Comparison of the Emergency Severity Index (ESI) and the Taiwan Triage System in Predicting Resource Utilization

Drinking from the Holy Grail-Does a Perfect Triage System Exist? And Where to Look for It?

The Emergency Department (ED) is a facility meant to treat patients in need of medical assistance. The choice of triage system hugely impactsed the organization of any given ED and it is important to analyze them for their effectiveness. The goal of this review is to briefly describe selected triage systems in an attempt to find the perfect one. Papers published in PubMed from 1990 to 2022 were reviewed. The following terms were used for comparison: "ED" and "triage system". The papers contained data on the design and function of the triage system, its validation, and its performance. After studies comparing the distinct means of patient selection were reviewed, they were meant to be classified as either flawed or non-ideal. The validity of all the comparable segregation systems was similar. A possible solution would be to search for a new, measurable parameter for a more accurate risk estimation, which could be a game changer in terms of triage assessment. The dynamic development of artificial intelligence (AI) technologies has recently been observed. The authors of this study believe that the future segregation system should be a combination of the experience and intuition of trained healthcare professionals and modern technology (artificial intelligence).

Models to predict length of stay in the emergency department: a systematic literature review and appraisal

INTRODUCTION

Prolonged Length of Stay (LOS) in ED (Emergency Department) has been associated with poor clinical outcomes. Prediction of ED LOS may help optimize resource utilization, clinical management, and benchmarking. This study aims to systematically review models for predicting ED LOS and to assess the reporting and methodological quality about these models.

METHODS

The online database PubMed, Scopus, and Web of Science (10 Sep 2023) was searched for English language articles that reported prediction models of LOS in ED. Identified titles and abstracts were independently screened by two reviewers. All original papers describing either development (with or without internal validation) or external validation of a prediction model for LOS in ED were included.

RESULTS

Of 12,193 uniquely identified articles, 34 studies were included (29 describe the development of new models and five describe the validation of existing models). Different statistical and machine learning methods were applied to the papers. On the 39-point reporting score and 11-point methodological quality score, the highest reporting scores for development and validation studies were 39 and 8, respectively.

CONCLUSION

Various studies on prediction models for ED LOS were published but they are fairly heterogeneous and suffer from methodological and reporting issues. Model development studies were associated with a poor to a fair level of methodological quality in terms of the predictor selection approach, the sample size, reproducibility of the results, missing imputation technique, and avoiding dichotomizing continuous variables. Moreover, it is recommended that future investigators use the confirmed checklist to improve the quality of reporting.

Triage Accuracy and Its Association with Patient Factors Using Emergency Severity Index: Findings from United Arab Emirates

Introduction

The Ministry of Health and Prevention of the UAE acquired an electronic medical record system (Wareed) through which they incorporated the Emergency Severity Index as the standard triaging tool. This raised the need to review population dynamics and the accuracy of triage performed by the health-care providers utilizing the tool.

Objective

This research aimed to study demographics and dynamics of the population presenting to emergency departments (EDs) during 2018, evaluate the accuracy of triage assessment using comparative analysis techniques, and determine relationships between patient factors (severity of illness, age-group) and the accuracy of triage.

Methods

This was an observational study that aimed to ascertain findings from ED data over 1 year (January 2018-December 2018) and explore factors associated with reduced accuracy in acuity assignment. We employed comparative analysis to measure the level of agreement between standard guidelines and local findings.

Results

A total of 576,154 patients visited EDs in 2018, of which 54.4% were male. A statistically significant increase in length of stay with increasing severity of illness was observed (Kruskal-Wallis test). Overall triage accuracy was 41.6%, with a positive association with increasing severity of illness. We found a positive association between severity of illness and accuracy of triage (OR 0.14, p=0). We also found on logistic regression that the age-group 11-20 years had the highest probability of accurate triage acuity (R ²=0.41, p=0).

Conclusion

Conducted on a very large data set from the UAE, our study reflects upon population dynamics and triage accuracy distribution among different variables. This study paves the way for further in-depth analysis of factors that may impact triage accuracy within EDs, and utilizing a similar approach it can be replicated in other settings as well.

