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

Reliability and Accuracy of the Pediatric Swiss Emergency Triage Scale-the SETSped Study

BACKGROUND AND IMPORTANCE

The Swiss Emergency Triage Scale (SETS) is an adult triage tool used in several emergency departments. It has been recently adapted to the pediatric population but, before advocating for its use, performance assessment of this tool is needed.

OBJECTIVES

The purpose of this study was to assess the reliability and the accuracy of the pediatric version of the SETS for the triage of pediatric patients.

DESIGN, SETTING, AND PARTICIPANTS

This study was a cross-sectional study among a sample of emergency triage nurses (ETNs) exposed to 17 clinical scenarios using a computerized simulator.

OUTCOME MEASURES AND ANALYSIS

The primary outcome was the reliability of the triage level performed by the ETNs. It was assessed using an intraclass correlation coefficient.Secondary outcomes included accuracy of triage compared with expert-based triage levels and factors associated with accurate triage.

MAIN RESULTS

Eighteen ETNs participated in the study and completed the evaluation of all scenarios, for a total of 306 triage decisions. The intraclass correlation coefficient was 0.80 (95% confidence interval, 0.69-0.91), with an agreement by scenario ranging from 61.1% to 100%. The overall accuracy was 85.8%, and nurses were more likely to undertriage (16.0%) than to overtriage (4.3%). No factor for accurate triage was identified.

CONCLUSIONS

This simulator-based study showed that the SETS is reliable and accurate among a pediatric population. Future research is needed to confirm these results, compare this triage scale head-to-head with other recognized international tools, and study the SETSped in real-life setting.

Evaluation of the Validity and Reliability of ANKUTRIAGE, a New Decision Support System in Pediatric Emergency Triage

BACKGROUND

The intensity of emergency services is an increasing health problem all over the world, necessitating an effective triage system. The aim of this study was to evaluate the validity and reliability of the "ANKUTRIAGE" in children.

METHODS

This prospective, longitudinal study was carried out at a pediatric emergency department. ANKUTRIAGE, a 5-level computer-aided triage decision support system, was developed. Patients younger than 18 years who do not need emergency intervention, who had complete vital sign measurements, who gave consent for the study, and who were admitted to the emergency service during working hours with trained personnel were included. For validity, agreement between the urgency levels determined by ANKUTRIAGE and the reference triage systems: Pediatric Canadian Triage and Acuity Scale and Emergency Severity Index, was evaluated. In addition, the association of urgency levels with clinical outcomes was studied. To assess reliability, patients were evaluated by 2 blinded healthcare professionals using ANKUTRIAGE and a quadratic weighted κ was estimated.

RESULTS

A total of 1232 children with a median age of 4.00 years were included. ANKUTRIAGE acuity levels significantly correlated with the number of resources used, the number of patients undergoing life-saving procedures, pediatric intensive care unit, and overall hospitalization rates, respectively ( P < 0.001, P < 0.001, P < 0.001, P < 0.001). The agreement of ANKUTRIAGE with Pediatric Canadian Triage and Acuity Scale was found to be 0.94 (95% confidence interval [CI], 0.93-0.94), with an Emergency Severity Index of 0.75 (95% CI, 0.70-0.80). The interrater agreement between 2 evaluators who used ANKUTRIAGE reflected as excellent consistency 0.92 (95% CI, 0.89-0.95; κ > 0.8).

CONCLUSIONS

ANKUTRIAGE demonstrated high agreement with clinical outcomes and with proven triage systems and reflected high reliability between users. ANKUTRIAGE will enable a more standardized and practical triage, especially in crowded pediatric emergency departments and in situations where triage is performed by health professionals with different experience and professions.

Cannabis-related emergency department visits by youths and their outcomes in Ontario: a trend analysis

BACKGROUND

Cannabis-related emergency department visits can be an entry point for youths to mental health and substance use care systems. We aimed to examine trends in cannabis-related emergency department visits as a function of youths' age and sex.

