Performance of the Canadian Triage and Acuity Scale for Children: A Multicenter Database Study

doi:10.1016/j.annemergmed.2012.05.024

Annals of Emergency Medicine

Volume 61, Issue 1, January 2013, Pages 27-32.e3

Presented in part at the Society of Pediatric Research–American Pediatric Association conference, April 2012, Boston, MA; Society of Academic Emergency Medicine Conference, May 2012, Chicago, IL; and the Canadian Pediatric Society conference, June 2012, London, Ontario, Canada.

https://doi.org/10.1016/j.annemergmed.2012.05.024 Get rights and content

Study objective

We evaluate the association between triage levels assigned using the Canadian Triage and Acuity Scale and surrogate markers of validity for real-life children triaged in multiple emergency departments (EDs).

Methods

This was a retrospective cohort study evaluating the triage assessment and outcomes of all children presenting to 12 pediatric EDs, all of which are members of the Pediatric Emergency Research Canada group, during a 1-year period (2010 to 2011). Anonymous data were retrieved from the ED computerized databases. The primary outcome measure was the proportion of children hospitalized for each triage level. Other outcomes were ICU admission, proportion of patients who left without being seen by a physician, and length of stay in the ED. Evaluation of all children visiting these EDs during 1 year was expected to provide more than 1,000 patients in each triage category.

Results

A total of 550,940 children were included. Pooled data demonstrated hospitalization proportions of 61%, 30%, 10%, 2%, and 0.9% for patients in Canadian Triage and Acuity Scale levels 1, 2, 3, 4, and 5, respectively. There was a strong association between triage level and admission to the ICU, probability of leaving without being seen by a physician, and length of stay.

Conclusion

The strong association between triage level and multiple markers of severity in 12 Canadian pediatric EDs suggests validity of the Canadian Triage and Acuity Scale for children.

Introduction

With prolonged waiting time and crowding,1, 2, 3 triage has become a critical “safety net” for emergency departments (EDs). The Canadian Triage and Acuity Scale is a 5-level triage tool that uses signs and symptoms assessed by a registered nurse to determine the urgency level of patients presenting to the ED.4, 5 The scale, ranging from triage level 1 (resuscitation) to level 5 (nonurgent), has been implemented for both adults and children.4, 5 During the last decade, the Canadian Triage and Acuity Scale has been implemented in many countries6, 7, 8, 9 and has become a mandatory practice in EDs of most Canadian provinces.¹

The validity of a triage scale is defined by its capacity to measure the level of urgency for patients presenting to the ED. To be useful, a triage scale must be able to properly identify patients in need of immediate assistance. It must also be able to safely identify less urgent patients who can wait to optimize use of limited resources.¹⁰

Previous studies have evaluated the validity of the Canadian Triage and Acuity Scale for children.11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26 However, these studies had weaknesses because they used an experimental model as opposed to real patients,15, 16, 18 involved a small number of children,17, 24 or were performed in a single hospital.17, 20, 24 Recently, a prospective study was conducted among 9 EDs of the Pediatric Emergency Research Canada network to evaluate the validity of the Canadian Triage and Acuity Scale.²⁷ This study demonstrated a good correlation between triage level and different markers of severity. Two limitations of this study were the exclusion of patients triaged at level 1 (resuscitation) and the relatively small sample size (1,464 children).

The main objective of the present study was to determine the validity of the Canadian Triage and Acuity Scale for actual children triaged with the scale in multiple EDs. In the absence of a criterion standard for triage, we evaluated the association between triage level and surrogate markers of validity. The primary marker of severity was hospitalization. Other markers of severity were the proportion of cases admitted to the ICU, the proportion of patients who left without being seen by a physician, and length of stay in the ED.

Section snippets

Study Design

This was a retrospective observational study using the computerized databases of multiple Canadian pediatric EDs.

