Pre-hospital triage performance and emergency medical services nurse’s field assessment in an unselected patient population attended to by the emergency medical services: a prospective observational study

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Abstract

Background

In 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.

Methods

A 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.

Results

Overall, 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.

Conclusions

In 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.

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Most cited references 40

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Emergency department triage revisited.

M. F. Gerdtz, Deborah Scott, Gerard FitzGerald … (2010)

Triage is a process that is critical to the effective management of modern emergency departments. Triage systems aim, not only to ensure clinical justice for the patient, but also to provide an effective tool for departmental organisation, monitoring and evaluation. Over the last 20 years, triage systems have been standardised in a number of countries and efforts made to ensure consistency of application. However, the ongoing crowding of emergency departments resulting from access block and increased demand has led to calls for a review of systems of triage. In addition, international variance in triage systems limits the capacity for benchmarking. The aim of this paper is to provide a critical review of the literature pertaining to emergency department triage in order to inform the direction for future research. While education, guidelines and algorithms have been shown to reduce triage variation, there remains significant inconsistency in triage assessment arising from the diversity of factors determining the urgency of any individual patient. It is timely to accept this diversity, what is agreed, and what may be agreeable. It is time to develop and test an International Triage Scale (ITS) which is supported by an international collaborative approach towards a triage research agenda. This agenda would seek to further develop application and moderating tools and to utilise the scales for international benchmarking and research programmes.

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Poor performance of quick-SOFA (qSOFA) score in predicting severe sepsis and mortality – a prospective study of patients admitted with infection to the emergency department

Åsa Askim, Florentin Moser, Lise T Gustad … (2017)

Background We aimed to evaluate the clinical usefulness of qSOFA as a risk stratification tool for patients admitted with infection compared to traditional SIRS criteria or our triage system; the Rapid Emergency Triage and Treatment System (RETTS). Methods The study was an observational cohort study performed at one Emergency Department (ED) in an urban university teaching hospital in Norway, with approximately 20,000 visits per year. All patients >16 years presenting with symptoms or clinical signs suggesting an infection (n = 1535) were prospectively included in the study from January 1 to December 31, 2012. At arrival in the ED, vital signs were recorded and all patients were triaged according to RETTS vital signs, presenting infection, and sepsis symptoms. These admission data were also used to calculate qSOFA and SIRS. Treatment outcome was later retrieved from the patients’ electronic records (EPR) and mortality data from the Norwegian population registry. Results Of the 1535 admitted patients, 108 (7.0%) fulfilled the Sepsis2 criteria for severe sepsis. The qSOFA score ≥2 identified only 33 (sensitivity 0.32, specificity 0.98) of the patients with severe sepsis, whilst the RETTS-alert ≥ orange identified 92 patients (sensitivity 0.85, specificity 0.55). Twenty-six patients died within 7 days of admission; four (15.4%) of them had a qSOFA ≥2, and 16 (61.5%) had RETTS ≥ orange alert. Of the 68 patients that died within 30 days, only eight (11.9%) scored ≥2 on the qSOFA, and 45 (66.1%) had a RETTS ≥ orange alert. Discussion In order to achieve timely treatment for sepsis, a sensitive screening tool is more important than a specific one. Our study is the fourth study were qSOFA finds few of the sepsis cases in prehospital or at arrival to the ED. We add information on the RETTS triage system, the two highest acuity levels together had a high sensitivity (85%) for identifying sepsis at arrival to the ED - and thus, RETTS should not be replaced by qSOFA as a screening and trigger tool for sepsis at arrival. Conclusion In this observational cohort study, qSOFA failed to identify two thirds of the patients admitted to an ED with severe sepsis. Further, qSOFA failed to be a risk stratification tool as the sensitivity to predict 7-day and 30-day mortality was low. The sensitivity was poorer than the other warning scores already in use at the study site, RETTS-triage and the SIRS criteria. Electronic supplementary material The online version of this article (doi:10.1186/s13049-017-0399-4) contains supplementary material, which is available to authorized users.

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Validation of the National Early Warning Score in the prehospital setting.

Daniel J Silcock, Alasdair R Corfield, Paul Gowens … (2015)

Early intervention and response to deranged physiological parameters in the critically ill patient improves outcomes. A National Early Warning Score (NEWS) based on physiological observations has been developed for use throughout the National Health Service (NHS) in the UK. Although a good predictor of mortality and deterioration in inpatients, its performance in the prehospital setting is largely untested. This study aimed to assess the validity of the NEWS in unselected prehospital patients.

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Author and article information

Contributors

Carl Magnusson:

ORCID: http://orcid.org/0000-0002-8037-0014

carl.magnusson@vgregion.se

Johan Herlitz: johan.herlitz@hb.se

Christer Axelsson: christer.axelsson@hb.se

Journal

Journal ID (nlm-ta): Scand J Trauma Resusc Emerg Med

Journal ID (iso-abbrev): Scand J Trauma Resusc Emerg Med

Title: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Publisher: BioMed Central (London )

ISSN (Electronic): 1757-7241

Publication date (Electronic): 17 August 2020

Publication date PMC-release: 17 August 2020

Publication date Collection: 2020

Volume: 28

Electronic Location Identifier: 81

Affiliations

[1 ]GRID grid.8761.8, ISNI 0000 0000 9919 9582, Department of Molecular and Clinical Medicine, Institute of Medicine, , Sahlgrenska Academy, University of Gothenburg, ; Gothenburg, Sweden

[2 ]GRID grid.412442.5, ISNI 0000 0000 9477 7523, Pre Hospen-Centre for Prehospital Research, Faculty of Caring Science, , Work Life and Social Welfare, University of Borås, ; Borås, Sweden

Author information

Carl Magnusson http://orcid.org/0000-0002-8037-0014

Article

Publisher ID: 766

DOI: 10.1186/s13049-020-00766-1

PMC ID: 7430123

PubMed ID: 32807224

SO-VID: f017e211-a38f-4270-944c-9ceabc5da106

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 12 May 2020

Date accepted : 15 July 2020

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ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: triage,emergency medical services,pre-hospital emergency nurse,field assessment,patient safety

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ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: triage, emergency medical services, pre-hospital emergency nurse, field assessment, patient safety

Pre-hospital triage performance and emergency medical services nurse’s field assessment in an unselected patient population attended to by the emergency medical services: a prospective observational study

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Most cited references 40

Emergency department triage revisited.

Poor performance of quick-SOFA (qSOFA) score in predicting severe sepsis and mortality – a prospective study of patients admitted with infection to the emergency department

Validation of the National Early Warning Score in the prehospital setting.

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