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Meta-Analysis
. 2019 May 28;9(5):e026471.
doi: 10.1136/bmjopen-2018-026471.

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

Joany M Zachariasse #  1 , Vera van der Hagen #  1 , Nienke Seiger  1 , Kevin Mackway-Jones  2 , Mirjam van Veen  1   3 , Henriette A Moll  1
Affiliations
Meta-Analysis

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

Joany M Zachariasse et al. BMJ Open. .

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.

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Conflict of interest statement

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

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.
See this image and copyright information in PMC

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MeSH terms