Development and interrater reliability of the UK Mental Health Triage Scale

Mental health triage scales are clinical tools used at point of entry to specialist mental health service to provide a systematic way of categorizing the urgency of clinical presentations, and determining an appropriate service response and an optimal timeframe for intervention. The aim of the present study was to test the interrater reliability of a mental health triage scale developed for use in UK mental health triage and crisis services. An interrater reliability study was undertaken. Triage clinicians from England and Wales (n = 66) used the UK Mental Health Triage Scale (UK MHTS) to rate the urgency of 21 validated mental health triage scenarios derived from real occasions of triage. Interrater reliability was calculated using Kendall's coefficient of concordance (w) and intraclass correlation coefficient (ICC) statistics. The average ICC was 0.997 (95% confidence interval (CI): 0.996–0.999 (F (20, 1300) = 394.762, P < 0.001). The single measure ICC was 0.856 (95% CI: 0.776–0.926 (F (20, 1300) = 394.762, P < 0.001). The overall Kendall's w was 0.88 (P < 0.001). The UK MHTS shows substantial levels of interrater reliability. Reliable mental health triage scales employed within effective mental health triage systems offer possibilities for not only improved patient outcomes and experiences, but also for efficient use of finite specialist mental health services.     

Optimizing triage consistency in Australian emergency departments: The Emergency Triage Education Kit

Objective: The Emergency Triage Education Kit was designed to optimize consistency of triage using the Australasian Triage Scale. The present study was conducted to determine the interrater reliability of a set of scenarios for inclusion in the programme. Methods: A postal survey of 237 paper‐based triage scenarios was utilized. A quota sample of triage nurses (n = 42) rated each scenario using the Australasian Triage Scale. The scenarios were analysed for concordance and agreement. The criterion for inclusion of the scenarios in the programme was κ ≥ 0.6. Results: Data were collected during 2 April to 14 May 2007. Agreement for the set was κ = 0.412 (95% CI 0.410–0.415). Of the initial set: 92/237 (38.8%, 95% CI 32.6–45.3) showed concordance ≥70% to the modal triage category (κ = 0.632, 95% CI 0.629–0.636) and 155/237 (65.4%, 95% CI 59.3–71.5) showed concordance ≥60% to the modal triage category (κ = 0.507, 95% CI 0.504–0.510). Scenarios involving mental health and pregnancy presentations showed lower levels of agreement (κ = 0.243, 95% CI 0.237–0.249; κ = 0.319, 95% CI 0.310–0.328). Conclusion: All scenarios that showed good levels of agreement have been included in the Emergency Triage Education Kit and are recommended for testing purposes; those that showed moderate agreement have been incorporated for teaching purposes. Both scenario sets are accompanied by explanatory notes that link the decision outcome to the Australasian College for Emergency Medicine Guidelines on the Implementation of the Australasian Triage Scale. Future analysis of the scenarios is required to identify how task‐related factors influence consistency of triage.     

Measuring the effectiveness of the national Mental Health Triage Scale in an emergency department

ABSTRACT:   The mainstreaming process has significantly altered the means of access to mental health services in Australia. Increasingly people seeking mental health care present at general hospital emergency departments. The triage system, which has proven effective for prioritizing physical illness and injury, has proven problematic when applied to mental health-related problems. This paper presents the results of a study undertaken in the emergency department of a Victorian public hospital. The Mental Health Triage Scale was introduced and used independently by triage nurses and the psychiatric nurse consultants employed in the department. Following a 3-month period, the two sets of triage scores for psychiatric presentations ( n =  137) were compared. The findings suggest that triage nurses are rating clients experiencing mental health problems as in more urgent need of care than their psychiatric nursing counterparts. This suggests that the introduction of the guidelines alone is insufficient, and that education is required for more effective use of the tool.     

