A review of the quality assurance processes for the Australasian Triage Scale (ATS) and implications for future practice

Five Level Triage vs. Four Level Triage in a Quaternary Emergency Department: National Analysis on Waiting Time, Validity, and Crowding-The CREONTE (Crowding and RE-Organization National TriagE) Study Group

Background and Objectives: Triage systems help provide the right care at the right time for patients presenting to emergency departments (EDs). Triage systems are generally used to subdivide patients into three to five categories according to the system used, and their performance must be carefully monitored to ensure the best care for patients. Materials and Methods: We examined ED accesses in the context of 4-level (4LT) and 5-level triage systems (5LT), implemented from 1 January 2014 to 31 December 2020. This study assessed the effects of a 5LT on wait times and under-triage (UT) and over-triage (OT). We also examined how 5LT and 4LT systems reflected actual patient acuity by correlating triage codes with severity codes at discharge. Other outcomes included the impact of crowding indices and 5LT system function during the COVID-19 pandemic in the study populations. Results: We evaluated 423,257 ED presentations. Visits to the ED by more fragile and seriously ill individuals increased, with a progressive increase in crowding. The length of stay (LOS), exit block, boarding, and processing times increased, reflecting a net raise in throughput and output factors, with a consequent lengthening of wait times. The decreased UT trend was observed after implementing the 5LT system. Conversely, a slight rise in OT was reported, although this did not affect the medium-high-intensity care area. Conclusions: Introducing a 5LT improved ED performance and patient care.

Strategies to improve the quality of nurse triage in emergency departments: A realist review protocol

AIM

The purpose of this realist review was to assess what works, for whom and in what context, regarding strategies that influence nurses' behaviour to improve triage quality in emergency departments (ED).

DESIGN

Realist review protocol.

METHODS

This protocol follows the PRISMA-P statement and will include any type of study on strategies to improve the triage process in the ED (using recognized and validated triage scales). The included studies were examined for scientific quality using the Mixed Methods Appraisal Tool. The framework for this realist review is based on the Behaviour Change Wheel (BCW) and the context-mechanism-outcome (CMO) models.

DISCUSSION

Nurses and ED decision makers will be informed on the evidence regarding strategies to improve the quality of triage and the factors required to maximize their effectiveness. Research gaps may also be identified to guide future research projects on the adoption of best practices in ED nursing triage.

Pre-triage wait times for non-ambulance arrivals in the emergency department: A retrospective video audit

BACKGROUND

Pre-triage emergency department (ED) waiting times can be lengthy when presentation numbers are high. Queuing is random, affecting flow management and patient care. We investigated pre-triage wait times and barriers to triage access at an Australian ED.

METHODS

A reviewer conducted a retrospective audit of triage reception security video camera footage (February-March, 2020). The reviewer manually documented self-presenting patients' wait-to-be-seen times and barriers to patient flow.

RESULTS

The audit identified three main topics: lengthy pre-triage wait times, pre-triage queuing and observed barriers to triage. Median pre-triage wait time was 12 min (IQR = 5-21; n = 141), with no apparent relationship between patients' wait time and time of arrival. During peak or busy periods, multiple random queues formed at the triage reception area. Triage nurses could not concurrently triage and provide queue control during busy periods.

CONCLUSIONS

Unrecorded pre-triage wait times may exceed 20 min. This unseen time may extend beyond the estimated post-triage wait times suggested by the Australasian Triage Scale (ATS). There was a degree of disorder in patient queueing, reducing effective door-to-triage productivity. Larger studies could determine these findings' external replicability, with additional research addressing potential benefits of pre-triage queuing processes or a departmental concierge.

Elderly patients presenting to a rural hospital emergency department in inland Croatia - A retrospective study

BACKGROUND

Emergency departments are faced with a high influx of patients presenting for various complaints. The aim of the present study was to assess the basic characteristics of elderly patients presenting to a rural hospital emergency department in inland Croatia in 2017.

METHODS

Retrospective data collected from the Hospital Information System and by analysis of medical records on patients presenting to emergency department in 2017 were used in the study.

