Current Triage Practices Research Articles

Cost-effectiveness of field trauma triage among injured children transported by emergency medical services.

A pediatric field triage strategy that meets the national policy benchmark of ≥95% sensitivity would likely improve health outcomes but increase heath care costs. Our objective was to compare the cost-effectiveness of current pediatric field triage practices to an alternative field triage strategy that meets the national policy benchmark of ≥95% sensitivity. We developed a decision-analysis Markov model to compare the outcomes and costs of the two strategies. We used a prospectively collected cohort of 3507 (probability weighted, unweighted n=2832) injured children transported by 44 emergency medical services (EMS) agencies to 28 trauma and non-trauma centers in the Northwestern United States from 1/1/2011 to 12/31/2011 to derive the alternative field triage strategy and to populate model probability and cost inputs for both strategies. We compared the two strategies by calculating quality adjusted life years (QALYs) and health care costs over a time horizon from the time of injury until death. We set an incremental cost-effectiveness ratio threshold of less than $100,000 per QALY for the alternative field triage to be a cost-effective strategy. Current pediatric field triage practices had a sensitivity of 87.4% (95% confidence interval [CI] 71.9 to 95.0%) and a specificity of 82.3% (95% CI 81.0 to 83.5%) and the alternative field triage strategy had a sensitivity of 97.3% (95% CI 82.6 to 99.6%) and a specificity of 46.1% (95% CI 43.8 to 48.4%). The alternative field triage strategy would cost $476,396 per QALY gained compared to current pediatric field triage practices and thus would not be a cost-effective strategy. Sensitivity analyses demonstrated similar findings. Current field triage practices do not meet national policy benchmarks for sensitivity. However, an alternative field triage strategy that meets the national policy benchmark of ≥95% sensitivity is not a cost-effective strategy.

COVID-19, disability and the context of healthcare triage in South Africa: Notes in a time of pandemic.

During disasters, when resources and care are scarce, healthcare workers are required to make decisions and prioritise which patients receive life-saving resources over others. To assist healthcare workers in standardising resources and care, triage policies have been developed. However, the current COVID-19 triage policies and practices in South Africa may exclude or disadvantage many disabled people, especially people with physical and intellectual impairments, from gaining intensive care unit (ICU) access and receiving ventilators if becoming ill. The exclusion of disabled people goes against the principles established in South Africa’s Constitution, in which all people are regarded as equal, have the right to life and inherent dignity, the right to access healthcare, as well as the protection of dignity. In addition, the triage policy contravenes the United Nations Convention on the Rights of Persons with Disabilities, which the South African government has signed and ratified. This article raises debates about whose lives matter and whose lives are ‘worth’ saving over others, and although the focus is on South Africa, the issues may be relevant to other countries where life-saving resources are being rationed.

Comorbidities, anticoagulants, and geriatric-specific physiology for the field triage of injured older adults.

Comorbid conditions and anticoagulants have been considered as field triage criteria to raise the sensitivity for identifying seriously injured older adults, but research is sparse. We evaluated the utility of comorbidities, anticoagulant use, and geriatric-specific physiologic measures to improve the sensitivity of the field triage guidelines for high-risk older adults in the out-of-hospital setting. This was a cohort study of injured adults 65 years or older transported by 44 emergency medical services agencies to 51 trauma and nontrauma hospitals in seven Oregon and Washington counties from January 1, 2011, to December 31, 2011. Out-of-hospital predictors included current field triage criteria, 13 comorbidities, preinjury anticoagulant use, and previously developed geriatric specific physiologic measures. The primary outcome (high-risk patients) was Injury Severity Score of 16 or greater or need for major nonorthopedic surgical intervention. We used binary recursive partitioning to develop a clinical decision rule with a target sensitivity of 95% or greater. There were 5,021 older adults, of which 320 (6.4%) had Injury Severity Score of 16 or greater or required major nonorthopedic surgery. Of the 2,639 patients with preinjury medication history available, 400 (15.2%) were taking an anticoagulant. Current field triage practices were 36.6% sensitive (95% confidence interval [CI], 31.2%-42.0%) and 90.1% specific (95% CI, 89.2%-91.0%) for high-risk patients. Recursive partitioning identified (in order): any current field triage criteria, Glasgow Coma Scale score of 14 or less, geriatric-specific vital signs, and comorbidity count of 2 or more. Anticoagulant use was not identified as a predictor variable. The new criteria were 90.3% sensitive (95% CI, 86.8%-93.7%) and 17.0% specific (95% CI, 15.8%-18.1%). The current field triage guidelines have poor sensitivity for high-risk older adults. Adding comorbidity information and geriatric-specific physiologic measures improved sensitivity, with a decrement in specificity. Prognostic/Epidemiologic, level II.