Education to improve the triage of mental health patients in general hospital emergency departments

General hospital emergency departments (EDs) are obvious places for individuals in distress or in a mental health crisis to seek assistance. However, triage nurses admit to a lack of expertise and confidence in psychiatric assessment which can result in less accurate assessments than for medical or trauma presentations. The objectives of a collaborative project between an Adult Mental Health Program and an Adult Emergency Program in a Canadian regional health authority were to: provide education and training to triage nurses regarding mental health and illness; monitor the transit of mental health patients through the ED; monitor wait times; and determine the adequacy of the Canadian Triage Acuity and Assessment Scale in the triage of psychiatric presentations. Although the percentages of patients triaged as "emergent" did not change as a result of the education, the percentage of patients who were triaged as "not urgent" but required hospitalization was significantly reduced. Although average lengths of stay in the ED were also reduced after the education, this may or may not have been related to the educational sessions. The project was successful in increasing collaboration between the two departments and has resulted in enhanced, on-going mental health education for ED nurses.     

Investigating the validity and usability of an interactive computer programme for assessing competence in telephone‐based mental health triage

Telephone‐based mental health triage services are frontline health‐care providers that operate 24/7 to facilitate access to psychiatric assessment and intervention for people requiring assistance with a mental health problem. The mental health triage clinical role is complex, and the populations triage serves are typically high risk; yet to date, no evidence‐based methods have been available to assess clinician competence to practice telephone‐based mental health triage. The present study reports the findings of a study that investigated the validity and usability of the Mental Health Triage Competency Assessment Tool, an evidence‐based, interactive computer programme designed to assist clinicians in developing and assessing competence to practice telephone‐based mental health triage.     

The triage of psychiatric patients in the hospital emergency department: a comparison between emergency department nurses and psychiatric nurse consultants

The triage of patients in the hospital emergency department (ED) has developed as an efficient method to determine the level of urgency and provide appropriate care and treatment. The triage process has been found to be less effective for patients presenting with mental health related problems. Triage guidelines specifically tailored for mental health needs have been introduced in the attempt to overcome existing problems, however, the effectiveness of these guidelines has not been extensively tested. This paper presents the findings of a study conducted in a large metropolitan hospital in Melbourne, Australia. All presentations to the ED for psychiatric problems (n = 137) were triaged using the mental health guidelines over a 3-month period. The same presentations were triaged by psychiatric nurse consultants employed in the ED and the results compared. The results indicate a high level of difference in the triage ranking by the two groups of nurses, with emergency nurses tending to classify presentations as more urgent than their psychiatric nurse colleagues. These findings suggest that mental health education for emergency nurses is necessary if the guidelines are to be used effectively and improve outcomes for patients presenting with psychiatric problems.     

Assessing the risk of suicide at triage

Mental health related presentations to Australian emergency departments are steadily increasing. There is a growing incidence of depression, substance abuse, and other mental illnesses in the Australian population. Mental health problems will contribute 15% of the total world disease burden by 2020. Triage nurses are pivotal to the early detection and management of mental health problems.

The rapid assessment of mental health presentations at triage requires skill, knowledge, experience and confidence. One of the more complex aspects of triage is suicide risk assessment.     

Factors influencing consistency of triage using the Australasian Triage Scale: Implications for guideline development

Objective: To examine the influence of the nurse, the type of patient presentation and the level of hospital service on consistency of triage using the Australasian Triage Scale. Methods: A secondary analysis of survey data was conducted. The main study was undertaken to measure the reliability of 237 scenarios for inclusion in a national training programme. Nurses were recruited from a quota sample of Australian ED according to peer group. Analysis was performed to determine concordance: the percentage of responses in the modal triage category. Analysis of variance (anova ) and Pearson correlations were used to investigate associations between the explanatory variables and concordance. Results: A total of 42/50 (84%) participants returned questionnaires, providing 9946 scenario responses for analysis. Significant differences in concordance were observed by variables describing the type of patient presentation and level of urgency. Mean scores for the comparison group (adult pain; 70.7%) were higher than the groups involving a mental health or pregnancy presentations (61.4%; P≤ 0.001; 65.0%; P= 0.02). Modal responses at the extreme ends of the scale were higher than in the middle categories (P≤ 0.001). There was a significant main effect on concordance by type of service according to peer group (P= 0.03). Of the nine variables that described nurse characteristics, age was the only factor to influence the outcome (P= 0.05). Conclusion: We identified significant problems with the consistency of triage for mental health and pregnancy presentations. Further research is needed to improve the guidelines on the implementation of the Australasian Triage Scale for these populations.     

