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A Method for Reviewing the Accuracy and Reliability of a Five-Level Triage Process (Canadian Triage and Acuity Scale) in a Community Emergency Department Setting: Building the Crowding Measurement Infrastructure  [PDF]
Michael K. Howlett,Paul R. T. Atkinson
Emergency Medicine International , 2012, DOI: 10.1155/2012/636045
Abstract: Objectives. Triage data are widely used to evaluate patient flow, disease severity, and emergency department (ED) workload, factors used in ED crowding evaluation and management. We defined an indicator-based methodology that can be easily used to review the accuracy of Canadian Triage and Acuity Scale (CTAS) performance. Methods. A trained nurse reviewer (NR) retrospectively triaged two separate month’s ED charts relative to a set of clinical indicators based on CTAS Chief Complaints. Interobserver reliability and accuracy were compared using Kappa and comparative statistics. Results. There were 2838 patients in Trial 1 and 3091 in Trial 2. The rate of inconsistent triage was 14% and 16% (Kappa 0.596 and 0.604). Clinical Indicators “pain scale, chest pain, musculoskeletal injury, respiratory illness, and headache” captured 68% and 62% of visits. Conclusions. We have demonstrated a system to measure the levels of process accuracy and reliability for triage over time. We identified five key clinical indicators which captured over 60% of visits. A simple method for quality review uses a small set of indicators, capturing a majority of cases. Performance consistency and data collection using indicators may be important areas to direct training efforts. 1. Introduction Accurate assessment of triage (a French term meaning “to sort”) processes and outcomes is central to any research on emergency department (ED) crowding. Patient volumes and acuity, the aging population, public demands for advanced technology, evidence-based medicine, and payor austerity measures increase pressure on emergency department processes. With increasing demand on EDs and increasing crowding issues, studies must examine factors that influence patient flow. These studies depend on accurate measurements of disease severity and workload. Triage data are used extensively as a proxy for both workload and patient acuity. Thus proper conduct of research into crowding and the ability to apply results across facilities depends on accuracy and reliability of the data. The five-level Canadian Triage and Acuity Scale (CTAS), using a standardized data element set including a validated Chief Complaint list, has been adopted by the Canadian Association of Emergency Physicians (CAEPs) and National Emergency Nurses Affiliation (NENA) as the standard methodology for emergency department triage [1–3]. Similar five-level systems are used in the United States, the United Kingdom, and Australia as well as in other jurisdictions. The Canadian Triage and Acuity Scale (CTAS) has been used not only for
Reliability and validity of triage systems in paediatric emergency care
Mirjam van Veen, Henriette A Moll
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine , 2009, DOI: 10.1186/1757-7241-17-38
Abstract: We performed a search in Pubmed and Cochrane on studies on reliability and validity of triage systems in childrenThe 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.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.Large numbers of patients visit the emergency department. Consulting patients in the order of attending will, in a crowded emergency department (ED), lead to long waiting times for seriously ill patients. It is important to prioritise patients who are seriously ill and would be at increased risk of morbidity or even mortality due to delay in the initiation of treatment.The aim of triage is to determine and classify the clinical priority of patients visiting the ED. [1] During a short assessment the nurse will identify signs and symptoms that determine the patient's urgency. The physician will see the patients in order of their urgency level. Patients requiring immediate care are identified. Moreover, patients are identified who can safely wait longer or who can be seen by another caregiver such as the general practitioner or nurse practitioner.Triage systems are developed by expert opinion. [2-5], the lowest level of evidence, and are mainly based on the adult population visiting the ED.
Chest pain in emergency department: Effectiveness of nursing intervention Triage  [PDF]
Sánchez Bermejo R.,Fernández Cantero F.,Rincón Fraile B.,Pe?a Cuevas S.
