Abstract
BackgroundIn Sweden, the rapid emergency triage and treatment system (RETTS-A) is used in the pre-hospital setting. With RETTS-A, patients triaged to the lowest level could safely be referred to a lower level of care. The national early warning score (NEWS) has also shown promising results internationally. However, a knowledge gap in optimal triage in the pre-hospital setting persists. This study aimed to evaluate RETTS-A performance, compare RETTS-A with NEWS and NEWS 2, and evaluate the emergency medical service (EMS) nurse’s field assessment with the physician’s final hospital diagnosis.MethodsA prospective, observational study including patients (≥16 years old) transported to hospital by the Gothenburg EMS in 2016. Three comparisons were made: 1) Combined RETTS-A levels orange and red (high acuity) compared to a predefined reference emergency, 2) RETTS-A high acuity compared to NEWS and NEWS 2 score ≥ 5, and 3) Classification of pre-hospital nurse’s field assessment compared to hospital physician’s diagnosis. Outcomes of the time-sensitive conditions, mortality and hospitalisation were examined. The statistical tests included Mann–Whitney U test and Fisher’s exact test, and several binary classification tests were determined.ResultsOverall, 4465 patients were included (median age 69 years; 52% women). High acuity RETTS-A triage showed a sensitivity of 81% in prediction of the reference patient with a specificity of 64%. Sensitivity in detecting a time-sensitive condition was highest with RETTS-A (73%), compared with NEWS (37%) and NEWS 2 (35%), and specificity was highest with NEWS 2 (83%) when compared with RETTS-A (54%). The negative predictive value was higher in RETTS-A (94%) compared to NEWS (91%) and NEWS 2 (92%). Eleven per cent of the final diagnoses were classified as time-sensitive while the nurse’s field assessment was appropriate in 84% of these cases.ConclusionsIn the pre-hospital triage of EMS patients, RETTS-A showed sensitivity that was twice as high as that of both NEWS and NEWS 2 in detecting time-sensitive conditions, at the expense of lower specificity. However, the proportion of correctly classified low risk triaged patients (green/yellow) was higher in RETTS-A. The nurse’s field assessment of time-sensitive conditions was appropriate in the majority of cases.
Highlights
In Sweden, the rapid emergency triage and treatment system (RETTS-A) is used in the pre-hospital setting
The emergency medical service (EMS) nurse assessed a higher proportion of patients having abdominal/flank pain with levels yellow and green, compared with level orange/red, whereas, the opposite was found for ‘chest/thoracic pain’, with the highest percentage found in level orange (12%)
Circulatory and respiratory system-related hospital diagnosis were more common in the high-acuity group, whereas the hospital diagnosis of symptoms, signs and abnormal clinical and laboratory findings were more common in the low-acuity group
Summary
In Sweden, the rapid emergency triage and treatment system (RETTS-A) is used in the pre-hospital setting. This study aimed to evaluate RETTS-A performance, compare RETT S-A with NEWS and NEWS 2, and evaluate the emergency medical service (EMS) nurse’s field assessment with the physician’s final hospital diagnosis. The Swedish RETTS-A has been evaluated at the ED, where it was used to discriminate between the severity of patients’ conditions on admission and inhospital mortality and is regarded as a reliable triage method [3] It revealed lower accuracy for mortality in the elderly than in younger patients [4]. In an ED in Norway, RETTS-A displayed a superior performance in detecting sepsis than the quick sepsis-related organ failure assessment (qSOFA) score [8] Another system based on vital signs (VS), that has attracted interest in the EMS, is the national early warning score (NEWS). This study aimed to 1) evaluate the performance of RETTS-A, 2) compare the performance of RETTS-A with that of NEWS and NEWS 2, and, 3) evaluate the EMS nurse’s field assessment with the physician’s final hospital diagnosis
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