An epidemiological study of a patient population, triage category allocations and principal diagnosis within the emergency centres of a private healthcare group in the Emirate of Dubai, United Arab Emirates

Aim

To describe, compare and correlate the number of patients seen, their demographics, triage category allocations and principal diagnosis in four emergency centres; to better understand the patient population and triage practices in this setting.

Design

An observational, cross-sectional, epidemiological study.

Methods

Electronic medical records were retrospectively evaluated from patients triaged in each of the four emergency centres over six months. Descriptive statistics were used to describe the patient demographics and variance between triage category allocations.

Results

A total of 56,984 patient records were captured, with an equal gender split and the workforce being the largest patient population (20-50 years). Acute upper respiratory infection was the most prolific diagnosis, and lower acuity triage categories were allocated the most. There were inconsistencies in the application of triage systems between the emergency centres, the most obvious being the variance in triage system selection and application.

Validity and Reliability of Emergency Severity Index and Conventional Three-Tier Triage System in the Emergency Department, Hospital Universiti Sains Malaysia

Background

The study aimed to examine the reliability and validity of the existing three-tier triaging system and a new five-level emergency triaging system, emergency severity index (ESI), in the Emergency Department (ED) of Hospital Universiti Sains Malaysia (HUSM).

Methods

This study was conducted in HUSM’s ED over two study periods. In the first three months, 300 patients were triaged under the three-tier triaging system, and, in the subsequent three months, 280 patients were triaged under the ESI. The patients were triaged by junior paramedics and the triage records were retained and later re-triaged by senior paramedics. The inter-rater reliability was evaluated using Cohen's Kappa statistics. The acuity ratings of the junior paramedics were compared with those of the expert panel to determine the sensitivity and specificity of each acuity level for both the ESI and the three-tier triaging system. The over-triage rate, under-triage rate, amount of resources used, admission rate and discharge rate were also determined.

Results

The inter-rater agreement for the three-tier triaging system was 0.81 while that of the ESI was 0.75. The ESI had a higher average sensitivity of 74.3% and a specificity of 94.4% while the three-tier system’s average sensitivity was 68.5% and its specificity 87.0%. The average under-triage and over-triage rates for the ESI were 10.7% and 6.2%, respectively, which were lower than the three-tier system’s average under-triage rate of 13.1% and over-triage rate of 17.1%. The urgency levels of both the ESI and the three-tier system were associated with increased admission rates and resources used in the ED.

Conclusion

The ESI’s inter-rater reliability was comparable to the three-tier triaging system and it demonstrated better validity than the existing three-tier system.

Effectiveness of Implementing Emergency Severity Index Triage System in a Selected Primary Health Care Center in Oman: A Quasi-Experimental Study

BACKGROUND

Because most primary health care centers in Oman do not use a formal triage system, there are no available data on the effectiveness of implementing this system.

PURPOSE

To assess the effectiveness of implementing an Emergency Severity Index triage system in primary health care centers in Oman.

METHODS

A pretest/posttest quasi-experimental design was used. The sample comprised 187 patients before Emergency Severity Index implementation and 102 patients after implementation. Waiting time, length of stay, patient satisfaction, and accuracy of classification were compared across the 2 groups.

RESULTS

The mean time (hour:minute) from registration to triage was reduced in the post-Emergency Severity Index group (mean = 0:18, SD = 0:14) compared with the pre-Emergency Severity Index group (mean = 0:23, SD = 0:19) (t = 2.59, P = 0.01). Furthermore, the mean length of stay was reduced in the post-Emergency Severity Index group (mean = 1:09, SD = 0:37) compared with that of the preimplementation group (mean = 1:24, SD = 0:41) (t = 3.10, P = 0.002). Patient satisfaction in the postimplementation group was improved (mean = 66.95, SD = 8.33) compared with that of the Emergency Severity Index group (mean = 65.01, SD = 8.73), but it did not reach statistical significance (t = -1.83, P = 0.07). The inter-rater agreement of triage level in post-Emergency Severity Index implementation markedly improved in the postimplementation group (Cohen's kappa = 0.910, P < 0.001) compared with that of the preimplementation group (Cohen's kappa = 0.082, P = 0.005).