METHODS

Using administrative data, we examined all visits to emergency departments in Ontario, Canada, from 2003 to 2017, by youth aged 10-24 years (grouped as 10-13, 14-18 and 19-24 yr) to determine trends in cannabis-related emergency department visits. Cannabis-related visits were identified using International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes for cannabis poisoning and mental disorders due to cannabinoids. We categorized presentations as "less severe" versus "more severe" using scores assigned by nurses at triage.

RESULTS

We examined 14 697 778 emergency department visits. Cannabis-related visits increased from 3.8 per 10 000 youths (95% confidence interval [CI] 3.5-4.0) in 2003 to 17.9 (95% CI 17.4-18.4) in 2017, a 4.8-fold increase (95% CI 4.4-5.1). Rates increased for both sexes and each age group. Males were more likely to have a visit than females (rate ratios ≥ 1.5 in 2003 and 2017). The number of cannabis-related visits in 2017 was 25.0 per 10 000 (95% CI 24.0-25.9) among youth aged 19-24 years, 21.9 per 10 000 (95% CI 20.9-22.9) among those aged 14-18 years, and 0.8 per 10 000 (95% CI 0.5-1.0) among those aged 10-13 years. In 2017, 88.2% (95% CI 87.3%-89.0%) of cannabis-related visits and 58.1% (95% CI 58.0%-58.2%) of non-cannabis-related visits were triaged as "more severe," (rate ratio 1.52, 95% CI 1.50-1.53). Similarly, in 2017, 19.0% (95% CI 18.0%-20.1%) of cannabis-related visits and 5.8% (95% CI 5.7%-5.8%) of non-cannabis-related visits resulted in hospital admission (rate ratio 3.3, 95% CI 3.1-3.5).

INTERPRETATION

Rates of cannabis-related emergency department visit by youths aged 10-24 years increased almost fivefold from 2003 to 2017, with increases in visit severity and hospital admissions. These trends describe an emerging public health problem, and research is needed to identify the causes of this increase and the health and social consequences of cannabis-related visits for these youths.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

VALIDADE E CONFIABILIDADE DE UM NOVO SISTEMA DE CLASSIFICAÇÃO DE RISCO PARA EMERGÊNCIAS PEDIÁTRICAS: CLARIPED

Objective:

To assess the validity and reliability of a triage system for pediatric emergency care (CLARIPED) developed in Brazil.

Methods:

Validity phase: prospective observational study with children aged 0 to 15 years who consecutively visited the pediatric emergency department (ED) of a tertiary hospital from July 2 to 18, 2013. We evaluated the association of urgency levels with clinical outcomes (resource utilization, ED admission rate, hospitalization rate, and ED length of stay); and compared the CLARIPED performance to a reference standard. Inter-rater reliability phase: a convenience sample of patients who visited the pediatric ED between April and July 2013 was consecutively and independently double triaged by two nurses, and the quadratic weighted kappa was estimated.

Results:

In the validity phase, the distribution of urgency levels in 1,416 visits was the following: 0.0% red (emergency); 5.9% orange (high urgency); 40.5% yellow (urgency); 50.6% green (low urgency); and 3.0% blue (no urgency). The percentage of patients who used two or more resources decreased from the orange level to the yellow, green, and blue levels (81%, 49%, 22%, and 2%, respectively, p<0.0001), as did the ED admission rate, ED length of stay, and hospitalization rate. The sensitivity to identify patients with high urgency level was 0.89 (confidence interval of 95% [95%CI] 0.78-0.95), and the undertriage rate was 7.4%. The inter-rater reliability in 191patients classified by two nurses was substantial (kw²=0.75; 95%CI 0.74-0.79).

Conclusions:

The CLARIPED system showed good validity and substantial reliability for triage in a pediatric emergency department.

Remote Presence Robotic Technology Reduces Need for Pediatric Interfacility Transportation from an Isolated Northern Community

BACKGROUND

Providing acutely ill children in isolated communities access to specialized care is challenging. This study aimed to evaluate remote presence robotic technology (RPRT) for enhancing pediatric remote assessments, expediting initiation of treatment, refining triaging, and reducing the need for transport.