Páginasenferurg.com , 2011,
Abstract: Prevalence of chest pain in the emergency departmentis 5-20% of visits. The diagnostic possibilities are numerousand range from trivial to emergency health conditions thatare time dependent, hence the need to perform anadequate priority at the time of triage.Objective: To evaluate the effectiveness of nursingintervention in triage in the emergency department (NIC6364) in patients with chest pain.Descriptive study conducted in the emergencydepartment of the Hospital Nuestra Se ora del Prado fromDecember 2008 until June 2009.1030 patients were included. It has been observed thatthe prevalence of chest pain and its characteristics is similarto that reported in other studies. We found that thediagnostic approach to the assessment made of the patient'smedical triage unstructured approaches the final diagnosisat discharge from it. It has been shown that testing timesare improved with respect to internationally establishedquality indicators.
The effectiveness of the South African Triage Score (SATS) in a rural emergency department
K Rosedale, ZA Smith, H Davies, D Wood
South African Medical Journal , 2011,
Abstract: Background. The Modified Early Warning Score (MEWS) is used to monitor medical inpatients in hospitals in the developed world. The South African Triage Score (SATS) was developed from the MEWS, and its use throughout South Africa has been proposed. Objectives. We aimed to assess the effectiveness of the SATS in an emergency department (ED) in a rural setting in KwaZulu-Natal (KZN). Methods. A prospective cross-sectional study undertaken over a 1-month period in June 2009 of patients in the ED of a government hospital in rural KZN, the referral centre for 22 peripheral hospitals. Data capture included physiological parameters, mobility and trauma scores, a list of selected clinical conditions (physician discriminator list), MEWS and SATS scores, final clinical diagnosis, and outcome in the ED (death, hospital admission or discharge). Outcome measures were under- and over-triage rates according to both systems. Results. Over the study period, 589 patients were triaged and their data analysed. The MEWS under-triaged 15.1% (over-triaged 8.3%) of cases that needed admission, compared with an undertriage rate of 4.4% (over-triage rate 4.3%) when the SATS was used. Conclusion. Our study supports use of the SATS as a primary triage score in South African urban and rural hospitals. The SATS is superior to the MEWS as a triage scoring system in a rural hospital ED in KZN, its rates of under- and over-triage falling within the limits of the American College of Surgeons Committee on Trauma (ACSCOT) guidelines.
Emergency Department Triage Scales and Their Components: A Systematic Review of the Scientific Evidence
Nasim Farrohknia, Maaret Castrén, Anna Ehrenberg, Lars Lind, Sven Oredsson, H?kan Jonsson, Kjell Asplund, Katarina E G?ransson
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine , 2011, DOI: 10.1186/1757-7241-19-42
Abstract: 1. Does assessment of individual vital signs or chief complaints affect mortality during the hospital stay or within 30 days after arrival at the ED?2. What is the level of agreement between clinicians' triage decisions compared to each other or to a gold standard for each scale (reliability)?3. How valid is each triage scale in predicting hospitalization and hospital mortality?A systematic search of the international literature published from 1966 through March 31, 2009 explored the British Nursing Index, Business Source Premier, CINAHL, Cochrane Library, EMBASE, and PubMed. Inclusion was limited to controlled studies of adult patients (≥15 years) visiting EDs for somatic reasons. Outcome variables were death in ED or hospital and need for hospitalization (validity). Methodological quality and clinical relevance of each study were rated as high, medium, or low. The results from the studies that met the inclusion criteria and quality standards were synthesized applying the internationally developed GRADE system. Each conclusion was then assessed as having strong, moderately strong, limited, or insufficient scientific evidence. If studies were not available, this was also noted.We found ED triage scales to be supported, at best, by limited and often insufficient evidence.The ability of the individual vital signs included in the different scales to predict outcome is seldom, if at all, studied in the ED setting. The scientific evidence to assess interrater agreement (reliability) was limited for one triage scale and insufficient or lacking for all other scales. Two of the scales yielded limited scientific evidence, and one scale yielded insufficient evidence, on which to assess the risk of early death or hospitalization in patients assigned to the two lowest triage levels on a 5-level scale (validity).Triage is a central task in an emergency department (ED). In this context, triage is viewed as the rating of patients' clinical urgency [1]. Rating is necessary to ident
