Performance of triage systems in emergency care: a systematic review and meta-analysis

Joany M Zachariasse, Vera van der Hagen, Nienke Seiger, Kevin Mackway-Jones, Mirjam van Veen, Henriette A Moll, Joany M Zachariasse, Vera van der Hagen, Nienke Seiger, Kevin Mackway-Jones, Mirjam van Veen, Henriette A Moll

Abstract

Objective: To assess and compare the performance of triage systems for identifying high and low-urgency patients in the emergency department (ED).

Design: Systematic review and meta-analysis.

Data sources: EMBASE, Medline OvidSP, Cochrane central, Web of science and CINAHL databases from 1980 to 2016 with the final update in December 2018.

Eligibility criteria: Studies that evaluated an emergency medical triage system, assessed validity using any reference standard as proxy for true patient urgency and were written in English. Studies conducted in low(er) income countries, based on case scenarios or involving less than 100 patients were excluded.

Review methods: Reviewers identified studies, extracted data and assessed the quality of the evidence independently and in duplicate. The Quality Assessment of studies of Diagnostic Accuracy included in Systematic Reviews -2 checklist was used to assess risk of bias. Raw data were extracted to create 2×2 tables and calculate sensitivity and specificity. ED patient volume and casemix severity of illness were investigated as determinants of triage systems' performance.

Results: Sixty-six eligible studies evaluated 33 different triage systems. Comparisons were restricted to the three triage systems that had at least multiple evaluations using the same reference standard (Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System). Overall, validity of each triage system to identify high and low-urgency patients was moderate to good, but performance was highly variable. In a subgroup analysis, no clear association was found between ED patient volume or casemix severity of illness and triage systems' performance.

Conclusions: Established triage systems show a reasonable validity for the triage of patients at the ED, but performance varies considerably. Important research questions that remain are what determinants influence triage systems' performance and how the performance of existing triage systems can be improved.

Keywords: epidemiology; public health.

Conflict of interest statement

Competing interests: KM-J is chair of the Manchester Triage Group.

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Flow diagram of study selection process.
Figure 2
Figure 2
Risk of bias of included studies.
Figure 3
Figure 3
Sensitivity and specificity of triage systems for identifying high-urgency patients as defined by ICU admission. CTAS, Canadian Triage and Acuity Scale; ESI, Emergency Severity Index; FP, false positive; FN, false negative; MTS, Manchester Triage System; TP, true positive; TN, true negative.
Figure 4
Figure 4
Sensitivity and specificity of triage systems for identifying low-urgency patients as defined by discharge home after the ED visit. CTAS, Canadian Triage and Acuity Scale; ED, emergency department; ESI, Emergency Severity Index; FP, false positive; FN, false negative; MTS, Manchester Triage System; TP, true positive; TN, true negative.