METHODS

We conducted a pilot prospective observational study at a primary/urgent care clinic in an isolated northern community. Participants (n = 38) were acutely ill children <17 years presenting to the clinic, whom local healthcare professionals had considered for interfacility transportation (IFT). Participants were assessed and managed by a tertiary center pediatric intensivist through a remote presence robot. The intensivist triaged participants to either remain at the clinic or be transported to regional/tertiary care. Controls from a pre-existing local transport database were matched using propensity scoring. The primary outcome was the number of IFTs among participants versus controls.

RESULTS

Fourteen of 38 (37%) participants required transport, whereas all controls were transported (p < 0.0001). Six of 14 (43%) transported participants were triaged to a nearby regional hospital, while no controls were regionalized (p = 0.0001). All participants who remained at the clinic stayed <24 h, and were matched to controls who stayed 4.9 days in tertiary care (p < 0.001). There was no statistically significant difference in hospital length of stay between transported participants and controls (6.0 vs. 5.7 days).

CONCLUSIONS

RPRT reduced the need for specialized pediatric IFT, while enabling regionalization when appropriate. This study may have implications for the broader implementation of RPRT, while reducing costs to the healthcare system.

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.

The Reliability of the Canadian Triage and Acuity Scale: Meta-analysis

Background:

Although the Canadian Triage and Acuity Scale (CTAS) have been developed since two decades ago, the reliability of the CTAS has not been questioned comparing to moderating variable.

Aims:

The study was to provide a meta-analytic review of the reliability of the CTAS in order to reveal to what extent the CTAS is reliable.

Materials and Methods:

Electronic databases were searched to March 2014. Only studies were included that had reported samples size, reliability coefficients, adequate description of the CTAS reliability assessment. The guidelines for reporting reliability and agreement studies (GRRAS) were used. Two reviewers independently examined abstracts and extracted data. The effect size was obtained by the z-transformation of reliability coefficients. Data were pooled with random-effects models and meta-regression was done based on method of moments estimator.

Results:

Fourteen studies were included. Pooled coefficient for the CTAS was substantial 0.672 (CI 95%: 0.599-0.735). Mistriage is less than 50%. Agreement upon the adult version, among nurse-physician and near countries is higher than pediatrics version, other raters and farther countries, respectively.

Conclusion:

The CTAS showed acceptable level of overall reliability in the emergency department but need more development to reach almost perfect agreement.

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&lt; 0.001). There was also a good correlation between triage levels and LOS and admission to PICU (bothp&lt; 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.

Best practices for improving flow and care of pediatric patients in the emergency department

This report provides a summary of best practices for improving flow, reducing waiting times, and improving the quality of care of pediatric patients in the emergency department.

Need for intervention in families presenting to the emergency department with multiple children as patients

Introduction:

To assess if families presenting to a pediatric emergency department (PED) with multiple children as patients require interventions at the same rate as families presenting with a single child.

Methods:

This is a retrospective chart review looking at PED encounters for families presenting with single children versus multiple children as patients. Patients presenting with siblings were retrospectively selected from the electronic tracking board, and we randomly selected age/gender matched single-patient controls from a comparable time period. The primary outcome was a comparison of visit acuity between families presenting with single versus multiple children, with the hypothesis that families presenting with multiple children as patients would require less utilization of services (as a surrogate for acuity). Admission, intravenous fluid administration (IVF), planned observation, subspecialty consultation, performance of procedures, laboratories and radiographs, administration of prescription medications, and prescription medications for home were all recorded and compared via chi-squared comparison. We considered 5 interventions (admission, subspecialty consultation, performance of procedures, IVF administration, and observation > 6 hours) “critical interventions” and compared them separately.

Results:

In our sample of 83 patients from 41 families registering multiple children and 248 singleton controls, we found a significant difference in the percentage of patients requiring critical interventions (4.8% versus 32.5%, P < 0.0001).

