Triage Performance in Emergency Medicine: A Systematic Review

Hinson, Jeremiah S.; Martínez, Diego A.; Cabral, Stephanie; George, Kevin; Whalen, Madeleine; Hansoti, Bhakti; Levin, Scott R.

doi:10.1016/j.annemergmed.2018.09.022

Cited by 182 publications

(219 citation statements)

References 58 publications

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“…In the literature, the sensitivity of 5-level triage systems in identifying patient requiring life-saving intervention ranges from 77%-98%. 8 A lower sensitivity in our study can be explained by the difference in evaluation methods (subjective judgement of the adjudicator vs objective record of life-saving intervention). Also, private ED nurses have a higher turnover rate than their counterparts in public EDs and they have less ED working experience.…”

Section: Discussionmentioning

confidence: 59%

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Performance of a three-level triage scale in live triage encounters in an emergency department in Hong Kong.

Lam

Kwok²,

Chaang

et al. 2020

Preprint

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Background Despite its continued use in many low-volume emergency departments (EDs), 3-level triage systems have not been extensively studied, especially on live triage cases. We have modified from the Australasian Triage Scale and developed a 3-level triage scale, and sought to evaluate its validity, reliability, over- and under-triage rates in real patient encounters in our setting. Method This was a cross-sectional study in a single ED with 24,000 attendances per year. At triage, each patient was simultaneously assessed by a triage nurse, an adjudicator (the “criterion standard”), and a study nurse independently. Predictive validity was determined by comparing clinical outcomes, such as hospitalization, across triage levels. The discriminating performance of the triage tool in identifying patient requiring earlier medical attention was determined. Inter-observer reliability between the triage nurse and criterion standard, and across providers were determined using kappa statistics. Results In total, 453 triage ratings of 151 triage cases, involving 17 ED triage nurses and 57 nurse pairs, were analysed. The proportion of hospital admission significantly increased with a higher triage rating. The performance of the scale in identifying patient requiring earlier medical attention was: sensitivity, 68.2% (95% CI 45.1-86.1%); specificity, 99.2% (95% CI 95.8-100%); positive predictive value, 93.8% (95% CI 67.6-99.1%); negative predictive value, 94.8% (95% CI 90.8-97.1%). The over-triage and under-triage rates were 0.7% and 4.6%, respectively. Agreement between the triage nurse and criterion standard was substantial (quadratic-weighted kappa = 0.76, 95% CI, 0.60-0.92, p<0.001), so was the agreement across nurses (quadratic-weighted kappa=0.81, 95% CI 0.65-0.97, p<0.001). Conclusions The 3-level triage system appears to have good validity and reasonable reliability in a low-volume ED setting. Further studies comparing 3-level and prevailing 5-level triage scales in live triage encounters and different ED settings are warranted.

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Section: Discussionmentioning

confidence: 59%

“…6, 7 However, previous studies on these triage systems vary considerably in study design and outcome measurements. 8 Also, there is a lack of strong scientific evidence to support their reliability and predictability of patient outcome. 9…”

mentioning

confidence: 99%

Performance of a three-level triage scale in live triage encounters in an emergency department in Hong Kong.

Lam

Kwok²,

Chaang

et al. 2020

Preprint

View full text Add to dashboard Cite

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“…One explanation for this finding could be an effect of undertriage were patients with medical urgency remain undetected by the triage tool. It is well described that patients with nonspecific symptoms and low clinical urgency often have increased hospitalization, increased ED-LOS, increased mortality and more often are of advanced age and frail [27,[37][38][39][40]. Different triage tools are often validated against proxy outcomes of ED performance such re-admission rate or mortality.…”

Section: Discussionmentioning

confidence: 99%

The association between length of stay in the emergency department and short term mortality

Wessman

Ärnlöv

Carlsson

et al. 2020

Preprint

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Background: The detrimental effects of increased length of stay at the emergency department (ED-LOS) for patient outcome have been sparsely studied in the Swedish setting. Our aim was to further explore the association between ED-LOS and short term mortality in patients admitted to the EDs of two large University hospitals in Sweden. Methods: All adult patients (> 18 years) visiting the ED at the Karolinska University Hospital, Sweden, from 1/1/2010 to 1/1/2015 (n=639 385) were retrospectively included. Logistic regression analysis was used to determine association between ED-LOS and 7 and 30-day mortality rates. All patients were triaged according to the RETTS-A into different levels of medical urgency and subsequently separated into five quintiles of ED-LOS. Results: We observed that prolonged ED-LOS was associated with increased mortality for patients with lowest triage priority (risk estimates for 30-day mortality were OR 1.49 (CI 95% 1.20-1.85) for patients with triage priority group 4 and the highest quintile of ED-LOS. No such association was observed in patients with the highest triage priority group and in patients admitted to in-hospital care. Conclusion : Our data suggest that increased ED-LOS could be associated with slightly increased short term mortality in patients with lower clinical urgency and dismissed from the ED but that this does not include patients admitted to in-hospital care.

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“…It is well described that patients with non-specific symptoms and low clinical urgency have prolonged hospitalization, an increased mortality and low triage priority [30,31]. This is particularly important in elderly frail patients [32] but also included critical ill patients [33]. Further studies are needed in order to address the possible effects of undertriage in RETTS-A.…”

Section: Discussionmentioning

confidence: 99%

The association between length of stay in the emergency department and short term mortality

Wessman

Ärnlöv

Carlsson

et al. 2019

Preprint

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Background: Prolonged length of stay at the emergency department (ED-LOS) has been associated with increased mortality and hospital stay. The aim of this study was to investigate the association between ED-LOS and 7- and 30-days mortality in patients triaged according to Rapid Emergency Triage and Treatment System – Adult (RETTS-A), the most common used triage tool in Sweden. Methods: All adult patients (> 18 years) visiting the ED at the Karolinska University Hospital, Sweden, from 1/1/2010 to 1/1/2015 (n=639 385) were included. Logistic regression analysis was used to determine association between prolonged ED-LOS and 7 and 30-days mortality rates. All patients were triaged according to the RETTS-A and subsequently separated into five quintiles of ED-LOS. Results : In patients triaged with the highest medical urgency, longer ED-LOS was associated with a lower risk for 7-days mortality, for triage priority 1: OR 0.94 (CI 95% 0.92-0.96) compared to OR 1.03 (CI 95% 0.99-1.07) for triage priority 4, and for 30-days mortality: OR 0.97 (CI 95% 0.96-0.99) OR for triage priority 1 compared to 1.03 (CI 95% 1.01-1.05) for triage priority 4. In contrast, the opposite pattern appeared evident in the 3 other triage groups, where a longer ED-LOS was generally associated with an increased mortality risk. Pro-longed ED-LOS in patients admitted to in-hospital care was associated with lower 30- and 7-days mortality independently of triage priority whereas the opposite was observed for patients not admitted to in-hospital care. Conclusion: Prolonged ED-LOS was associated with increased short term mortality in patients with lower clinical urgency and in patients not admitted to in-hospital care.

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Triage Performance in Emergency Medicine: A Systematic Review

Cited by 182 publications

References 58 publications

Performance of a three-level triage scale in live triage encounters in an emergency department in Hong Kong.

Performance of a three-level triage scale in live triage encounters in an emergency department in Hong Kong.

The association between length of stay in the emergency department and short term mortality

The association between length of stay in the emergency department and short term mortality

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