The Diagnostic Evaluation of the SINEH Cardiopulmonary Triage Scale and the Emergency Severity Index in the Emergency Department: A Comparative Study.

Introduction: The diagnostic evaluation of the emergency severity index (ESI) in the triage of patients with cardiopulmonary complaints has a high sensitivity but a low specificity in the emergency department (ED). Therefore, triage scales with more accurate diagnostic evaluation are required. As a result, accuracy of the SINEH triage scale (SinTS) and the ESI was compared to compare mistriage of critically ill patients with cardiopulmonary complaints. Methods: This descriptive, analytical and cross-sectional study was conducted between December 2022 and April 2023. In this study, two nurses independently examined each patient using two triage scales. The admission unit and length of hospital stay were also recorded. The outcome was classified as high-risk admission (cardiac care unit and intensive care unit) and low-risk admission (internal unit or discharge from the ED). Undertriage and overtiage were defined as high-risk admission with triage level 3 and 4 and low-risk admission with triage level 1 or 2, respectively. A panel of experts evaluated content validity of SinTS and kappa designating agreement on relevance reported. The inter-rater reliability of two scales was also reported. Results: Finally, the study included 145 patients. The average age of the patients studied was 61.35 years. SinTS has a total mistriage of 29.63%, with 4.13% being undertriage and 25.5% being overtriage. In ESI, the total mistriage is 66.8%, with 1.3% being undertriage and 65.5% being overtriage. The undertriage of the two scales did not differ significantly by admission unit (p=0.26), but the overtriage of the two methods did (p=0.001). The sensitivity, specificity, and accuracy of SinTS were 86.3%, 63.37%, and 72.27%, respectively, while those of ESI were 95.4%, 5.94%, and 32.79%, respectively. Conclusion: SINEH triage scale has achieved the optimal accuracy in recognizing the acuity of the patients with chest pain and dyspnea by using SpO2, pressure of end-tidal carbon dioxide, troponin I, and peak expiratory flow. When triaging patients with chest pain and dyspnea, SinTS may exhibit a higher level of accuracy compared to ESI. More research is needed to improve accuracy of triage scales in patient with cardiopulmonary complaints.

Comments on "Triage Knowledge and Practice and Associated Factors Among Emergency Department Nurses".

It is to be hoped that much more attention should be drawn toward properly constructing scenarios to ensure the accuracy of the decisions made by triage nurses, because there is a history of poorly-constructed scenarios in previous research, leading to biases in their results. Consequently, scenarios are expected to meet the main criteria for a triage, such as demographic characteristics, major complaints, vital signs and accompanying symptoms, and physical examinations, to simulate what nurses might encounter in triaging a real patient. Moreover, further studies are suggested to report mistriage, including undertriage and overtriage rates.

Are Pediatric Triage Systems Reliable in the Emergency Department?

BACKGROUND: Few studies have focused on the agreement level of pediatric triage scales (PTSs). The aim of this meta-analytic review was to examine the level of inter-rater reliability of PTSs. METHODS: Detailed searches of a number of electronic databases were performed up to 1 March 2019. Studies that reported sample sizes, reliability coefficients, and a comprehensive description of the assessment of the inter-rater reliability of PTSs were included. The articles were selected according to the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) taxonomy. Two reviewers were involved in the study selection, quality assessment, and data extraction and performed the review process. The effect size was estimated by z-transformation of reliability coefficients. Data were pooled with random-effects models, and a metaregression analysis was performed based on the method of moments estimator. RESULTS: Thirteen studies were included. The pooled coefficient for the level of agreement was 0.727 (confidence interval (CI) 95%: 0.650-0.790). The level of agreement on PTSs was substantial, with a value of 0.25 (95% CI: 0.202-0.297) for the Australasian Triage Scale (ATS), 0.571 (95% CI: 0.372-0.720) for the Canadian Triage and Acuity Scale (CTAS), 0.810 (95% CI: 0.711-0.877) for the Emergency Severity Index (ESI), and 0.755 (95% CI: 0.522-0.883) for the Manchester Triage System (MTS). CONCLUSIONS: Overall, the reliability of pediatric triage systems was substantial, and this level of agreement should be considered acceptable for triage in the pediatric emergency department. Further studies on the level of agreement of pediatric triage systems are needed.

