Development And Application Of Emergency Rapid Triage Assessment

Emergency department is the most important and most complicated critical chain in the emergency medical service. It is the first line of hospital medical service, continuously carrying out the urgent cares of various kinds of illness in the 24 hours. The efficacy and quality of triage exert important effects on the following treatment and medical activities of the emergent patients. Emergent triages in foreign countries arrange the visiting order based on the severity and urgency of the patients. In China, there is no unified emergency triage system. Triage nurses perform triage activity based on their clinical experiences. Except for opening fast track for very critical ill patients, they do not distinguish the severity and urgency of the patients, and have not the triage tools for reference. Therefore, the accuracy of the severity of the patients is limited and the risks of medical errors exist. We need to establish a rapid evaluation tool for triage in our country.[Objective]To establish a rapid evaluation tool for emergency triage and validate its clinical efficacy.[Patients and Methods]1 Patients:All those patients who visited our emergency department were included, except for those, whose age were< 18 years and those outpatient department patients who visited emergency department only for medicines and chemistry test, and those who refused the evaluation.2 Establish the drafts of rapid evaluation tool of emergency triageBased on vigorous researches of Chinese and foreign literatures and also referred to both current Chinese and foreign triage system and< Instructing principles of grading severity of emergency department patients (For seeking advices version)>, Emergency Rapid Triage Assessment (ERTA) was worked out, including 6 index and 4 grades. See details in the following Table.3 Preliminary testRandomly apply the draft of ERTA to evaluate the severity of illness in 100 emergency department patients, recording the necessary time to finish triage, and follow up the outcome, recorded if the patients would be admitted to resuscitation room, ICU and observation room, sum up all the problems encountered during the application.4 Consultancy from specialistsThe ERTA and the results of preliminary test was summarized to 12 specialists, including professors, associated professors, senior chief nurses, associated senior chief nurses from affiliated hospitals to Second Military Medical University and Shanghai Jiaotong University. All the specialists have practiced emergency medicine for many years. The specialists carefully analyzed and refined the 6 indexes and 4 grades.5 Working out the final version of ERTAThrough preliminary tests and consultancy from specialists, the severity of illness was divided into 4 grades. However, considering the national conditions and current fast track system, some of the patients had very serious conditions and need to be into fast track immediately, rescue and evaluation simultaneously. Therefore, A grade patients were defined as those patients who needs to be in fast track, the major complains and symptoms were clearly defined. The previous A grade patients were regulated into B grade, previous B grade patients were regulated into C grade; Previous C grade patients were combined with previous D grade patients and all were regulated into D grade. The reasons for combining previous C grade and D grade patients were that 95% of the patients who were suggested to visit outpatient department would not go to visit outpatient department. The perform ability was poor.6 Comparative studiesComparative studies were performed between ERTA and MEWS to compare the evaluation efficacy of the two kinds of evaluation tools for emergency triage of patients.[Results]1 Results analysis of preliminary testsOne hundred patients, who visited our emergency department during Nov,2012 to Jan, 2013 were randomly enrolled in this study and received illness evaluation triage, except for those, whose age were<18 years and those outpatient department patients who visited emergency department only for medicines and chemistry test, and those who refused the evaluation. In those high risk patients who were admitted to resuscitation room and ICU, A grade patients> B grade patients> C grade patients, indicating that this evaluation tool met the requirements for judge the severity of illness. In those admitted to observation room/general ward, B grade patients> C grade patients> A grade patients, indicating that B grade patients by this evaluation tool mainly were admitted to observation room. Seventeen patients were into fast track directly without evaluation. During emergency triage, some patients were extremely ill and need to be sent into resuscitation room immediately. These patients were sent to resuscitation room directly for rescue and evaluation simultaneously without the necessity to be evaluated in triage table.2 Results of comparison between ERTA and MEWS for triage evaluation of illness.2.1 Comparing time of ERTA method and MEWS for triage evaluation Time for ERTA evaluation was 2.05+/-0.33 min, time for MEWS evaluation was 7.34 +/-1.37 min, t=83.94, P<0.001, indicating statistical significance. Time for ERTA evaluation was significantly shorter than that for MEWS method.2.2 Comparing detection rate of critical ill patients between ERTA method and MEWS See detail in Table 4. The detection rate of high risk patients, who were admitted to resuscitation room, in A grade and B grade patients by ERTA method was statistically different from that in patients whose MEWS score> 9, P<0.01. However, the detection rates of patients who admitted to ICU within 24 hours did not show statistical difference.2.3 Comparing detection rate of potential risk patients and mild patients, who were admitted to general ward/observation room, between ERTA method and MEWS. See details in Table 5. Potential risk patients by ERTA method and MEWS showed no statistical difference in hospital/observation room admission rate (P>0.05), mild patients by ERTA method and MEWS showed statistical significant difference in hospital/observation room admission rate (P<0.01).2.4 Inter-rater agreement analysis between ERTA tool, MEWS score and physician’s judgments.Data were described by sensitivity and specificity and analyzed by Kappa coefficient. See details of the inter-rater agreement between ERTA tool and physician’s judgments in Table 6. For rates of resuscitation room admission, ICU admission and observation room admission, the sensitivity was 81.4%, the specificity was 97.4%. Statistical analysis showed that the Kappa coefficient was 0.802, the inter-agreement analysis u=48.33, P<0.05. The data suggested ERTA highly agree with physician’s judgments. For agreement between MEWS score and physician’s judgment, the sensitivity and specificity for admission rate of resuscitation room, ICU and observation room were 72.6% and 47.84% respectively. The Kappa coefficient was 0.194, inter-agreement analysis u=7.47, P<0.05. The data suggested MEWS weakly agree with physician’s judgments.[Conclusions and suggestions]1 ConclusionsEmergency rapid triage assessment may rapidly, directly, simply, and accurately evaluate the severity of illness for emergency department patients. It is easy to use and grasp for nurses, and settles the foundation of information management for emergency triage. It is suitable for national conditions of our country and has the value for generalization in large hospitals.2 Provided basisThe tool could be used as supporting evaluation method of《Instructing principles of grading severity of emergency department patients (For seeking advices version)》 by National Health Department in 2011. The tool provide basis for making and establishment of national criteria of emergency triage.