Comparison of triple triage system and CTAS (Canadian Triage and Acuity Scale) system in the emergency department: Triage and CTAS: Emergency department comparisons

Mehmet Koşargelir; Güleser Akpınar

doi:10.28982/josam.8315

Authors

Mehmet Koşargelir Istanbul Başakşehir Çam and Sakura City Hospital Emergency Medicine Department, Istanbul, Turkey https://orcid.org/0000-0003-1948-022X
Güleser Akpınar Istanbul Başakşehir Çam and Sakura City Hospital Emergency Medicine Department, Istanbul, Turkey https://orcid.org/0000-0001-8559-5098

DOI:

https://doi.org/10.28982/josam.8315

Keywords:

Triage , CTAS Emergency, TR

Abstract

Background/Aim: Triage systems are crucial for determining patient care priorities and efficiently utilizing resources in emergency departments. The aim of this study is to compare the effectiveness of the three-stage triage system (TR) and the Canadian Triage and Acuity Scale (CTAS) system in terms of patient safety, resource management, and alignment with expert opinions in an adult emergency department.

Methods: A prospective, cross-sectional, single-blind clinical study was conducted in an adult emergency department between October 1 and October 15, 2021. Patients aged 15 years and older with a Glasgow Coma Scale (GCS) score of 15 were included in the study. Trauma patients, patients transported by ambulance, and patients under 15 years of age were excluded from the study.

CTAS was applied by a single emergency medicine resident on odd days of the month, while TR was applied on the even days. The specialist physician who provided the reference triage categories was unaware of the initial assessments. Primary outcomes included inter-rater agreement (weighted kappa coefficient), triage accuracy, and resource utilization patterns. Statistical analysis used the Kruskal-Wallis H test, Fisher's exact test, and a weighted kappa coefficient with a significance level set at P<0.05.

Results: A total of 620 patients were evaluated (TR: n=290, CTAS: n=330). CTAS demonstrated significantly higher agreement with expert opinion compared to TR (κ=0.375, P<0.001) (κ=0.835, P<0.001). In CTAS, the rate of inadequate triage was significantly lower (12%) compared to TR (28%). CTAS demonstrated a more balanced patient distribution across emergency levels and rational resource utilization, resulting in appropriate requests for radiological examinations at T3 level (32.35% compared to 78.95% in the yellow zone of TR, P<0.001). Hospital admission rates were higher in CTAS (seven patients) compared to TR (one patient).

Conclusion: The CTAS system demonstrated significantly higher compliance and lower triage error rates compared to the TR system, with expert consensus, thereby showing superior performance in terms of patient safety and resource management. The implementation of CTAS in emergency departments may improve the quality of patient care and optimize resource utilization.

Downloads

Download data is not yet available.

References

Farrohknia N, Castrén M, Ehrenberg A, Lind L, Oredsson S, Jonsson H, et al. Emergency department triage scales and their components: a systematic review of the scientific evidence. Scand J Trauma Resusc Emerg Med. 2011;19(1):42. DOI: https://doi.org/10.1186/1757-7241-19-42

Christ M, Grossmann F, Winter D, Bingisser R, Platz E. Modern triage in the emergency department. Dtsch Arztebl Int. 2010;107(50):892-8. DOI: https://doi.org/10.3238/arztebl.2010.0892

Bullard MJ, Unger B, Spence J, Grafstein E, CTAS National Working Group. Revisions to the Canadian emergency department triage and acuity scale (CTAS) adult guidelines. CJEM. 2008;10(2):136-42. DOI: https://doi.org/10.1017/S1481803500009854

Dong SL, Bullard MJ, Meurer DP, Blitz S, Ohinmaa A, Holroyd BR, et al. Reliability of computerized emergency triage. Acad Emerg Med. 2006;13(3):269-75. DOI: https://doi.org/10.1197/j.aem.2005.10.014

Bullard MJ, Chan T, Brayman C, Warren D, Musgrave E, Unger B; Members of the CTAS National Working Group. Revisions to the Canadian Emergency Department Triage and Acuity Scale (CTAS) Guidelines. CJEM. 2014 Nov;16(6):485-9. DOI: https://doi.org/10.1017/S148180350000350X

