Critical appraisal of papers describing triage systems

Liquid biopsies: the future of cancer early detection

Cancer is a worldwide pandemic. The burden it imposes grows steadily on a global scale causing emotional, physical, and financial strains on individuals, families, and health care systems. Despite being the second leading cause of death worldwide, many cancers do not have screening programs and many people with a high risk of developing cancer fail to follow the advised medical screening regime due to the nature of the available screening tests and other challenges with compliance. Moreover, many liquid biopsy strategies being developed for early detection of cancer lack the sensitivity required to detect early-stage cancers. Early detection is key for improved quality of life, survival, and to reduce the financial burden of cancer treatments which are greater at later stage detection. This review examines the current liquid biopsy market, focusing in particular on the strengths and drawbacks of techniques in achieving early cancer detection. We explore the clinical utility of liquid biopsy technologies for the earlier detection of solid cancers, with a focus on how a combination of various spectroscopic and -omic methodologies may pave the way for more efficient cancer diagnostics.

Reliability of Korean Triage and Acuity Scale: Interrater Agreement between Two Experienced Nurses by Real-Time Triage and Analysis of Influencing Factors to Disagreement of Triage Levels

BACKGROUND

All emergency centers in Korea use the Korean Triage and Acuity Scale (KTAS) as their initial triage tool. However, KTAS has been used without verification of its reliability. In this study, we assess the interrater agreement of KTAS by two independent nurses in real-time and analyse the factors which have an effect on the disagreement of KTAS levels.

METHODS

This study was a prospective observational study conducted with patients who visited an emergency department (ED). Two teams, each composed of two nurses, triaged patients and recorded KTAS level and the main complaint from the list of 167 KTAS complaints, as well as modifiers. Interrater reliability between the two nurses in each team was assessed by weighted-kappa. Pearson's χ² test was conducted to determine if there were differences between each nurse's KTAS levels, depending on whether they chose the same complaints and the same modifiers or not.

RESULTS

The two teams triaged a total of 1,998 patients who visited the ED. Weighted-kappa value was 0.772 (95% confidence interval [CI], 0.750-0.794). Patients triaged by different chosen complaints showed (38.0%) higher inconsistency rate in KTAS levels than those triaged by the same complaint (10.9%, P < 0.001). When nurses chose the same complaint and different modifiers, the ratio of different levels (50.5%) was higher than that of the same complaint and same modifier (8.1%, P < 0.001).

CONCLUSION

This study showed that KTAS is a reliable tool. Selected complaints and modifiers are confirmed as important factors for reliability; therefore, selecting them properly should be emphasized during KTAS training courses.

The Copenhagen Triage Algorithm is non-inferior to a traditional triage algorithm: A cluster-randomized study

Introduction

Triage systems with limited room for clinical judgment are used by emergency departments (EDs) worldwide. The Copenhagen Triage Algorithm (CTA) is a simplified triage system with a clinical assessment.

Methods

The trial was a non-inferiority, two-center cluster-randomized crossover study where CTA was compared to a local adaptation of Adaptive Process Triage (ADAPT). CTA involves initial categorization based on vital signs with a final modification based on clinical assessment by an ED nurse. We used 30-day mortality with a non-inferiority margin at 0.5%. Predictive performance was compared using Receiver Operator Characteristics.

Results

We included 45,347 patient visits, 23,158 (51%) and 22,189 (49%) were triaged with CTA and ADAPT respectively with a 30-day mortality of 3.42% and 3.43% (P = 0.996) a difference of 0.01% (95% CI: -0.34 to 0.33), which met the non-inferiority criteria. Mortality at 48 hours was 0.62% vs. 0.71%, (P = 0.26) and 6.38% vs. 6.61%, (P = 0.32) at 90 days for CTA and ADAPT. CTA triaged at significantly lower urgency level (P<0.001) and was superior in predicting 30-day mortality, Area under the curve: 0.67 (95% CI 0.65–0.69) compared to 0.64 for ADAPT (95% CI 0.62–0.66) (P = 0.03). There were no significant differences in rate of admission to the intensive care unit, length of stay, waiting time nor rate of readmission within 30 or 90 days.

Conclusion

A novel triage system based on vital signs and a clinical assessment by an ED nurse was non-inferior to a traditional triage algorithm by short term mortality, and superior in predicting 30-day mortality.

Trial registration

Clinicaltrials.gov NCT02698319

The danish regions pediatric triage model has a limited ability to detect both critically ill children as well as children to be sent home without treatment - a study of diagnostic accuracy

Background

The Danish Regions Pediatric Triage model (DRPT) was introduced in 2012 and subsequent implemented in most Danish acute pediatric departments. The aim was to evaluate the validity of DRPT as a screening tool to detect both the most serious acute conditions and the non-serious conditions in the acute referred patients in a pediatric department.

