Validity of ED: Addressing heterogeneous definitions of over-triage and under-triage

Lentz, Brian; Jenson, Alexander; Hinson, Jeremiah S.; Levin, Scott R.; Cabral, Stephanie; George, Kevin; Hsu, Edbert B.; Kelen, Gabor D.; Hansoti, Bhakti

doi:10.1016/j.ajem.2017.02.012

Cited by 22 publications

(34 citation statements)

References 50 publications

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“…Additionally, lack of consensus on what most appropriately constitutes over-and under-triage and lack of validated target metrics for these measures are inherent to all triage studies. 17,24,25 Multiple established target metrics have been reported on here to mitigate this. However, the fact these target metrics have been developed in high-income countries, further compounds this challenge.…”

Section: Limitationsmentioning

confidence: 99%

Dispatcher Triage Accuracy in the Western Cape Government Emergency Medical Services System, Cape Town, South Africa

Alshehri

Pigoga

Wallis

2020

Prehosp. Disaster med.

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Introduction: Triage - the sorting of patients according to urgency of need for clinical care - is an essential part of delivering effective and efficient emergency care. But when frequent over- or under-triaging occurs, finite time and resources are diverted away from those in greatest need of care and the entire Emergency Medical Services (EMS) system is strained. In resource-constrained settings, such as South Africa, poor triage in EMS only serves to compound other contextual challenges. This study examined the accuracy of dispatcher triage over a one-year period in the Western Cape Government (WCG) EMS system in South Africa. Methods: A retrospective analysis of existing dispatch and EMS data to assess the accuracy of dispatch-assigned priorities was conducted. The mismatch between dispatcher-assigned call priority and triage levels determined by EMS personnel was analyzed via over- and under-triage rates, sensitivity and specificity, and positive and negative predictive values (PPVs and NPVs, respectively). Results: A total of 185,166 records from December 2016 through November 2017 were analyzed. Across all dispatch complaints, the over-triage rate was 67.6% (95% CI, 66.34-68.76) and the under-triage rate was 16.2% (95% CI, 15.44-16.90). Dispatch triage sensitivity for all included records was 49.2% (95% CI, 48.10-50.38), specificity 71.9% (95% CI, 71.00-72.92), PPV 32.5% (95% CI, 30.02-34.88), and NPV 83.8% (95% CI, 81.93-85.73). Conclusion: This study provides the first evaluation of dispatch triage accuracy in the WCG EMS system, identifying that the system is suffering from both under- and over-triage. Despite variance across dispatch complaints, both under- and over-triage remained higher than widely accepted norms, and all rates were significantly above acceptable target metrics described in similar studies. Results of this study will be used to motivate the development of more rigorous training programs and resources for WCG EMS dispatchers, including improved dispatch protocols for conditions suffering from high over- and under-triage.

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Section: Limitationsmentioning

confidence: 99%

Dispatcher Triage Accuracy in the Western Cape Government Emergency Medical Services System, Cape Town, South Africa

Alshehri

Pigoga

Wallis

2020

Prehosp. Disaster med.

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“…Como principal limitación, nuestra definición fue pragmática y basada en la factibilidad de medición más allá de las definiciones bibliográficas de subtriaje 17 . Sin embargo, no permite discriminar el desacuerdo entre la evaluación inicial por parte de enfermería del triaje y la evaluación final por parte de un médico (decisión de hospitalización en UCI), si el mismo fue realmente una evaluación errónea en la interpretación del paciente a su ingreso 18 o fue explicado debido a la evolución tórpida durante el proceso de atención.…”

Section: Discussionunclassified

Medición del subtriaje como indicador de calidad y seguridad en un servicio de urgencias

