Evolution of triage systems

The French word “trier”, the origin of the word “triage”, was originally applied to a process of sorting, probably around 1792, by Baron Dominique Jean Larrey, Surgeon in Chief to Napoleon's Imperial Guard. Larrey was credited with designing a flying ambulance: the Ambulance Volante. Baron Francois Percy also contributed to the organisation of a care system for the ongoing management of casualties. Out of the French Service de Santé, not only emerged the concept of triage, but the organisational structure necessary to handle the growing number of casualties in modern warfare.     

5级预检分诊系统的研究进展

对不同国家和地区医院急诊分诊使用的5级预检分诊系统的发展过程、分诊方法及优缺点进行了比较。预检分诊作为急诊护理服务的第一步,在急诊医疗护理服务中处于重要地位。随着急诊医学和社会经济的发展,当今急诊医疗服务需求的扩展已超越了急诊室有限的空间与资源,预检分诊需要判断出哪些患者需要立即救治,哪些患者病情并不危急,从而保证患者安全,防止分检不足或过度分检,合理有效的利用急诊医疗资源,预检分诊的质量直接关系到患者救治效果和对医院的满意度〔1〕。建立一个高效、便捷的预检体系或评分标尺     

The effect on the patient flow in a local health care after implementing reverse triage in a primary care emergency department: a longitudinal follow-up study

Objective: Reverse triage means that patients who are not considered to be in need of medical services are not placed on the doctor’s list in an emergency department (ED) but are sent, after face-to-face evaluation by a triage nurse, to a more appropriate health care unit. It is not known how an abrupt application of such reverse triage in a combined primary care ED alters the demand for doctors’ services in collaborative parts of the health care system.

Design: An observational study.

Setting: Register-based retrospective quasi-experimental longitudinal follow-up study based on a before–after setting in a Finnish city.

Subjects: Patients who consulted different doctors in a local health care unit.

Main outcome measures: Numbers of monthly visits to different doctor groups in public and private primary care, and numbers of monthly referrals to secondary care ED from different sources of primary care were recorded before and after abrupt implementation of the reverse triage.

Results: The beginning of reverse triage decreased the number of patient visits to a primary ED doctor without increasing mortality. Simultaneously, there was an increase in doctor visits in the adjacent secondary care ED and local private sector. The number of patients who came to secondary care ED without a referral or with a referral from the private sector increased.

Conclusions: The data suggested that the reverse triage causes redistribution of the use of doctors’ services rather than a true decrease in the use of these services.     

Paramedics and triage: Effect of one training session on triage in the emergency department

This 3-stage intervention study enrolled all adult patients referred to a universitybased emergency department (ED) during randomly assigned 1-week preeducation or posteducation periods. Triage decisions recorded by ED paramedics (n=8) both before and after an educational training session were compared to decisions made by emergency physicians (EPs). Triage decisions of paramedics and EPs in the preeducation phase showed poor consistency (κ =0.317, κ=0.388). Triage decisions in the posteducation phase increased slightly but were still found to be low. On the other hand, consistency between the triage assessments recorded by paramedics and EPs of the general appearance of patients increased from low in the preeducation phase to moderate in the posteducation phase (κ =0.327, κ=0.500, respectively). The training session was associated with a slight increase in the consistency of triage decisions recorded by paramedics and EPs.     

Patients’ conceptions of the triage encounter at the Emergency Department

Scand J Caring Sci; 2010; 24; 746–754
Patients’ conceptions of the triage encounter at the Emergency Department Background: Little is known about patients’ conceptions of the triage encounter and what the point of the encounter is in the triage. Aim: To describe the patients’ conceptions of the triage encounter at the emergency department (ED). Method: Interviews with 20 patients from different triage categories visiting the ED at a central hospital in southern Sweden were analysed using the phenomenographic approach. Findings: Five encounters emerged based on 16 conceptions: the insecure, humanistic, logistical, information exchange and surrounding encounters. Conclusions: To facilitate more positive experiences of the triage encounter, the personnel need to care and treat the patients as whole human beings, i.e. in a holistic approach. An improved logistical and informative triage encounter is vital in order to minimize the waiting time and make the waiting time acceptable for patients, as well decreasing worries that arise because of illness in an unknown environment.     

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.     