Method

The study was prospective observational, with follow-up on all children with acute referral to pediatric department from October to December 2015. The DRPT was evaluated by comparison to a predefined reference standard and to the actual clinical outcomes: critically ill children and children returned to home without any treatment. The sensitivity, specificity, positive predictive value, negative predictive value, accuracy and likelihood for positive and negative test were calculated.

Results

Five hundred fifty children were included. The DRPT categorized 7% very urgent, 28% urgent, 29% standard and 36% non-urgent. The DRPT was equal to the reference standard in 31% of the children (CI: 27-35%). DRPT undertriaged 55% of the children (CI: 51-59%) and overtriaged 14% of the children (CI: 11-17%). For the most urgent patients the sensitivity of DRPT was 31% (CI: 20-48%) compared to the reference standard and 20% (CI: 7-41) for critically ill. For children with non-urgent conditions the specificity of DRPT was 66% (CI: 62-71%) compared to the reference standard and 68% (CI: 62-75%) for the children who went home with no treatment. In none of the analyses, the likelihood ratio of the negative test was less than 0.7 and the positive likelihood ratio only reached more than 5 in one of the analyses.

Discussion

This study is the first to evaluate the DRPT triage system. From the very limited validity studies of other well-established triage systems, it is difficult to judge whether the DRPT performs better or worse than the alternatives. The DRPT errs to the undertriage side. If the sensitivity is low, a number of the sickest children are undetected and this is a matter of concern.

Conclusion

The DRPT is a triage tool with limited ability to detect the critically ill children as well as the children who can be returned to home without any treatment.

Trial registration

Not relevant

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-017-0397-6) contains supplementary material, which is available to authorized users.

The Copenhagen Triage Algorithm: a randomized controlled trial

BACKGROUND

Crowding in the emergency department (ED) is a well-known problem resulting in an increased risk of adverse outcomes. Effective triage might counteract this problem by identifying the sickest patients and ensuring early treatment. In the last two decades, systematic triage has become the standard in ED's worldwide. However, triage models are also time consuming, supported by limited evidence and could potentially be of more harm than benefit. The aim of this study is to develop a quicker triage model using data from a large cohort of unselected ED patients and evaluate if this new model is non-inferior to an existing triage model in a prospective randomized trial.

METHODS

The Copenhagen Triage Algorithm (CTA) study is a prospective two-center, cluster-randomized, cross-over, non-inferiority trial comparing CTA to the Danish Emergency Process Triage (DEPT). We include patients ≥16 years (n = 50.000) admitted to the ED in two large acute hospitals. Centers are randomly assigned to perform either CTA or DEPT triage first and then use the other triage model in the last time period. The CTA stratifies patients into 5 acuity levels in two steps. First, a scoring chart based on vital values is used to classify patients in an immediate category. Second, a clinical assessment by the ED nurse can alter the result suggested by the score up to two categories up or one down. The primary end-point is 30-day mortality and secondary end-points are length of stay, time to treatment, admission to intensive care unit, and readmission within 30 days.

DISCUSSION

If proven non-inferior to standard DEPT triage, CTA will be a faster and simpler triage model that is still able to detect the critically ill. Simplifying triage will lessen the burden for the ED staff and possibly allow faster treatment.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT02698319 , registered 24. of February 2016, retrospectively registered.

Inter-observer agreement using the Canadian Emergency Department Triage and Acuity Scale

Objective:

To determine the inter-observer agreement on triage assignment by first-time users with diverse training and background using the Canadian Emergency Department Triage and Acuity Scale (CTAS).

Methods:

Twenty emergency care providers (5 physicians, 5 nurses, 5 Basic Life Support paramedics and 5 Advanced Life Support paramedics) at a large urban teaching hospital participated in the study. Observers used the 5-level CTAS to independently assign triage levels for 42 case scenarios abstracted from actual emergency department patient presentations. Case scenarios consisted of vital signs, mode of arrival, presenting complaint and verbatim triage nursing notes. Participants were not given any specific training on the scale, although a detailed one-page summary was included with each questionnaire. Kappa values with quadratic weights were used to measure agreement for the study group as a whole and for each profession.

Results:

For the 41 case scenarios analyzed, the overall agreement was significant (quadratic-weighted κ = 0.77, 95% confidence interval, 0.76–0.78). For all observers, modal agreement within one triage level was 94.9%. Exact modal agreement was 63.4%. Agreement varied by triage level and was highest for Level I (most urgent). A reasonably high level of intra- and inter-professional agreement was also seen.