Substance misuse, anxiety and depression and urgency of presentation to a public emergency department in Australia

Objectives: To establish the prevalence and comorbidity of substance‐related problems and anxiety and depression, among ED presentations, and to compare the prevalence of these conditions among more and less urgent presentations. Design and setting: Cross‐sectional survey of ED presentations over a 14 day period (24 h/day) at the Gold Coast Hospital Emergency Department in south‐east Queensland, Australia, in October 2002. Measures: Usual level of alcohol consumption (Alcohol Use Disorders Identification Test), acute alcohol and illicit drug use (during 24 h prior to interview), symptoms of anxiety and depression (Hospital Anxiety and Depression Scale) and triage category (Australasian Triage Scale). Results: Thirty‐one per cent of the sample reported usually consuming alcohol at a hazardous or harmful level. Twenty per cent of participants reported clinically significant levels of anxiety and/or depression, which were in turn significantly associated with hazardous and harmful levels of alcohol use. Hazardous/harmful alcohol consumption was over‐represented among less urgent ED presentations, whereas anxiety and depression were more prevalent among more urgent ED presentations. Conclusions: Emergency departments in Australia are appropriate settings for the detection of both substance use and mental health problems in the wider community. The prevalence of these problems in ED settings is high and there is a need for the development of systematic screening and referral processes. The evidence of a link between urgency of presentation and these problems needs to be further explored.     

Emergency Triage: Comparing a Novel Computer Triage Program with Standard Triage

Background: Emergency department (ED) triage prioritizes patients based on urgency of care; however, little previous testing of triage tools in a live ED environment has been performed. Objectives: To determine the agreement between a computer decision tool and memory‐based triage. Methods: Consecutive patients presenting to a large, urban, tertiary care ED were assessed in the usual fashion and by a blinded study nurse using a computerized decision support tool. Triage score distribution and agreement between the two triage methods were reported. A random subset of patients was selected and reviewed by a blinded expert panel as a consensus standard. Results: Over five weeks, 722 ED patients were assessed; complete data were available from 693 (96%) score pairs. Agreement between the two methods was poor (κ= 0.202; 95% confidence interval [95% CI] = 0.150 to 0.254); however, agreement improved when using weighted κ (0.360; 95% CI = 0.305 to 0.415) or “within one” level κ (0.732; 95% CI = 0.644 to 0.821). When compared with the expert panel, the nurse triage scores showed lower agreement (0.263; 95% CI = 0.133 to 0.394) than the tool (κ= 0.426; 95% CI = 0.289 to 0.564). There was a significant down‐triaging of patients when patients were triaged without the computerized tool. Admission rates also differed between the triage systems. Conclusions: There was significant discrepancy by nurses using memory‐based triage when compared with a computer tool. Triage decision support tools can mitigate this drift, which has administrative implications for EDs.     

A study of triage of paediatric patients in Australia

Objectives: To describe the triage of children in a sample of mixed and paediatric emergency departments in Australia in 1999 and to measure the inter‐rater reliability of the National Triage Scale when used by triage nurses for the triage of paediatric patients. Methods: A questionnaire was sent to 11 hospitals, including one paediatric and one mixed emergency department, in each state studied. Triage nurses were asked to assess 25 paediatric patient profiles and to assign appropriate triage categories to each profile. The number of responses within the modal triage category (concurrence), the percentage of responses with a concurrence of at least 50% and the number of responses within one triage category of the modal response (spread) of responses were measured. Triage data for 1999 from the same emergency departments were collected and numbers of children seen and admitted in each triage category were described. The patterns of distribution of triage categories for specific paediatric diagnoses (triage ‘footprints’) were also described. Data from mixed emergency departments were grouped and compared with data from paediatric emergency departments and any differences were described. Results: Seventy‐eight nurses in 10 hospitals responded to the questionnaire. Sixty‐three per cent of all responses had a concurrence of greater than 50%. Ninety‐four per cent of patient profiles were triaged to within one triage category of their modal response. Nurses in paediatric emergency departments (concurrence greater than 50% for 79% of responses) were significantly more consistent in their use of the National Triage Scale compared with nurses in mixed emergency departments (concurrence greater than 50% for 50% of responses). Paediatric emergency department triage nurses were more likely to use the full range of the National Triage Scale and were fourfold as likely to allocate triage categories 4 and 5 to patient profiles. Paediatric hospitals allocated patients to triage categories 4 and 5 for an average of 71% of presentations compared with 47% for mixed emergency departments. Specific diagnoses had characteristic distributions of triage categories, with similar differences seen when comparisons were made between mixed and paediatric emergency departments. Conclusion: Use of the National Triage Scale for the triage of paediatric patients by triage staff is not consistent and there are significant differences between the triage practices of paediatric and mixed emergency departments.     