Temporal Delays Along the Neurosurgical Care Continuum for Traumatic Brain Injury Patients at a Tertiary Care Hospital in Kampala, Uganda.

BACKGROUNDSignificant care continuum delays between acute traumatic brain injury (TBI) and definitive surgery are associated with poor outcomes. Use of the “3 delays” model to evaluate TBI outcomes in low- and middle-income countries has not been performed.OBJECTIVETo describe the care continuum, using the 3 delays framework, and its association with TBI patient outcomes in Kampala, Uganda.METHODSProspective data were collected for 563 TBI patients presenting to a tertiary hospital in Kampala from 1 June to 30 November 2016. Four time intervals were constructed along 5 time points: injury, hospital arrival, neurosurgical evaluation, computed tomography (CT) results, and definitive surgery. Time interval differences among mild, moderate, and severe TBI and their association with mortality were analyzed.RESULTSSignificant care continuum differences were observed for interval 3 (neurosurgical evaluation to CT result) and 4 (CT result to surgery) between severe TBI patients (7 h for interval 3 and 24 h for interval 4) and mild TBI patients (19 h for interval 3 and 96 h for interval 4). These postarrival delays were associated with mortality for mild (P = .05) and moderate TBI (P = .03) patients. Significant hospital arrival delays for moderate TBI patients were associated with mortality (P = .04).CONCLUSIONDelays for mild and moderate TBI patients were associated with mortality, suggesting that quality improvement interventions could target current triage practices. Future research should aim to understand the contributors to delays along the care continuum, opportunities for more effective resource allocation, and the need to improve prehospital logistical referral systems.

The Use of Field Triage in Disaster and Mass Casualty Incidents: A Survey of Current Practices by EMS Personnel

Background: Mass casualty incident (MCI) triage and the use of triage tags to assign treatment priorities are not fully implemented despite emergency medical services (EMS) personnel training during drills and exercises. Objectives: To compare current field triage practices during both training and actual MCIs and identify any potential barriers to use. Methods: During training sessions from November 2015 through March 2016, an anonymous survey was distributed to personnel in 3 distinct types of paid full-time EMS systems: Boston EMS (2-tiered, municipal third-service); Portland Fire Department (fire department-based ALS); and Stokes County EMS (county-based ALS) combined with Forsyth County EMS (county-based ALS). Data included personnel demographics and previous participation experiences in both drill and actual MCIs. Personnel with any prior MCI experience were queried regarding triage tag use and type of algorithm used. Data on barriers to use of triage tags and methods of communication of patient information were also collected. Descriptive statistics were used to analyze responses. Results: Overall survey participation rate was 77.9% (464/596). Among all respondents, 38.7% (179/464) reported participating in both a drill and actual MCI's. In these cases, respondents reported less likely use of triage tags during actual MCI's compared to drills, (34.1 vs. 91.8%, p < 0.01), less likely to complete full triage (16.3 vs. 68.7%, p < 0.01) and less likely to employ geographical triage (56.8 vs. 90.4% p < 0.01). Verbal report was the most common communication method to hospitals (93.1%) when triage tags were not used. Responders reported proximity to the hospital as the most common reason for not using triage tags during an actual MCI (29.5%). Conclusions: Despite being a fundamental skill in MCI response, triage and other standard practices have not always been utilized in actual events despite training. EMS educators and disaster planners should consider strategies to better incorporate MCI practices during real world events.