Conclusions:

Despite minimal experience with the CTAS, inter-observer agreement among emergency care providers with different backgrounds was significant.

Analysis of emergency medical services triage and dispatch errors by registered nurses in Italy

INTRODUCTION

The major elements of an effective emergency medical services (EMS) system include a single telephone access number, accurate assessment of the urgency of the health problem, and timely dispatch of appropriate personnel and equipment. In Italy, EMS calls are managed by emergency operations centers by registered nurses who have received specialized education in this function. The nurses determine the criticality of the situations and assign an EMS response priority level identified by a color code, ranging from red (very critical) to green (not critical). At times, the severity of a situation may be underestimated, resulting in assignment of a lower EMS response priority and the potential for patient death (code black). The purpose of this study was to analyze factors associated with registered nurse under-triage of EMS calls subsequently found to be associated with deaths, termed "green-black code" cases.

METHODS

We carried out a retrospective qualitative analysis of EMS telephone conversations using Fele's conversation analysis method. The characteristics of green-black code calls were compared with the characteristics of the population of all EMS calls during the study period.

RESULTS

The study patients were older, with a mean age of 81.6 years. The callers were individuals calling on behalf of the patients, rather than the patients themselves. The callers reported symptoms that were not life-threatening. Nurse operators did not always inquire about the patients' vital signs as required by the Medical Priority Dispatch System protocol. The phone conversations were shorter than normal (54.26 seconds vs 65 seconds).

DISCUSSION

Although the importance of dispatch system protocols is wellknown, it is also important that nurse triage operators have proper training to ensure that major parameters such as vital signs and symptomatology are obtained and to reduce caller stress level.

Is Overtriage Associated With Increased Mortality? Insights From a Simulation Model of Mass Casualty Trauma Care

Purpose: To examine the relationship between overtriage and critical mortality after a mass casualty incident (MCI) using a simulation model of trauma system response.

Methods: We created a discrete event simulation model of trauma system management of MCIs involving individual patient triage and treatment. Model variables include triage performance, treatment capability, treatment time, and time-dependent mortality of critically injured patients. We model triage as a variable selection process applied to a hypothetical population of critically and noncritically injured patients. Treatment capability is represented by staffed emergency department trauma bays with associated staffed operating rooms that are recycled after each use. We estimated critical and noncritical patient treatment times and time-dependent mortality rates from the trauma literature.

Results: In this simulation model, overtriage, the proportion of noncritical patients among all of those labeled as critical, has a positive, negative, or variable association with critical mortality depending on its etiology (ie, related to changes in triage sensitivity or to changes in the prevalence and total number of critical patients). In all of the modeled scenarios, the ratio of critical patients to treatment capability has a greater impact on critical mortality than overtriage level or time-dependent mortality assumption.

Conclusions: Increasing overtriage may have positive, negative, or mixed effects on critical mortality in this trauma system simulation model. These results, which contrast with prior analyses describing a positive linear relationship between overtriage and mortality, highlight the need for alternative metrics to describe trauma system response after MCIs. We explore using the relative number of critical patients to available and staffed treatment units, or the critical surge to capability ratio, which exhibits a consistent and nonlinear association with critical mortality in this model. (Disaster Med Public Health Preparedness. 2007;1(Suppl 1):S14–S24)

Emergency department triage: do experienced nurses agree on triage scores?

BACKGROUND

The reproducibility of the Canadian Triage & Acuity Scale (CTAS), designed and introduced in the late 1990s in all Canadian emergency departments (EDs), has been studied mostly using measures of interrater agreement. However, each of these studies shares a common limitation: the nurses had received fresh CTAS training, which is likely to have led to an overestimation of the reproducibility of CTAS.

OBJECTIVES

This study aims to assess the interrater reliability of the CTAS in current clinical practice, that is, as used by experienced ED nurses without recent certification or recertification.

METHODS

A prospective sample of 100 patients arriving by ambulance was identified and yielded a set of 100 written scenarios. Five experienced ED nurses reviewed and blindly assigned a CTAS score to each scenario. The agreement among nurses was measured using the Kappa statistic calculated with quadratic weights. Kappa values were generated for each pair of nurses and a global Kappa coefficient was calculated to measure overall agreement.

RESULTS

Overall interrater agreement was moderate, with a global Kappa of 0.44 (95% confidence interval 0.40-0.48). However, pairwise, Kappa values were heterogeneous (0.30 to 0.61, p=0.0013).