Conclusion:

Families presenting with multiple children concurrently to an ED require critical interventions at a much lower rate than children presenting as single patients. Many of these families could be well-served at an urgent care or primary care provider.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Pediatric surgery triage: problems and improvements

BACKGROUND

The Canadian Paediatric Triage and Acuity Scale (P-CTAS) is used and modified at hospitals as a triage tool for pediatric patients before they are seen in emergency rooms. Pediatric surgery patients account for very few of the many patients in emergency departments, but they should be triaged as emergency or urgent because they might be candidates for surgery. Problems with and improvements for triaging pediatric surgery patients using the P-CTAS were studied.

METHODS

This retrospective study evaluated all patients <16 years old who visited the emergency department of Kyorin University Hospital during an approximately 4 year period between 1 May 2005, and 11 February 2009. Pediatric surgery patients were divided into two groups to evaluate the efficiency of P-CTAS triage. Patients who needed emergency treatment were in group A, and the others were in group B.

RESULTS

Most group A patients were level I, II, or III (97%, 111/114). In contrast, 60% (71/119) of group B patients were level IV or greater. Some problems with and suggestions for the P-CTAS were identified. Many patients with trauma were under 1 year of age, and many with a foreign body were under 2 years of age. Age categories should be added for patients with trauma or foreign body aspiration. Patients with abdominal pain, and without anal bleeding or vomiting who are >2 years old are triaged as level IV and they accounted for 12% of patients with possible intussusception in this study. A category of 'possible intussusception' should be made for level II. Most patients with acute scrotum, whether operated on or not, were level III. 'Red or purple color of scrotal skin' and/or 'within 6 h from onset' could be added to level II for patients with acute scrotum.

CONCLUSIONS

P-CTAS worked well for pediatric surgery patients, and it needs to be modified and improved for such patients based on these results.

Adherence to the guideline 'Triage in emergency departments': a survey of Dutch emergency departments

AIMS AND OBJECTIVES

The aim of this study was to evaluate the adherence to the 2004 guideline Triage in emergency departments three years after dissemination in Dutch emergency departments.

BACKGROUND

In 2004, a Dutch guideline Triage in emergency departments was developed. Triage is the first step performed by nurses when a patient arrives at an emergency department. It includes the prioritisation of patients to ensure that doctors see patients with the highest medical needs first. Although the national guideline was developed and disseminated in 2004, three years on there was no insight into the level of implementation of the guideline in practice.

DESIGN

A cross-sectional descriptive design.

METHODS

In February 2007, data were collected from ward managers and triage nurses at all emergency departments in the Netherlands (n = 108), using a questionnaire that was based on the recommendations and performance indicators of the guideline.

RESULTS

In total, 79% of all 108 Dutch emergency departments responded. The main findings showed that over 31% of the emergency departments did not use a triage system. Emergency departments using the Manchester Triage System had a mean adherence rate of 61% of the guideline's recommendations and emergency departments using the Emergency System Index adhered to a mean of 65%.

CONCLUSION

The guideline Triage in emergency departments was disseminated in 2004, but results from this study indicate that an improvement in adherence to this guideline is required.

RELEVANCE TO CLINICAL PRACTICE

Adherence to guidelines is important to standardise practice to ensure that patients receive the appropriate treatment and to improve quality of care.

Exploring differences in the clinical management of pediatric mental health in the emergency department

OBJECTIVE

: We examine psychiatric and pediatric clinical management of pediatric mental health in the emergency department (ED).

METHODS

: We conducted a retrospective review of health care delivery with a random sample of all pediatric mental health presentations (≤18 years) to 2 urban tertiary care EDs between 2004 and 2006 (N = 580).