Role of Guideline Adherence in Improving Field Triage

Objective: To compare the sensitivity of current field triage practices for identifying high-risk trauma patients to strict guideline adherence, including changes in triage specificity, ambulance transport patterns, and trauma center volumes. Methods: This was a pre-planned secondary analysis of an out-of-hospital prospective cohort of injured children and adults transported by 44 EMS agencies to 28 trauma and non-trauma hospitals in 7 Northwest U.S. counties from January 1, 2011 through December 31, 2011. Outcomes included Injury Severity Score (ISS) ≥16 (primary) and early critical resource use. Strict adherence of the triage guidelines was based on evidence in the EMS chart for patients meeting any current field triage criteria, calculated with and without strict interpretation of the age criterion (<15 or >55 years). Due to the probability sampling nature of the cohort, strata and weights were included in all analyses. Results: 17,633 injured patients were transported by EMS (weighted to represent 53,487 transported patients), including 3.1% with ISS ≥16 and 1.7% requiring early critical resources. Field triage sensitivity for identifying patients with ISS ≥16 increased from the current 66.2% (95% CI 60.2–71.7%) to 87.3% (95% CI 81.9–91.2%) for strict adherence without age and to 91.0% (95% CI 86.4–94.2%) for strict adherence with age. Specificity decreased with increasing adherence, from 87.8% (current) to 47.6% (strict adherence without age) and 35.8% (strict adherence with age). Areas under the curve (AUC) were 0.78, 0.73, and 0.72, respectively. Results were similar for patients requiring early critical resources. We estimate the number of triage-positive patients transported each year by EMS to an individual major trauma center (on average) to increase from 1,331 (current) to 5,139 (strict adherence without age) and to 6,256 (strict adherence with age). Conclusions: The low sensitivity of current triage practices would be expected to improve with strict adherence to current triage guidelines, with a commensurate decrease in triage specificity and an increase in the number of triage-positive patients transported to major trauma centers.

Triage processes at multidisciplinary chronic pain clinics: An international review of current procedures

ABSTRACTBackground: Multidisciplinary pain clinics are considered the gold standard for the treatment of chronic pain, yet access to such clinics is difficult and patients’ conditions deteriorate while waiting. Instituting a triage process is one way of reducing wait time for some patients and ensuring optimal access given the limited resources available. Surprisingly, there are no established guidelines on how to optimally triage chronic pain patients at tertiary multidisciplinary pain clinics.Aims: The goal of this study was to gather information regarding existing triage systems in multidisciplinary chronic pain clinics worldwide as an initial step toward establishing a definitive evidence-based set of triage guidelines.Methods: A total of 66 multidisciplinary pain clinics worldwide completed an online survey detailing current triage practices at their clinic. The survey was distributed via international and national pain associations.Results: Results showed that the vast majority of multidisciplinary pain clinics (94%) use a triage system, yet many difficulties with these systems have been identified (time requirement, administrative burden, lack of control over scheduling, missing high-priority patients, and prioritizing low-priority patients). The level of satisfaction was noted to be higher in those clinics using a structured triage template.Conclusions: This study identified a need for the elaboration of best practice clinical guidelines for triage processes at tertiary pain clinics. The use of a structured referral template could become a central element to such guidelines.

Cost-Effectiveness of Field Trauma Triage among Injured Adults Served by Emergency Medical Services

The American College of Surgeons Committee on Trauma sets national targets for the accuracy of field trauma triage at ≥95% sensitivity and ≥65% specificity, yet the cost-effectiveness of realizing these goals is unknown. We evaluated the cost-effectiveness of current field trauma triage practices compared with triage strategies consistent with the national targets. This was a cost-effectiveness analysis using data from 79,937 injured adults transported by 48 emergency medical services agencies to 105 trauma and nontrauma hospitals in 6 regions of the western United States from 2006 through 2008. Incremental differences in survival, quality-adjusted life years (QALYs), costs, and the incremental cost-effectiveness ratio (costs per QALY gained) were estimated for each triage strategy during a 1-year and lifetime horizon using a decision analytic Markov model. We considered an incremental cost-effectiveness ratio threshold of <$100,000 to be cost-effective. For these 6 regions, a high-sensitivity triage strategy consistent with national trauma policy (sensitivity 98.6%, specificity 17.1%) would cost $1,317,333 per QALY gained, and current triage practices (sensitivity 87.2%, specificity 64.0%) cost $88,000 per QALY gained, compared with a moderate sensitivity strategy (sensitivity 71.2%, specificity 66.5%). Refining emergency medical services transport patterns by triage status improved cost-effectiveness. At the trauma-system level, a high-sensitivity triage strategy would save 3.7 additional lives per year at a 1-year cost of $8.78 million, and a moderate sensitivity approach would cost 5.2 additional lives and save $781,616 each year. A high-sensitivity approach to field triage consistent with national trauma policy is not cost-effective. The most cost-effective approach to field triage appears closely tied to triage specificity and adherence to triage-based emergency medical services transport practices.