Doctor at triage – Effect on waiting time and patient satisfaction in a Jamaican hospital

IntroductionWaiting time in the Emergency Departments is a major source of patient dissatisfaction in hospitals. Triage attempts to have the most critically ill patients seen first with an overall reduction in waiting time. Triage teams may include specially trained nurses or alternatively a specialist physician. The aim of this study was to determine if inclusion of a specialist physician on the triage team at the University Hospital of the West Indies (UHWI) in Kingston Jamaica reduced waiting time and improved patient satisfaction.MethodsA prospective, cross sectional survey of ambulatory care patients was undertaken in 2006. Triage was completed by a team consisting of a doctor and two nurses during the first week and by nurses only during the second week.ResultsThe study showed that there was no significant difference in the length of time patients spent in the emergency department based on whether or not they were triaged by a physician led team or by a team of nurses only. Type of triage team did not affect the level of patient satisfaction. Waiting time was significantly influenced by factors which came into play after triage such as the wait for X-ray and laboratory services.ConclusionsThere appears to be no reduction in waiting times experienced by patients at the UHWI emergency department as a result of inclusion of a specialist emergency physician in the triage process. This suggests that specialist emergency department nurses are adequately trained in triage, and that delays in the triage process at UHWI are due to other factors.     

Comparison of Canadian triage acuity scale to Australian Emergency Mental Health Scale triage system for psychiatric patients

ObjectivesThe purpose of the study was to compare the Canadian Triage and Acuity Scale protocol to the Australian Emergency Mental Health Triage System protocol for evaluation of psychiatric patients and time to be evaluated in the emergency department.MethodsA convenience sample of 105 patients who presented with psychiatric complaints at triage was given the Canadian Triage and Acuity Scale (CTAS) by the nurse at triage. A second triage assessment using the Australian Emergency Mental Health Triage Scale was performed by trained research fellows. The study was performed at an inner city level one trauma center with 40,000 visits per year during 2012. The study was approved by the IRB.ResultsUse of the CTAS rated almost half the patients (48%) urgent and (29%) emergent. The Australian Emergency Mental Health Triage Scale scored the same patients differently with (75%) coding as no danger to self or others, (18%) scoring as in moderate distress. The CTAS was not able to meet the recommended times to be seen, especially for patients rated as urgent. The Australian Emergency Mental Health Scale system, with the exception of triage level 1, was able to meet the recommendations for wait times to be medically evaluated and in the case of the lower levels seen sooner than recommended.ConclusionsThe use of the CTAS protocol does not correlate with patients' being medically evaluated within the time frames recommended especially for the more urgent patients. The Australian Emergency Mental Health Scale rated patients' presentations as far less urgent and thus the time frame recommendations to be evaluated were more closely aligned with the protocol as compared to the CTAS system. The Australian Emergency Mental Health Scale provided less ambiguous mental health specific triage guidelines that allowed for improvements in patient outcomes by better matching the ED's resources to the psychiatric patients' specific needs.     

The Canadian Triage and Acuity Scale: A Canadian perspective on emergency department triage

The Canadian Triage and Acuity Scale has received widespread acceptance in Canada as a reliable and valid tool for emergency department triage. The importance of accurate triage becomes more apparent as emergency department volumes increase, and resources shrink. The need to ensure that those patients requiring more urgent care receive care first is the basis for all triage scales. Through the Canadian Triage and Acuity Scale National Working Group, the scale became the recommended triage tool for Canadian emergency departments. Work has been done on the interrater reliability of Canadian Triage and Acuity Scale among health care providers. There is a need to further assess the validity of the scale. This scale has now been applied in the out of hospital setting by paramedics and is being used in measurements of emergency physician workload. The future may see an electronic triage tool develop for emergency department use to reduce variability in its application. The Canadian Triage and Acuity Scale has become an integral component of Canadian emergency departments.     

