Reliability and validity of a new French-language triage algorithm: the ELISA scale

Validation of a modified South African triage scale in a high-resource setting: a retrospective cohort study

BACKGROUND

Triage systems are widely used in emergency departments, but are not always validated. The South African Triage Scale (SATS) has mainly been studied in resource-limited settings. The aim of this study was to determine the validity of a modified version of the SATS for the general population of patients admitted to an ED at a tertiary hospital in a high-income country. The secondary objective was to study the triage performance according to age and patient categories.

METHODS

We conducted a retrospective cohort study of patients presenting to the Emergency Department of Haukeland University Hospital in Norway during a four-year period. We used short-term mortality, ICU admission, and the need for immediate surgery and other interventions as the primary endpoints.

RESULTS

A total of 162,034 emergency department visits were included in the analysis. The negative predictive value of a low triage level to exclude severe illness was 99.1% (95% confidence interval: 99.0-99.2%). The level of overtriage, defined as the proportion of patients assigned to a high triage level who were not admitted to the hospital, was 4.1% (3.9-4.2%). Receiver operating characteristic (ROC) curves showed an area under the ROC for the detection of severe illness of 0.874 (95% confidence interval: 0.870-0.879) for all patients and 0.856 (0.837-0.875), 0.884 (0.878-0.890) and 0.869 (0.862-0.876) for children, adults and elderly individuals respectively.

CONCLUSION

We found that the modified SATS had a good sensitivity to identify short-term mortality, ICU admission, and the need for rapid surgery and other interventions. The sensitivity was higher in adults than in children and higher in medical patients than in surgical patients. The over- and undertriage rates were acceptable.

Reliability and Validity of a New Computer-Based Triage Decision Support Tool: ANKUTRIAGE

OBJECTIVE

Triage is a tool used to determine patients' severity of illness or injury within minutes of arrival. This study aims to assess the reliability and validity of a new computer-based triage decision support tool, ANKUTRIAGE, prospectively.

METHODS

ANKUTRIAGE, a 5-level triage tool was established considering 2 major factors, patient's vital signs and characteristics of the admission complaint. Adult patients admitted to the ED between July and October, 2019 were consecutively and independently double triaged by 2 assessors using ANKUTRIAGE system. To measure inter-rater reliability, quadratic-weighted kappa coefficients (Kw) were calculated. For the validity, associations among urgency levels, resource use, and clinical outcomes were evaluated.

RESULTS

The inter-rater reliability between users of ANKUTRIAGE was excellent with an agreement coefficient (Kw) greater than 0.8 in all compared groups. In the validity phase, hospitalization rate, intensive care unit admission and mortality rate decreased from level 1 to 5. Likewise, according to the urgency levels, resource use decreased significantly as the triage level decreased (P < 0.05).

CONCLUSIONS

ANKUTRIAGE proved to be a valid and reliable tool in the emergency department. The results showed that displaying the key discriminator for each complaint to assist decision leads to a high inter-rater agreement with good correlation between urgency levels and clinical outcomes, as well as between urgency levels and resource consumptions.

Advanced triage to redirect non-urgent Emergency Department visits to alternative care centers: the PERSEE algorithm

OBJECTIVES

Primary care treatable visits in the Emergency Department (ED) are part of the different factors leading to the overcrowding. Their triage and diversion to alternative care centers could potentially help manage the increasing inflow provided the establishment of an advanced triage to ensure patients' safety. We aim to suggest a new triage tool, PERSEE, and prove its feasibility, safety and performance.

METHODS

All self-referrals presented to the ED were triaged with the PERSEE algorithm: first, patients were classified with a five-level ED acuity scale and then evaluated by algorithms to determine their appropriate category (ED or Primary Care). Patients were eligible for a redirection if they were triaged by the acuity scale as level 3 or lower, considered as ambulatory patients and finally categorized as primary care patients. We defined appropriate redirections as patients requiring less than three emergency resources, no emergency-specific treatment and no hospitalization.

RESULTS

During the study, 1999 patients were admitted to the ED. Among those, 1333 patients were self-referred (66.9%) of whom 1167 patients were triaged as level 3 or below (58.6%) and 775 patients triaged as ambulatory (39.0%). Among the 775 patients, 200 patients were categorized as primary care treatable (10.0%) and thereby, as potentially eligible for a redirection. We noticed an error rate of 7%, sensitivity of 24.06% and specificity of 97.6%. The redirection rate reached 15% of the self-referrals.

CONCLUSION

These results indicate that PERSEE triage could lead to a safe redirection and could be an efficient tool to reduce ED crowding provided several adjustments.