Abstract: Category Allocation and Education for Accident/Emergency Department Nurses at Referral Hospital in Kigali, Rwanda

Abstract Background Triage is the process including the initial assessment followed by the prioritization of patients needing emergency care and assign them according to their actual need or likely benefit from immediate medical treatment. Triage is an important concept in accident and emergency (A/E) care since failure to ensure that patients are seen in a timely manner can and will result in negative outcomes, such as prolonged hospitalization, Intensive Care Unit admissions, increased resource consumption, and even death. Triage of patients at the referral hospital was complicated by existence of multiple step triage process which increased the likelihood of incorrect triage even with the use of the Australian Triage Scale (ATS). While the use of ATS triage scale may not necessarily cause delay in waiting time for consultation, inappropriate categorization could adversely influence both subsequent treatment and patient outcomes. Objectives To improve patient care through appropriate allocation of the ATS and verify education of A/E staff in triage protocol implementation and evaluation of current and past triage practices. Methods A real time motion study was conducted with 35 patients identifying waiting time from triage to doctor consultation. A retrospective chart review was conducted with evaluation of the volume of each triage category using the Australian Triage Scale (ATS), and the staff‘s ability to assign the appropriate ATS score was tested using a standardized written case scenario. Data collection occurred between October 2013 and July 2014. Staff education sessions reintroducing the ATS and the appropriate use based on clinical scenarios was conducted, retrospective audits of triage documentation and followed by group discussion regarding accurate triage category allocation was done. Remodeling and reorganization of the physical layout of A/E triage nurse station was done; in order to facilitate patient flow and increase early identification of critically ill patients. Results There was a slight increase in categories 4 and 5 post training, but there might have been other factors such as a change in triage practice and institution of a day care room in A/E. Staff knowledge increased in accuracy of triage category allocation from 51% to 64%. Conclusions Recommendations for the future includes quarterly chart audits and ongoing evaluation of the A/E staff, implementation and evaluation of data collection tools and their use to effectively measure triage practice, and continued orientation of new staff to the ATS system of triage. Key words : triage category allocation and education, accident and emergency (A/E), Rwanda

Improving early identification of the high-risk elderly trauma patient by emergency medical services

We sought to (1) define the high-risk elderly trauma patient based on prognostic differences associated with different injury patterns and (2) derive alternative field trauma triage guidelines that mesh with national field triage guidelines to improve identification of high-risk elderly patients. This was a retrospective cohort study of injured adults ≥65 years transported by 94 EMS agencies to 122 hospitals in 7 regions from 1/1/2006 through 12/31/2008. We tracked current field triage practices by EMS, patient demographics, out-of-hospital physiology, procedures and mechanism of injury. Outcomes included Injury Severity Score≥16 and specific anatomic patterns of serious injury using abbreviated injury scale score ≥3 and surgical interventions. In-hospital mortality was used as a measure of prognosis for different injury patterns. 33,298 injured elderly patients were transported by EMS, including 4.5% with ISS≥16, 4.8% with serious brain injury, 3.4% with serious chest injury, 1.6% with serious abdominal-pelvic injury and 29.2% with serious extremity injury. In-hospital mortality ranged from 18.7% (95% CI 16.7-20.7) for ISS≥16 to 2.9% (95% CI 2.6-3.3) for serious extremity injury. The alternative triage guidelines (any positive criterion from the current guidelines, GCS≤14 or abnormal vital signs) outperformed current field triage practices for identifying patients with ISS≥16: sensitivity (92.1% [95% CI 89.6-94.1%] vs. 75.9% [95% CI 72.3-79.2%]), specificity (41.5% [95% CI 40.6-42.4%] vs. 77.8% [95% CI 77.1-78.5%]). Sensitivity decreased for individual injury patterns, but was higher than current triage practices. High-risk elderly trauma patients can be defined by ISS≥16 or specific non-extremity injury patterns. The field triage guidelines could be improved to better identify high-risk elderly trauma patients by EMS, with a reduction in triage specificity.

