File Name: canadian triage and acuity scale .zip
Michael K. Howlett, Paul R. Triage data are widely used to evaluate patient flow, disease severity, and emergency department ED workload, factors used in ED crowding evaluation and management. Interobserver reliability and accuracy were compared using Kappa and comparative statistics.
Electronic databases were searched to March Only studies were included that had reported samples size, reliability coefficients, adequate description of the CTAS reliability assessment.
Two reviewers independently examined abstracts and extracted data. The effect size was obtained by the z-transformation of reliability coefficients. Data were pooled with random-effects models and meta-regression was done based on method of moments estimator. Fourteen studies were included. Pooled coefficient for the CTAS was substantial 0.
Agreement upon the adult version, among nurse-physician and near countries is higher than pediatrics version, other raters and farther countries, respectively. The CTAS showed acceptable level of overall reliability in the emergency department but need more development to reach almost perfect agreement. Patients are categorized based on clinical acuity in the emergency departments EDs so the more critically-ill patient is, the more immediate treatment and care needs.
The CTAS is based on a comprehensive list of patients' complaints is used to ascertain the triage level. Each complaint has been described in details covering high-risk indicators.
Several studies[ 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 ] have investigated the validity and reliability of the CTAS in adult and pediatric populations; but it's still unclear to what extent the CTAS would support consistency in triage nurses' decision making in Canada comparing to other countries, considering the wide variety of health care systems around the world.
Besides, some studies[ 16 , 17 ] have addressed contextual influences on the triage decision making process, therefore it is necessary to discover the impact of these variables on the reliability of triage scale. However some studies reported moderate consistency for CTAS,[ 18 ] it needs to be more explored in terms of participants, statistics, instruments and other influencing criteria as well as mistriage.
The reliability of triage scales should be assessed by internal consistency, repeatability and inter-rater agreement. Meta-analysis is a systematic approach for introduction, evaluation, synthesis and unifying results in relation to studying research questions. It also produces the strongest evidence for intervention. A review on reliability of the CTAS demonstrated that kappa ranges from 0. So in view of the methodological limitations of the triage scale reliability, context-based triage decision making and the necessity of comprehensive insight into scale reliability in the EDs, the aim of this study was to provide a meta-analytic review of the reliability of the CTAS in order to examine to what extent the CTAS is reliable.
The University Research ethics committee approved the study. In the first phase of the study, a literature search was conducted through investigating Cinahl, Scopus, Medline, Pubmed, Google Scholar and Cochrane Library databases until the 1 st March Meta-analysis has been performed from Jan to July and authors started to collect data from March Searching databases were not limited to time periods.
Relevant citations in reference lists of final studies were hand-searched to identify additional articles regarding the reliability of CTAS. Two researchers independently examined the search results in order to recover potentially eligible articles [ Figure 1 ]. Authors of research articles were contacted to retrieve supplementary information if needed. Irrelevant and duplicated results were eliminated.
Irrelevant article has been defined as article which was not related in any manner to the Canadian triage and acuity scale or didn't contain reliability coefficient. Only English language publications were reviewed. Each item was graded qualified if described in sufficient detail in the paper.
Disagreements were resolved by consensus. The articles in which the type of reliability was not reported were excluded from the analyses. Researchers also recorded moderator variables such as participants, raters, origin and publication year of study. In the next phase, participants age-group, size , raters profession, size , instruments live, scenario , origin and publication year of study, reliability coefficient and method were retrieved.
Reliability coefficients were extracted from articles as below:. In meta-regression, each sample was considered as a unit of analysis.
If the same sample were reported in more than two articles, it was included once. In contrast, if several samples regarding different populations were reported in one study, each sample was separately included as a unit of analysis.
Pooling data was performed for all three types of reliability. Data was analyzed using Comprehensive Meta Analysis software Version 2. Simple meta-regression analysis was performed according to method of moments estimator.
Z-transformed reliability coefficients are regressed on the following variables: Origin and publication year of study. Meta-regression was performed using a random effects model because of the presence of significant between-study variation. Search strategy introduced primary citations relevant to the reliability of CTAS.
Finally, Fourteen unique citations emerged 4. Two clinicians A. Minor disagreements have been discussed to reach a consensus. The level of agreement among reviewers through final selection of articles was almost perfect. A total of cases were included in analysis [ Figure 2 ]. The reliability of CTAS has been assessed in two different countries. The publication year of studies ranged from with median Thirty percent of all studies have been conducted using the latest version of triage scale after Inter-rater reliability had been used in all studies except for one study using intra-rater reliability.
No study in our analysis used alpha coefficient to report internal consistency in reliability analysis. Weighted kappa coefficient was the most common statistics [ Table 1 ]. Overall pooled coefficient for the CTAS was substantial 0. Participants' pooled coefficients ranged from substantial 0.