The German Version of the Manchester Triage System and Its Quality Criteria – First Assessment of Validity and Reliability  [PDF]
Ingo Gr?ff, Bernd Goldschmidt, Procula Glien, Manuela Bogdanow, Rolf Fimmers, Andreas Hoeft, Se-Chan Kim, Daniel Grigutsch
PLOS ONE , 2014, DOI: 10.1371/journal.pone.0088995
Abstract: Background The German Version of the Manchester Triage System (MTS) has found widespread use in EDs across German-speaking Europe. Studies about the quality criteria validity and reliability of the MTS currently only exist for the English-language version. Most importantly, the content of the German version differs from the English version with respect to presentation diagrams and change indicators, which have a significant impact on the category assigned. This investigation offers a preliminary assessment in terms of validity and inter-rater reliability of the German MTS. Methods Construct validity of assigned MTS level was assessed based on comparisons to hospitalization (general / intensive care), mortality, ED and hospital length of stay, level of prehospital care and number of invasive diagnostics. A sample of 45,469 patients was used. Inter-rater agreement between an expert and triage nurses (reliability) was calculated separately for a subset group of 167 emergency patients. Results For general hospital admission the area under the curve (AUC) of the receiver operating characteristic was 0.749; for admission to ICU it was 0.871. An examination of MTS-level and number of deceased patients showed that the higher the priority derived from MTS, the higher the number of deaths (p<0.0001 / χ2 Test). There was a substantial difference in the 30-day survival among the 5 MTS categories (p<0.0001 / log-rank test).The AUC for the predict 30-day mortality was 0.613. Categories orange and red had the highest numbers of heart catheter and endoscopy. Category red and orange were mostly accompanied by an emergency physician, whereas categories blue and green were walk-in patients. Inter-rater agreement between expert triage nurses was almost perfect (κ = 0.954). Conclusion The German version of the MTS is a reliable and valid instrument for a first assessment of emergency patients in the emergency department.
Swedish emergency department triage and interventions for improved patient flows: a national update
Nasim Farrokhnia, Katarina E G?ransson
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine , 2011, DOI: 10.1186/1757-7241-19-72
Abstract: In 2009 and 2010 the Swedish Council on Health Technology Assessment sent out a questionnaire to the ED managers in all (74) Swedish hospital emergency departments. The questionnaire comprised questions about triage and interventions to improve patient flows.Nearly all (97%) EDs in Sweden employed a triage scale in 2010, which was an increase from 2009 (73%). Further, the Medical Emergency Triage and Treatment System was the triage scale most commonly implemented across the country. The implementation of flow-related interventions was not as common, but more than half (59%) of the EDs have implemented or plan to implement nurse requested X-ray.There has been an increase in the use of triage scales in Swedish EDs during the last few years, with acceleration for the past two years. Most EDs have come to use the Medical Emergency Triage and Treatment System, which also indicates regional co-operation. The implementation of different interventions for improved patient flows in EDs most likely is explained by the problem of crowding. Generally, more studies are needed to investigate the economical aspects of these interventions.When patients can not been seen by a doctor immediately upon arrival to the emergency department (ED), some sort of order for treatment is needed. ED triage, developed since the mid 1900's [1], is nowadays a universal approach for handling such queues [2-4]. Triage is often carried out by registered nurses (RNs) using a triage scale to guide their decision in allocating an acuity level. The development of ED triage varies across the world; Australia being one of the first countries to introduce a five level triage scale, the National Triage Scale (NTS), later renamed the Australasian Triage Scale (ATS) [5]. Anglo-Saxon countries have dominated the development of triage scales, and internationally commonly used scales are the Canadian Emergency Department Triage and Acuity Scale (CTAS), the Manchester Triage Scale (MTS) from the UK and the Emergenc
Emergency Severity Index triage system and implementation experience in a university hospital