Physiologic Field Triage Criteria for Identifying Seriously Injured Older Adults

Objective. To evaluate the ability of out-of-hospital physiologic measures to predict serious injury for field triage purposes among older adults and potentially reduce the undertriage of seriously injured elders to non-trauma hospitals. Methods. This was a retrospective cohort study involving injured adults 55 years and older transported by 94 emergency medical services (EMS) agencies to 122 hospitals (trauma and non-trauma) in 7 regions of the western United States from January 1, 2006 to December 31, 2008. We evaluated initial out-of-hospital Glasgow Coma Scale (GCS) score, systolic blood pressure (SBP), respiratory rate, heart rate, shock index (SBP ÷ heart rate), out-of-hospital procedures, mechanism of injury, and patient demographics. The primary outcome was “serious injury,” defined as Injury Severity Score (ISS) ≥ 16, as a measure of trauma center need. We used multivariable regression models, fractional polynomials and binary recursive partitioning to evaluate appropriate physiologic cut-points and the value of different physiologic triage criteria. Results. A total of 44,890 injured older adults were evaluated and transported by EMS, of whom 2,328 (5.2%) had ISS ≥ 16. Nonlinear associations existed between all physiologic measures and ISS ≥ 16 (unadjusted and adjusted p ≤ 0.001 for all,), except for heart rate (adjusted p = 0.48). Revised physiologic triage criteria included GCS score ≤ 14; respiratory rate < 10 or > 24 breaths per minute or assisted ventilation; and SBP < 110 or > 200 mmHg. Compared to current triage practices, the revised criteria would increase triage sensitivity from 78.6 to 86.3% (difference 7.7%, 95% CI 6.1–9.6%), reduce specificity from 75.5 to 60.7% (difference 14.8%, 95% CI 14.3–15.3%), and increase the proportion of patients without serious injuries transported to major trauma centers by 60%. Conclusions. Existing out-of-hospital physiologic triage criteria could be revised to better identify seriously injured older adults at the expense of increasing overtriage to major trauma centers.

The trade-offs in field trauma triage: a multiregion assessment of accuracy metrics and volume shifts associated with different triage strategies.

National benchmarks for trauma triage sensitivity (≥95%) and specificity (≥50%) have not been rigorously evaluated across broad populations of injured patients. We evaluated the impact of different field triage schemes for identifying seriously injured patients across a range of sensitivity values. Impact metrics included specificity and number of undertriaged and overtriaged patients compared with current triage practices. This was a retrospective cohort study of injured children and adults transported by 48 emergency medical service (EMS) agencies to 105 hospitals in 6 regions of the Western United States from 2006 through 2008. Hospital outcomes were probabilistically linked to EMS records through trauma registries, state discharge databases, and state emergency department databases. The primary outcome was an Injury Severity Score (ISS) of 16 or greater. We evaluated 40 field predictor variables, including 31 current field triage criteria, using classification and regression tree analysis and cross-validation to generate estimates for sensitivity and specificity. A total of 89,261 injured patients were evaluated and transported by EMS providers during the 3-year period, of whom 5,711 (6.4%) had ISS of 16 or greater. As the 95% sensitivity target for triage was approached (from the current value of 87.5%), decision tree complexity increased, specificity decreased (from 62.8% to 18.7%), and the number of triage-positive patients without serious injury doubled (67,927 vs. 31,104). Analyses restricted to children and older adults were similar. The most consistent modification to the current triage algorithm to increase sensitivity without a major decrease in specificity was altering the Glasgow Coma Scale (GCS) score cutoff point from 13 or less to 14 or less (sensitivity increase to 90.4%). Reaching the field triage sensitivity benchmark of 95% would require a large decrease in specificity (increase in overtriage). A 90% sensitivity target seems more realistic and may be obtainable by modest changes to the current triage algorithm.