RESULTS

Study results indicated that a lower proportion of elderly individuals aged 65-74 were hospitalized following emergency department workup. A statistically significantly higher proportion of patients older than 74 years was presented to ED due to various discomforts and diseases (ICD-10 group I; χ2 = 324.85; p < 0.01) than due to cardiorespiratory diseases and acute abdomen (χ2 = 285.04; p < 0.01).

CONCLUSION

Our findings highlight the need for a complex approach in care for elderly people, given that they are a fragile population with multiple comorbidities, chronic diseases, atypical symptoms, and often with cognitive and functional impairments.

E-Triage Systems for COVID-19 Outbreak: Review and Recommendations

With population growth and aging, the emergence of new diseases and immunodeficiency, the demand for emergency departments (EDs) increases, making overcrowding in these departments a global problem. Due to the disease severity and transmission rate of COVID-19, it is necessary to provide an accurate and automated triage system to classify and isolate the suspected cases. Different triage methods for COVID-19 patients have been proposed as disease symptoms vary by country. Still, several problems with triage systems remain unresolved, most notably overcrowding in EDs, lengthy waiting times and difficulty adjusting static triage systems when the nature and symptoms of a disease changes. In this paper, we conduct a comprehensive review of general ED triage systems as well as COVID-19 triage systems. We identified important parameters that we recommend considering when designing an e-Triage (electronic triage) system for EDs, namely waiting time, simplicity, reliability, validity, scalability, and adaptability. Moreover, the study proposes a scoring-based e-Triage system for COVID-19 along with several recommended solutions to enhance the overall outcome of e-Triage systems during the outbreak. The recommended solutions aim to reduce overcrowding and overheads in EDs by remotely assessing patients' conditions and identifying their severity levels.

Mild Head Trauma: Is Antiplatelet Therapy a Risk Factor for Hemorrhagic Complications?

Background and objectives: In patients who receive antiplatelet therapy (APT), the bleeding risk profile after mild head trauma (MHT) still needs clarification. Some studies have demonstrated an association with bleeding risk, whereas others have not. We studied the population of our level II emergency department (ED) trauma center to determine the risk of bleeding in patients receiving APT and whether bleeding results not from antiplatelet agents but rather from age. We assessed the bleeding risk, the incidence of intracranial hemorrhage (ICH) that necessitated hospitalization for observation, the need for cranial neurosurgery, the severity of the patient's condition at discharge, and the frequency of ED revisits for head trauma in patients receiving APT. Materials and Methods: This retrospective single-center study included 483 patients receiving APT who were in the ED for MHT in 2019. The control group consisted of 1443 patients in the ED with MHT over the same period who were not receiving APT or anticoagulant therapy. Our ED diagnostic therapeutic protocol mandates both triage and the medical examination to identify patients with MHT who are taking any anticoagulant or APT. Results: APT was not significantly associated with bleeding risk (p > 0.05); as a risk factor, age was significantly associated with the risk of bleeding, even after adjustment for therapy. Patients receiving APT had a greater need of surgery (1.2% vs. 0.4%; p < 0.0001) and a higher rate of hospitalization (52.9% vs. 37.4%; p < 0.0001), and their clinical condition was more severe (evaluated according to the exit code value on a one-dimensional quantitative five-point numerical scale) at the time of discharge (p = 0.013). The frequency of ED revisits due to head trauma did not differ between the two groups. Conclusions: The risk of bleeding in patients receiving APT who had MHT was no higher than that in the control group. However, the clinical condition of patients receiving APT, including hospital admission for ICH monitoring and cranial neurosurgical interventions, was more severe.

Identifying 'at-risk' critically ill patients who present to the emergency department and require intensive care unit admission: A retrospective observational cohort study

BACKGROUND

Emergency department (ED) triage is the process of prioritising patients by medical urgency. Delays in intensive care unit (ICU) admission can adversely affect patients.

OBJECTIVES

This study aimed to identify characteristics associated with ICU admission for patients triaged as Australasian Triage Scale (ATS) 3 but subsequently admitted to the ICU within 24 h of triage.

METHODS

This retrospective, observational cohort study was conducted in a public teaching hospital in Queensland, Australia. Patients older than 18 y triaged with an ATS 3 and admitted to the ICU within 24 h of triage or admitted to the ward between January 1, 2012, and December 31, 2012, were included. The demographic and clinical profiles of ICU admissions vs. all other ward admissions for patients triaged an ATS of 3 were compared. Multivariable regression analysis compared characteristics of patients triaged with an ATS of 3 who did and did not require ICU transfer. Descriptive data are reported as n (%) and median and interquartile range (IQR). Regression analysis is reported as adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs).