Emergency department mental health triage scales improve outcomes

The assessment and management of clients with mental illness is an important facet of providing emergency care. In Australian emergency departments, it is usually the generalist registered nurses* without adequate preparation in the assessment and care for clients with mental illness who conduct the initial assessment at triage. A search of the literature revealed a limited number of publications addressing the provision of triage and management guidelines to assist nurses to make objective clinical decisions to ensure appropriate care for clients with mental illness. This paper examines the need for such guidelines and reviews a number of mental health triage scales that have been evaluated for use in emergency departments. Findings show that these triage scales have led to improvements in staff confidence and attitudes when dealing with clients with mental health problems, resulting in improved outcomes for clients. Strengths and limitations of the evaluations have also been explored. Highlighted is the need for consideration of the inclusion of clients' reactions to the impact of this change to service delivery in future evaluations.     

我国二级及以上医院急诊分诊依据现状调查

目的调查国内急诊分诊执行情况及分诊依据的现状。方法采用自制调查问卷,对国内113所医院的274名急诊科护士进行急诊分诊执行情况及分诊依据现状的调查。结果目前急诊分诊护士要求不统一,急诊分诊标准存在不足,急诊分诊护士现有培训不能满足临床需要。结论我国在急诊分诊护士培养和急诊分诊标准的建立等方面尚不完善,建立统一规范的分诊标准和专职分诊护士将成为急诊分诊发展的趋势。     

Current status of emergency department triage in mainland China: A narrative review of the literature

In this review, the current status of emergency department triage in mainland China is explored, with the purpose of generating a deeper understanding of the topic. Literature was identified through electronic databases, and was included for review if published between 2002 and 2012, included significant discussion of daily emergency department triage in mainland China, was peer reviewed, and published in English or Chinese. Thematic analysis was used to identify themes which emerged from the reviewed literature. This resulted in 21 articles included for review. Four themes emerged from the review: triage process, triage training, qualification of triage nurses, and quality of triage. The review demonstrates that there is currently not a unified approach to emergency department triage in mainland China. Additionally, there are limitations in triage training for nurses and confusion around the role of triage nurses. This review highlights that emergency department triage in mainland China is still in its infancy and that more research is needed to further develop the role of triage.     

标准操作规范在急诊接诊与分流中的应用

目的 探讨急诊接诊与分流中应用标准操作规范的方法与效果.方法 制订急诊接诊与分流标准操作规范,合理配置人力资源并进行培训.结果 加快了急诊接诊与分流速度(P<0.05),分诊失误率下降(P<0.01),患者满意度提高(P<0.05).结论 规范化、科学的急诊接诊与分流标准实现了快速救治,提高了患者满意度.     

Impact of an ABCDE team triage process combined with public guidance on the division of work in an emergency department

Objective. To study the effects of applying an emergency department (ED) triage system, combined with extensive publicity in local media about the “right” use of emergency services, on the division of work between ED nurses and general practitioners (GPs). Design. An observational and quasi-experimental study based on before–after comparisons. Setting. Implementation of the ABCDE triage system in a Finnish combined ED where secondary care is adjacent, and in a traditional primary care ED where secondary care is located elsewhere. Subjects. GPs and nurses from two different primary care EDs. Main outcome measures. Numbers of monthly visits to different professional groups before and after intervention in the studied primary care EDs and numbers of monthly visits to doctors in the local secondary care ED. Results. The beginning of the triage process increased temporarily the number of independent consultations and patient record entries by ED nurses in both types of studied primary care EDs and reduced the number of patient visits to a doctor compared with previous years but had no effect on doctor visits in the adjacent secondary care ED. No further decrease in the number of nurse or GP visits was observed by inhibiting the entrance of non-urgent patients. Conclusion. The ABCDE triage system combined with public guidance may reduce non-urgent patient visits to doctors in different kinds of primary care EDs without increasing visits in the secondary care ED. However, the additional work to implement the ABCDE system is mainly directed to nurses, which may pose a challenge for staffing.     

Accuracy and concordance of nurses in emergency department triage

In the emergency department (ED) Registered Nurses (RNs) often perform triage, i.e. the sorting and prioritizing of patients. The allocation of acuity ratings is commonly based on a triage scale. To date, three reliable 5-level triage scales exist, of which the Canadian Triage and Acuity Scale (CTAS) is one. In Sweden, few studies on ED triage have been conducted and the organization of triage has been found to vary considerably with no common triage scale. The aim of this study was to investigate the accuracy and concordance of emergency nurses acuity ratings of patient scenarios in the ED setting. Totally, 423 RNs from 48 (62%) Swedish EDs each triaged 18 patient scenarios using the CTAS. Of the 7,550 triage ratings, 57.6% were triaged in concordance with the expected outcome and no scenario was triaged into the same triage level by all RNs. Inter-rater agreement for all RNs was kappa = 0.46 (unweighted) and kappa = 0.71 (weighted). The fact that the kappa-values are only moderate to good and the low concordance between the RNs call for further studies, especially from a patient safety perspective.     

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.