Limitations in validating emergency department triage scales

The Canadian Triage and Acuity Scale (CTAS) has been used not only for determining the priority by which patients are evaluated by physicians but also as a proxy for disease severity, nurse and physician workload, a tool in quality improvement processes, and in funding methodologies.

Evaluation of the accuracy and reliability of CTAS performance becomes essential for reliable information.

Accurate assessment of triage (a French term meaning “to sort”) processes and outcomes is central to any research on emergency department (ED) crowding.

The NR retrospectively triaged two separate month’s ED charts one year apart blinded to physician data and triage score.The second data collection was performed one year later to determine the reproducibility of results after staff turnover occurred (approximately 25% of triage staff).Turnover led to the requirement that all triage staff undergo Continuing Education on the CTAS guidelines during the year between the two trials (one-day seminar using the same CAEP/NENA materials and the CEDIS Chief Complaint List).Inter-observer reliability (IR) was performed between the original charted CTAS score and the NR score.IR results were compared using raw and quadratic weighted Kappa [4–7] (Quick Calcs by Graph Pad Software Inc. The NR was externally tested for accuracy in the use of the CTAS guidelines using a random case subset and independent review by a Master’s prepared ED nurse educator (RM) with research experience in CTAS Guidelines (both adults and pediatrics) and inter-observer reliability testing.

Focus groups chose, by consensus, five Indicator Groups for triage performance review that were felt to represent common and clinically important Chief Complaints (CCs).Data were collected in aggregate fashion to test the inclusiveness and performance of the chosen indicators.Multiple indicators were classified as CC #1, #2, and #3.Triage in this hospital was routinely performed by an experienced group of ED nurses who had been given CTAS training in the past and had national CTAS Guidelines materials including the CEDIS Chief Complaint list, a validated set of chief complaints for ED triage [8].An experienced emergency nurse underwent further specific training with CAEP/NENA training materials to become the study’s nurse reviewer (NR).CTAS performance has been measured through representative case evaluation and scoring by triage nurses, indirect measurement of ED statistics comparability between centers, prospective independent scoring in a live environment by duplicated triage staff, and by interobserver reliability studies.