Background

Triage and triage related work has been performed in Swedish Emergency Departments (EDs) since the mid-1990s. According to two national surveys from 2005 to 2011, triage was carried out with different triage scales and without guidelines or formal education. Furthermore, a review from 2010 questioned the scientific evidence for both triage as a method as well as the Swedish five level triage scale Medical Emergency Triage and Treatment System (METTS); nevertheless, METTS was applied in 65% of the EDs in 2011. Subsequently, METTS was renamed to Rapid Emergency Triage and Treatment System (RETTS©). The hypothesis for this study is that the method of triage is still applied nationally and that the use of METTS/RETTS© has increased. Hence, the aim is to describe the occurrence and application of triage and triage related work at Swedish Emergency Departments, in comparison with previous national surveys.

Methods

In this cross-sectional study with a descriptive and comparative design, an electronic questionnaire was developed, based on questionnaire from previous studies. The survey was distributed to all hospital affiliated EDs from late March to the middle of July in 2019. The data was analysed with descriptive statistics, by IBM SPSS Statistics, version 26.

Results

Of the 51 (75%) EDs partaking in the study, all (100%) applied triage, and 92% used the Swedish triage scale RETTS©. Even so, there was low concordance in how RETTS© was applied regarding time frames i.e., how long a patient in respective triage level could wait for assessment by a physician. Additionally, the results show a major diversion in how the EDs performed education in triage.

Conclusion

This study confirms that triage method is nationally implemented across Swedish EDs. RETTS© is the dominating triage scale but cannot be considered as one triage scale due to the variation with regard to time frames per triage level. Further, a diversion in introduction and education in the pivotal role of triage has been shown. This can be counteracted by national guidelines in what triage scale to use and how to perform triage education.

Background: Triage and triage related work has been performed in Swedish Emergency Departments (EDs) since the mid-1990s. The Rapid Emergency Triage and Treatment System (RETTS(©)), with annual updates, is the most applied triage system. However, the national implementation has been performed despite low scientific foundation for triage as a method, mainly related to the absence of adjustment to age and gender. Furthermore, there is a lack of studies of RETTS(©) in Swedish ED context, especially of RETTS(©) validity. Hence, the aim the study was to determine the validity of RETTS(©). Methods: A longitudinal retrospective register study based on cohort data from a healthcare region comprising two EDs in southern Sweden. Two editions of RETTS(©) was selected; year 2013 and 2016, enabling comparison of crude data, and adjusted for age-combined Charlson comorbidity index (ACCI) and gender. All patients >= 18 years visiting either of the two EDs seeing a physician, was included. Primary outcome was ten-day mortality, secondary outcome was admission to Intensive Care Unit (ICU). The data was analysed with descriptive, and inferential statistics. Results: Totally 74,845 patients were included. There was an increase in patients allocated red or orange triage levels (unstable) between the years, but a decrease of admission, both to general ward and ICU. Of all patients, 1031 (1.4%) died within ten-days. Both cohorts demonstrated a statistically significant difference between the triage levels, i.e. a higher risk for ten-day mortality and ICU admission for patients in all triage levels compared to those in green triage level. Furthermore, significant statistically differences were demonstrated for ICU admission, crude as well as adjusted, and for adjusted data ten-day mortality, indicating that ACCI explained ten-day mortality, but not ICU admission. However, no statistically significant difference was found for the two annual editions of RETTS(©) considering ten-day mortality, crude data. Conclusion: The annual upgrade of RETTS(©) had no statistically significant impact on the validity of the triage system, considering the risk for ten-day mortality. However, the inclusion of ACCI, or at least age, can improve the validity of the triage system.

Background

From a patient safety perspective, it is of great importance that decision support systems such as triage scales are evidence based. In the most recent national survey, the majority of Swedish Emergency Departments (EDs) apply the Swedish triage scale known as the Medical Emergency Triage Treatment Scale (METTS), subsequently renamed the Rapid Emergency Triage Treatment Scale (RETTS©). Despite national widespread implementation, there has been limited research on METTS/RETTS©.

Aim

To determine the reliability of application by registered nurses of the RETTS© triage scale in two Swedish emergency departments.

Methods

In this prospective, cross-sectional study at two EDs, 46 written patient scenarios were triaged by 28 registered nurses (RNs). Data were analysed with descriptive statistics and Fleiss kappa (κ).

Results

The RNs allocated 1281 final triage levels. There was concordance in seven (15%) of the scenarios, and dispersion over two or more triage levels in 39 (85%). Dispersion across the stable/unstable patient boundary was found in 21 (46%) scenarios. Fleiss κ was 0.562, i.e. moderate agreement.

Conclusion

The inability of the triage scale to distinguish between stable/unstable patients can lead to serious consequences from a patient safety perspective. No general pattern regarding concordance or dispersion was found.