et al. 2020

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Undertriage as quality of care parameter in an emergency department Background: Undertriage or the underestimation of the urgency of the condition of a person arriving in an emergency department (ED) represents a measure of quality care. Aim: To estimate the prevalence of undertriage in a high complexity hospital of Argentina; to describe characteristics and mortality of these patients. Material and Methods: All consultations admitted to the ED during 2014 were analyzed. Those assigned to a lower level of admission risk (classified as Emergency Severity Index-ESI-3 to 5) but required hospitalization in intensive care units (ICU) as the first hospitalization place were considered as an undertriage. A random sample of correctly categorized admissions (ESI 1 or 2), who were subsequently hospitalized in the ICU, was selected as a comparison group. Results: The global undertriage prevalence was 0.30% (316/104,832). Among patients admitted to the ICU, the prevalence was 21% (316/1,461; 95% confidence intervals (CI) 19-24). The 316 patients whose severity was underestimated had a median age of 73 years, and admitted between 7 a.m. and 9 p.m. in a greater proportion. Overall hospital mortality was 8.9% (95% CI 6.78-11.38), and all deaths occurred after the patient was transferred from the emergency room. There were no differences in mortality between patients with correct triage or undertriage (11 and 7% respectively, p = 0.09). No differences were observed either in the total number of critical interventions during care in the first 24 hours. Significant differences were observed in requirements for mechanical ventilation (11 and 4% respectively, p = 0.01), orotracheal intubation (10 and 5% respectively p = 0.01) and non-invasive ventilation (8 and 4% respectively, p = 0.05). Conclusions: Undertriage rate in this series was low, but it can be improved.

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“…The four‐level triage system has been shown to exhibit a good reliability and validity using expert‐based metrics of over‐/under‐triage in China . Some studies have pointed out that outcome‐based metrics (such as admission/discharge) have been chosen as the preferred methodology in numerous studies, so we measured over‐/under‐triage by analyzing the proportion of patients under emergency observation, and found that older people are more prone to under‐triage . According to China's triage criteria, level IV patients have stable vital signs, and the proportion of young patients assigned to observation status (1.8%) is reasonable, but the proportion of older level IV patients is up to 12%; this shows that the severity of older patients’ conditions cannot be explained solely by their state at the time of the visit.…”

Section: Discussionmentioning

confidence: 99%

“…15 Some studies have pointed out that outcomebased metrics (such as admission/discharge) have been chosen as the preferred methodology in numerous studies, so we measured over-/under-triage by analyzing the proportion of patients under emergency observation, and found that older people are more prone to under-triage. 16,17 According to China's triage criteria, level IV patients have stable vital signs, and the proportion of young patients assigned to observation status (1.8%) is reasonable, but the proportion of older level IV patients is up to 12%; this shows that the severity of older patients' conditions cannot be explained solely by their state at the time of the visit. We believe that there should be a more relaxed standard of triage for older adults, or older adults receive priority under the same criteria, because it is possible that older patients were more seriously ill than their younger counterparts at the same triage level.…”

Section: Discussionmentioning

confidence: 99%

Older adults are prioritized in terms of waiting time under the emergency triage system in Guangzhou, China

Pan

Zhang

et al. 2019

Geriatrics Gerontology Int

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Aim To assess whether elderly patients are prioritized under the emergency triage system in Guangzhou, China. Methods This was a cross‐sectional survey of clinical data from adult visitors to the emergency department of the Third Affiliated Hospital of Sun Yat‐sen University between 1 August 2015 and 31 December 2017. The primary end‐point was receiving the first medical service within the target waiting time, which varied according to the triage level of the patient. Multivariate logistic regression was used to determine whether age was an independent predictor of a shorter waiting time. Results Data from 262 282 emergency patients were analyzed. The mean age of patients was 35.97 years, and 7.5% were aged ≥65 years. In total, 88.3% of patients received medical service within the target waiting time, and 87.4% of elderly patients received medical service within the target waiting time. Multivariate logistic regression analysis showed that advanced age was independently associated with receiving medical service within the target waiting time (adjusted odds ratio 1.258, 95% confidence interval 1.198–1.321; P < 0.001). The triage level, type of emergency subdivision, availability of outpatient services and time of day were also associated with receiving medical service within the target waiting time. Conclusion Under the emergency triage system of the hospital, older adults are more likely to receive medical service within the target waiting time than younger patients. Geriatr Gerontol Int 2019; 19: 786–791.

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Validity of ED: Addressing heterogeneous definitions of over-triage and under-triage

Cited by 22 publications

References 50 publications

Dispatcher Triage Accuracy in the Western Cape Government Emergency Medical Services System, Cape Town, South Africa

Dispatcher Triage Accuracy in the Western Cape Government Emergency Medical Services System, Cape Town, South Africa

Medición del subtriaje como indicador de calidad y seguridad en un servicio de urgencias

Older adults are prioritized in terms of waiting time under the emergency triage system in Guangzhou, China

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