Validity of the Taiwan Triage and Acuity Scale in mainland China: a retrospective observational study

OBJECTIVES

The Taiwan Triage and Acuity Scale (TTAS), developed for use in EDs, has been shown to be an excellent tool for triaging patients with high predictive performance, with an area under the receiver operating curve (AUROC) of 0.75. TTAS has been widely used in hospitals in Taiwan since 2010, but its utility has not been studied outside of Taiwan. Thus, the aim of this study was to evaluate the validity of using the TTAS in the ED of a tertiary hospital in mainland China to predict patient outcomes.

METHODS

A retrospective observational study was performed on patients 14 years of age or older attending the ED of a tertiary hospital in mainland China between 1 January 2016 and 31 March 2016. The validity of the TTAS in predicting hospital admission, intensive care unit (ICU) admission, death, ED length of stay (LOS) and ED resource utilisation was evaluated by determining the correlation of these outcomes with the TTAS, AUROC and test characteristics.

RESULTS

A total of 7843 patients were included in this study. There were significant differences between the TTAS categories in disposition, ED LOS and ED resource utilisation (p<0.0001). The TTAS was significantly correlated with patient disposition at discharge, hospital admission, ICU admission and death in the ED (Kendall rank correlations were 0.254, -0.254, -0.079 and -0.071, respectively; p=0.001). The AUROCs for the prediction of hospital admissions, ICU admissions and deaths in the ED were 0.749 (95% CI 0.732 to 0.765), 0.869 (95% CI 0.797 to 0.942) and 0.998 (95% CI 0.995 to 1.000), respectively. Our results demonstrated better performance using the TTAS for predictions of ICU admission and death.

CONCLUSIONS

The TTAS had good validity in predicting patient outcomes and ED resource utilisation in a tertiary hospital in mainland China. Compared with the performance of the TTAS in Taiwan, our results suggest that the TTAS can usefully be applied outside of Taiwan.

Triage for out-of-hours primary care calls: a reliability study of a new French-language algorithm, the SALOMON rule

Introduction: Triage systems for out-of-hours primary care physician (PCP) calls have been implemented empirically but no triage algorithm has been validated to date. A triage algorithm named SALOMON (Système Algorithmique Liégeois d'Orientation pour la Médecine Omnipraticienne Nocturne) was developed to guide triage nurses. This study assessed the performance of the algorithm using simulated PCP calls. Methods: Ten nurses were involved in 130 simulated PCP call scenarios, allowing the determination of SALOMON's inter-rater agreement by comparing the actual choices of a specific triage flowchart and the level of care selected as compared with reference assignments. Intra-rater agreement was estimated by comparing triage after training (T1) and 3 to 6 months after SALOMON use in clinical practice (T2). Results: Overall selection of flowcharts was accurate for 94 .1% of scenarios at T1 and 98.7% at T2. Level of triage was adequate for 93.4% of scenarios at T1 and 98.5% at T2. Both flowchart and triage level accuracy improved significantly from T1 to T2 (p < 0.0001). SALOMON algorithm use is associated with a 0.97/0.99 sensitivity and 0.97/0.99 specificity, at T1/T2 respectively. Conclusions: Results revealed that using the SALOMON algorithm is valid for out-of-hours PCP calls triage by nurses. The criterion validity of this algorithm should be further evaluated through its implementation in a real life setting.

Triage des patients à l’accueil d’une structure d’urgences. Présentation de l’échelle de tri élaborée par la Société française de médecine d’urgence : la FRench Emergency Nurses Classification in Hospital (FRENCH)

La Société française de médecine d’urgence (SFMU) a recommandé la création d’une échelle spécifique, unique au niveau national, pour le triage des patients à l’accueil d’une structure d’urgences, prenant en compte les spécificités de l’adulte et de l’enfant. La commission de l’évaluation et de la qualité de la SFMU a créé, à l’instar des échelles de tri internationales, une échelle de tri avec cinq niveaux de priorité croissante (tris 5 à 1, du moins urgent au plus urgent) auxquels correspondent des motifs de recours aux soins de complexité/sévérité croissante. Le tri 3 a été subdivisé en deux groupes pour distinguer (et prioriser) les patients qui ont au moins une comorbidité en rapport avec le motif de recours aux soins ou qui sont adressés par un médecin (3A) des autres patients (3B). L’échelle de tri FRENCH (FRench Emergency Nurses Classification in Hospital) a donc six niveaux de priorité. À chaque niveau de tri correspondent des motifs de recours aux soins fréquents en médecine d’urgence, des modulateurs de tri, une répartition rationnelle des circuits patients et un délai maximum d’attente avant prise en charge médicale, après évaluation par l’infirmier(ière) d’accueil. Une première évaluation de la FRENCH a montré qu’elle répondait aux objectifs du triage en facilitant le repérage de l’urgence complexe/sévère de façon fiable et reproductible. De nouvelles évaluations sont nécessaires dans d’autres structures d’urgences pour confirmer sa performance et favoriser son évolution.