References

    1. Blunt I, Edwards N, Merry L. What’s behind the A&E ’crisis'? Briefing 2015.
    1. Australasian College for Emergency Medicine. Access Block and Overcrowding in Emergency departments, 2004.
    1. Hospital-based emergency care: at the breaking point, 2013.
    1. Mackway-Jones K, Marsden J, Windle J. Emergency triage. London: BMJ, 2006.
    1. Warren DW, Jarvis A, LeBlanc L, et al. . CTAS National Working Group Canadian Association of Emergency Physicians National Emergency Nurses Affiliation Association des Médecins d’Urgence du Québec Canadian Paediatric Society Society of Rural Physicians of Canada. Revisions to the Canadian Triage and Acuity Scale paediatric guidelines (PaedCTAS). CJEM 2008;10:224–32. 10.1017/S1481803500010149
    1. Gilboy NT, Travers P, Rosenau DA, et al. . Version 4: Implementation Handbook. Rockville, MD: Agency for Healthcare Research and Quality, 2005.
    1. Australian College for Emergency Medicine. Guidelines on the implementation of the australasian triage scale in emergency departments. .
    1. Christ M, Grossmann F, Winter D, et al. . Modern triage in the emergency department. Dtsch Arztebl 2010;107:892–8.
    1. Farrohknia N, Castrén M, Ehrenberg A, et al. . Emergency department triage scales and their components: a systematic review of the scientific evidence. Scand J Trauma Resusc Emerg Med 2011;19:42 10.1186/1757-7241-19-42
    1. Parenti N, Ferrara L, Bacchi Reggiani ML, et al. . Reliability and validity of two four-level emergency triage systems. Eur J Emerg Med 2009;16:115–20. 10.1097/MEJ.0b013e328310b594
    1. Stroup DF, Berlin JA, Morton SC, et al. . Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000;283:2008–12.
    1. World Bank Group. World Bank Country and Lending Groups. (Accessed October 5th, 2017).
    1. Whiting PF, Rutjes AW, Westwood ME, et al. . QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 2011;155:529–36. 10.7326/0003-4819-155-8-201110180-00009
    1. Kuriyama A, Urushidani S, Nakayama T. Five-level emergency triage systems: variation in assessment of validity. Emerg Med J 2017;34 10.1136/emermed-2016-206295
    1. R: A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing, 2008.
    1. IBM SPSS Statistics for Windows [program]. 21 version. Armonk, NY, 2011.
    1. Review Manager (RevMan) [program]. 5.3 version. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.
    1. Chang YC, Ng CJ, Wu CT, et al. . Effectiveness of a five-level Paediatric Triage System: an analysis of resource utilisation in the emergency department in Taiwan. Emerg Med J 2013;30:735–9. 10.1136/emermed-2012-201362
    1. Chi CH, Huang CM. Comparison of the Emergency Severity Index (ESI) and the Taiwan Triage System in predicting resource utilization. J Formos Med Assoc 2006;105:617–25. 10.1016/S0929-6646(09)60160-1
    1. Maleki M, Fallah R, Riahi L, et al. . Effectiveness of Five-Level Emergency Severity Index Triage System Compared With Three-Level Spot Check: An Iranian Experience. Arch Trauma Res 2015;4:e29214 10.5812/atr.29214
    1. Ng CJ, Hsu KH, Kuan JT, et al. . Comparison between Canadian Triage and Acuity Scale and Taiwan Triage System in emergency departments. J Formos Med Assoc 2010;109:828–37. 10.1016/S0929-6646(10)60128-3
    1. Ng CJ, Yen ZS, Tsai JC, et al. . Validation of the Taiwan triage and acuity scale: a new computerised five-level triage system. Emerg Med J 2011;28:1026–31. 10.1136/emj.2010.094185
    1. Yuksen C, Sawatmongkornkul S, Suttabuth S, et al. . Emergency severity index compared with 4-level triage at the emergency department of Ramathibodi University Hospital. Asian Biomed 2016;10:155–61.
    1. Travers DA, Waller AE, Bowling JM, et al. . Five-level triage system more effective than three-level in tertiary emergency department. J Emerg Nurs 2002;28:395–400.
    1. Gouin S, Gravel J, Amre DK, et al. . Evaluation of the Paediatric Canadian Triage and Acuity Scale in a pediatric ED. Am J Emerg Med 2005;23:243–7.
    1. Storm-Versloot MN, Ubbink DT, Kappelhof J, et al. . Comparison of an informally structured triage system, the emergency severity index, and the manchester triage system to distinguish patient priority in the emergency department. Acad Emerg Med 2011;18:822–9. 10.1111/j.1553-2712.2011.01122.x
    1. van der Wulp I, Schrijvers AJ, van Stel HF. Predicting admission and mortality with the Emergency Severity Index and the Manchester Triage System: a retrospective observational study. Emerg Med J 2009;26:506–9. 10.1136/emj.2008.063768
    1. Worster A, Fernandes CM, Eva K, et al. . Predictive validity comparison of two five-level triage acuity scales. Eur J Emerg Med 2007;14:188–92. 10.1097/MEJ.0b013e3280adc956
    1. Ghafarypour-Jahrom M, Taghizadeh M, Heidari K, et al. . Validity and Reliability of the Emergency Severity Index and Australasian Triage System in Pediatric Emergency Care of Mofid Children’s Hospital in Iran. Bull Emerg Trauma 2018;6:329–33. 10.29252/beat-060410
    1. Aeimchanbanjong K, Pandee U. Validation of different pediatric triage systems in the emergency department. World J Emerg Med 2017;8:223–7. 10.5847/wjem.j.1920-8642.2017.03.010
    1. Azeredo TR, Guedes HM, Rebelo de Almeida RA, et al. . Efficacy of the Manchester Triage System: a systematic review. Int Emerg Nurs 2015;23:47–52. 10.1016/j.ienj.2014.06.001
    1. Souza CC, Araujo FA, Chianca TC. Scientific Literature on the Reliability and Validity of the Manchester Triage System (MTS) Protocol: A Integrative Literature Review Producao cientifica sobre a validade e confiabilidade do Protocolo de Manchester: revisao integrativa da literature. Rev Esc Enferm USP 2015;49:144–51.
    1. van Veen M, Moll HA. Reliability and validity of triage systems in paediatric emergency care. Scand J Trauma Resusc Emerg Med 2009;17:38 10.1186/1757-7241-17-38
    1. de Magalhães-Barbosa MC, Robaina JR, Prata-Barbosa A, et al. . Validity of triage systems for paediatric emergency care: a systematic review. Emerg Med J 2017;34:711–9. 10.1136/emermed-2016-206058
    1. Hansoti B, Jenson A, Keefe D, et al. . Reliability and validity of pediatric triage tools evaluated in Low resource settings: a systematic review. BMC Pediatr 2017;17:37 10.1186/s12887-017-0796-x
    1. Jenson A, Hansoti B, Rothman R, et al. . Reliability and validity of emergency department triage tools in low- and middle-income countries: a systematic review. Eur J Emerg Med 2018;25:154–60. 10.1097/MEJ.0000000000000445
    1. [Accessed 5th Oct 2017].
    1. [Accessed 5th Oct 2017].
    1. [Accessed 5th Oct 2017].
    1. Moll HA. Challenges in the validation of triage systems at emergency departments. J Clin Epidemiol 2010;63:384–8. 10.1016/j.jclinepi.2009.07.009

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren