UK triage – An improved tool for an evolving threat

Background. Triage is one of the core requirements for the provision of effective emergency care and has been shown to reduce patient mortality. However, in low-and middle-income countries this strategy is underused, under-resourced and poorly researched. Objective. To assess the inter-and intra-rater reliability and accuracy of nurse triage ratings when using the South African Triage Scale (SATS) in an emergency department (ED) in Timergara, Pakistan. Methods. Fifteen ED nurses assigned triage ratings to a set of 42 reference vignettes (written case reports of ED patients) under classroom conditions. Inter-rater reliability was assessed by comparing these triage ratings; intra-rater reliability was assessed by asking the nurses to re-triage 10 random vignettes from the original set of 42 vignettes and comparing these duplicate ratings. Accuracy of the nurse ratings was measured against the reference standard. Results. Inter-rater reliability was substantial (intraclass correlation coefficient 0.77; 95% confidence interval (CI) 0.69 -0.85). The intrarater agreement was also high with 87% exact agreement (95% CI 67 -100) and 100% agreement allowing for a one-level discrepancy in triage ratings. Overall, the SATS had high specificity (97%) and moderate sensitivity (70%). Across all acuity levels the proportion of overtriage did not exceed the acceptable threshold of 30 -50%. Under-triage was acceptable for all except emergency cases (66%). Conclusion. ED nurses in Pakistan can reliably use the SATS to assign triage acuity ratings. While the tool is accurate for 'very urgent' and 'routine' cases, importantly, it may under-triage 'emergency' cases requiring immediate attention. Approaches that will improve accuracy and validity are discussed.

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“…22,23 Within a military setting, simple modifications have been proposed to the heart rate and respiratory rate components of the military sieve, demonstrating an improvement in its performance characteristics. 9 During a subsequent prospective validation and comparative analysis, the modified military sieve was demonstrated to have a statistically significant increase in performance when compared to existing methods. 11 Table 4: Comparative analysis by study.…”

Section: Discussionmentioning

confidence: 98%

“…11 Table 4: Comparative analysis by study. 5,9,10 This study has successfully created the Modified Physiological Triage Tool and is the first study where physiological thresholds within triage tools have been derived using logistical regression to individually predict need for life-saving intervention. Whilst ISS was measured within our population, we chose specifically to measure triage tool performance against need for life-saving intervention.…”

Section: Discussionmentioning

confidence: 99%

“…5,7 Definitions exist for the paediatric and military patient, but until recently there has not been an accepted, consensus definition of what constitutes a civilian priority one adult patient at a major incident. 4,8,9 To date, there has been no prospective validation of the major incident triage tools during a major incident; this is unlikely to be possible in the future due to both ethical and logistical constraints.…”

Section: Introductionmentioning

confidence: 99%

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Major incident triage: Derivation and comparative analysis of the Modified Physiological Triage Tool (MPTT)

Vassallo

Beavis

Smith

et al. 2017

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Major Incident triage: derivation and comparative analysis of the Modified Physiological Triage Tool (MPTT). Background:Triage is a key principle in the effective management at a major incident. There are at least three different triage systems in use worldwide and previous attempts to validate them, have revealed limited sensitivity. Within a civilian adult population, there has been no work to develop an improved system. Methods:A retrospective database review of the UK Joint Theatre Trauma Registry was performed for all adult patients (>18 years) presenting to a deployed Military Treatment Facility between 2006-2013.Patients were defined as Priority One if they had received one or more life-saving interventions from a previously defined list.Using first recorded hospital physiological data (HR/RR/GCS), binary logistic regression models were used to derive optimum physiological ranges to predict need for life-saving intervention. This allowed for the derivation of the Modified Physiological Triage Tool -MPTT (GCS<14, HR>100, 1222). A comparison of the MPTT and existing triage tools was then performed using sensitivities and specificities with 95% confidence intervals. Differences in performance were assessed for statistical significance using a McNemar test with Bonferroni correction. Results:Of 6095 patients, 3654 (60.0%) had complete data and were included in the study, with 1738 (47.6%) identified as priority one. Existing triage tools had a maximum sensitivity of 50.9% (Modified Military Sieve) and specificity of 98.4% (Careflight). The MPTT (sensitivity 69.9%, 95% CI 0.677-0.720, specificity 65.3%, 95% CI 0.632-0.675) showed an absolute increase in sensitivity over existing tools ranging from 19.0% (Modified Military Sieve) to 45.1% (Triage Sieve). There was a statistically significant difference between the performance (p < 0.001) between the MPTT and the Modified Military Sieve. Discussion & Conclusion:The performance characteristics of the MPTT exceed existing major incident triage systems, whilst maintaining an appropriate rate of over-triage and minimising under-triage within the context of predicting the need for a life-saving intervention in a military setting. Further work is required to both prospectively validate this system and to identify its performance within a civilian environment, prior to recommending its use in the major incident setting. Keywords:Triage, Major incidents, life-saving intervention, physiological predictors

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UK triage – An improved tool for an evolving threat

Cited by 25 publications

References 23 publications

Usefulness of the Shock Index as a secondary triage tool

Usefulness of the Shock Index as a secondary triage tool

Reliability and accuracy of the South African Triage Scale when used by nurses in the emergency department of Timergara Hospital, Pakistan

Major incident triage: Derivation and comparative analysis of the Modified Physiological Triage Tool (MPTT)

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