RESULTS

: The EDs differed significantly in services offered. General emergency medicine-trained physicians provided care at 1 site (54.6%) with a number of visits also managed by a psychiatric crisis team (45.4%). Care at the other ED was delivered by pediatric emergency medicine-trained physicians (99.4%) with no regular on-site psychiatric services. The most common assessment provided across sites and all presentations was for suicidality (66.2%). After controlling for potential confounders, receipt of clinical assessment for homicidality, mood, or reality testing differed between EDs (P = 0.044, P = 0.006, and P = 0.002) with more assessments documented at the psychiatric-resourced ED. Brief counseling was lacking for visits (absence of documentation: 56.1% pediatric-resourced, 23.1% psychiatric-resourced ED); there was no evidence of site differences in provision. More psychiatric consultation was provided at the psychiatric-resourced ED (34.1% vs 27.4%, P = 0.030). Discharge recommendations were lacking in both EDs but were more incomplete for pediatric-resourced ED visits (P = 0.035).

CONCLUSIONS

: Consistent and comprehensive clinical management of pediatric mental health presentations was lacking in EDs that had pediatric and psychiatric resources. Prospective evaluations are needed to determine the effect of current clinical ED practices on patient and family outcomes, including symptom reduction and stress, as well as subsequent system use.

Telephone triage by nurses in primary care out-of-hours services in Norway: an evaluation study based on written case scenarios

Background

The use of nurses for telephone-based triage in out-of-hours services is increasing in several countries. No investigations have been carried out in Norway into the quality of decisions made by nurses regarding our priority degree system. There are three levels: acute, urgent and non-urgent.

Methods

Nurses working in seven casualty clinics in out-of-hours districts in Norway (The Watchtowers) were all invited to participate in a study to assess priority grade on 20 written medical scenarios validated by an expert group. 83 nurses (response rate 76%) participated in the study. A one-out-of-five sample of the nurses assessed the same written cases after 3 months (n=18, response rate 90%) as a test–retest assessment.

Results

Among the acute, urgent and non-urgent scenarios, 82%, 74% and 81% were correctly classified according to national guidelines. There were significant differences in the proportion of correct classifications among the casualty clinics, but neither employment percentage nor profession or work experience affected the triage decision. The mean intraobserver variability measured by the Cohen kappa was 0.61 (CI 0.52 to 0.70), and there were significant differences in kappa with employment percentage. Casualty clinics and work experience did not affect intrarater agreement.

Conclusion

Correct classification of acute and non-urgent cases among nurses was quite high. Work experience and employment percentage did not affect triage decision. The intrarater agreement was good and about the same as in previous studies performed in other countries. Kappa increased significantly with increasing employment percentage.

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.

An observational study of patients triaged in category 5 of the Emergency Severity Index

OBJECTIVE

Patients triaged in category 5 of the Emergency Severity Index (ESI) do not need any resources before discharge from the emergency department (ED). We studied the characteristics of these patients and focused on those who were admitted or sent to the outpatient department after their ED visit.

METHODS

A retrospective observational study was conducted on 117 740 patient presentations. Patients were included in the study when they were triaged with the ESI and presented to one of the two EDs under study between 1 September 2004 and 1 June 2006.

RESULTS

Overall, 22.2% of the patients were triaged in ESI 5. Patients aged less than 40 years, women, and self-referred patients were most likely triaged in ESI 5, as well as patients presenting with complaints such as 'checkup appointments at the ED' and 'complaints of the skin'. Patients triaged in ESI 5 who were admitted or sent to the outpatient department were most likely elderly (aged above 65 years) and referred patients. They were also more likely to present with complaints such as 'postoperative complications, wound care problems, and plaster problems' and 'complaints of the genitourinary system'.

CONCLUSION

Although younger patients and women were more likely triaged in ESI 5, patients within this category who were admitted or sent to the outpatient department were more likely elderly and referred patients. Being admitted or sent to the outpatient department and triaged in ESI 5 indicates undertriage. Revision of the system is required to properly account for these patient groups.

Calculating kappas from adjusted data improved the comparability of the reliability of triage systems: a comparative study

OBJECTIVES

It is difficult to compare the reliability of triage systems with the kappa statistic. In this article, a method for comparing triage systems was developed and applied to previously conducted triage reliability studies.