Orhan CINAR,Erdem CEVIK,Necati SALMAN,Bilgin COMERT
Turkish Journal of Emergency Medicine , 2010,
Abstract: Objective: Emergency Severity Index (ESI) is a simple to use, five-level triage instrument that categorizes emergency department patients in four decision points by evaluating both patient acuity and resources. Aim of this study was to introduce the ESI triage system and sharing the implementation experience of it in a university hospital emergency department. Methods: We planned to use ESI triage system in Gulhane Military Medical Academy Department of Emergency Medicine at November 2009. Education materials were provided from Agency for Healthcare Research and Quality (AHRQ). A two day long case based training program was planned for ESI education. We included 34 emergency nurses to training program in 3 seperate groups. ESI Implementation Handbook used as the primary source for training. Triage algoritm posters and triage games were prepared to make education more interesting. We evaluated the efficiency of training by using two different method: Pre/post evaluation and pre/post test method. Results: Determining the correct triage level was increase from 30% (9.52±2.53) to 80% (24.88±3.01) in pre/post test method which include 30 cases and 40% to 76% in pre/post evaluation method which include 10 cases. Conclusions: We concluded that ESI is simple to learn, practical system for emergency triage and two day case based training program was effective to teach it.
Triage Emergency Method Version 2 (TEM v2). A new triage within hospital method
Nicola Parenti,Vito Serventi,Rossella Miglio,Stefano Masi
Emergency Care Journal , 2011, DOI: 10.4081/ecj.2011.3.27
Abstract: Our aim was to check if TEM v1, a new four-level in-hospital triage with good inter- and intra-rater reliability, reaches a large consensus among Italian triage experts. Finally we tried to improve the model and to create a new model: TEM v2. A 2 round modified Delphi study was conducted including 25 triage experts. The predetermined consensus level was considered 80%. Total return rate was 72% (18/25), the return rate for round one and two was 92% (23/25) and 78% (18/23) respectively. After the first round, a set of 11 questions was sent with the new TEM v2. Eight items of round 2 reached more than 80% of consensus. Using the Delphi technique we developed from TEM v1, the new triage tool TEM v2 which reached a large consensus among a panel of triage experts. This is, to our knowledge, the first Italian study which uses the Delphi technique to reach consensus on a triage system and to improve it.
Emergency department triage: an ethical analysis
Ramesh P Aacharya, Chris Gastmans, Yvonne Denier
BMC Emergency Medicine , 2011, DOI: 10.1186/1471-227x-11-16
Abstract: In emergency department triage, medical care might lead to adverse consequences like delay in providing care, compromise in privacy and confidentiality, poor physician-patient communication, failing to provide the necessary care altogether, or even having to decide whose life to save when not everyone can be saved. These consequences challenge the ethical quality of emergency care. This article provides an ethical analysis of "routine" emergency department triage. The four principles of biomedical ethics - viz. respect for autonomy, beneficence, nonmaleficence and justice provide the starting point and help us to identify the ethical challenges of emergency department triage. However, they do not offer a comprehensive ethical view. To address the ethical issues of emergency department triage from a more comprehensive ethical view, the care ethics perspective offers additional insights.We integrate the results from the analysis using four principles of biomedical ethics into care ethics perspective on triage and propose an integrated clinically and ethically based framework of emergency department triage planning, as seen from a comprehensive ethics perspective that incorporates both the principles-based and care-oriented approach.Emergency care is one of the most sensitive areas of health care. This sensitivity is commonly based on a combination of factors such as urgency and crowding [1]. Urgency of care results from a combination of physical and psychological distress, which appears in all emergency situations in which a sudden, unexpected, agonizing and at times life threatening condition leads a patient to the emergency department (ED).The Australasian College for Emergency Medicine (ACEM) defines ED overcrowding as the situation where ED function is impeded primarily because the number of patients waiting to be seen, undergoing assessment and treatment, or waiting to leave exceeds the physical and/or staffing capacity of the ED [2]. ED overcrowding is a common
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