RESULTS

Of the 27 454 adult ED presentations triaged with an ATS of 3, 22.4% (n = 6138) required hospital admission, comprising 5302 individuals, 2.1% of whom (n = 110) were admitted to the ICU within 24 h of triage. Age- and sex-adjusted predictors of ICU admission for patients triaged with an ATS of 3 included infectious (aOR: 3.7; 95% CI: 2.0-6.9), neurological (aOR: 2.8; 95% CI: 1.6-5.0), and gastrointestinal disorders (aOR: 2.2; 95% CI 1.2-3.5); arriving by ambulance; arriving after hours; or arriving on weekends. Regardless of diagnosis or sex, persons older than 80 y were less likely to be admitted to the ICU (aOR: 0.4; 95% CI: 0.2-0.8).

CONCLUSIONS

Patients triaged as ATS 3 presenting on weekends or after hours, and those with infectious, gastrointestinal, or neurological conditions warrant careful attention as these factors were associated with higher odds of ICU admission. Ongoing staff education regarding triage and signs of deterioration are important to prevent avoidable outcomes.

<p>Validation of the Cipto Triage Method: A Single-Centre Study from Indonesia</p>

Purpose

A national referral hospital in Indonesia developed a three-category triage acuity method called the Cipto Triage Method (CTM) for emergency departments (ED) in developing countries. This was a validation study to assess the performance of the triage method.

Methods

This cohort, retrospective, single-centre study was conducted in the ED of Cipto Mangunkusumo Hospital that receives approximately 30,000 patient visits per year. The ED medical records throughout the year 2017 were randomly selected as the study sample. Completely written forms of triage and ED initial assessment were included in this study. Validation of the CTM decision was done by using expert panel opinion as reference standard, and also using surrogate conditions such as patient outcome for hospital admission and in-hospital mortality.

Results

There were 1348 samples assigned to the following three categories: resuscitation (14.9%), urgent (63.8%) and non-urgent (21.3%). Overall accuracy was more than 80%, positive predictive value and negative predictive value for resuscitation category were 99% (95% confidence interval [CI], 96.5–99.9) and 96.9% (95% CI, 95.7−97.8), respectively. Resuscitation category had a relative risk (RR) for admission of 1.341 (95% CI, 1.259–1.429) and a RR for mortality of 4.294 (95% CI, 3.180–5.799). Undertriage increases the risk of mortality compared to correct triage (RR, 3.1; 95% CI, 2.11–4.54).

Conclusion

CTM has a good criterion and construct validity; it is also easy to understand and can accommodate a simple ED design in the majority of hospitals in Indonesia.

The accuracy of the Manchester Triage System in an emergency service

ABSTRACT Objective: To verify the accuracy of the Manchester Triage System (MTS) and the outcomes of adult patients in an emergency hospital service. Method: Cross-sectional study, conducted through an inspection of records of risk classification of adult patients treated in the emergency service of a hospital. Results: The patients (n = 400) were classified according to priority levels, in red (0.8%), orange (58.2%), and yellow (41.0%). The accuracy levels between auditors and nurses were substantial for the flowchart (K = 0.75), and moderate for discriminating factors (k = 0.46) and priority levels (k = 0.42). The accuracy of the MTS was 68.8% with regard to priority levels. Regarding outcomes, 60% of patients were discharged, 37% were transferred to other units, and 3% died. Conclusion: The MTS proved to be a good predictor of the assessed outcomes, showing that 65.9% of Low Urgency patients progress to discharges, and 3.8% of High Urgency patients progress to death. The accuracy of the MTS was moderate, which suggests the need to implement inspections in emergency services.

The use and feasibility of an online software system to support assessment of accuracy and consistency in applying the Australasian Triage Scale

BACKGROUND

The purpose of this study was to evaluate the use and feasibility of a software system called the Triage Quality Assessment Software in New South Wales emergency departments, to assist in evaluating triage decision accuracy and consistency of emergency nurses in applying the Australasian Triage Scale.

