Reliability And Validity Of Emergency Triage System

ObjectivesTo conduct a systematic review on the reliability and validity of emergency triage system.To assess the reliability and validity of The Taiwan Triage and Acuity Scale(TTAS)in a tertiary emergency hospital of Mainland China.Methods1.Seven databases including CENTRAL,MEDLINE(OVID),EMBASE(OVID),CNKI database,China WANFANG datebase and China WEIPU database were searched.Two reviewers screened literature according to the inclusion and exclusion criteria,assessed the quality of included studies and extracted date independently.Data was analyzed using Comprehensive Meta Analysis software(Version 2.0).2.The study was carried out on 10 case-based scenarios which were validated by six triage experts.Fifteen Emergency Department(ED)nurses assigned to rate the 10 case-based scenarios.Accuracy of the triage rating was measured agaist the expert.Interrater relaibility was assessed by comparing nurses.Intrarater relaibility was assessed by retriage the 10 case-based scenarios in two weeks.The statistics of t-test,one-way ANOVA,Kendall W and kappa were used to evaluate the reliability.3.A propective cohort study was used in this study in emergercy department of a tertiary hospital from 1st January 2016 to 31 st March 2016.The general demographic of the patient,the triage level,disposition,length of stay in the ED,the resource of use,the items of blood test were collected for each patient.The statistics of t-test,one-way ANOVA,Kendall W and kappa were used to evaluate the reliability.Correlations between triage level and proxy variables were measured by Chi-square test,Kendall rank correlation coefficient,Kruskal-Wallis test and area under the subject operating characteristic curve(AUROC).Results1.Totally 62 studies were identified from 3479 papers which were including Australasian Triage Scale(ATS),Canadian Triage and Acuity Scale(CTAS),Emergency Severity Index(ESI),Manchester Triage Scale(MTS),South Africa Triage Scale(SATS),French Emergency Nurses Classification in Hospital scale(FRENCH),Echelle Liégeoise d'Index de Sévéritéà l'Admission(ELISA)and Taiwan Triage and Acuity Scale(TTAS).Pooled coefficient for the ATS was 0.411(95%CI 0.334-0.483).Pooled coefficients for CTAS ranged from 0.753(95%CI 0.714-0.788)of weight Kappa,0.486(95%CI 0.378-0.581)of unweight Kappa.The ESI reliability were 0.847(95%CI 0.780-0.894)of weight Kappa and 0.607(95%CI 0.447-0.728)of unweight Kappa.Pooled coefficient for the MTS were 0.849(95%CI 0.744-0.914)of weight Kappa and 0.648(95%CI 0.552-0.727)of unweight Kappa.Pooled coefficients for SATS was 0.538(95%CI 0.502-0.571).72.7% studies used proxy variables as validity indicators to assess the validity of the triage system.The result showed that triage level was positively related to the rate of hospital admission,rate of admission to intensive care unit,mortality rate,and utilization of resources.Due to the important heterogeneity among these studies,we only took a narrative synthesis of the main findings on the validity of the triage system.2.The accuracy of the triage rating was 61.33%.The interrater reliability Kendall W was 0.860.The quadratically weighted kappa was 0.85(95%CI0.835-0.862).The intrarater reliability was 0.92(95%CI0.76-1.00)which was compared with the first time triage by nurses in two weeks.3.7843 patients were triaged by TTAS.The number of patients were triaged at 1,2,3,4 and 5 was 20(0.3%),245(3.1%),2960(37.7%),3907(49.8%),711(9.1%).The rate of discharge,hospitalization,admitted to intensive care unit(ICU)and mortality were 91.3%,8.2%,0.3% and 0.2% respectively.The hospitalization,admitted to ICU,mortality,the length of stay,the resource of use,the items of blood test correlated significantly with the triage level.The Kendall rank correlation values between tiage level and discharge,hospitalization,admitted to ICU,mortality were 0.254,-0.254,-0.079,-0.071 respectively(P=0.000).The AUROC for the predictive ability of the TTAS for hospitalization,admitted to ICU and mortality were 0.754(95%CI 0.736-0.772),0.869(95%CI 0.797-0.942),0.869 (95%CI 0.797-0.942)respectively.Conclusions1.The most widely distributed triage systems are the ATS,CTAS,MTS,ESI and SATS,all of which possess satisfactory to very good validity and reliability.But for variable quality and high heterogeneity among these studies,it need to be caution to use these evidences in clinical practice.In addition,no studies from Mainland of China are included in this review.For the effect of the national conditions,culture,economy and so on,the conclusion should be caution to use in mainland China.Additionally,more high quality,suitable for the situation of domestic studies are needed in the future.2.The TTAS has a moderate to substantial reliability and a moderate accuracy in a tertiary hospital in Mainland China.3.The TTAS has a good validity in a tertiary hospital in Mainland China.The nurse can use the tool to identify the patient's priorities effectively.