Modern triage in the emergency department

Abstract

Background: Because the volume of patient admissions to an emergency department (ED) cannot be precisely planned, the available resources may become overwhelmed at times ("crowding"), with resulting risks for patient safety. The aim of this study is to identify modern triage instruments and assess their validity and reliability.

Methods: Review of selected literature retrieved by a search on the terms "emergency department" and "triage."

Results: Emergency departments around the world use different triage systems to assess the severity of incoming patients' conditions and assign treatment priorities. Our study identified four such instruments: the Australasian Triage Scale (ATS), the Canadian Triage and Acuity Scale (CTAS), the Manchester Triage System (MTS), and the Emergency Severity Index (ESI). Triage instruments with 5 levels are superior to those with 3 levels in both validity and reliability (p<0.01). Good to very good reliability has been shown for the best-studied instruments, CTAS and ESI (κ-statistics: 0.7 to 0.95), while ATS and MTS have been found to be only moderately reliable (κ-statistics: 0.3 to 0.6). MTS and ESI are both available in German; of these two, only the ESI has been validated in German-speaking countries.

Conclusion: Five-level triage systems are valid and reliable methods for assessment of the severity of incoming patients' conditions by nursing staff in the emergency department. They should be used in German emergency departments to assign treatment priorities in a structured and dependable fashion.

Figure 1

Emergency departments of Nuremberg Hospital (Nuremberg Hospital South: dark bars; Nuremberg Hospital North: light bars):

Figure 2

Triage algorithm of the Emergency Severity Index, version 4. An accompanying brief description of this algorithm (8) supports the members of staff concerned during the triage process. The triage system is explained in detail in the original English handbook (6). At decision point D (danger zone vitals?) there are defined age-dependent thresholds (m, months; y, years) for heart rate (HR) in beats per minute, respiratory rate (RR) in breaths per minute, and oxygen saturation as measured by pulse oximetry (SpO2). If these thresholds are exceeded, the triage nurse may decide to assign the patient to a higher priority level.