METHOD

A descriptive, exploratory study comprising of retrospective audit data and survey, was conducted 12-months post-implementation of the Triage Quality Assessment Software system.

RESULTS

Between January to December 2018, a total of 39 audits were completed comprising 4214 triage records, of which 3952 (93.3%) contained sufficient information to be evaluated. Triage decision accuracy was 58.3% with a moderate level (K_W=0.57) of consistency demonstrated. Overall feasibility was high (4.2). Findings confirmed learnability (4.3), usability (4.2) and acceptability (4.2) of Triage Quality Assessment Software.

CONCLUSION

This is the first software system to be developed to assist in evaluating triage decision accuracy and consistency in applying the Australasian Triage Scale. This study provides evidence that triage decision accuracy and consistency are detectable and quantifiable. The feasibility of Triage Quality Assessment Software is supported, with further testing needed to fully evaluate its role in emergency department triage quality improvement.

Triage in Australian emergency departments: Results of a New South Wales survey

AIM

To describe current models of triage, the preparation and education of triage nurses, and methods of auditing triage practice in New South Wales emergency departments.

BACKGROUND

Triage is a critical component of emergency department practice; affecting patient safety and access to emergency care. Within Australia, triage is an autonomous role predominantly conducted by trained emergency nurses. Patient safety and timely access to emergency care relies upon the experience, education and training of emergency triage nurses. To date, little is known about triage models of care, the preparation and education of triage nurses, and assessment of triage practice and decision accuracy.

METHOD

Descriptive, exploratory study design employing a self-reporting cross-sectional survey of clinical nurse consultants and educators in New South Wales.

RESULTS

The survey results reveal variability in models of triage, and the eligibility, preparation and education requirements of triage nurses; that appear geographically related. Auditing of triage practice was commonly undertaken retrospectively; feedback to triage nurses was infrequent. The survey found evidence of locally developed guidelines directing triage category allocation for specific conditions or symptoms.

CONCLUSION

The purpose of triage is to ensure that the level of emergency care provided is commensurate with clinical urgency. Variability in the preparation, education and evaluation of triage nurses may in and of itself, contribute to poor patient outcomes. Further, workforce size and geography may impede auditing and the provision of feedback, which are critical to improving triage practice and triage nurse performance. It is imperative that the Emergency Triage Education Kit be revised and maintained in tandem with future revisions of the Australasian Triage Scale.

Development and preliminary testing of an online software system to facilitate assessment of accuracy and consistency in applying the Australasian Triage Scale

PURPOSE

The aim of this project was to design and evaluate an online software system to facilitate the assessment of triage decision accuracy and consistency in applying the Australasian Triage Scale.

BACKGROUND

Triage is a critical component of emergency nursing practice, which affects patient access to emergency care. Accurate and consistent triage decisions are vital to ensuring patient safety, timely access to care and ED operation. Presently, there is no standard process to examine triage decisions, measure current performance and support department and individual performance development activities to improve patient safety and quality of emergency care.

METHOD

An iterative design guided by a human factors development approach was used to develop a retrospective, focus-based analysis system to evaluate triage decision accuracy and consistency, and enable the exploration of service gaps and opportunities for practice change and professional development.

RESULTS

Triage decision accuracy and consistency, including areas for improvement are detectable and quantifiable. Findings generated may aid in departmental performance and professional development of triage nurses.

CONCLUSION

This is the first system developed to assess decision accuracy and consistency in applying the Australasian Triage Scale. This paper has described the development and preliminary testing of a user-centred design process and implementation of a web-based system to evaluate triage decision accuracy and consistency.

Transition in care from paramedics to emergency department nurses: a systematic review protocol

BACKGROUND

Effective and efficient transitions in care between emergency medical services (EMS) practitioners and emergency department (ED) nurses is vital as poor clinical transitions in care may place patients at increased risk for adverse events such as delay in treatment for time sensitive conditions (e.g., myocardial infarction) or worsening of status (e.g., sepsis). Such transitions in care are complex and prone to communication errors primarily caused by misunderstanding related to divergent professional perspectives leading to misunderstandings that are further susceptible to contextual factors and divergent professional lenses. In this systematic review, we aim to examine (1) factors that mitigate or improve transitions in care specifically from EMS practitioners to ED nurses, and (2) effectiveness of interventional strategies that lead to improvements in communication and fewer adverse events.

METHODS

We will search electronic databases (DARE, MEDLINE, EMBASE, Cochrane, CINAHL, Joanna Briggs Institute EBP; Communication Abstracts); gray literature (gray literature databases, organization websites, querying experts in emergency medicine); and reference lists and conduct forward citation searches of included studies. All English-language primary studies will be eligible for inclusion if the study includes (1) EMS practitioners or ED nurses involved in transitions for arriving EMS patients; and (2) an intervention to improve transitions in care or description of factors that influence transitions in care (barriers/facilitators, perceptions, experiences, quality of information exchange). Two reviewers will independently screen titles/abstracts and full texts for inclusion and methodological quality. We will use narrative and thematic synthesis to integrate and explore relationships within the data. Should the data permit, a meta-analysis will be conducted.

DISCUSSION

This systematic review will help identify factors that influence communication between EMS and ED nurses during transitions in care, and identify interventional strategies that lead to improved communication and decrease in adverse events. The findings can be used to develop an evidence-informed transitions in care tool that ensures efficient transfer of accurate patient information, continuity of care, enhances patient safety, and avoids duplication of services. This review will also identify gaps in the existing literature to inform future research efforts.

TRIAL REGISTRATION

PROSPERO CRD42017068844.

Parameters affecting length of stay in a pediatric emergency department: a retrospective observational study

Prolonged emergency department (ED) length of stay (LOS) is used as a proxy for ED overcrowding and is associated with adverse outcomes of patients requiring therapy and reduced patient satisfaction. Our aim was to identify and quantify variables which affect ED-LOS. Patients admitted to the pediatric ED of a large regional Swiss hospital during a 1-year period were analyzed for LOS (in minutes). Predictor variables included patient-associated parameters (time of admission and discharge, ED occupancy, triage score, diagnosis, and demographic data) and external factors (weekday, time, and season). A total of 4885 visits were included in a multivariable logistic regression analysis. Median LOS was 124 min. The most important factors associated with prolonged LOS were physician referral (adjusted odds ratio [OR], 1.97; 95% confidence interval [CI], 1.47-2.62); morning admissions, especially before noon (OR, 1.92; 95% CI, 1.23-3.07); and gastrointestinal infections (OR, 1.38; 95% CI, 1.08-1.76). Upper airway infections (OR, 0.37; 95% CI, 0.27-0.49) and triage level 5 (OR, 0.18; 95% CI, 0.06-0.61) were inversely associated with ED-LOS. Together with ED occupancy, these factors did significantly contribute to log LOS in a stepwise backward multiple regression model (p < 0.001).

CONCLUSION

Several parameters are associated with prolonged ED-LOS. Notably, morning arrivals represent possible targets for strategies to reduce LOS. What is Known: • Prolonged length of stay (LOS) may affect care delivered to admitted patients in the emergency department (ED) and is well studied in the setting of adult patients with high acuity conditions. • Little is known about parameters which impact LOS in European pediatric EDs. What is New: • Several predictors of prolonged LOS could be identified in a European pediatric setting. • Our results indicate that prolonged LOS is associated with modifiable factors like morning and summer admission, which have the potential to be addressed by modification in staffing, infrastructure, and higher attention to faster processing.

The Sydney Triage to Admission Risk Tool (START) to predict Emergency Department Disposition: A derivation and internal validation study using retrospective state-wide data from New South Wales, Australia

Background

Disposition decisions are critical to the functioning of Emergency Departments. The objectives of the present study were to derive and internally validate a prediction model for inpatient admission from the Emergency Department to assist with triage, patient flow and clinical decision making.

Methods

This was a retrospective analysis of State-wide Emergency Department data in New South Wales, Australia. Adult patients (age ≥ 16 years) were included if they presented to a Level five or six (tertiary level) Emergency Department in New South Wales, Australia between 2013 and 2014. The outcome of interest was in-patient admission from the Emergency Department. This included all admissions to short stay and medical assessment units and being transferred out to another hospital. Analyses were performed using logistic regression. Discrimination was assessed using area under curve and derived risk scores were plotted to assess calibration.

Results

1,721,294 presentations from twenty three Level five or six hospitals were analysed. Of these 49.38% were male and the mean (sd) age was 49.85 years (22.13). Level 6 hospitals accounted for 47.70% of cases and 40.74% of cases were classified as an in-patient admission based on their mode of separation. The final multivariable model including age, arrival by ambulance, triage category, previous admission and presenting problem had an AUC of 0.82 (95% CI 0.81, 0.82).

Conclusion

By deriving and internally validating a risk score model to predict the need for in-patient admission based on basic demographic and triage characteristics, patient flow in ED, clinical decision making and overall quality of care may be improved. Further studies are now required to establish clinical effectiveness of this risk score model.

Statewide retrospective study of low acuity emergency presentations in New South Wales, Australia: who, what, where and why?

OBJECTIVE

The present study aims to use a statewide population-based registry to assess the prevalence of low acuity emergency department (ED) presentations, describe the trend in presentation rates and to determine whether they were associated with various presentation characteristics such as the type of hospital as well as clinical and demographic variables.

DESIGN AND SETTING

This was a retrospective analysis of a population-based registry of ED presentations in New South Wales (NSW). Generalised estimating equations with log links were used to determine factors associated with low acuity presentations to account for repeat presentations and the possibility of clustering of outcomes.

PARTICIPANTS

Patients were included in this analysis if they presented to an ED between January 2010 and December 2014. The outcomes of interest were low acuity presentation, defined as those who self-presented (were not transported by ambulance), were assigned a triage category of 4 or 5 (semiurgent or non-urgent) and discharged back to usual residence from ED.

RESULTS

There were 10.7 million ED presentations analysed. Of these, 45% were classified as a low acuity presentation. There was no discernible increase in the rate of low acuity presentations across NSW between 2010 and 2014. The strongest predictors of low acuity ED presentation were age <40 years of age (OR 1.77); injury or musculoskeletal administrative and non-urgent procedures (OR 2.96); ear, nose and throat, eye or oral (OR 5.53); skin or allergy-type presenting problems (OR 2.84).

CONCLUSIONS

Low acuity ED presentations comprise almost half of all ED presentations. Alternative emergency models of care may help meet the needs of these patients.

Improving emergency department throughput: An outcomes evaluation of two additional models of care

OBJECTIVE

The aim of this study was to explore the impact of incorporating a physician at triage (PAT) and the implementation of a medical assessment unit (MAU) on emergency department (ED) patient throughput.

METHODS

A retrospective comparative analysis of two additional models of care (standard care, T1; PAT, T2 and PATplusMAU, T3) was undertaken. Patient presentations to a large public teaching hospital in South-East Queensland between 10th January 2013 and 25th February 2013, and the same time period in 2012, were included. The impact of these care models on ED length of stay and other outcomes (time to be seen by a clinician, time from bed request to ward transfer, meeting 4 hour transit targets, admission rates and the proportion of patients who did not wait) were compared.

RESULTS

Compared to standard care, ED length of stay appeared to decrease with the introduction of both models, but was only significantly decreased after PATplusMAU was implemented (2013; T1, 186 min; T2, 181 min; T3, 175 min: T1 vs T3, P < 0.001). Outcomes that improved included: time to be seen by a clinician, proportion of patients who did not wait; increase in meeting 4-hour length of stay target for both admitted and not-admitted patients.

CONCLUSION

Placing a physician at triage and implementing a medical assessment unit were viable models of care that promoted patient flow and helped meet several time-sensitive health service targets.

Current status of emergency department triage in mainland China: A narrative review of the literature

In this review, the current status of emergency department triage in mainland China is explored, with the purpose of generating a deeper understanding of the topic. Literature was identified through electronic databases, and was included for review if published between 2002 and 2012, included significant discussion of daily emergency department triage in mainland China, was peer reviewed, and published in English or Chinese. Thematic analysis was used to identify themes which emerged from the reviewed literature. This resulted in 21 articles included for review. Four themes emerged from the review: triage process, triage training, qualification of triage nurses, and quality of triage. The review demonstrates that there is currently not a unified approach to emergency department triage in mainland China. Additionally, there are limitations in triage training for nurses and confusion around the role of triage nurses. This review highlights that emergency department triage in mainland China is still in its infancy and that more research is needed to further develop the role of triage.