Reliability of Canadian Emergency Department Triage and Acuity Scale (CTAS) in Saudi Arabia

Evaluation of patients with decreased general condition and comparing HOTEL, WPS, and REMS for mortality prediction

The emergency department (ED) plays a crucial role in evaluating patients with decreased general condition (DGC). Prompt diagnosis and precise risk stratification enhances clinical care outcomes. This study aimed to reveal which scoring system is better for predicting mortality in patients with DGC. This single-center prospective study was conducted between 1 March 2021 and 1 June 2021 in a tertiary university hospital's ED. All patients presented with DGC were included. The scores assessed upon ED admission for patients include the Hypotension, Oxygen saturation, low Temperature, ECG changes, and Loss of independence, abbreviated as HOTEL score, Rapid Emergency Medicine Score (REMS), and the Worthing Physiological Scoring (WPS). The study aimed to compare the scoring systems to identify which is the best mortality predictor. Independent risk factors for 30-day mortality were analyzed using binary logistic regression and ROC curves to assess the effectiveness of HOTEL, REMS, and WPS scores in predicting mortality. The study was conducted with 137 DGC patients. The median age of patients presented to the ED with DGC was 77 (66.5-87), and 50.4% were male. 52.6% of patients died within one month. Analysis of mortality risk factors revealed that gender, age, day of admission, visit type, home oxygen, urinary catheter use, and speech status were not independent risk factors. For one-month mortality prediction, AUCs were: HOTEL 0.644 (cut-off 1), REMS 0.635 (cut-off 8), WPS 0.547 (cut-off 5). For mechanical ventilation: HOTEL 0.689 (10), REMS 0.790 (10), WPS 0.777 (4). For ICU admission: HOTEL 0.697 (2), REMS 0.770 (9), WPS 0.728 (4). Both the HOTEL and REMS scoring systems have moderate prognostic value in predicting mortality in patients with a DGC. The REMS, and WPS scores are also more helpful in determining the need for intensive care unit admission and mechanical ventilation.

Identifying the obstacles facing emergency nurses regarding treating CTAS1 and CTAS2 in Saudi Arabia

BACKGROUND

Emergency nurses play a pivotal role in delivering efficient emergency healthcare, yet they often encounter numerous challenges, especially while managing life-threatening cases, impacting both their well-being and patient satisfaction. This study seeks to identify the prevalent challenges faced by these nurses in Saudi hospitals when handling Canadian Triage and Acuity Scale (CTAS1 and CTAS2) cases, with the aim of mitigating or managing these issues in the future.

METHODS

This study incorporated a mixed-method approach to identify obstacles in Emergency Department (ED) nursing treatment of CTAS1 and CTAS2 cases in two major Saudi Arabian hospitals. The research began with qualitative focus group interviews with expert ED nurses, followed by a quantitative survey to measure and explore relationships among the qualitative findings. Data analysis leveraged qualitative thematic analysis and principal component analysis, ensuring rigorous examination and validation of data to drive meaningful conclusions.

FINDINGS

From expert interviews, key challenges for emergency nurses were identified, including resource management, communication, training compliance, and psychological factors. A survey of 172 nurses further distilled these into five major issues: patient care management, handling critical cases, administration support, patient care delay, and stress from patients' families.

CONCLUSION

Through a mixed-method approach, this study pinpoints five pivotal challenges confronting emergency nurses in Saudi hospitals. These encompass difficulties in patient care management, the psychological toll of handling critical cases, inadequate administrative support, delays due to extended patient stays, and the stress induced by the presence of patients' families, all of which significantly impede emergency department efficiency and compromise nurse well-being.

Geriatric Population Triage: The Risk of Real-Life Over- and Under-Triage in an Overcrowded ED: 4- and 5-Level Triage Systems Compared: The CREONTE (Crowding and R E Organization National TriagE) Study