The influence of patient acuity on satisfaction with emergency care: perspectives of family, friends and carers

Aims and objectives. To investigate the factors that influence satisfaction with emergency care among individuals accompanying patients to the emergency department and explore agreement between the triage nurse and accompanying person regarding urgency. Background. Many patients seeking treatment in hospital are escorted by an accompanying person, who may be a friend, family member or carer. Several factors influence patient satisfaction with emergency care, including waiting time and time to treatment. It is also influenced by provision of information and interpersonal relations between staff and patients. Research on satisfaction has focused on the patient perspective; however, individuals who accompany patients are potential consumers. Knowledge about the ways accompanying persons perceive the patient's medical condition and level of urgency will identify areas for improved patient outcomes. Design and methods. A prospective cross‐sectional survey with a consecutive sample (n = 128 response rate 83·7%) was undertaken. Data were collected in an Australian metropolitan teaching hospital with about 32,000 visits to the emergency department each year. The Consumer Emergency Satisfaction Scale was used to measure satisfaction with nursing care. Results. Significant differences in perceptions of patient urgency between accompanying persons and nurses were found. Those people accompanying patients of a higher urgency were significantly more satisfied than those accompanying patients of a lower urgency. These results were independent of real waiting time or the accompanying person's knowledge of the patients’ triage status. In addition, older accompanying persons were more satisfied with emergency care than younger accompanying persons. Discussion. Little attention has been paid to the social interactions that occur between nurses and patients at triage and the ways in which these interactions might impact satisfaction with emergency care. Relevance to clinical practice. Good interpersonal relationships can positively influence satisfaction with the emergency visit. This relationship can contribute to improved patient care and health outcomes.     

Effects of a Triage Process Conversion on the Triage of High‐risk Presentations

Objectives: The objective was to determine effects of a modification in triage process on triage acuity distribution in general and among patients with conditions requiring time‐sensitive therapy. Methods: The authors retrospectively reviewed triage acuity distributions before and after modification of their triage process that entailed conversion from the Canadian Triage and Acuity Scale (CTAS) to the Emergency Severity Index (ESI). The authors calculated the ratio of the odds of being triaged to a nonemergent level (3, 4, or 5) under ESI to the odds of being triaged as nonemergent under CTAS. The authors calculated sensitivity and specificity of triage to an emergent acuity level (1 or 2) for identifying patients with common presentations who required time‐sensitive care. Results: There were shifts from higher to lower acuity levels for all subsets, with odds ratios ranging from 2.80 (95% confidence interval [CI] = 2.75 to 2.86) for all patients to 21.39 (95% CI = 14.66 to 31.21) for patients over 55 years of age with a chief complaint of chest pain. The sensitivity of triage for identifying abdominal pain patients requiring admission to an intensive care unit (ICU) or operating room (OR) or emergency department (ED) death was 80.7% (95% CI = 73.2 to 86.5) before versus 50.8% (95% CI = 43.5 to 58.1) following the transition to ESI. Specificity under CTAS, 55.2% (95% CI = 54.0 to 56.4), was significantly lower than under ESI, 83.6% (95% CI = 82.7 to 84.4). The authors found similar effects for patients presenting with chest pain. Conclusions: Monitoring for changes in the sensitivity of the triage process for detecting patients with potentially time‐sensitive conditions should be considered when modifying triage processes. Further work should be done to determine if the decreased sensitivity seen in this study occurs in other institutions converting to ESI, and potential causative factors should be explored.     

The clinical practice of Emergency Department Triage: Application of the Australasian Triage Scale—An extended literature review Part I: Evolution of the ATS

The aim of this extended literature review was to identify themes in the current Australian and international literature that relate to the clinical application of the Australasian Triage Scale in Australian Emergency Departments. The review has been divided into three parts. Part I—The Evolution of the Australasian Triage Scale details the history of Emergency Department Triage in Australia.