Setting

Twelve tertiary care, pediatric, university-affiliated hospitals dispersed across 7 provinces in Canada were invited to participate in the study, and they all provided data. These EDs had an annual census varying between 25,000 and 75,000 visits and were all members of the Pediatric Emergency Research Canada network. Among the 12 settings, 9 had a fast-track clinic covering between

Results

During the study period, a total of 550,940 children visited the 12 EDs and were included. Baseline demographics of these children are presented in the Table. In brief, 54% of the children were boys and the median age was 47 months. The triage category with the lowest number of participants was level 1 (3,516 children), whereas triage level 4 represented 44% of the study population. Approximately 85% of the children were discharged home. A total of 2,080 (0.4%) patients were admitted directly

Limitations

The absence of a criterion standard for triage is always a limitation for studies aiming to evaluate the validity of a triage tool.²⁹ Hospitalization, admission to the ICU, proportion of children leaving without being seen by a physician, and length of stay are only surrogate markers of the urgency of a situation and thus do not represent a perfect criterion standard for triage. For example, patients triaged at level 1 had a length of stay in the ED similar to patients triaged at level 2. The

Discussion

This study demonstrated an excellent association between Canadian Triage and Acuity Scale triage level and several surrogate markers of severity. Specifically, triage level was strongly predictive of hospitalization, admission to the ICU, the proportion of patients leaving without being seen, and length of stay in the ED. These data suggest the validity of the Canadian Triage and Acuity Scale tool and support its implementation in EDs.

The conclusion of the present study is consistent with those

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Cited by (66)