CONCLUSIONS

The moderate interrater agreement observed in this study is disappointingly low and suggests that CTAS reliability may be lower than expected, and this warrants further research. Intra-observer reliability of CTAS should be ascertained more extensively among experienced nurses, and a future evaluation should involve several institutions.

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.

Revealing triage behaviour patterns in ER using a new technology for handwritten data acquisition

INTRODUCTION

Data acquisition is still one of the important challenges to be met in clinical settings. This is even more critic in settings with high cognitive workloads, such as emergency room (ER). Observations in these settings are difficult to realize without biases and there is little means to trace fine acquisition activities done in natural environments, using pen and papers. This study is based on the usage of a digital pen and paper (DPP) technology for the acquisition of triage information by nurses in ER. The DPP technology has been used to ease acquisition using a natural mechanism; it also minimizes the external influence of observation during acquisition activities. The aim of this study is to determine whether data recorded by the DPP technology allows explaining how ER triage nurses use the triage forms in real working conditions.

METHODOLOGY

The chief physicians of the ER service wanted to have answers about three main concerns pertaining to the triage process: (1) the average time spent during the triage process; (2) the sequence in which the fields of the forms were filled and; (3) the contribution of objective measurements, such as vital signs, to the triage emergency level and decisions. In order to answer these questions, detailed log data recorded by the DPP during form filling as been analyzed and allowed to built several representations of the triage process. In addition, we completed this analysis with ethnographical-like observations.

RESULTS

For seven consecutive days, 1183 triage forms have been recorded in the ER for all patients admitted. Among them, 954 forms have been digitalized and 906 forms have been considered as valid and complete. Based on this set of data, the median duration of the triage process is 143 s. There are no converging habits in filling the forms and the sequence of filling fields present a high variability. The emphasis of the objective measurements in the decisional process is rather low, as vital signs are recorded in less than 17% of the cases.

CONCLUSION

The DPP technology is an original approach to study data acquisition processes in unbiased conditions. The technical raw data recorded by the DPP allows building the time series of all activities on the paper, therefore letting to constructing several representations of the process. However, the technology is not able to provide information about the context of use, for example interruptions of the form filling processes due to calls or other activities. Therefore, it is necessary to complete these analyses with qualitative approaches such as observational studies and interviews. Noticeably, as a result of this study, the head physicians of ER have redesigned the triage form to enforce the use of objective measurements and ease the data acquisition process.

The Soterion Rapid Triage System: Evaluation of inter-rater reliability and validity

The Soterion Rapid Triage System is a new, computerized, five-level triage acuity system. The purpose of this study was to evaluate the system's inter-rater reliability and validity for stratifying patient acuity. The study was comprised of two components. A prospective evaluation of inter-rater reliability was conducted by the blinded, paired simultaneous triage of 423 patients. A retrospective evaluation of validity consisted of the analysis of 33,850 patients triaged with the system over an 8-month period. The system's validity was measured by in-hospital admission rate, Emergency Department (ED) length-of-stay, hospital charges and Current Procedural Terminology (CPT) Codes 99281-99285. Evaluation of inter-rater reliability demonstrated a weighted kappa of 0.87 (95% confidence interval 0.84, 0.91). The in-hospital admission rates for patients triaged as Level 1 Immediate-Level 5 Non-Urgent were 43%, 30%, 13%, 3% and 1%, respectively (p < 0.0001). Similarly, there were significant differences in the means for all hospital charges, ED lengths-of-stay, and CPT Codes. In conclusion, the Soterion Rapid Triage System possesses high inter-rater reliability and validity. The system's reliability and validity, and the availability of the system's electronically archived data are characteristics beneficial to the development of a national standardized five-level triage acuity system.

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

BACKGROUND/PURPOSE

The importance of accurate triage in Taiwan is becoming more apparent with the increasing number of emergency department (ED) patients, and resources for the National Health Insurance becoming constrained. This study compared the ability of the Taiwan triage system (TTS) and the standardized 5-level Emergency Severity Index (ESI) triage system to predict ED resource utilization.

METHODS

Patients arriving at the ED were triaged by both TTS and by using a two-page checklist of ESI criteria during the 3-month study period. The ESI triage level was calculated independently to avoid bias. Disease category (trauma vs. nontrauma), length of stay (LOS) and hospitalization data were evaluated.