Agreement regarding adult and pediatric version of the CTAS was substantial 0. Agreement regarding paper-based scenario assessment was substantial 0. Agreement regarding inter-rater and intra-rater reliability was substantial 0.
Agreement relating to weighted kappa was substantial 0. Also agreement regarding most updated version was substantial 0. Overall agreement was Mistriage decisions were The Contingency table of triage decision distribution relating to each CTAS category among ED raters[ 4 , 7 , 8 , 9 , 11 , 30 , 31 , 32 ].
Meta-regression analysis based on the method of moments for moderators distance and publication year was performed. The overall reliability of the CTAS is substantial in the emergency departments. The CTAS showed acceptable level of reliability to guarantee decisions were made consistently regarding allocating patients to appropriate categories. It supports evidence-based practice in the emergency department. So probably it's important to bear in mind that the CTAS reliability is actually at the moderate level which is congruent with several studies.
A calculated However Post-hoc analysis revealed that level III has been predominant among Dong et al. However ESI has tendency towards categorizing patients as level 2 In fact, the CTAS appropriately distribute patients into triage categories, so it has not a tendency to allocate patients into any specific level. Therefore it guarantees to prevent influx of patients in specific category. This influx could create significant disturbance in patient flow in the EDs and causes other parts of ED to remain unusable.
Comparing to other triage scales, mistriage in ESI Unlikely, Worster et al. The CTAS show diverse pooled reliability coefficients regarding participants, patients, raters, reliability method and statistics. Results demonstrated agreement upon adult version and among nurse-physician were higher than pediatrics version and the other groups of raters, respectively.
This result is congruent with ESI moderators. In this way, metaregression showed there is a significant difference in terms of distance from origin of CTAS. One reason refers to complaint-based nature of CTAS that could be translated changeably in routine practice comparing to the Canada. This result is opposed to ESI triage scale generalizability which has shown the ESI triage scale could be adopted successfully in other countries in spite of cultural diversities.
Meta-regression of Fisher's z-transformed kappa coefficients on predictor variables Studies with weighted kappa. The third edition of CTAS has been released[ 15 ] and the reliability of triage scales has not been significantly improved through the years indicating revisions had considerably been effective. Fisher's Z-transformed kappa coefficients in relation to the Publication year of study. In general, intra-rater reliability is more satisfactory than inter-rater reliability,[ 34 ] so it revealed almost perfect agreement comparing to substantial agreement for inter-rater reliability.
While intra and inter rater reliability are intended to report the degree to which measurements taken by the same and different observers are similar, respectively; other methods of examining reliability has remained uncommon in studies regarding the triage reliability.
Weighted kappa coefficient showed substantial agreement. In fact, weighted kappa coefficient revealed higher reliability than un-weighted kappa coefficient because it put more emphasis on the large differences between ratings than to small differences.
So un-weighted kappa statistics provides more realistic estimation of triage scales reliability. A number limitation of this study must be noted. In our analysis, none of these studies have reported raw agreement for each individual CTAS level and only few studies have presented contingency table for inter-rater agreement between raters.
Since this study is limited to overall reliability, some inconsistencies may exist across each CTAS level, therefore the results should be interpreted with caution. Overall, the CTAS triage scale showed acceptable level of reliability in the emergency department, also it appropriately distributes patients into triage categories. Therefore it needs more development to reach almost perfect agreement and decrease disagreement especially undertriage.
The Triage Process. Critical Look - rapid visual assessment. Infection Control. Presenting Complaint. 1st Order Modifiers. 2nd Order Modifiers. CTAS Level.
Show all documents Time interval was measured to assess the effect- iveness of triage system which are time before triage TBT , time to be seen by physician TBP , and total length of stay TLS. The mean, median, and SD of those intervals were measured.
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Show all documents This sorting process is called triage NENA, CTAS guidelines provide a five-level triage system where each patient presenting to an ED will be assigned a number from one to five, with one representing the highest priority and needing immediate intervention and five being the least urgent and able to safely wait for at least two hours for physician assessment CAEP, b. Canadian Triage and Acuity Scale: testing the mental health categories Based on this sample, the influence of education, confi- dence, and comfort level on the accuracy or inter-rater reli- ability of urgency ratings among triage nurses is not yet clear. Overall, the inter-rater reliability was fair to moderate despite high levels of reported confidence and educational prepara- tion with triaging mental health presentations. The influence of second-order modifiers on the accuracy or urgency ratings may be significant.
Each patient is assigned an acuity score consistent with guidelines provided in the Canadian Triage and Acuity Scale. (CTAS). Page 8. 4. It is important to.
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