Elderly patients, when they present to the emergency department (ED) or are admitted to the hospital, are at higher risk of adverse outcomes such as higher mortality and longer hospital stays. This is mainly due to their age and their increased fragility. In order to minimize this already increased risk, adequate triage is of foremost importance for fragile geriatric (>75 years old) patients who present to the ED. The admissions of elderly patients from 1 January 2014 to 31 December 2020 were examined, taking into consideration the presence of two different triage systems, a 4-level (4LT) and a 5-level (5LT) triage system. This study analyzes the difference in wait times and under- (UT) and over-triage (OT) in geriatric and general populations with two different triage models. Another outcome of this study was the analysis of the impact of crowding and its variables on the triage system during the COVID-19 pandemic. A total of 423,257 ED presentations were included. An increase in admissions of geriatric, more fragile, and seriously ill individuals was observed, and a progressive increase in crowding was simultaneously detected. Geriatric patients, when presenting to the emergency department, are subject to the problems of UT and OT in both a 4LT system and a 5LT system. Several indicators and variables of crowding increased, with a net increase in throughput and output factors, notably the length of stay (LOS), exit block, boarding, and processing times. This in turn led to an increase in wait times and an increase in UT in the geriatric population. It has indeed been shown that an increase in crowding results in an increased risk of UT, and this is especially true for 4LT compared to 5LT systems. When observing the pandemic period, an increase in admissions of older and more serious patients was observed. However, in the pandemic period, a general reduction in waiting times was observed, as well as an increase in crowding indices and intrahospital mortality. This study demonstrates how introducing a 5LT system enables better flow and patient care in an ED. Avoiding UT of geriatric patients, however, remains a challenge in EDs.

The Effectiveness and Relevance of the Canadian Triage System at Times of Overcrowding in the Emergency Department of a Private Tertiary Hospital: A United Arab Emirates (UAE) Study

OBJECTIVE

A systematic and straightforward triage system is crucial for the proper and timely care of patients within the emergency department (ED). This study unfolds a detailed understanding of the impact of the Canadian Triage and Acuity Scale (CTAS) on patient care and resource allocation in a private tertiary hospital. To the best of our knowledge, this is the only article studying the impact of the CTAS in one of the private hospitals in the United Arab Emirates (UAE) to achieve triage optimisation strategies. There is scope for further research in both public and private hospitals in the UAE. A triage system not only helps healthcare professionals prioritise cases conveniently but also guides patients to the most suitable area for a consultation. As a general rule, EDs follow an algorithm for the purpose of triage, and the aim of our study is to assess one such five-level triage system, CTAS, for its effectiveness and relevance during overcrowding in a UAE ED.

METHOD

Within a period of approximately three weeks, a total of 351 CTAS-triaged patients were included in a prospective observational study during peak hours (17:00-22:00) of an ED in the UAE. The CTAS app was used as the triage tool to assess relevance, in terms of patient waiting times, resource allocation, and urgency level distribution, to the Canadian scale. All patients presenting to the ED were included with no exclusion criteria. The relationship between urgency level, duration of visit, and resources used was assessed, and the department's triage results were compared with those of the CTAS app.

RESULTS

Our sample showed a female (187; 53.3%) and adult preponderance (215; 61.3%) with most of the adult patients aged between 30 and 40 (96; 44.65%). 41.5% (145) of the triage was mismatched between the department and the CTAS app with 115 (79.3%) cases of under-triaging and 30 (20.7%) cases of over-triaging. There was a statistically significant difference (p=0.004) between average waiting times across triage categories 4 and 5 with the former category patients waiting for a longer period of time. Cohen's kappa showed moderate inter-relatability (k=0.42). The average utilisation costs per triage category showed a positive correlation with the urgency level for CTAS (Pearson's r=0.59); however, the costs declined as the urgency level rose for the department.

CONCLUSIONS

The high compliance rate demonstrates that the CTAS can be applicable to institutions outside of Canada. The categorisation of patients by the CTAS and their resource allocation were more accurate than the standard triage proving its effectiveness as a triage tool. Lack of synchronisation among the triage nurses and inadequate triage training are the most plausible reasons for this comparison. The recommended "time to be seen by a physician" was achievable in our ED, and that, along with the expected relationship between CTAS and resource utilisation, can be seen as valid indicators for a quality triage system for use in the UAE.

The Prevalence and Utilization of Prehospital IV Access in Critically Ill Patients in the Emergency Department

BACKGROUND

Despite the pivotality of emergency medical services (EMS) in prehospital care for patient stabilization, prehospital intravenous (IV) access, a standard practice, remains an ambiguity in Saudi Arabia in terms of its prevalence of placement, justification, and utilization.

OBJECTIVES

In this study, we aim to estimate the prevalence and utilization rate of prehospital IV access placement in patients transported to King Khalid University Hospital (KKUH) Emergency Medicine Department in Riyadh by EMS and determine the relationship between the prevalence and utilization rate of prehospital IV access in Canadian Triage and Acuity Scale (CTAS) levels 1 and 2 in trauma and non-trauma patients.

METHODS

This observational cross-sectional study was conducted over six months. A total of 181 cases of CTAS levels 1 and 2 adult patients were included. Data were collected by trained nurses using convenient sampling through an author-developed questionnaire.

RESULTS

 The prevalence of prehospital IV line placement was 28.7%, with a utilization rate of 50%, and was notably higher among CTAS level 1 cases (69.2%). Additionally, trauma cases had a higher prevalence of prehospital IV access (53.5%) compared to medical cases (odds ratio (OR): 4.73, 95% confidence interval (CI): 4.73, 4.73, p<0.05). Among patients with prehospital IV lines, the majority (92.3%) were patent and functional. Upon arrival, 73.1% of patients had their prehospital IV line replaced, with hospital protocol being the most common reason for the replacement (73.7%).

CONCLUSION

A minority of the patients had prehospital vascular access, and of those, half remained unused. Trauma cases and CTAS level 1 patients had a higher prevalence and utilization of prehospital IV access. Furthermore, trauma cases were more associated with prehospital IV access establishment and utilization.

Analysis of Emergency Department Use by Non-Urgent Patients and Their Visit Characteristics at an Academic Center

Objective

We studied the extent and reasons for non-urgent emergency department (ED) visits in a single university hospital, their predictors, and patient outcomes to propose solutions suitable for Middle Eastern healthcare systems.

Design

We conducted a retrospective review of electronic medical records, including all non- and less-urgent ED visits with complete triage records (levels 4 and 5 triage based on the Canadian Triage and Acuity Scale (CTAS) over one year. The data on patient demographics, visit characteristics, and patient disposition were analyzed using SPSS software.

Setting

The study was conducted in the ED at King Abdullah Bin Abdul-Aziz University Hospital (KAAUH), a Saudi university hospital located within the campus of Princess Nourah Bint Abdulrahman University.

Participants

A chart review was carried out for 18,880 patients with CTAS 4 or 5 visiting the KAAUH ED between July 2020 and July 2021. Additionally, a total of "11,857" patients with missing triage acuity or CTAS levels 1, 2, or 3 were excluded from the study.

Results

The majority (61.4%) of the 30,737 ED visits were less-urgent or non-urgent. The most common reasons for non-urgent visits were routine examination/investigation (40.9%), medication refilling (14.6%), and upper respiratory tract infection/symptoms (9.9%). Most visits (73.4%) were during weekdays and resulted in the prescription of medication (94.2%), laboratory tests (62.8%), sick leaves (4.7%), radiology examinations (3.6%), and a visit to primary healthcare clinics (family medicine) within a week of the emergency visit (3.6%).

Conclusion

Less- and non-urgent ED visits often did not need any further follow-ups or admission and represented a burden better managed by a primary healthcare center. Policymakers should mitigate unnecessary ED visits through public awareness, establish clear regulations for ED visits, improve the quality of care in primary healthcare centers, facilitate booking for outpatient department appointments, and regulate the systems of payment coverage/insurance and referral by other organizations.

Metacognition and learning transfer under uncertainty

OBJECTIVES

This study examined the possible correlation between metacognition and learning experience transfer of nursing students after engaging in an urgent and cognitively demanding clinical situation.

METHODS

This is a one-group post-test- only study design in which participants engaged in an emergency care scenario simulation and completed the Meta-Cognitive Awareness Scale - Domain Specific (MCAS-DS).

RESULTS

Study results revealed that participants' metacognitive awareness is significantly correlated to the learning transfer (p=0.0001) and GPA (p=0.006). There is also a positive correlation between learning transfer and GPA (p=0.04), clinical settings-based training experience (p=0.021) and metacognitive confidence (p=0.0001).

CONCLUSIONS

This study may imply that academic achievement can be used as a potential screening tool to identify students requiring metacognitive training. It may also imply that metacognitive abilities can be enhanced indirectly through considering factors that may influence the transfer of learning such as increasing the hours of clinical training.

Exception from informed consent for biomedical research in emergency settings: A study from Jordan

BACKGROUND

Research conduction in emergency settings is of paramount importance to promote knowledge and experiences related to treating acutely ill patients. However, the complexity of situations creates a considerable ethical challenge facing researchers who basically deal with emergent cases. This study aimed to determine attitudes of healthcare providers (HCPs) towards exception from informed consent (EFIC) and enrollment willingness in emergency research in Jordan.

METHODS

A quantitative research with face-to-face questionnaire was conducted by an interviewer during 6-month period in 2019. Survey measures included items related to EFIC policy and overall willingness of HCPs to participate or support their family members' participation in emergency research.

RESULTS

A total of 151 HCPs in the emergency departments (EDs) in Jordan was recruited. Positive attitude toward emergency research dominated among participants; about 21.9% of participants reported previous experience in the conduction of emergency research and 12.3% had related publications. Regarding EFIC policy, there was a general consensus of disagreement to most of the examined items. There was a trend for little support of EFIC policy when questioned about the enrollment of family members or public in emergency research, however, the application of EFIC was accepted for self-enrollment of respondents in emergency research. No significant differences (P = 0.37), among participants from different disciplines, were reported regarding the attitudes towards EFIC items or willingness to enroll in emergency research.

CONCLUSIONS

Generally, HCPs reported an overall positive support to emergency research despite a consensus of disagreement related to EFIC terms. Therefore, it is recommended to pursue future studies to compare well-informed subjects; recruited from well-developed institutions in regard to emergency research potentials; with the present basic attitudinal surveillance in order to dissipate the effect of such confounder and to get better insight of the actual attitudes related to emergency research and EFIC. In addition, efficient multidisciplinary communication channels between researchers and policy makers can lather the way to collaborative research with simultaneous innovative delivery of quality emergency care.

Pediatric triage variations among nurses, pediatric and emergency residents using the Canadian triage and acuity scale

Background

Emergency care continues to be a challenge, since patients’ arrival is unscheduled and could occur at the same time which may fill the Emergency Department with non-urgent patients. Triaging is an integral part of every busy ED. The Canadian Triage and Acuity Scale (CTAS) is considered an accurate tool to be used outside Canada. This study aims to identify the chosen triage level and compare the variation between registered nurses, pediatric and adult emergency residents by using CTAS cases.

Method

This study was conducted at King Abdulaziz Medical City,Saudi Arabia. A cross-sectional self-administered questionnaire was used, and which contains 15 case scenarios with different triage levels. All cases were adopted from a Canadian triage course after receiving permission. Each case provides the patient’s symptoms, clinical signs and mode of arrival to the ED. The participants were instructed to assign a triage level using the following scale. A non-random sampling technique was used for this study. The rates of agreement between residents were calculated using kappa statistics (weighted-kappa) (95%CI).

Result

A total of 151 participants completed the study questionnaire which include 15 case scenarios. 73 were nurses and 78 were residents. The results showed 51.3, 56.6, and 59.9% mis-triaged the cases among the nurses, emergency residents, and pediatric residents respectively. Triage scores were compared using the Kruskal Wallis test and were statistically significant with a p value of 0.006. The mean ranks for nurses, emergency residents and pediatric residents were 86.41, 73.6 and 59.96, respectively. The Kruskal Wallis Post-Hoc test was performed to see which groups were statistically significant, and it was found that there was a significant difference between nurses and pediatrics residents (P value = 0.005). Moreover, there were no significant differences found between nurses and ER residents (P value> 0.05).

Conclusion

The triaging system was found to be a very important tool to prioritize patients based on their complaints. The results showed that nurses had the greatest experience in implementing patients on the right triage level. On the other hand, ER and pediatric residents need to develop more knowledge about CTAS and become exposed more to the triaging system during their training.

The Impact of COVID-19 on the Service of Emergency Department

(1) Introduction: the COVID-19 pandemic significantly impacted the number and acuity of emergency departments (ED) patients, specifically those with non-COVID-19-related health problems. However, the exact impact of the COVID-19 pandemic on ED services is the subject of comprehensive debate. (2) Aim: to gain insight into the consequences of the first wave of the COVID-19 pandemic based on non-COVID-19 presentations and patient acuity using the Canadian Triage and Acuity Scale (CTAS). (3) Method: in Phase 1, the ED records of one of the main regional non-COVID-19 hospitals in Saudi Arabia were retrospectively audited from August 2020 to February 2021—after the first wave of COVID-19—then compared to information collected for the same period in previous year. Phase 2 included calculating the waiting time to identify delays and issues that may impact the triage effectiveness. (4) Results: a change across all CTAS levels was observed post the 1st wave of COVID-19 pandemic. Specifically, there was an increase in the number of patients presenting as higher acuity (CTAS 1 and 2) and a decrease in patients presenting as lower acuity (CTAS 4 and 5). Longer waiting times for patients presenting to ED were also reported. Specifically, 83% of patients presenting as higher acuity experienced a delay. (5) Conclusion: further studies are required to investigate association between the 1st wave of COVID-19 and patient presentations and/or acuity or patient demand and ED capacity.