Validity of the Brazilian pediatric triage system CLARIPED at a secondary level of emergency care
2023, Jornal de Pediatria
Citation Excerpt :
Even considering that several aspects can influence the hospitalization rate, such as infrastructure, case mix, and variable policies among different institutions, the authors can say that CLARIPED proved to be a very safe and efficient tool. This study showed a very high negative predictive value and a much lower hospitalization rate of less urgent patients than the rates observed in other triage systems (1 to 12%).11–20 The emergency unit length of stay ranged from 12 to 362 min from the lowest to the highest level of urgency, corroborating the discriminative capacity of CLARIPED.
To evaluate the validity of the triage system CLARIPED in a pediatric population in the city of São Paulo, Brazil.
Prospective, observational study in a secondary-level pediatric emergency service from Sep-2018 to Ago-2019. A convenience sample of all patients aged 0–18 years triaged by the computerized CLARIPED system was selected. Associations between urgency levels and patient outcomes were analyzed to assess construct validity. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) to identify the most urgent patients were estimated, as well as under-triage and over-triage rates.
The distribution of 24,338 visits was: RED 0.02%, ORANGE 0.9%, YELLOW 23.5%, GREEN 47.9%, and BLUE 27.7% (highest to the lowest level of urgency). The frequency of the following outcomes increased with increasing urgency: hospital admission (0.0%, 0.02%, 0.1%, 7.1% and 20%); stay in ED observation room (1.9%, 2,4%, 4.8%, 24.1%, 60%); use of ≥ 2 diagnostic/therapeutic resources (2.3%, 3.0%, 5.9%, 28.8%, 40%); ED length of stay (12, 12, 15, 99.5, 362 min). The most urgent patients (RED, ORANGE, and YELLOW) exhibited higher chances of using ≥ 2 resources (OR 2.55; 95%CI: 2.23–2.92) or of being hospitalized (OR 23.9; 95%CI: 7.17–79.62), compared to the least urgent (GREEN and BLUE). The sensitivity to identify urgency was 0.88 (95%CI: 0.70–0.98); specificity, 0.76 (95%CI: 0.75–0.76); NPV, 0.99 (95%CI: 0.99–1.00); overtriage rate, 23.0%, and undertriage, 11.5%.
This study corroborates the validity and safety of CLARIPED, demonstrating significant correlations with clinical outcomes, good sensitivity, and low undertriage rate in a secondary-level Brazilian pediatric emergency service.
Triage performance in adolescent patients with SARS-CoV-2 infection in Israel
2022, American Journal of Emergency Medicine
The aim of this study was to assess the performance of the Pediatric Canadian Triage and Acuity Scale (PaedCTAS) in adolescent patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.
A time-series study was conducted in the Emergency Departments (EDs) of 17 public hospitals during the Delta (B.1.617.2) variant spread in Israel. Data were collected prospectively from June 11, 2021 to August 15, 2021. Multivariate regression analyses were performed to identify independent variables associated with hospital admission and with admission to an Intensive Care Unit (ICU).
During the study period, 305 SARS-CoV-2 patients ages 12–18 years presenting to the ED were included, and 267 (87.5%) were unvaccinated. Sixty-seven (22.0%) and 12 (3.9%) patients were admitted to pediatric wards and ICUs, respectively. PaedCTAS level 1–2 and the presence of chronic disease increased the odds of hospital admission (adjusted odds ratio (aOR) 5.74, 95% CI, 2.30–14.35, p < 0.0001), and (aOR 2.9, 95% CI, 1.48–5.67, p < 0.02), respectively. PaedCTAS level 1–2 and respiratory symptoms on presentation to ED increased the odds of ICU admission (aOR 27.79; 95% CI, 3.85–176.91, p < 0.001), and (aOR 26.10; 95% CI, 4.47–172.63, p < 0.0001), respectively. PaedCTAS level 3–5 was found in 217/226 (96%) of the patients who were discharged home from the ED.
The findings suggest that PaedCTAS level 1–2 was the strongest factor associated with hospital and ICU admission. Almost all the patients who were discharged home had PaedCTAS level 3–5. Study findings suggest good performance of the PaedCTAS in this cohort.
Outcomes of patients discharged from the pediatric emergency department with abnormal vital signs
2022, American Journal of Emergency Medicine
Vital signs (VS) are used to triage and identify children at risk for severe illness. Few studies have examined the association of pediatric VS at emergency department (ED) discharge with patient outcomes.
To determine if children discharged from the ED with abnormal VS have high rates of return visits, admission or adverse outcomes.
We conducted a retrospective cohort study of children discharged from 2 pediatric EDs with abnormal VS between July 2018–June 2019. We queried electronic health records (EHR) for children ages 0–18 years discharged from the ED with abnormal last recorded VS. VS were considered erroneously entered and thus excluded from analysis if heart rate was <30 or ≥ 300, respiratory rate was 0 or ≥ 100 or oxygen saturation was <50. Patients who were declared deceased at index visit were excluded. Demographic, clinical, and outcome data including return visits within 48 h and adverse outcomes after the initial ED discharge were obtained.
Of the 97,824 children evaluated in the EDs during the study period, 17,661 (18.1%) were discharged with abnormal VS. 404 (2.28%) returned to the ED, of which 95 (23.5%) were admitted for the same chief complaint within 48 h. In comparison, the 48-h return rate for children discharged with normal VS was 2.45% (p = 0.219). Children discharged with abnormal VS were more likely to return if they had 2 or more abnormal VS (OR 1.6; 95% CI 1.23–2.07), were less than 3 years old (OR 1.69, 95% CI 1.39–2.06) or their initial acuity level was high (OR 1.34; 95% CI 1.1–1.63). Higher initial acuity level and age less than 3 years were also associated with admission at revisit (OR 2.58; 95% CI 1.59–4.2; OR 2.20, 95% CI 1.36–3.55). Four of the children who returned required PICU admission, but none died, required CPR or endotracheal intubation.
Although many children were discharged from the ED with abnormal VS, few returned and required admission. Having 2 or more abnormal VS, age less than 3 years and higher acuity increased odds of revisit. Few children suffered serious adverse outcomes.
Validity of the computerized version of the pediatric triage system CLARIPED for emergency care
2022, Jornal de Pediatria
Citation Excerpt :
These findings corroborate the tool's validity and support its implementation in pediatric emergency care with similar populations. The distribution of levels of urgency in the study population is similar to that found in other validity studies on different triage systems, conducted in tertiary hospitals of developed countries, using consecutive samples, which describe 70 to 90% of the visits in the levels 3 or 4.12-17 The strong association between increased urgency levels and increased frequency of severity outcomes (use of two or more resources, admission to the emergency observation room, length of stay in the emergency department, and hospitalization) demonstrated the convergent construct validity of the CLARIPED system.