Comparison between Emergency Severity Index and Heart Failure Triage Scale in heart failure patients: A randomized clinical trial.

BACKGROUND: It is not clear whether Emergency Severity Index (ESI) is valid to triage heart failure (HF) patients and if HF patients benefit more from a customized triage scale or not. The aim of study is to compare the effect of Heart Failure Triage Scale (HFTS) and ESI on mistriage among patients with HF who present to the emergency department (ED). METHODS: A randomized clinical trial was conducted from April to June 2017. HF patients with dyspnea were randomly assigned to HFTS or ESI groups. Triage level, used resources and time to electrocardiogram (ECG) were compared between both groups among HF patients who were admitted to coronary care unit (CCU), cardiac unit (CU) and discharged patients from the ED. Content validity was examined using Kappa designating agreement on relevance (K*). Reliability of both scale was evaluated using inter-observer agreement (Kappa). RESULTS: Seventy-three and 74 HF patients were assigned to HFTS and ESI groups respectively. Time to ECG in HFTS group was significantly shorter than that of ESI group (2.05 vs. 16.82 minutes). Triage level between HFTS and ESI groups was significantly different among patients admitted to CCU (1.0 vs. 2.8), cardiac unit (2.26 vs. 3.06) and discharged patients from the ED (3.53 vs. 2.86). Used resources in HFTS group was significantly different among triage levels (H=25.89; df=3; P<0.001). CONCLUSION: HFTS is associated with less mistriage than ESI for triaging HF patients. It is recommended to make use of HFTS to triage HF patients in the ED.

Comparison between Emergency Severity Index plus peak flow meter and Emergency Severity Index in the dyspneic patients with chronic obstructive pulmonary disease: A randomized clinical trial.

INTRODUCTION: It is unclear whether the Emergency Severity Index (ESI) can identify high-risk patients with Chronic Obstructive Pulmonary Disease (COPD). This study aims to compare the mistriage rates of the ESI plus the Peak Expiratory Flowmeter (PEF) approach and ESI approach among dyspneic patients with COPD. METHODS: This study was a randomized clinical trial conducted between July and October 2018. We randomly assigned COPD patients with dyspnea to the ESI + PEF or ESI groups. Triage levels, disposition rates, number of resources used, and time to first physician contact were compared in patients admitted to the Intensive Care Unit (ICU), the Pulmonary Care Unit (PU), or discharged from the ED. Reliability of the ESI was evaluated by using the interobserver agreement (Kappa). RESULTS: Seventy COPD patients were equally assigned to the ESI + PEF and ESI groups. The under-triage rates were 11.42% and 0%, the over-triage rates were 31.42% and 2.85% in the ESI and ESI + PEF groups, respectively. The triage levels of the patients admitted to the ICU (2 vs. 3), the PU (2 vs. 4), or discharged from the ED (3 vs. 2) were significantly different between the ESI + PEF and ESI groups. CONCLUSIONS: Addition of PEF to the ESI provides a more accurate method for triaging COPD patients compared to ESI alone. We recommend using PEF for the triage of COPD patients in the ED.

Determination of mis-triage in trauma patients: a systematic review.

PURPOSE: Mis-triage including undertriage and overtriage is associated with morbidity and mortality. It is not clear what the extent of mis-triage rates among traumatic patients is. The aim of this study is to determine of mis-triage (undertriage and overtriage) in traumatic patients. METHODS: This study was a systematic review about mis-triage rate among trauma patients. The following electronic databases were searched (Web of Knowledge, Scoups, PubMed, Cochrane library) from conception through February 1, 2018. Search terms included trauma, undertriage, and over-triage. Inclusion criteria were studies which report overtriage or undertriage rate in regard to triage of trauma patients; patients older than 18 years old, English-written papers. Irrelevant papers as well as conference abstract, letter, editorial, thesis and studies on special population were excluded. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Checklist was used to examine review process. RESULTS: Twenty-one papers were included in this study. Sample size ranged from 244 to 550683 trauma patients. Fourteen studies originated from USA. Definition of mis-triage was summarized into four categories: ISS used to define undertriage error, formula for mis-triage (1-sensitivity), need for life-saving emergency intervention and patients triaged to a non-trauma center. Undertriage rate ranged from 1 to 71.9% and overtriage rate ranged from 19 to 79%. CONCLUSIONS: The standardization of mis-triage definitions is vital to estimate true rate of mis-triage among different studies and clarify the role of triage scales. The trauma triage scales need to be further developed to provide more valid and reliable results.