STUDY DESIGN AND SETTING

From simulations with theoretical distributions, the minimum, normal, and maximum weighted kappa for 3- to 5-level triage systems were computed. To compare the reliability of triage systems in previously conducted triage reliability studies, the normal kappa was calculated. Furthermore, the reported quadratically weighted kappas were compared with the minimum, normal, and maximum weighted kappa to characterize the degree and direction of skewness of the data.

RESULTS

The normal kappa was higher in 3-level triage systems (median: κ=0.84) compared with 4-level (median: κ=0.37) and 5-level (median: κ=0.57) systems. In 3-level triage systems, the percentages observed agreement were unequally distributed, which resulted in small quadratically weighted kappas. In 4- and 5-level systems, the percentages observed agreement were more equally distributed compared with 3-level systems, which resulted in higher quadratically weighted kappa values.

CONCLUSION

When comparing triage systems with different numbers of categories, one should report both the normal and quadratically weighted kappa. Calculating normal kappas from previously conducted triage reliability studies revealed substantial theoretical differences in interrater reliability of triage systems than previously reported.

Reliability and validity of triage systems in paediatric emergency care

BACKGROUND

Triage in paediatric emergency care is an important tool to prioritize seriously ill children. Triage can also be used to identify patients who do not need urgent care and who can safely wait. The aim of this review was to provide an overview of the literature on reliability and validity of current triage systems in paediatric emergency care

METHODS

We performed a search in Pubmed and Cochrane on studies on reliability and validity of triage systems in children

RESULTS

The Manchester Triage System (MTS), the Emergency Severity Index (ESI), the Paediatric Canadian Triage and Acuity Score (paedCTAS) and the Australasian Triage Scale (ATS) are common used triage systems and contain specific parts for children. The reliability of the MTS is good and reliability of the ESI is moderate to good. Reliability of the paedCTAS is moderate and is poor to moderate for the ATS.The internal validity is moderate for the MTS and confirmed for the CTAS, but not studied for the most recent version of the ESI, which contains specific fever criteria for children.

CONCLUSION

The MTS and paedCTAS both seem valid to triage children in paediatric emergency care. Reliability of the MTS is good, moderate to good for the ESI and moderate for the paedCTAS. More studies are necessary to evaluate if one triage system is superior over other systems when applied in emergency care.

Interrater agreement between nurses for the Pediatric Canadian Triage and Acuity Scale in a tertiary care center

OBJECTIVES

The objective was to measure the interrater agreement between nurses assigning triage levels to children visiting a pediatric emergency departments (EDs) assisted by a computerized version of the Pediatric Canadian Triage and Acuity Scale (PedCTAS).

METHODS

This was a prospective cohort study evaluating children triaged from Level 2 (emergent) to Level 5 (nonurgent). A convenience sample of patients triaged during 38 shifts from April to September 2007 in a tertiary care pediatric ED was evaluated. All patients were initially triaged by regular triage nurses using a computerized version of the PedCTAS. Research nurses performed a second evaluation blinded to the first evaluation using the same triage tool. These research nurses were regular ED nurses performing extra hours for research purposes exclusively. The primary outcome measure was the interrater agreement between the two nurses as measured by the linear weighted kappa score. Secondary outcomes included the proportion of patient for which nurses did not apply the triage level suggested by Staturg (override) and agreement for these overrides.

RESULTS

A total of 499 patients were recruited. The overall interrater agreement was moderate (linear weighted kappa score of 0.55 [95% confidence interval {CI} = 0.48 to 0.61] and quadratic weighted kappa score of 0.61 [95% CI = 0.42 to 0.80]). There was a discrepancy of more than one level in only 10 patients (2% of the study population). Overrides occurred in 23.2 and 21.8% for regular and research triage nurses, respectively. These overrides were equally distributed between increase and decrease in triage level.