To evaluate the validity of the computerized version of the pediatric triage system CLARIPED.
Prospective, observational study in a tertiary emergency department (ED) from Jan-2018 to Jan-2019. A convenience sample of patients aged 0-18 years who had computerized triage and outcome variables registered. Construct validity was assessed through the association between urgency levels and patient outcomes. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), undertriage, and overtriage rates were assessed.
19,122 of 38,321 visits were analyzed. The urgency levels were: RED (emergency) 0.02%, ORANGE (high urgency) 3.21%, YELLOW (urgency) 35.69%, GREEN (low urgency) 58.46%, and BLUE (no urgency) 2.62%. The following outcomes increased according to the increase in the level of urgency: hospital admission (0.4%, 0.6%, 3.1%, 11.9% and 25%), stay in the ED observation room (2.8%, 4.7%, 15.9%, 40.4%, 50%), ≥ 2 diagnostic or therapeutic resources (7.8%, 16.5%, 33.7%, 60.6%, 75%), and ED length of stay in minutes (18, 24, 67, 120, 260). The odds of using ≥ 2 resources or being hospitalized were significantly greater in the most urgent patients (Red, Orange, and Yellow) compared to the least urgent (Green and Blue): OR 7.88 (95%CI: 5.35-11.6) and OR 2.85 (95%CI: 2.63-3.09), respectively. The sensitivity to identify urgency was 0.82 (95%CI: 0.77-0.85); specificity, 0.62 (95%CI: 0.61-0.6; NPV, 0.99 (95%CI: 0.99-1.00); overtriage rate, 4.28% and undertriage, 18.41%.
The computerized version of CLARIPED is a valid and safe pediatric triage system, with a significant correlation with clinical outcomes, good sensitivity, and low undertriage rate.
Validity of the Japan Acuity and Triage Scale in elderly patients: A cohort study
2019, American Journal of Emergency Medicine
Citation Excerpt :
These studies examine an unspoken hypothesis that, as the triage level is higher (more emergent), the patient outcomes are more severe. Many of the previous studies on the CTAS and other triage systems examined the association between triage levels and markers of severity to determine the validity of the triage system [17,19,23-29]. Similarly, our study found that, as the JTAS level was higher, overall admission and ED length of stay increased, as did ICU admission and in-hospital mortality.
In developed nations, the age of patients in emergency departments (ED) continues to increase. Many emergency triage systems, such as the Canadian Triage and Acuity Scale (CTAS), triage patients as a homogenous group, regardless of age. However, older adults have multiple comorbidities and a higher risk of undertriage. The Japan Acuity and Triage Scale (JTAS) was developed based on the CTAS and has been validated for overall adults. We assessed the validity of the JTAS for use in elderly ED patients.
This was a secondary analysis of a cohort study that previously validated the JTAS in self-presenting adults of all ages in the ED of a Japanese tertiary-care hospital. We included non-transferred patients who were ≥65 years old and triaged between June 2013 and May 2014. Our primary outcome measures were overall admission and ED length of stay. Our secondary outcomes included admission to the intensive care units (ICUs) and in-hospital mortality. We examined the association between the triage level and patient outcomes with multivariable logistic regression analysis (overall and ICU admission and in-hospital mortality) and the Kruskal-Wallis rank-sum test (ED length of stay).
We included a total of 11,087 elderly patients in our study. Higher odds ratios for overall and ICU admission and in-hospital mortality corresponded to higher acuity levels. ED length of stay was significantly longer in patients with a higher JTAS level (p < 0.001). Twenty-nine percent of admissions who were triaged as lower acuity levels were related to non-acute diseases including malignancy-related events.
Our study suggests an association between the JTAS triage level and clinical outcomes in self-presenting elderly patients, thereby demonstrating the validity of the JTAS in these patients. However, admission due to chronic diseases including malignancy was common in patients who were rated as low acuity level.
Triage Performance in Emergency Medicine: A Systematic Review
2019, Annals of Emergency Medicine
Rapid growth in emergency department (ED) triage literature has been accompanied by diversity in study design, methodology, and outcome assessment. We aim to synthesize existing ED triage literature by using a framework that enables performance comparisons and benchmarking across triage systems, with respect to clinical outcomes and reliability.
PubMed, EMBASE, Scopus, and Web of Science were systematically searched for studies of adult ED triage systems through 2016. Studies evaluating triage systems with evidence of widespread adoption (Australian Triage Scale, Canadian Triage and Acuity Scale, Emergency Severity Index, Manchester Triage Scale, and South African Triage Scale) were cataloged and compared for performance in identifying patients at risk for mortality, critical illness and hospitalization, and interrater reliability. This study was performed and reported in adherence to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.
A total of 6,160 publications were identified, with 182 meeting eligibility criteria and 50 with sufficient data for inclusion in comparative analysis. The Canadian Triage and Acuity Scale (32 studies), Emergency Severity Index (43), and Manchester Triage Scale (38) were the most frequently studied triage scales, and all demonstrated similar performance. Most studies (6 of 8) reported high sensitivity (>90%) of triage scales for identifying patients with ED mortality as high acuity at triage. However, sensitivity was low (<80%) for identification of patients who had critical illness outcomes and those who died within days of the ED visit or during the index hospitalization. Sensitivity varied by critical illness and was lower for severe sepsis (36% to 74%), pulmonary embolism (54%), and non–ST-segment elevation myocardial infarction (44% to 85%) compared with ST-segment elevation myocardial infarction (56% to 92%) and general outcomes of ICU admission (58% to 100%) and lifesaving intervention (77% to 98%). Some proportion of hospitalized patients (3% to 45%) were triaged to low acuity (level 4 to 5) in all studies. Reliability measures (κ) were variable across evaluations, with only a minority (11 of 42) reporting κ above 0.8.
We found that a substantial proportion of ED patients who die postencounter or are critically ill are not designated as high acuity at triage. Opportunity to improve interrater reliability and triage performance in identifying patients at risk of adverse outcome exists.

