Emergency department (ED) triage is used to identify patients' level of urgency and treat them based on their triage level. The global advancement of triage scales in the past two decades has generated considerable research on the validity and reliability of these scales. This systematic review aims to investigate the scientific evidence for published ED triage scales. The following questions are addressed:1. Does assessment of individual vital signs or chief complaints affect mortality during the hospital stay or within 30 days after arrival at the ED?2. What is the level of agreement between clinicians' triage decisions compared to each other or to a gold standard for each scale (reliability)?3. How valid is each triage scale in predicting hospitalization and hospital mortality?A systematic search of the international literature published from 1966 through March 31, 2009 explored the British Nursing Index, Business Source Premier, CINAHL, Cochrane Library, EMBASE, and PubMed. Inclusion was limited to controlled studies of adult patients (≥15 years) visiting EDs for somatic reasons. Outcome variables were death in ED or hospital and need for hospitalization (validity). Methodological quality and clinical relevance of each study were rated as high, medium, or low. The results from the studies that met the inclusion criteria and quality standards were synthesized applying the internationally developed GRADE system. Each conclusion was then assessed as having strong, moderately strong, limited, or insufficient scientific evidence. If studies were not available, this was also noted.We found ED triage scales to be supported, at best, by limited and often insufficient evidence.The ability of the individual vital signs included in the different scales to predict outcome is seldom, if at all, studied in the ED setting. The scientific evidence to assess interrater agreement (reliability) was limited for one triage scale and insufficient or lacking for all other scales. Two of the scales yielded limited scientific evidence, and one scale yielded insufficient evidence, on which to assess the risk of early death or hospitalization in patients assigned to the two lowest triage levels on a 5-level scale (validity).

BackgroundOvercrowding in emergency departments is a worldwide problem. A systematic literature review was undertaken to scientifically explore which interventions improve patient flow in emergency departments.MethodsA systematic literature search for flow processes in emergency departments was followed by assessment of relevance and methodological quality of each individual study fulfilling the inclusion criteria. Studies were excluded if they did not present data on waiting time, length of stay, patients leaving the emergency department without being seen or other flow parameters based on a nonselected material of patients. Only studies with a control group, either in a randomized controlled trial or in an observational study with historical controls, were included. For each intervention, the level of scientific evidence was rated according to the GRADE system, launched by a WHO-supported working group.ResultsThe interventions were grouped into streaming, fast track, team triage, point-of-care testing (performing laboratory analysis in the emergency department), and nurse-requested x-ray. Thirty-three studies, including over 800,000 patients in total, were included. Scientific evidence on the effect of fast track on waiting time, length of stay, and left without being seen was moderately strong. The effect of team triage on left without being seen was relatively strong, but the evidence for all other interventions was limited or insufficient.ConclusionsIntroducing fast track for patients with less severe symptoms results in shorter waiting time, shorter length of stay, and fewer patients leaving without being seen. Team triage, with a physician in the team, will probably result in shorter waiting time and shorter length of stay and most likely in fewer patients leaving without being seen. There is only limited scientific evidence that streaming of patients into different tracks, performing laboratory analysis in the emergency department or having nurses to request certain x-rays results in shorter waiting time and length of stay.

Objective To compare immediate computed tomography during triage for admission with observation in hospital in patients with mild head injury. Design Multicentre, pragmatic, non-inferiority randomised trial.

Objective To compare the costs of immediate computed tomography during triage for admission with those of observation in hospital in patients with mild head injury. Design Prospective cost effectiveness analysis within a multicentre, pragmatic randomised trial. Setting 39 acute hospitals in Sweden Participants 2602 patients (aged ≥ 6) with mild head injury. Interventions Immediate computed tomography or admission for observation. Main outcome measures Direct and indirect costs related to the mild head injury during the acute and three month follow-up period. Results Outcome after three months was similar for both strategies (non-significantly in favour of computed tomography). For the acute stage and complications, the cost was 461 euros (£314, $582) per patient in the computed tomography group and 677 euros (£462, $854) in the observation group; an average of 32% less in the computed tomography group (216 euros, 95% confidence interval -272 to -164; P < 0.001). Sensitivity analysis showed that computed tomography was the most cost effective strategy under a broad range of assumptions. After three months, total costs were 718 euros and 914 euros per patient-that is, 196 euros less in the computed tomography group ( − 281 to − 114; P < 0.001). The lower cost of the computed tomography strategy at the acute stage thus remained unchanged during follow-up. Conclusion Patients with mild head injury attending an emergency department can be managed more cost effectively with computed tomography rather than admission for observation in hospital. Trial registration ISRCTN81464462.

There was no obvious advantage with initial high-dose thrombolysis, which may be a type-2 error. A reduction of major re-interventions was recorded.