CONCLUSIONS

Although this is a single-setting study, the results have shown that the Emergency Severity Index system can contribute to a decrease in the negative crowding outcomes in primary health care centers in Oman.

Validation of the Emergency Severity Index (Version 4) for the Triage of Adult Emergency Department Patients With Active Cancer

BACKGROUND

Patients with active cancer account for a growing percentage of all emergency department (ED) visits and have a unique set of risks related to their disease and its treatments. Effective triage for this population is fundamental to facilitating their emergency care.

OBJECTIVES

We evaluated the validity of the Emergency Severity Index (ESI; version 4) triage tool to predict ED-relevant outcomes among adult patients with active cancer.

METHODS

We conducted a prespecified analysis of the observational cohort established by the National Cancer Institute-supported Comprehensive Oncologic Emergencies Research Network's multicenter (18 sites) study of ED visits by patients with active cancer (N = 1075). We used a series of χ² tests for independence to relate ESI scores with 1) disposition, 2) ED resource use, 3) hospital length of stay, and 4) 30-day mortality.

RESULTS

Among the 1008 subjects included in this analysis, the ESI distribution skewed heavily toward high acuity (>95% of subjects had an ESI level of 1, 2, or 3). ESI was significantly associated with patient disposition and ED resource use (p values < 0.05). No significant associations were observed between ESI and the non-ED based outcomes of hospital length of stay or 30-day mortality.

CONCLUSION

ESI scores among ED patients with active cancer indicate higher acuity than the general ED population and are predictive of disposition and ED resource use. These findings show that the ESI is a valid triage tool for use in this population for outcomes directly relevant to ED care.

Improving the timeliness and accuracy of injury severity data in road traffic accidents in an emerging economy setting

Road traffic injuries (RTIs) are among the leading causes of injury and fatality worldwide. RTI casualties are continually increasing in Taiwan; however, because of a lack of an advanced method for classifying RTI severity data, as well as the fragmentation of data sources, road traffic safety and health agencies encounter difficulties in analyzing RTIs and their burden on the healthcare system and national resources. These difficulties lead to blind spots during policy-making for RTI prevention and control. After compiling classifications applied in various countries, we summarized data sources for RTI severity in Taiwan, through which we identified data fragmentation. Accordingly, we proposed a practical classification for RTI severity, as well as a feasible model for collecting and integrating these data nationwide. This model can provide timely relevant data recorded by medical professionals and is valuable to healthcare providers. The proposed model's pros and cons are also compared to those of other current models.

Performance of triage systems in emergency care: a systematic review and meta-analysis

OBJECTIVE

To assess and compare the performance of triage systems for identifying high and low-urgency patients in the emergency department (ED).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

EMBASE, Medline OvidSP, Cochrane central, Web of science and CINAHL databases from 1980 to 2016 with the final update in December 2018.

ELIGIBILITY CRITERIA

Studies that evaluated an emergency medical triage system, assessed validity using any reference standard as proxy for true patient urgency and were written in English. Studies conducted in low(er) income countries, based on case scenarios or involving less than 100 patients were excluded.

REVIEW METHODS

Reviewers identified studies, extracted data and assessed the quality of the evidence independently and in duplicate. The Quality Assessment of studies of Diagnostic Accuracy included in Systematic Reviews -2 checklist was used to assess risk of bias. Raw data were extracted to create 2×2 tables and calculate sensitivity and specificity. ED patient volume and casemix severity of illness were investigated as determinants of triage systems' performance.

RESULTS

Sixty-six eligible studies evaluated 33 different triage systems. Comparisons were restricted to the three triage systems that had at least multiple evaluations using the same reference standard (Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System). Overall, validity of each triage system to identify high and low-urgency patients was moderate to good, but performance was highly variable. In a subgroup analysis, no clear association was found between ED patient volume or casemix severity of illness and triage systems' performance.

CONCLUSIONS

Established triage systems show a reasonable validity for the triage of patients at the ED, but performance varies considerably. Important research questions that remain are what determinants influence triage systems' performance and how the performance of existing triage systems can be improved.

Correlation between the pre-hospital triage scale and emergency department triage scale

Background:

While emergency patient triage system is effective when the pre-hospital triage acuity scale is linked with the in-hospital triage acuity scale. However, the 119 emergency medical triage system and the Korea Triage and Acuity Scale are not linked in Korea.

Objective:

This study aimed to investigate the correlation between the two triage systems and to utilize the results as basic data for the future development of a pre-hospital triage system.

Methods:

Among the 1114 patients who visited a regional emergency medical center by a 119 ambulance from April to May 2016, we analyzed the correlation between the pre-hospital and in-hospital triage systems based on the general characteristics of the patients and their reason of hospital visit (non-trauma or trauma).

Results:

Upon reclassifying the pre-hospital and in-hospital triage systems into three levels, among the 289 patients (28.1%) in level 3 of the pre-hospital triage, 79 (27.3%) were reclassified as the highest level (Resuscitation) in the in-hospital triage. The kappa coefficient as a measure of agreement between the two triage systems was very low at 0.211 (95% confidence interval, 0.164–0.258), and the kappa coefficient of the paramedic category was 0.232 (95% confidence interval, 0.161–0.303).

Conclusion:

There is a low agreement between the pre-hospital and in-hospital triage systems.

Validity and Reliability of the Emergency Severity Index and Australasian Triage System in Pediatric Emergency Care of Mofid Children's Hospital in Iran

Objective:

To evaluate the validity, reliability, sensitivity, and specificity of the Emergency Severity Index (ESI) and Australasian Triage System (ATS) for children visiting admitted to the emergency department (ED).

Methods:

This was a prospective study occurred in the Mofid children's Hospital in Iran from August 2017 to November 2018 and children had aged ≤14 years and presented at the ED with a medical symptom were considered eligible for participation. This study was divided into two phases: in the first phase, we determined the inter-rater reliability of ESI version 4 and ATS by triage nurses and pediatric residents. In the second phase, to analyze the validity, sensitivity, and specificity of each triage system. Reliability and agreement rates were measured using kappa statistics.

Results:

ESI showed inter-rater reliability with kappa of 0.65–0.92 (P<0.001) and ATS showed inter-rater reliability with kappa of 0.51–0.87 ESI had sensitivity ranged from 81% to 95% and specificity ranged from 73% to 86%. In addition, sensitivity ranged of the ATS were 80% to 95% and specificity ranged from 74% to 87%. Under triage and over triage occurred in 12% and 15% of patients respectively in ESI and 13% and 15% of patients respectively in ATS.

Conclusion:

The ESI and ATS both valid to triage children in the ED section of Mofid children's Hospital paediatric. Reliability of the ESI is good, moderate to good for the ATS.

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.

Taiwanese medical students' narratives of intercultural professionalism dilemmas: exploring tensions between Western medicine and Taiwanese culture

In an era of globalization, cultural competence is necessary for the provision of quality healthcare. Although this topic has been well explored in non-Western cultures within Western contexts, the authors explore how Taiwanese medical students trained in Western medicine address intercultural professionalism dilemmas related to tensions between Western medicine and Taiwanese culture. A narrative interview method was employed with 64 Taiwanese medical students to collect narratives of professionalism dilemmas. Noting the prominence of culture in students' narratives, we explored this theme further using secondary analysis, identifying tensions between Western medicine and Taiwanese culture and categorizing students' intercultural professionalism dilemmas according to Friedman and Berthoin Antal's 'intercultural competence' framework: involving combinations of advocacy (i.e., championing one's own culture) and inquiry (i.e., exploring one's own and others' cultures). One or more intercultural dilemmas were identified in nearly half of students' professionalism dilemma narratives. Qualitative themes included: family relations, local policy, end-of-life care, traditional medicine, gender relations and Taiwanese language. Of the 62 narratives with sufficient detail for further analysis, the majority demonstrated the 'suboptimal' low advocacy/low inquiry approach (i.e., withdrawal or inaction), while very few demonstrated the 'ideal' high advocacy/high inquiry approach (i.e., generating mutual understanding, so 'intercultural competence'). Though nearly half of students' professionalism narratives concerned intercultural dilemmas, most narratives represented disengagement from intercultural dilemmas, highlighting a possible need for more attention on intercultural competence training in Taiwan. The advocacy/inquiry framework may help educators to address similar disconnects between Western medicine and non-Western cultures in other contexts.