In Part II themes are examined specifically in relation to their effect on the clinical application of the Australasian Triage Scale and include Validity and Reliability, Decision-making, Role and Process, Education, Outcome Measurement, Research Methodology, Emergency Nurse Practitioners, and Control and Controls.

In Part III impact of the Australasian Triage Scale on previously identified problems within the literature relating to the National Triage Scale, lack of triage education, lack of paediatric and mental health applicability, defining waiting time, doctor seen time, relevance in the rural setting, and idiosyncrasies in application, are also examined in regards to improvement since the introduction of the Australasian Triage Scale.

Finally, the evidence is examined in relation to the themes and issues raised during the extended literature review. Triage education is the overriding issue which impacts all other themes and issues within this review. Eleven specific but interrelated recommendations are made to ensure triage fulfils its ethical and moral obligations to patients who present to Australian Emergency Departments in the future.     

Predictors of critical care admission in emergency department patients triaged as low to moderate urgency

Title. Predictors of critical care admission in emergency department patients triaged as low to moderate urgency. Aim. This paper is a report of a study to identify predictors of critical care admission in emergency department patients triaged as low to moderate urgency that may be apparent early in the emergency department episode of care. Background. Observations of clinical practice show that a number of emergency department patients triaged as low to moderate urgency require critical care admission, raising questions about the relationship between illness severity and physiological status early in the emergency department episode of care. Methods. A retrospective case control design was used. All participants were aged over 18 years, triaged to Australasian Triage Scale categories 3, 4 or 5, and attended emergency department between 1 July 2004 and 30 June 2005. Cases were admitted to intensive care unit or coronary care unit and controls were admitted to general medical or surgical units. Cases (n = 193) and controls (n = 193) were matched by age, gender, emergency department discharge diagnosis and triage category. Results. Critical care admission associated with: (i) a presenting complaint of nausea, vomiting and diarrhoea (OR = 3·40, 95%CI:1·22–9·47, P = 0·019), (ii) heart rate abnormalities at triage (OR = 2·10, 95%CI:1·19–3·71, P = 0·011), (iii) temperature abnormalities at triage (OR = 2·87 95%CI:1·05–7·89, P = 0·041), (iv) respiratory rate at first nursing assessment (OR = 1·66, 95%CI:1·05–2·06, P = 0·31) or (v) heart rate abnormalities at first nursing assessment (OR = 1·57, 95%CI = 1·04?2·39, P = 0·033). Conclusion. Derangements in temperature, respiratory rate and heart appear to increase risk of critical care admission. Further work using a prospective approach is needed to establish which physiological parameters have the highest predictive validity, the level(s) of physiological abnormality with highest clinical utility, and the optimal timing for collection of physiological data.     

Implementation and Refinement of the Emergency Severity Index

OBJECTIVES: To implement a new five-level emergency department (ED) triage algorithm, the Emergency Severity Index (ESI), into nursing practice, and validate the instrument with a population-based cohort using hospitalization and ED length of stay as outcome measures. METHODS: The five-level ESI algorithm was introduced to triage nurses at two university hospital EDs, and implemented into practice with reinforcement and change management strategies. Interrater reliability was assessed by a posttest and by a series of independent paired patient triage assignments, and a staff survey was performed. A cohort validation study of all adult patients registered during a one-month period immediately following implementation was performed. RESULTS: Eight thousand two hundred fifty-one ED patients were studied. Weighted kappa for reproducibility of triage assignments was 0.80 for the posttest (n = 62 nurses), and 0.73 for patient triages (n = 219). Hospitalization was 28% overall and was strongly associated with triage level, decreasing from 58/63 (92%) of patients in triage category 1, to 12/739 (2%) in triage category 5. Median lengths of stay were two hours shorter at either triage extreme (high and low acuity) than in intermediate categories. Outcomes followed a-priori predictions. Staff nurses rated the new program easier to use, and more useful as a triage instrument than previous three-level triage. They provided feedback, which resulted in significant revisions to the algorithm and educational materials. CONCLUSIONS: Triage nurses at these two hospitals successfully implemented the ESI algorithm and provided useful feedback for further refinement of the instrument. Emergency Severity Index triage reproducibly stratifies patients into five groups with distinct clinical outcomes.