident and Emergency (A & E) nursing, triage is a term meaning to classify or sort patients according to their need for care (Blythin 1988). Burgess (1992) views this process as a means of prioritizing patients in order, so that the more seriously ill or injured are seen first (Table 1). Triage performance is measured in the author's department by computer. This technological source is used to record the patient's arrival time and the time at which the patient is triaged. Technology is defined by the Oxford Dictionary (1996) as 'the study of mechanical arts and science, their application in industry'. This paper explores the impact of this technology and the related issues on the A & E triage nurse, and will focus on issues related to the Patients' Charter (1991), resource implications, safety and staff training. In conclusion, the quality of a patient's total care, in which the author participated, is discussed with reference to the related issues and implications for future practice.