Visual Triage in the ED Better at Predicting Mortality

Jennifer Garcia

October 16, 2018

When evaluating patients presenting to an emergency department (ED), a quick, visual assessment ("eyeball triage") is better than a formal triage when it comes to predicting mortality, a study has found.

"In this prospective study we found that a simple clinical assessment by nonclinician hospital staff was a significantly better predictor of death in an unselected ED patient group," write the authors of the study, which was published online October 15 in the Emergency Medicine Journal.

Anne Kristine Servais Iversen, MD, from the Rigshospitalet, Copenhagen, Denmark, and colleagues analyzed patient visit data for all patients presenting to the ED of a regional level 2 hospital in Denmark. Included in the analysis were 6290 patients seen in the ED from September 2013 through December 2013, all of whom were evaluated using both a formalized triage process (the Danish Emergency Process Triage [DEPT]) and a nonsystematic, clinical assessment based on patient appearance (Eyeball triage). DEPT was performed by nurses who had undergone formal training in the use of DEPT, while Eyeball triage was performed by phlebotomists who had no formal training in patient evaluation.

In both methods, patients were categorized into the following triage levels: red (resuscitation, constant reevaluation); orange (emergent, reevaluation every 15 min); yellow (potentially unstable, reevaluation every 60 min); green (nonurgent, reevaluation every 180 min); and blue (minor injuries or complaints, reevaluation every 240 min). The study excluded patients in the blue category.

The researchers evaluated the association between triage level and 48-hour and 30-day mortality as well as agreement between DEPT and Eyeball triage.

Overall, Iverson and colleagues found that Eyeball triage was more sensitive and specific than DEPT at predicting mortality (30-day mortality sensitivity, 52.9% vs 43.7%; specificity, 83.5% vs 73%). Further, there was little agreement between the two protocols (kappa 0.05), with the same patient often being categorized into two different triage levels, depending on the triage protocol used.

The researchers note that "there is no evidence establishing that formalised triage is superior to informally structured triage with regard to the prediction of clinical endpoints" and conclude that "the results from this study suggest that a clinical evaluation should potentially have a larger role in future triage algorithms."

In an accompanying editorial, Ellen J. Weber, MD, from the University of California, San Francisco, suggests possible study limitations, including that the research was conducted at a single center and used a formalized triage protocol that is not widely used on an international level.

Despite these study limitations, Weber highlights several previous studies that evaluated different triage protocols and that also found that unstructured triage systems can improve sensitivity without sacrificing specificity.

As emergency departments become busier and the need for accurate triage of patients becomes even more critical, Weber posits, "can we really continue to devote the time and resources to this function when simpler solutions may be just as good — or even better?"

Weber notes that in an effort to minimize "door to needle time...we have adopted complex systems that take up the time of highly qualified nurses, potentially delay care, to create what is probably, at best, a 'meh' result." She suggests that the current study by Iverson and colleagues "should make us rethink our current process and the evidence behind it."

The study received no funding. The authors and Dr Weber have disclosed no relevant financial relationships.

Emerg Med J. Published online October 15, 2018. Full text, Editorial

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