Emergency severity index compared with 4-level triage at the emergency department of Ramathibodi University Hospital

Background

Emergency department (ED) triage is important for categorizing and prioritizing patients. Effective triage may assist in crowd reduction in the ED and appropriate patient management. There are several systems, including the 5-level Emergency Severity Index (ESI) and the 4-level Ramathibodi-nurse triage. Currently, there are limited data by which to compare the 5- versus 4-level triage; particularly on health outcomes, such as length of stay in the ED, mortality, and resource needs.

Objective

To compare the accuracy of 5- and 4-level triage in an ED.

Method

This observational study was conducted on a cross-section of patients in the ED at Ramathibodi Hospital of Mahidol University, Bangkok, Thailand. Eligible patients were those who visited the ED and were evaluated by ESI and nurse triage. Each evaluation was blinded to the results of the other. Discrimination performance between the 5- and 4-level triage was compared by using the area under a receiver operating characteristic (ROC) curve and concordance statistic for prediction of life saving intervention. Net reclassification improvement (NRI) of the 5-level ESI over the 4-level triage was performed.

Result

Study criteria were met by 520 patients. The areas under the ROC curves of the ESI and nurse triage on life-saving intervention were 92.2% (95% confidence intervals were 87.3%, 96.9%) and 81.3% (95% CI 75.2%, 87.3%), respectively. Areas under the ROC curve differed significantly (P < 0.001). The overall reclassification improvement was 42.4%.

Conclusion

The 5-level emergency severity index was more accurate than the 4-level triage in terms of lifesaving intervention.

Outcomes for emergency severity index triage implementation in the emergency department

INTRODUCTION

Hospital triage scale in emergency departments needs to be valid and reliable. Lack of sufficient data exists on triage scale rigor in emergency departments of Iran. This study aimed to determine the impact of the emergency severity index (ESI) triage scale in the emergency department.

MATERIALS AND METHODS

A single-center study was conducted. Proportion of triage categories allocated to high-risk patients admitted to high-acuity departments was examined in observational period in June 2012 and May 2013. True triage score was reported based on patients` paper- based scenario questionnaire. Interrater reliability was assessed using unweighted kappa. Concordance among experts, nurses and physicians was examined. The Chi-square test and Kappa statistics was used for statistical analysis.

RESULTS

Triage decisions regarding high-risk patients before and after implementation period are independent from each other (χ2= 22.254; df=1; p<0.05) and more high-risk patients were recognized after implementation of the ESI. Overall agreement and concordance were (79%) and (κ=0.54) among nurses; (71%) and (κ=0.45) among physicians, (85%) and (κ=0.81) among experts, respectively. Correct triage decisions among clinicians were increased after implementation of the ESI.

CONCLUSION

The ESI as valid and reliable tool improving desirable outcomes` in the emergency department has been recommended but it may not reveal optimal outcomes in developing countries comparing to what have been achieved in the developed countries. In addition, patient influx in ESI level II could create considerable controversy with clinicians.

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.

Definition of a prospective payment system to reimburse emergency departments

BACKGROUND

Payers are increasingly turning to Prospective Payment Systems (PPSs) because they incentivize efficiency, but their application to emergency departments (EDs) is difficult because of the high level of uncertainty and variability in the cost of treating each patient.To the best of our knowledge, our work represents the first attempt at defining a PPS for this part of hospital activity.

METHODS

Data were specifically collected for this study and relate to 1011 patients who were triaged at an ED of a major Italian hospital, during 1 week in December 2010.The cost for each patient was analytically estimated by adding up several components: 1) physician and other staff costs that were imputed on the basis of the time each physician claimed to have spent treating the patient; 2) the cost for each test/treatment each patient actually underwent; 3) overhead costs, shared among patients using the time elapsed between first examination and discharge from the ED.

RESULTS

The distribution of costs by triage code shows that, although the average cost increases across the four triage groups, the variance within each code is quite high. The maximum cost for a yellow code is €1074.7, compared with €680 for red, the most serious code. Using cluster analysis, the red code cluster is enveloped by yellow, and their costs are therefore indistinguishable, while green codes span all cost groups. This suggests that triage code alone is not a good proxy for the patient cost, and that other cost drivers need to be included.

CONCLUSIONS

Crude triage codes cannot be used to define PPSs because they are not sufficiently correlated with costs and are characterized by large variances. However, if combined with other information, such as the number of laboratory and non-laboratory tests/examinations, it is possible to define cost groups that are sufficiently homogeneous to be reimbursed prospectively. This should discourage strategic behavior and allow the ED to break even or create profits, which can be reinvested to improve services. The study provides health policy administrators with a new and feasible tool to implement prospective payment for EDs, and improve planning and cost control.

Impact of the ABCDE triage in primary care emergency department on the number of patient visits to different parts of the health care system in Espoo City

BACKGROUND

Many Finnish emergency departments (ED) serve both primary and secondary health care patients and are therefore referred to as combined emergency departments. Primary care doctors are responsible for the initial assessment and treatment. They, thereby, also regulate referral and access to secondary care. Primary health care EDs are easy for the public to access, leading to non-acute patient visits to the emergency department. This has caused increased queues and unnecessary difficulties in providing immediate treatment for urgent patients. The primary aim of this study was to assess whether the flow of patients was changed by implementing the ABCDE-triage system in the EDs of Espoo City, Finland.

METHODS

The numbers of monthly visits to doctors were recorded before and after intervention in Espoo primary care EDs. To study if the implementation of the triage system redirects patients to other health services, the numbers of monthly visits to doctors were also scored in the private health care, the public sector health services of Espoo primary care during office hours and local secondary health care ED (Jorvi hospital). A face-to-face triage system was applied in the primary care EDs as an attempt to provide immediate treatment for the most acute patients. It is based on the letters A (patient sent directly to secondary care), B (to be examined within 10 min), C (to be examined within 1 h), D (to be examined within 2 h) and E (no need for immediate treatment) for assessing the urgency of patients' treatment needs. The first step was an initial patient assessment by a health care professional (triage nurse). The introduction of this triage system was combined with information to the public on the "correct" use of emergency services.

RESULTS

After implementation of the ABCDE-triage system the number of patient visits to a primary care doctor decreased by up to 24% (962 visits/month) as compared to the three previous years in the EDs. The Number of visits to public sector GPs during office hours did not alter. Implementation of ABCDE-triage combined with public guidance was associated with decreased total number of doctor visits in public health care. During same period, the number of patient visits in the private health care increased. Simultaneously, the number of doctor visits in secondary health care ED did not alter.

CONCLUSIONS

The present ABCDE-triage system combined with public guidance may reduce patient visits to primary health care EDs but not to the secondary health care EDs. Limiting the access of less urgent patients to ED may redirect the demands of patients to private sector rather than office hours GP services.

Emergency department triage scales and their components: a systematic review of the scientific evidence

Emergency department (ED) triage is used to identify patients' level of urgency and treat them based on their triage level. The global advancement of triage scales in the past two decades has generated considerable research on the validity and reliability of these scales. This systematic review aims to investigate the scientific evidence for published ED triage scales. The following questions are addressed: 1. Does assessment of individual vital signs or chief complaints affect mortality during the hospital stay or within 30 days after arrival at the ED?2. What is the level of agreement between clinicians' triage decisions compared to each other or to a gold standard for each scale (reliability)? 3. How valid is each triage scale in predicting hospitalization and hospital mortality? A systematic search of the international literature published from 1966 through March 31, 2009 explored the British Nursing Index, Business Source Premier, CINAHL, Cochrane Library, EMBASE, and PubMed. Inclusion was limited to controlled studies of adult patients (≥ 15 years) visiting EDs for somatic reasons. Outcome variables were death in ED or hospital and need for hospitalization (validity). Methodological quality and clinical relevance of each study were rated as high, medium, or low. The results from the studies that met the inclusion criteria and quality standards were synthesized applying the internationally developed GRADE system. Each conclusion was then assessed as having strong, moderately strong, limited, or insufficient scientific evidence. If studies were not available, this was also noted.We found ED triage scales to be supported, at best, by limited and often insufficient evidence.The ability of the individual vital signs included in the different scales to predict outcome is seldom, if at all, studied in the ED setting. The scientific evidence to assess interrater agreement (reliability) was limited for one triage scale and insufficient or lacking for all other scales. Two of the scales yielded limited scientific evidence, and one scale yielded insufficient evidence, on which to assess the risk of early death or hospitalization in patients assigned to the two lowest triage levels on a 5-level scale (validity).

Modern triage in the emergency department

BACKGROUND

Because the volume of patient admissions to an emergency department (ED) cannot be precisely planned, the available resources may become overwhelmed at times ("crowding"), with resulting risks for patient safety. The aim of this study is to identify modern triage instruments and assess their validity and reliability.

METHODS

Review of selected literature retrieved by a search on the terms "emergency department" and "triage."

RESULTS

Emergency departments around the world use different triage systems to assess the severity of incoming patients' conditions and assign treatment priorities. Our study identified four such instruments: the Australasian Triage Scale (ATS), the Canadian Triage and Acuity Scale (CTAS), the Manchester Triage System (MTS), and the Emergency Severity Index (ESI). Triage instruments with 5 levels are superior to those with 3 levels in both validity and reliability (p<0.01). Good to very good reliability has been shown for the best-studied instruments, CTAS and ESI (κ-statistics: 0.7 to 0.95), while ATS and MTS have been found to be only moderately reliable (κ-statistics: 0.3 to 0.6). MTS and ESI are both available in German; of these two, only the ESI has been validated in German-speaking countries.

CONCLUSION

Five-level triage systems are valid and reliable methods for assessment of the severity of incoming patients' conditions by nursing staff in the emergency department. They should be used in German emergency departments to assign treatment priorities in a structured and dependable fashion.

"Be quick": a systems response to overcrowding in the pediatric emergency department

OBJECTIVE

The purpose of this study was to evaluate the combined effects of focused system changes on several key measures of emergency department (ED) quality (length of stay, waiting time, rate of leaving without being seen, and patient satisfaction) in a children's hospital ED.

METHODS

System-wide ED changes were made and implemented during a 6-month period. The combined changes are called "be quick"--BEQK. The components were bedside registration, the Bed-ahead program, electronic medical records and tracking board, quick triage, and Kids Express. Three study periods were evaluated: before BEQK (2005) and the 2 periods after BEQK (2006 and 2007).

RESULTS

The primary outcome measures, namely wait time, length of stay, and leaving without being seen rates, were all decreased during the 2 post-BEQK periods compared with the pre-BEQK period (2005). The mean waiting time was 46 minutes (95% confidence interval [CI], 39-53 minutes) in 2005 and this decreased to 22 minutes (95% CI, 21-23 minutes) and 14 minutes (95% CI, 13-15 minutes) in 2006 and 2007, respectively. The mean length of stay was 151 minutes (95% CI, 139-163 minutes) in 2005 and this decreased to 136 minutes (95% CI, 135-137 minutes) and 115 minutes (95% CI, 114-116 minutes) in 2006 and 2007, respectively. The rate of leaving without being seen was 2.45% of patient visits per month in 2005 and this decreased to 1.67% in 2006 and to 0.92% in 2007.

CONCLUSIONS

In our pediatric ED, focused system changes significantly decreased wait time, leaving without being seen, and length of stay and improved patient satisfaction.