Investigating Indicators of Waiting Time and Length of Stay in Emergency Departments

Purpose

To investigate potential indicators of patients' waiting time and length of stay in emergency departments (ED) at the Ministry of Health (MOH) hospitals in order to determine the causes of delayed patient care and to recommend clinical implications to achieve a better ED system.

Materials and Methods

This exploratory study was conducted in the EDs at four tertiary hospitals of MOH. A random sample of 1360 people was tested from December 2019 to February 2020. Data included patient Canadian Triage Acuity and System (CTAS) level, registration time, triage time, physician examination time, decision time, and disposition time. Descriptive statistics, multivariate analysis, multiple linear regression analysis and Pearson correlation were used according to SPSS (version 24).

Results

The findings showed that 89.6% of total emergency patients were categorized as levels 3, 4 and 5. Around 73.5% of emergency patients stayed less than 4 hours due to registration or triage to disposition, while 26.5% of those patients stayed more than 4 hours.

Conclusion

The majority of patients' total stay in EDs was less than 4 hours. According to ED international standard of length of stay, this is appropriate. The highest effective indicator in total length of stay was the decision to disposition time in EDs.

Mild Head Trauma: Is Antiplatelet Therapy a Risk Factor for Hemorrhagic Complications?

Background and objectives: In patients who receive antiplatelet therapy (APT), the bleeding risk profile after mild head trauma (MHT) still needs clarification. Some studies have demonstrated an association with bleeding risk, whereas others have not. We studied the population of our level II emergency department (ED) trauma center to determine the risk of bleeding in patients receiving APT and whether bleeding results not from antiplatelet agents but rather from age. We assessed the bleeding risk, the incidence of intracranial hemorrhage (ICH) that necessitated hospitalization for observation, the need for cranial neurosurgery, the severity of the patient's condition at discharge, and the frequency of ED revisits for head trauma in patients receiving APT. Materials and Methods: This retrospective single-center study included 483 patients receiving APT who were in the ED for MHT in 2019. The control group consisted of 1443 patients in the ED with MHT over the same period who were not receiving APT or anticoagulant therapy. Our ED diagnostic therapeutic protocol mandates both triage and the medical examination to identify patients with MHT who are taking any anticoagulant or APT. Results: APT was not significantly associated with bleeding risk (p > 0.05); as a risk factor, age was significantly associated with the risk of bleeding, even after adjustment for therapy. Patients receiving APT had a greater need of surgery (1.2% vs. 0.4%; p < 0.0001) and a higher rate of hospitalization (52.9% vs. 37.4%; p < 0.0001), and their clinical condition was more severe (evaluated according to the exit code value on a one-dimensional quantitative five-point numerical scale) at the time of discharge (p = 0.013). The frequency of ED revisits due to head trauma did not differ between the two groups. Conclusions: The risk of bleeding in patients receiving APT who had MHT was no higher than that in the control group. However, the clinical condition of patients receiving APT, including hospital admission for ICH monitoring and cranial neurosurgical interventions, was more severe.

Consistency of triage scores by presenting complaint pre- and post-implementation of a real-time electronic triage decision support tool

OBJECTIVE

eCTAS is a real-time electronic decision-support tool designed to standardize the application of the Canadian Triage and Acuity Scale (CTAS). This study addresses the variability of CTAS score distributions across institutions pre- and post-eCTAS implementation.

METHODS

We used population-based administrative data from 2016-2018 from all emergency departments (EDs) that had implemented eCTAS for 9 months. Following a 3-month stabilization period, we compared 6 months post-eCTAS data to the same 6 months the previous year (pre-eCTAS). We included triage encounters of adult (≥17 years) patients who presented with 1 of 16 pre-specified, high-volume complaints. For each ED, consistency was calculated as the absolute difference in CTAS distribution compared to the average of all included EDs for each presenting complaint. Pre-eCTAS and post-eCTAS change scores were compared using a paired-samples t-test. We also assessed if eCTAS modifiers were associated with triage consistency.

RESULTS

There were 363,214 (183,231 pre-eCTAS, 179,983 post-eCTAS) triage encounters included from 35 EDs. Triage scores were more consistent (P < 0.05) post-eCTAS for 6 (37.5%) presenting complaints: chest pain (cardiac features), extremity weakness/symptoms of cerebrovascular accident, fever, shortness of breath, syncope, and hyperglycemia. Triage consistency was similar pre- and post-eCTAS for altered level of consciousness, anxiety/situational crisis, confusion, depression/suicidal/deliberate self-harm, general weakness, head injury, palpitations, seizure, substance misuse/intoxication, and vertigo. Use of eCTAS modifiers was associated with increased triage consistency.

CONCLUSIONS

eCTAS increased triage consistency across many, but not all, high-volume presenting complaints. Modifier use was associated with increased triage consistency, particularly for non-specific complaints such as fever and general weakness.

Factors Associated with Triage Modifications Using Vital Signs in Pediatric Triage: a Nationwide Cross-Sectional Study in Korea

BACKGROUND

Previous studies on inter-rater reliability of pediatric triage systems have compared triage levels classified by two or more triage providers using the same information about individual patients. This overlooks the fact that the evaluator can decide whether or not to use the information provided. The authors therefore aimed to analyze the differences in the use of vital signs for triage modification in pediatric triage.

METHODS

This was an observational cross-sectional study of national registry data collected in real time from all emergency medical services beyond the local emergency medical centers (EMCs) throughout Korea. Data from patients under the age of 15 who visited EMC nationwide from January 2016 to December 2016 were analyzed. Depending on whether triage modifications were made using respiratory rate or heart rate beyond the normal range by age during the pediatric triage process, they were divided into down-triage and non-down-triage groups. The proportions in the down-triage group were analyzed according to the triage provider's profession, mental status, arrival mode, presence of trauma, and the EMC class.

RESULTS

During the study period, 1,385,579 patients' data were analyzed. Of these, 981,281 patients were eligible for triage modification. The differences in down-triage proportions according to the profession of the triage provider (resident, 50.5%; paramedics, 47.7%; specialist, 44.9%; nurses, 44.2%) was statistically significant (P < 0.001). The triage provider's professional down-triage proportion according to the medical condition of the patients showed statistically significant differences except for the unresponsive mental state (P = 0.502) and the case of air transport (P = 0.468).

CONCLUSION

Down-triage proportion due to abnormal heart rates and respiratory rates was significantly different according to the triage provider's condition. The existing concept of inter-rater reliability of the pediatric triage system needs to be reconsidered.

Interrater Reliability, Accuracy, and Triage Time Pre- and Post-implementation of a Real-Time Electronic Triage Decision-Support Tool

STUDY OBJECTIVE

The electronic Canadian Triage and Acuity Scale (eCTAS) is a real-time electronic triage decision-support tool designed to improve patient safety and quality of care by standardizing the application of the Canadian Triage and Acuity Scale (CTAS). The objective of this study is to determine interrater agreement of triage scores pre- and post-implementation of eCTAS.

METHODS

This was a prospective, observational study conducted in 7 emergency departments (EDs), selected to represent a mix of triage documentation practices, hospital types, and patient volumes. A provincial CTAS auditor observed triage nurses in the ED pre- and post-implementation of eCTAS and assigned an independent CTAS score in real time. Research assistants independently recorded triage time. Interrater agreement was estimated with κ statistics with 95% confidence intervals (CIs).

RESULTS

A total of 1,491 individual triage assessments (752 pre-eCTAS, 739 post-implementation) were audited during 42 7-hour triage shifts (21 pre-eCTAS, 21 post-implementation). Exact modal agreement was achieved for 567 patients (75.4%) pre-eCTAS compared with 685 patients (92.7%) triaged with eCTAS. With the auditor's CTAS score as the reference, eCTAS significantly reduced the number of patients over-triaged (12.0% versus 5.1%; Δ 6.9; 95% CI 4.0 to 9.7) and under-triaged (12.6% versus 2.2%; Δ 10.4; 95% CI 7.9 to 13.2). Interrater agreement was higher with eCTAS (unweighted κ 0.89 versus 0.63; quadratic-weighted κ 0.93 versus 0.79). Median triage time was 312 seconds (n=3,808 patients) pre-eCTAS and 347 seconds (n=3,489 patients) with eCTAS (Δ 35 seconds; 95% CI 29 to 40 seconds).

CONCLUSION

A standardized, electronic approach to performing triage assessments improves both interrater agreement and data accuracy without substantially increasing triage time.

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.

VALIDITY AND RELIABILITY OF THE MANCHESTER SCALE USED IN THE ORTHOPEDIC EMERGENCY DEPARTMENT

Objectives:

To describe the clinical utility of the Manchester triage scale adapted for orthopedic emergency departments and to evaluate its validity in identifying patients with the need for hospital care and its reliability when reproduced by different professionals.

Methods:

Five triage flowcharts were developed based on the Manchester scale for the following orthopedic disorders: traumatic injuries, joint pain, vertebral pain, postoperative disorders, and musculoskeletal infections. A series of patients triaged by two orthopedists was analyzed to assess the concordance between the evaluators (reliability) and the validity of the Manchester scale as predictive of severity.

Results:

The reliability analysis included 231 patients, with an inter-observer agreement of 84% (Kappa = 0.77, p <0.001). The validity analysis included 138 patients. The risk category had a strong association with the need for hospital care in patients with trauma (OR = 6.57, p = 0.001) and was not significant for non-traumatic disorders (OR = 2.42; p = 0.208). The overall sensitivity and specificity were 64% and 76%, respectively.

Conclusion:

The evaluated system presented high reliability. Its validity was adequate, with good sensitivity for identifying patients requiring hospital care among those with traumatic lesions. However, the sensitivity was low for patients with non-traumatic lesions. Level of Evidence III, Retrospective Study.

Triage Performance in Emergency Medicine: A Systematic Review

STUDY OBJECTIVE

Rapid growth in emergency department (ED) triage literature has been accompanied by diversity in study design, methodology, and outcome assessment. We aim to synthesize existing ED triage literature by using a framework that enables performance comparisons and benchmarking across triage systems, with respect to clinical outcomes and reliability.

METHODS

PubMed, EMBASE, Scopus, and Web of Science were systematically searched for studies of adult ED triage systems through 2016. Studies evaluating triage systems with evidence of widespread adoption (Australian Triage Scale, Canadian Triage and Acuity Scale, Emergency Severity Index, Manchester Triage Scale, and South African Triage Scale) were cataloged and compared for performance in identifying patients at risk for mortality, critical illness and hospitalization, and interrater reliability. This study was performed and reported in adherence to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

RESULTS

A total of 6,160 publications were identified, with 182 meeting eligibility criteria and 50 with sufficient data for inclusion in comparative analysis. The Canadian Triage and Acuity Scale (32 studies), Emergency Severity Index (43), and Manchester Triage Scale (38) were the most frequently studied triage scales, and all demonstrated similar performance. Most studies (6 of 8) reported high sensitivity (>90%) of triage scales for identifying patients with ED mortality as high acuity at triage. However, sensitivity was low (<80%) for identification of patients who had critical illness outcomes and those who died within days of the ED visit or during the index hospitalization. Sensitivity varied by critical illness and was lower for severe sepsis (36% to 74%), pulmonary embolism (54%), and non-ST-segment elevation myocardial infarction (44% to 85%) compared with ST-segment elevation myocardial infarction (56% to 92%) and general outcomes of ICU admission (58% to 100%) and lifesaving intervention (77% to 98%). Some proportion of hospitalized patients (3% to 45%) were triaged to low acuity (level 4 to 5) in all studies. Reliability measures (κ) were variable across evaluations, with only a minority (11 of 42) reporting κ above 0.8.

CONCLUSION

We found that a substantial proportion of ED patients who die postencounter or are critically ill are not designated as high acuity at triage. Opportunity to improve interrater reliability and triage performance in identifying patients at risk of adverse outcome exists.