RESULTS

A total of 3172 patients with both ESI and TWN evaluation were included. The distributions of ESI ratings within TTS level 1 were: ESI 1, 21.1%; ESI 2, 68.1%; ESI 3, 7.4%; ESI 4, 3.4%; ESI 5, 0%. For TTS level 3, they were: ESI 1, 0.1%; ESI 2, 26.2%; ESI 3, 39.5%; ESI 4, 27.5%; ESI 5, 6.8%. Hospitalization rates were 74.5%, 40.9% and 22.2% in TTS levels 1, 2 and 3, respectively; and were 96.2%, 47.0%, 30.9%, 6.7%and 6.6% in ESI levels 1, 2, 3, 4 and 5, respectively. TTS triaged more trauma patients as life-threatening/emergent condition than nontrauma patients (68.8% vs. 48.4%, p < 0.001). Triage by ESI, however, showed no significant difference in the percentage of trauma and nontrauma patients with highly acute conditions (44.2% vs. 46.6%, p = 0.230). Patients with ESI level 4 or 5 have significantly shorter ED LOS than those with ESI level 3.

CONCLUSION

ESI produces more accurate discriminating patient acuity, ED LOS and hospitalization rate than TTS. Adopting a standardized 5-level triage tool might improve resource utilization planning of ED practice.

Effect of JumpSTART training on immediate and short-term pediatric triage performance

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of JumpSTART training in changing prehospital care personnel and/or school nursing personnel performance in triaging pediatric patients involved in a multiple casualty incident immediately posttraining and at a 3- to 4-month follow-up interval.

METHODS

This research involved a traditional pretest, training, posttest, and follow-up test format. However, since the variable of interest was performance rather than cognition, the measures were the individual student's ability to triage 10 children with simulated injuries into 1 of 4 possible categories within a 5-minute time window. A convenience sample of participants was selected from 3 divergent geographic locations. Standardized training and performance evaluation measures were employed.

RESULTS

Significant performance improvements in pediatric triage were noted immediately following a 1-hour lecture, discussion, and case review. Changes in performance were maintained over a 3-month posttraining period. Prehospital personnel and school nurses benefited equally from pediatric triage training.

CONCLUSIONS

Structured training results in triage performance improvement among prehospital and nursing personnel. This improvement is maintained for a period of at least 3 months. Additional research pertaining to the length of time between necessary retraining and/or refresher is warranted. Additionally, the relationship between staged scenario performance and responses to actual multiple casualty incidents needs to be established.

The Canadian Triage and Acuity Scale: A Canadian perspective on emergency department triage

The Canadian Triage and Acuity Scale has received widespread acceptance in Canada as a reliable and valid tool for emergency department triage. The importance of accurate triage becomes more apparent as emergency department volumes increase, and resources shrink. The need to ensure that those patients requiring more urgent care receive care first is the basis for all triage scales. Through the Canadian Triage and Acuity Scale National Working Group, the scale became the recommended triage tool for Canadian emergency departments. Work has been done on the interrater reliability of Canadian Triage and Acuity Scale among health care providers. There is a need to further assess the validity of the scale. This scale has now been applied in the out of hospital setting by paramedics and is being used in measurements of emergency physician workload. The future may see an electronic triage tool develop for emergency department use to reduce variability in its application. The Canadian Triage and Acuity Scale has become an integral component of Canadian emergency departments.

Implementation and refinement of the emergency severity index

OBJECTIVES

To implement a new five-level emergency department (ED) triage algorithm, the Emergency Severity Index (ESI), into nursing practice, and validate the instrument with a population-based cohort using hospitalization and ED length of stay as outcome measures.

METHODS

The five-level ESI algorithm was introduced to triage nurses at two university hospital EDs, and implemented into practice with reinforcement and change management strategies. Interrater reliability was assessed by a posttest and by a series of independent paired patient triage assignments, and a staff survey was performed. A cohort validation study of all adult patients registered during a one-month period immediately following implementation was performed.

RESULTS

Eight thousand two hundred fifty-one ED patients were studied. Weighted kappa for reproducibility of triage assignments was 0.80 for the posttest (n = 62 nurses), and 0.73 for patient triages (n = 219). Hospitalization was 28% overall and was strongly associated with triage level, decreasing from 58/63 (92%) of patients in triage category 1, to 12/739 (2%) in triage category 5. Median lengths of stay were two hours shorter at either triage extreme (high and low acuity) than in intermediate categories. Outcomes followed a-priori predictions. Staff nurses rated the new program easier to use, and more useful as a triage instrument than previous three-level triage. They provided feedback, which resulted in significant revisions to the algorithm and educational materials.

CONCLUSIONS

Triage nurses at these two hospitals successfully implemented the ESI algorithm and provided useful feedback for further refinement of the instrument. Emergency Severity Index triage reproducibly stratifies patients into five groups with distinct clinical outcomes.