Impacts of the introduction of a triage system in Japan: A time series study

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Abstract

The aim of the present study was to measure and compare the effectiveness of nursing triage before and after introduction of the Japanese Triage and Acuity Scale (JTAS), the Japanese version of the Canadian Triage and Acuity Scale (CTAS), during emergency treatment. Surveys of triage nurses and emergency physicians were conducted before and after JTAS introduction. Respondents were triage nurses (before 112 cases, after 94 cases), emergency physicians (before 50, after 41), and triaged patients (before 1057, after 1025) from seven separate emergency medical facilities. The results showed that nursing triage using the JTAS shortened “time from registration to triage” by 3.8 min, “triage duration” by 1 min, “time from registration to physician” by 11.2 min, and “waiting time perceived by patients to see a physician” by 18.6 min (p < 0.001). The difference in assigned level of urgency between triage nurses and emergency physicians decreased from 34.2% to 12.2% (p < 0.001), over-triage decreased from 24.7% to 8.6% (p < 0.001), and under-triage decreased from 9.5% to 3.6% (p < 0.001). Furthermore, assessment agreement between triage nurses and emergency physicians increased significantly, from weighted κ = 0.486 to weighted κ = 0.820. These findings suggest that the introduction of the JTAS promoted more effective nursing triage and medical care.

Introduction

Emergency department (ED) overcrowding is one of the most complex and challenging issues currently facing health care systems worldwide (Holroyd et al., 2007). Studies in other countries have shown that about 50–80% of patients visit an ED for non-urgent care (Baker and Baker, 1994, Carter and Chochinov, 2007, Qureshi, 2010). This indicates the presence of a mixture of non-urgent patients and highly urgent patients in EDs.

A similar situation is occurring in Japan, where an increase in patient visits to EDs has also been seen. However, EDs in Japan have had difficulties in dealing with incoming patients due to the shortage of emergency physicians. This has resulted in insufficient medical care of patients in EDs.

In 2010, the Japanese Society for Emergency Medicine, the Japanese Association for Acute Medicine, the Japanese Society of Emergency Pediatrics, and the Japanese Association for Emergency Nursing developed the Japanese Triage and Acuity Scale (JTAS). This is the first standardized triage system in Japan. Its fundamental ideas are based on the Canadian Triage and Acute Scale (CTAS) developed by the Canadian Association of Emergency Physicians. The prototype of the JTAS was made through translation of the CTAS; it was later evaluated by the four official emergency healthcare associations, and items related to medical conditions commonly seen in Japan, such as heat stroke, were included in the scale.

The reason why the CTAS was used as the model was that it has demonstrated excellent interrater reliability when assigning patients to acuity categories (Beveridge et al., 1999a, Beveridge et al., 1999b, Manos et al., 2002, Grafstein et al., 2003, Dong et al., 2007). The JTAS was expected to function in a similar way. The purpose of this study was to measure and compare the effectiveness of nursing triage in EDs before and after the introduction of the JTAS. This is the first attempt to evaluate the JTAS.

Section snippets

Methods

A time series study was used to measure the effects of triage before and after the introduction of the JTAS. This design was selected because it permits differences in the background of triage cases, differences between the facilities where the survey was conducted, and differences among the regions where the facilities are located to be eliminated.

Results

A total of 2082 triage cases, comprising 1057 cases before and 1025 cases after JTAS introduction, was analyzed. The triage cases for the first 3 days after starting the survey were excluded from analysis because the triage nurses were not yet accustomed to filling out the survey form.

Summary of triage

Mean age, age category, and sex of the triage cases were similar before and after JTAS introduction. The chief complaints of patients when visiting the ED included the same top 12 symptoms, without bias in the type of disorder before and after JTAS introduction. Therefore, the subjects analyzed in this study were groups with similar background characteristics. Grouping the sample of triage cases and using a time series design allowed us to maintain similarity between groups and to control for

Conclusion

The present findings demonstrate that the introduction of the JTAS has affected nursing triage and medical care in a positive way. It was clearly shown that triage was successfully performed in a shorter time after JTAS introduction. Furthermore, triage nurses and emergency physicians have established better coordination in triage.

In the future, we expect to increase the number of target facilities in order to collect more evidence of the effectiveness of the JTAS. It has been assumed that the

Funding statement

This study was supported by a 2010 Collaborative Domestic Research Grant from the Pfizer Health Research Foundation.

Acknowledgements

The authors would like to thank the triage nurses and emergency physicians who participated in this survey. The authors would also like to thank the emergency department directors, nursing directors, and research representatives of each facility for their gracious cooperation.

This study was supported by a 2010 Collaborative Domestic Research Grant from the Pfizer Health Research Foundation. The study sponsor was not involved in data collection or in the analysis or interpretation of data.

References (11)

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