Triaging in dietetics: Do we prioritise the right patients?

AbstractAim: Triage, or prioritisation, is a process used to assign patients to treatment categories for clinical management and to support the allocation of staffing resources. The literature is limited regarding dietetic triage processes, and evaluation of their validity and reliability. The aims of this study were to compare the dietetic triage guidelines used in a sample of Australian hospitals; acquire demographic information describing the dietetic department and its services; and obtain feedback from dietetic managers on the benefits/disadvantages of their triage guidelines.Methods: A questionnaire was developed to elicit demographic data and qualitative comments from a convenience sample of two hospitals in each Australian state and territory. Data collection occurred electronically and results were analysed qualitatively.Results: Ten responses were received (62.5% response rate). The number of inpatient beds at each hospital ranged from 180 to 980. Dietetic staffing ranged from 3.3 to 27.25 equivalent full‐time positions. All participating hospitals had triage guidelines in use with prioritisation categories similar for inpatients but not outpatients. Validity and inter‐rater reliability were poorly evaluated. Strengths and weaknesses identified by dietetic managers were consistent with those reported in other disciplines.Conclusions: Both consensus and lack of consistency within current dietetic triage practices were highlighted in this exploratory study. The lack of evaluation of validity and reliability shows a limited evidence base in this area of practice and these areas need to be addressed. Consideration should also be given to changes in priority and focus of dietetic practice which will impact on triage categories.

Emergency department triaging of admitted stroke patients—A Bayesian Network analysis

This study uses hospital administrative data to ascertain the differences in the patient characteristics, process and outcomes of care between the Emergency Department (ED) triage categories of patients admitted from an ED presentation into a large metropolitan teaching hospital with a Stroke Care Unit. Bayesian Networks (BNs) derived from the administrative data were used to provide the descriptive models. Nearly half the patients in each stroke subtype were triaged as 'Urgent' (to be seen within 30 minutes). With a decrease in the urgency of triage categories, the proportion admitted within 8 hours decreased dramatically and the proportion of formal discharge increased. Notably, 45% of transient ischaemic attacks (TIAs) were categorized as 'Semi-urgent' (to be attended within 60 minutes), indicating an opportunity to improve emergency assessment of TIAs. The results illustrate the utility of hospital administrative data and the applicability of BNs for review of the current triage practices and subsequent impact.

Triage Assessment in Pediatric Emergency Departments

Because of the varying physiological and developmental stages in children, the taking of vital signs and other assessments at triage in an emergency department (ED) can be challenging. The purpose of this study was to examine current triage practices in pediatric EDs in the United States. A mailed survey was sent in August 2006 to the medical directors of the 99 pediatric EDs listed on the National Association of Children's Hospitals and Related Institutions Web site, with follow-up mailing in October 2006 and subsequent phone contact. Eighty-eight surveys were returned (90% response rate). When asked what assessments are done on all patients at triage, all EDs (100%) obtain pulse rate and respiratory rate, 92% measure temperature, 60% measure blood pressure, 41% measure pulse oximetry, and 13% assess Glasgow Coma Scale. The methods used to measure temperature were widely variable. Multiple methods are used to assess pain: for those aged 0 to 2 years, 44% use a Wong FACES Scale and 48% use a behavioral scale; at 2 to 4 years, most (80%) use the Wong FACES Scale, but in older 10- to 18-year-old patients, most (81%) use a numerical scale. The use of standing orders at triage is variable. Despite the important decisions made based on triage assessment in a pediatric ED, there is wide variability in the parameters assessed and the methodology used. Additional research should focus on the validity and reliability of each assessment to determine the best practices.