The accuracy of acuity scoring tools to predict 24-h mortality in traumatic brain injury patients: A guide to triage criteria.

BACKGROUND AND AIM: Prompt identification of traumatic brain injury (TBI) is vital for patients in critical condition; however, it is not clear which acuity scoring tools are associated with short-term mortality. The aim of this study was to determine the accuracy of acuity scoring tools and 24-h mortality among TBI patients in both prehospital and hospital settings. METHODS: This study was an observational, prospective cohort, in which patients with TBI were followed from the accident scene to the hospital. Vital signs and acuity scoring tools, including the Revised Trauma Score (RTS), Injury Severity Score (ISS), National Early Warning Score (NEWS), Shock Index (SI), Modified Shock Index (MSI) and Trauma and Injury Severity Score (TRISS), were collected both on the scene as well as at the hospital. A logistic regression was performed to ascertain the effects of clinical parameters on the likelihood of survival of patients with TBI regarding 24-h mortality. RESULTS: A total of 185 patients were included in this study. The mortality rate was 14% (25/185). The logistic regression model was statistically significant at χ2=60.8, p=0.001. A hierarchical forward stepwise logistic regression analysis showed that age, hospital RTS and prehospital NEWS significantly improved mortality predictions. The model explained the 51.2% variance in survival of patients with TBI. CONCLUSIONS: The NEWS and the RTS may be used to triage TBI patients for prehospital and hospital emergency care, respectively. Therefore, because traditional vital signs criteria may be of limited use for the triage of TBI patients, it is recommended that acuity scoring tools be used in such cases.

Recognizing Sudden Cardiac Arrest May Require More Than Two Questions during Telephone Triage: Developing a Complementary Checklist.

OBJECTIVE: To develop decision-support tools to identify patients experiencing sudden cardiac arrest (SCA). METHODS: Eighty calls related to SCA were content analyzed, and the contextual patterns that emerged were organized into a checklist. Two researchers independently analyzed the recorded calls and compared their findings. Eighteen dispatchers scored 20 cases (which included SCA and non-SCA cases) both with and without the checklist. Correct responses for each case and agreement among dispatchers have been reported. RESULTS: Eighty audio files (total time, 96 min) were analyzed, and a total of 602 codes were extracted from the text and recordings. The caller's tone of voice and presence or absence of background voices, calling for an ambulance and giving the dispatcher the address promptly, and description of the primary complaint and respirations accounted for 38%, 39%, and 23% of all codes, respectively. A 15-item complementary checklist has been developed. The mean percentages of correct responses were 66.9%+27.96% prior to the use of checklist and 80.05%+10.84% afterwards. Results of the independent t test for checklist scores showed that statistically significant differences were present between the SCA and non-SCA cases (t=5.88, df=18, p=0.000). CONCLUSION: Decision support tools can potentially increase the recognition rate of SCA cases, and therefore produce a higher rate of dispatcher-directed CPR.

The reliability of the Manchester Triage System (MTS): a meta-analysis.

OBJECTIVE: Although the Manchester Triage System (MTS) was first developed two decades ago, the reliability of the MTS has not been questioned through comparison with a moderating variable; therefore, the aim of this study is to determine the extent of the reliability of MTS using a meta-analytic review. METHOD: Electronic databases were searched up to 1 March 2014. Studies were only included if they had reported sample sizes, reliability coefficients, and adequate description of the reliability assessment. The Guidelines for Reporting Reliability and Agreement Studies was used. Two reviewers independently examined abstracts and extracted data. The effect size was obtained by the z-transformation of reliability coefficients. Data were pooled with random-effects models, and meta-regression was performed based on the method-of-moments estimator. RESULTS: Seven studies were included. The pooled coefficient for the MTS was substantial at 0.751 (CI 95%: 0.677 to 0.810); the incidence of mistriage is greater than 50%. Agreement is higher for the latest version of MTS (for adults) among nurse-experts and in countries in closer proximity to the country of MTS origin (the UK, in Manchester) than for the oldest (pediatric) version, nurse-nurse raters, and countries at a greater distance from the UK. CONCLUSION: The MTS showed an acceptable level of overall reliability in the emergency department, but more development is required to attain almost perfect agreement.