CONCLUSIONS

Nurses using Staturg, which is a computerized version of the PedCTAS, demonstrated moderate interrater agreement for assignment of triage level to children presenting to a pediatric ED.

Professional judgment and the interpretation of viable mold air sampling data

Although mold air sampling is technically straightforward, interpreting the results to decide if there is an indoor source is not. Applying formal statistical tests to mold sampling data is an error-prone practice due to the extreme data variability. With neither established exposure limits nor useful statistical techniques, indoor air quality investigators often must rely on their professional judgment, but the lack of a consensus "decision strategy" incorporating explicit decision criteria requires professionals to establish their own personal set of criteria when interpreting air sampling data. This study examined the level of agreement among indoor air quality practitioners in their evaluation of airborne mold sampling data and explored differences in inter-evaluator assessments. Eighteen investigators independently judged 30 sets of viable mold air sampling results to indicate: "definite indoor mold source," "likely indoor mold source," "not enough information to decide," "likely no indoor mold source," or "definitely no indoor mold source." Kappa coefficient analysis indicated weak inter-observer reliability, and comparison of evaluator mean scores showed clear inter-evaluator differences in their overall scoring patterns. The responses were modeled on indicator "traits" of the data sets using a generalized, linear mixed model approach and showed several traits to be associated with respondents' ratings, but they also demonstrated distinct and divergent inter-evaluator response patterns. Conclusions were that there was only weak overall agreement in evaluation of the mold sampling data, that particular traits of the data were associated with the conclusions reached, and that there were substantial inter-evaluator differences that were likely due to differences in the personal decision criteria employed by the individual evaluators. The overall conclusion was that there is a need for additional work to rigorously explore the constellation of decision criteria, the weightings employed by individual practitioners, and the rationale under which criteria are adopted as first steps toward the larger goal of developing a consensus mold decision strategy.

Manchester triage system in paediatric emergency care: prospective observational study

OBJECTIVE

To validate use of the Manchester triage system in paediatric emergency care.

DESIGN

Prospective observational study.

SETTING

Emergency departments of a university hospital and a teaching hospital in the Netherlands, 2006-7.

PARTICIPANTS

17,600 children (aged <16) visiting an emergency department over 13 months (university hospital) and seven months (teaching hospital).

INTERVENTION

Nurses triaged 16,735/17,600 patients (95%) using a computerised Manchester triage system, which calculated urgency levels from the selection of discriminators embedded in flowcharts for presenting problems. Nurses over-ruled the urgency level in 1714 (10%) children, who were excluded from analysis. Complete data for the reference standard were unavailable in 1467 (9%) children leaving 13,554 patients for analysis.

MAIN OUTCOME MEASURES

Urgency according to the Manchester triage system compared with a predefined and independently assessed reference standard for five urgency levels. This reference standard was based on a combination of vital signs at presentation, potentially life threatening conditions, diagnostic resources, therapeutic interventions, and follow-up. Sensitivity, specificity, and likelihood ratios for high urgency (immediate and very urgent) and 95% confidence intervals for subgroups based on age, use of flowcharts, and discriminators.

RESULTS

The Manchester urgency level agreed with the reference standard in 4582 of 13,554 (34%) children; 7311 (54%) were over-triaged and 1661 (12%) under-triaged. The likelihood ratio was 3.0 (95% confidence interval 2.8 to 3.2) for high urgency and 0.5 (0.4 to 0.5) for low urgency; though the likelihood ratios were lower for those presenting with a medical problem (2.3 (2.2 to 2.5) v 12.0 (7.8 to 18.0) for trauma) and in younger children (2.4 (1.9 to 2.9) at 0-2 months [corrected] v 5.4 (4.5 to 6.5) at 8-16 years).

CONCLUSIONS

The Manchester triage system has moderate validity in paediatric emergency care. It errs on the safe side, with much more over-triage than under-triage compared with an independent reference standard for urgency. Triage of patients with a medical problem or in younger children is particularly difficult.

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.