View all citing articles on Scopus

: Supervising editor: Steven M. Green, MD

: Author contributions: JG conceived the study and designed the trial, performed the primary analysis of the data, and drafted the article. All authors contributed to the design, provided data from their own setting, contributed substantially to revision of the article, and saw and approved the submission of this version of the article. JG takes responsibility for the paper as a whole.

: Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.

: Please see page 28 for the Editor's Capsule Summary of this article.

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: A podcast for this article is available at www.annemergmed.com.

: Publication date: Available online July 27, 2012.

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Pediatrics/original researchPerformance of the Canadian Triage and Acuity Scale for Children: A Multicenter Database Study

Study objective

Methods

Results

Conclusion

Introduction

Section snippets

Study Design

Setting

Results

Limitations

Discussion

J Formos Med Assoc

Ann Emerg Med

Am J Emerg Med

J Emerg Med

Am J Emerg Med

CAEP issuesThe Canadian Triage and Acuity Scale: a new and critical element in health care reform. Canadian Association of Emergency Physicians

J Emerg Med

Frequent overcrowding in US emergency departments

Acad Emerg Med

Waits to see an emergency department physician: US trends and predictors, 1997-2004

Health Aff (Millwood)

Revisions to the Canadian Emergency Department Triage and Acuity Scale (CTAS) adult guidelines

CJEM

Revisions to the Canadian Triage and Acuity Scale paediatric guidelines (PaedCTAS)

CJEM

Implementation of the Canadian Emergency Department Triage and Acuity Scale (CTAS) in the Principality of Andorra: can triage parameters serve as emergency department quality indicators?

CJEM

The impact of a fast track area on quality and effectiveness outcomes: a Middle Eastern emergency department perspective

BMC Emerg Med

Accuracy and concordance of nurses in emergency department triage

Scand J Caring Sci

Triage of the pediatric patient in the emergency department: are we all in agreement?

Pediatrics

Manchester Triage System in paediatric emergency care: prospective observational study

BMJ

Repeatability of the Manchester Triage System for children

Emerg Med J

Pediatrics/original research
Performance of the Canadian Triage and Acuity Scale for Children: A Multicenter Database Study