Fernandes CM, Tanabe P, Gilboy N, Johnson LA, McNair RS, Rosenau AM, et al. Five-level triage: a report from the ACEP/ENA Five-level Triage Task Force. J Emerg Nurs. 2005;31(1):39-50. DOI: https://doi.org/10.1016/j.jen.2004.11.002

Beveridge R, Ducharme J, Janes L, Beaulieu S, Walter S. Reliability of the Canadian emergency department triage and acuity scale: interrater agreement. Ann Emerg Med. 1999;34(2):155-9. DOI: https://doi.org/10.1016/S0196-0644(99)70223-4

Van der Wulp I, Van Baar ME, Schrijvers AJP. Reliability and validity of the Manchester Triage System in a general emergency department patient population in the Netherlands: results of a simulation study. Emerg Med J. 2008;25(7):431-4. DOI: https://doi.org/10.1136/emj.2007.055228

Storm-Versloot MN, Ubbink DT, Kappelhof J, Luitse JS. Comparison of an informally structured triage system, the emergency severity index, and the manchester triage system to distinguish patient priority in the emergency department. Acad Emerg Med. 2011;18(8):822-9. DOI: https://doi.org/10.1111/j.1553-2712.2011.01122.x

FitzGerald G, Jelinek GA, Scott D, Gerdtz MF, Jelinek GA, Knott J, et al. Emergency department triage revisited. Emerg Med J. 2010;27(2):86-92. DOI: https://doi.org/10.1136/emj.2009.077081

Grossmann FF, Zumbrunn T, Frauchiger A, Delport K, Bingisser R, Nickel CH. At risk of undertriage? Testing the performance and accuracy of the emergency severity index in older emergency department patients. Ann Emerg Med. 2012;60(3):317-25. DOI: https://doi.org/10.1016/j.annemergmed.2011.12.013

Gräff I, Goldschmidt B, Glien P, Bogdanow M, Fimmers R, Hoeft A, et al. The German Version of the Manchester Triage System and its quality criteria--first assessment of validity and reliability. PLoS One. 2014;9(2):e88995. DOI: https://doi.org/10.1371/journal.pone.0088995

Kuriyama A, Urushidani S, Nakayama T. Five-level emergency triage systems: variation in assessment of validity. Emerg Med J. 2017;34(11):703-10. DOI: https://doi.org/10.1136/emermed-2016-206295

Jiménez JG, Murray MJ, Beveridge R, Pons JP, Cortés EA, Garrigós JBF, et al. Implementation of the Canadian Emergency Department Triage and Acuity Scale (CTAS) in the Principality of Andorra: Can triage parameters serve as emergency department quality indicators? CJEM. 2003;5(5):315-22.

Zachariasse JM, Seiger N, Rood PP, Alves CF, Freitas P, Smit FJ, et al. Validity of the Manchester Triage System in emergency care: A prospective observational study. PLoS One. 2017;12(2):e0170811. DOI: https://doi.org/10.1371/journal.pone.0170811

Ng CJ, Yen ZS, Tsai JCH, Chen LC, Lin SJ, Sang YY, et al. Validation of the Taiwan triage and acuity scale: a new computerised five-level triage system. Emerg Med J. 2011;28(12):1026-31. DOI: https://doi.org/10.1136/emj.2010.094185

Fernandes CM, McLeod S, Krause J, Shah A, Jewell J, Smith B, et al. Reliability of the Canadian Triage and Acuity Scale: interrater and intrarater agreement from a community and an academic emergency department. CJEM. 2013;15(4):227-32. DOI: https://doi.org/10.2310/8000.2013.130943

Storm-Versloot MN, Ubbink DT, Choi VC, Luitse JSK. Observer agreement of the Manchester Triage System and the Emergency Severity Index: a simulation study. Emerg Med J. 2009;26(8):556-60. DOI: https://doi.org/10.1136/emj.2008.059378

Mirhaghi A, Heydari A, Mazlom R, Ebrahimi M. The reliability of the Canadian Triage and Acuity Scale: meta-analysis. N Am J Med Sci. 2015;7(7):299-305. DOI: https://doi.org/10.4103/1947-2714.161243

Van der Wulp I, Schrijvers AJP, Van Stel HF. Predicting admission and mortality with the Emergency Severity Index and the Manchester Triage System: a retrospective observational study. Emerg Med J. 2009;26(7):506-9. DOI: https://doi.org/10.1136/emj.2008.063768