CONCORDÂNCIA DE UM PROTOCOLO INSTITUCIONAL DE AVALIAÇÃO COM CLASSIFICAÇÃO DE RISCO

RESUMO Objetivo: avaliar a concordância entre os enfermeiros na aplicação de um protocolo institucional de avaliação com classificação de risco em uma unidade de emergência hospitalar. Método: estudo quantitativo de abordagem transversal e retrospectivo, realizado na unidade de emergência adulto de um hospital geral do Estado de Santa Catarina, baseado em fichas de atendimento. A coleta de dados ocorreu entre outubro e dezembro de 2013. A amostra fora constituída de 380 fichas de atendimento, selecionadas por aleatorização simples. O grau de concordância se determinou pelo coeficiente Kappa. Resultados: a concordância geral entre os enfermeiros na aplicação do protocolo institucional foi substancial (Kappa=0,786) representando 331 (87,2%) fichas. Entre os níveis de classificação houve concordância quase perfeita para todos eles (Kappa=1 para o nível vermelho, Kappa=0,836 para o nível laranja, Kappa=0,884 para o nível amarelo, Kappa=0,865 para o nível verde e Kappa=1 para o nível azul). Conclusão: a concordância geral na aplicação do protocolo institucional se mostrou substancial, sendo evidenciada uma concordância quase perfeita em todos os níveis de classificação. Houve superestimação e subestimação da classificação de risco em relação ao protocolo. Sugere-se que os enfermeiros que realizam a classificação de risco recebam treinamento por parte da instituição quanto à aplicabilidade do protocolo, a fim de minimizar a superestimação e subestimação da classificação de risco. Este trabalho contribui ao avaliar a aplicação de um protocolo novo implantado, com subsídios para uma melhor concordância na sua implementação por enfermeiros.

Risk classification priorities in an emergency unit and outcomes of the service provided

Objective:

to check the association of the proposed priorities of the institutional protocol of risk classification with the outcomes and evaluate the profile of the care provided in an emergency unit.

Method:

observational epidemiological study based on data from the computerized files of a Reference Emergency Unit. Care provided to adults was evaluated regarding risk classification and outcomes (death, hospitalization and hospital discharge) based on the information recorded in the emergency bulletin.

Results:

the mean age of the 97,099 registered patients was 43.4 years; 81.5% cases were spontaneous demand; 41.2% had been classified as green, 15.3% yellow, 3.7% blue, 3% red and 36.and 9% had not received a classification; 90.2% of the patients had been discharged, 9.4% hospitalized and 0.4% had died. Among patients who were discharged, 14.7% had been classified as yellow or red, 13.6% green or blue, and 1.8% as blue or green.

Conclusion:

the protocol of risk classification showed good sensitivity to predict serious situations that can progress to death or hospitalization.

Carbon monoxide poisoning cases presenting with non-specific symptoms

Carbon monoxide (CO) is a colourless and odourless gas appearing as a result of incomplete combustion of carbon-containing fuels. Many domestic or occupational poisonings are caused by CO exposure. Malfunctioning heating systems, improperly ventilated motor vehicles, generators, grills, stoves and residential fires may be listed in the common sources of CO exposure. The aim of this study was to emphasize the significance of early diagnosis of CO poisoning with non-invasive measurement of CO levels of the patients with non-specific symptoms using a pulse oximeter device in the triage. Our study was a cross-sectional study. Patients who presented to the emergency department (ED) due to non-specific symptoms and had a Canadian Triage and Acuity scale level of 4 or 5 were included in the study; 106 (5.9%) of 1788 patients admitted during the study period were diagnosed with CO poisoning. Patients with CO poisoning and the other patients had statistically significant differences in terms of presenting symptoms, namely, headache, dizziness, nausea, and vomiting. More CO poisoning cases were admitted in the fall and winter compared to the spring and summer. The number of CO poisoning victims can be decreased if preventive measures like CO monitoring systems and well-designed ventilation systems are generalized at homes and workplaces. Measurement of carboxyhaemoglobin levels of patients presenting to ED due to non-specific symptoms like headache and dizziness during cold seasons and winter months using a pulse CO-oximeter should be a part of the routine of emergency medicine triage.

Comment on Alquraini et al.: reliability of Canadian Emergency Department Triage and Acuity Scale (CTAS) in Saudi Arabia

It is very common to examine reliability of triage scales using (weighted) kappa statistics. The point is that weighted kappa has grossly underestimated disagreements by one category and put more emphasis on extreme category disagreements; therefore, low prevalence of critically-ill and non-urgent patients has excluded the effect of extreme categories disagreement from calculated kappa coefficient and also contributed to significant overestimation. As a result, weighted kappa coefficient as an estimate of scale reliability is overestimated by the anchoring effect.