Validité de la FRENCH, l’échelle de tri des urgences hospitalières élaborée par la Société française de médecine d’urgence

Introduction : La Société française de médecine d’urgence a créé en 2016 une échelle de tri pour les infirmier( ière)s d’accueil dans une structure d’urgences. Cette échelle appelée FRENCH (FRench Emergency Nurses Classification in Hospital) classe les tris de 5 à 1 (du moins urgent au plus urgent) en fonction du pronostic et de la complexité/ sévérité des motifs de recours aux soins. Le tri 3, groupe hétérogène dans les échelles de tri internationales, a été subdivisé en deux niveaux pour prioriser les patients qui ont une comorbidité en rapport avec le motif de recours aux soins ou qui sont adressés par un médecin et qui sont prioritaires (3A) par rapport aux autres patients (3B).

Objectif : Évaluer la pertinence de la FRENCH.

Méthode : Nous avons analysé les données démographiques, les paramètres vitaux, les examens complémentaires prescrits et les durées de prise en charge de tous les patients accueillis dans un hôpital universitaire sur une période de neuf mois consécutifs. Le critère de jugement était l’existence d’une relation croissante entre le niveau de complexité/ sévérité des patients — reflétée par le taux d’hospitalisation et la prescription d’examens complémentaires—et le niveau de priorité du tri.

Résultats : L’étude a inclus 27 598 patients. La répartition des patients par niveaux de tri était : 0,4 (tri 1), 6,7 (tri 2), 13,3 (tri 3A), 29,4 (tri 3B), 43,1 (tri 4) et 7,1 % (tri 5). Le taux d’hospitalisation était croissant quand l’ordre de priorité augmentait. La relation entre les niveaux de tri et le taux d’hospitalisation mesurée par l’aire sous la courbe (0,83 : intervalle de confiance à 95 % : [0,82–0,83]) était bonne. La prescription des examens complémentaires était croissante quand l’ordre de priorité augmentait. La corrélation entre les niveaux de tri et un indice global d’examens complémentaires prescrits était modérée (K = 0,51).

Conclusion : Cette étude monocentrique valide la pertinence de l’échelle de tri FRENCH à six niveaux par sa bonne capacité à classer les patients selon leur complexité/sévérité. De nouvelles évaluations sont nécessaires dans d’autres structures d’urgences pour confirmer sa performance et favoriser son évolution.

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.

A Semantic-Based Model for Triage Patients in Emergency Departments

Triage is a process performed in an emergency department that aims to sort patients according to their need for care. When performed speedily and correctly, this process can potentially increase the chances of survival for a patient with serious complications. This study aims to develop a computer model, called UbiTriagem, which supports the process of triage using the concepts of web semantics and ubiquitous computing focused on healthcare. For evaluating the proposal, we performed an analysis of scenario-driven triage based on previously determined ratings. In addition, we conducted a usability evaluation in emergency department with the developed prototype with two user groups: nurses and patients. The main scientific contribution is the automatic triage assessment based on the gathering of patient data on mobile devices, performed automatically through the use of a reasoning technique in an ontology. The results for all evaluations were very positive. The automatic triage assessment has been assertive in 93.3% of the cases and, after adjustments in the model, in 100% of the cases. Regarding user satisfaction, we obtained rates of 98.7% and 96% when considering perception of utility and ease of use, respectively.

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.

Validation of the modified Japanese Triage and Acuity Scale-based triage system emphasizing the physiologic variables or mechanism of injuries

Background

The Canadian Triage and Acuity Scale is a valid triage system. The system was translated and implemented in the Japanese emergency departments (EDs) from 2012. This system was named the Japanese Triage and Acuity Scale; however, the validation studies of the Japanese Triage and Acuity Scale have been limited. In addition, for a patient with multiple complaints, it could become challenging, due to its requirement of a single complaint. Therefore, we hypothesized that a modified version of the Japanese Triage and Acuity Scale using first-order modifiers without chief complaint detection is accurate.

Methods

A retrospective cohort study evaluated a correlation between the modified triage scale level and outcomes of all adult emergency department patients at a Japanese hospital.

Construct validity of the modified triage scale level was assessed based on comparisons of total admission rate (including hospitalizations, emergency department deaths) and length of stay between triage levels.

Results

The distributions of five levels of the triage scale (level 1 is the most urgent) among the 17,121 cases are as follows: 1:451, 2:1148, 3:7703, 4:7652, and 5:167. Total admission rates by each level were 1:89.8, 2:68.2, 3:26.4, 4:6.6, and 5:0.6 %, which progressively increased from level 5 to 1 and were significant (p < 0.01). Compared with patients in level 3, the odds of total admission rates were 14.4, 5.1, 0.27, and 0.030 for the patients in levels 1, 2, 4, and 5. The length of stay was longer in the patients with the more urgent levels except for those with level 1.

Conclusions

The modified version of the Japanese Triage and Acuity Scale is a valid predictor of total admission and length of stay and may enable the nurses to triage patients without detecting the chief complaints.