A National Survey of Triage Practices in Pediatric Emergency Departments

Triage is used in most emergency departments (ED) to perform a rapid assessment of each patient and to determine the order in which patients are seen. Because of the varying physiological and developmental stages in children, the triage assessment can be challenging. The purpose of this study was to examine current triage practices in pediatric EDs in the United States. Methods: A mailed survey was sent in August, 2005 to the medical directors of the 99 EDs listed on the National Association of Children’s Hospitals and Related Institutions website.

Reliability and validity of the Toowoomba adult trauma triage tool: a Queensland, Australia study

In Australia a nationally adopted five tiered triage scale called the Australasian triage scale (ATS) is used for the purpose of differentiating patient acuity levels for all patients that present to an emergency department (ED). The scale was formulated with the aim of promoting a standardized approach to triage. Numerous studies now suggest that the ATS has not been successful in achieving this intention. The Toowoomba adult trauma triage tool (TATTT) seeks to address this deficiency by providing an evidence based, reproducible, reliable and valid method of triage categorisation, albeit in a select group of patients. Ten triage nurses from Toowoomba health service (THS) and five from Princess Alexandra Hospital in Queensland, Australia were enrolled in the study. Each participant rated five written simulations before receiving training in the TATTT. Each participant then rated nine written scenarios, five simulated scenarios on video and one computer simulated scenario with the TATTT. Parallel triaging of actual adult injury based presentations to THS ED was also undertaken. The overall percentage agreement for all simulations for which data were available was 87%. The overall kappa statistic was 0.82 with a 95% confidence interval from 0.76 to 0.88. The overall percentage agreement between the triage category assigned using existing triage practices and the triage category assigned by the TATTT was approximately 47% with an estimated kappa of kappa(') = 0.19 (95% confidence interval [-0.02,0.40]). Evidence from this study suggests that the TATTT provides systematically different results compared to current triage practices utilising the ATS. This provided evidence that triage practices did not reflect current evidence or available descriptors. Additionally TATTT has greater reliability than current triage practices.

Current triage practice and influences affecting clinical decision-making in emergency departments in NSW, Australia

In Australia, as elsewhere, the nature of triage decision making, patient referral, investigations, physical resources, triage policies, educational requirements and clinical expertise is often unclear and differs between organizations (Gerdtz & Bucknell 2000; Standen 1998). The study described here was undertaken in order to explore current triage practices throughout New South Wales (NSW) and to describe the range of clinical reasoning tasks performed by nurses.

Helicopter transport of injured children: system effectiveness and triage criteria

The authors compared air and ground transport to a level I pediatric trauma center to assess the effectiveness of helicopter transport of injured children. They also performed a retrospective assessment of triage criteria and utilization patterns for helicopter transports. The sample comprised 3,861 children who were admitted (consecutively) to an urban level I pediatric trauma center during a 4-year period and who were transported by emergency mediacal services. TRISS probability of survival (Ps), z, and W scores were used to compare outcomes of ground and air transports. An absolute value of z greater than 1.96 indicates a statistically significant difference in mortality rate; the 4 statistic represents the number of survivors more than expected per 100 patients treated. Receiver operator characteristic (ROC) curves were used to identify optimal triage criteria, using Ps < .95 to define children who potentially could benefit from air transport. The triage criteria were applied to the air transport group to determine overtriage rates. Nearly 75% of the children arrived directly from the scene of injury. Those transported by air were more severely injured, as shown by significant differences in the mean Glasgow Coma Scale (GCS), Ps, Injury Severity Score, and mortality rate. The better survival rate for children transported by helicopter was indicated by a TRISS z score of 2.81, compared with a z score of 0.31 for those transported by ambulance. The W statistic for the children transported by air was 1.11. ROC analysis identified GCS < 12 and heart rate > 160 beats per minute as optimal air triage criteria; these yielded 99% sensitivity and 90% specificity. Using these criteria, approximately 85% of air transports would be considered overtriage. The authors conclude that (1) helicopter transport was associated with better survival rates among urban injured children; (2) pediatric helicopter triage criteria based on GCS and heart rate may improve helicopter resource utilization without compromising care; and (3) current air triage practices result in overuse of helicopters in approximately 85% of flights.