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Validation of the five-tier Taiwan Triage and Acuity Scale for prehospital use by Emergency Medical Technicians
  1. Chip-Jin Ng1,
  2. Cheng-Yu Chien1,2,
  3. Julian Chen-June Seak1,
  4. Shang-Li Tsai1,3,
  5. Yi-Ming Weng4,
  6. Chung-Hsien Chaou1,
  7. Chan-Wei Kuo4,
  8. Jih-Chang Chen1,4,
  9. Kuang-Hung Hsu1,5,6,7,8,9
  1. 1 Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou and Chang Gung University College of Medicine, Tao-Yuan, Taiwan
  2. 2 Department of Emergency Medicine, Ton-Yen General Hospital, Zhupei, Taiwan
  3. 3 Department of Emergency Medicine, Chang Gung Memorial Hospital Taipei Branch, Taipei, Taiwan
  4. 4 Department of Emergency Medicine, Taoyuan General Hospital, Ministry of Health and Welfare, Tao-Yuan, Taiwan
  5. 5 Laboratory for Epidemiology, Chang Gung University, Kwei-Shan, Taiwan
  6. 6 Department of Urology, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
  7. 7 Department of Health Care Management, and Healthy Aging Research Center, Chang Gung University, Tao-Yuan, Taiwan
  8. 8 Research Center for Food and Cosmetic Safety, College of Human Ecology, Chang Gung University of Science and Technology, Taoyuan, Taiwan
  9. 9 Department of Safety, Health and Environmental Engineering, Ming Chi University of Technology, New Taipei City, Taiwan
  1. Correspondence to Dr Jih-Chang Chen, Emergency Department Taoyuan General Hospital, Ministry of Health and Welfare Tao-Yuan Taiwan; a9999999{at} and Phd. Kuang-Hung Hsu, Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan; khus{at}


Objectives This study aimed to determine the inter-rater reliability of the five-level Taiwan Triage and Acuity Scale (TTAS) when used by emergency medical technicians (EMTs) and triage registered nurses (TRNs). Furthermore, it sought to validate the prehospital TTAS scores according to ED hospitalisation rates and medical resource consumption.

Methods This was a prospective observational study. After training in five-level triage, EMTs triaged patients arriving to the ED and agreement with the nurse triage (TRN) was assessed. Subsequently, these trained research EMTs rode along on ambulance calls and assigned TTAS scores for each patient at the scene, while the on-duty EMTs applied their standard two-tier prehospital triage scale and followed standard practice, blinded to the TTAS scores. The accuracy of the TTAS scores in the field for prediction of hospitalisation and medical resource consumption were analysed using logistic regression and a linear model, respectively, and compared with the accuracy of the current two-tier prehospital triage scale.

Results After EMT’s underwent initial training in five-level TTAS, inter-rater agreement between EMTs and TRNs for triage of ED patients was very good (κw=0.825, CI 0.750 to 0.900). For the outcome of hospitalisation, TTAS five-level system (Akaike’s Information Criteria (AIC)=486, area under the curve (AUC)=0.75) showed better discrimination compared with TPTS two-level system (AIC=508, AUC=0.66). Triage assignments by the EMTs using the the five-level TTAS was linearly associated with hospitalisation and medical resource consumption.

Conclusions A five-level prehospital triage scale shows good inter-rater reliability and superior discrimination compared with the two-level system for prediction of hospitalisation and medical resource requirements.

  • triage
  • training
  • pre-hospital
  • paramedics, education

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  • Contributors C-JN, C-YC, J-CC and K-HH conceived and designed the study. JC-JS, Y-MW, C-WK, S-LT and C-YC supervised the conduct of the trial and data collection. C-HC, S-LT, C-JN, K-HH and J-CC undertook recruitment of participating centers and patients and managed the data, including quality control, provided statistical advice on study design and analysed the data. C-YC chaired the data oversight committee. C-HC, C-JN, C-YC and J-CC drafted the manuscript, and all authors contributed substantially to its revision. J-CC and K-HH take responsibility for the paper as a whole.

  • Funding This study was supported by a grant from the Taiwan Department of Health (DOH-TD-M113-100004) and National Science Council Taiwan (contract number MOST 106-2410-H-182-020, MOST 103-2314-B-182A-019, NSC-101-2410-H-182-015, NSC-102-2410-H-182-010-MY2, NSC-103-2410-H-161-001, MOST 104-2410-H-182-028-MY2), NMRPG3D0181 and the Healthy Aging Research Center of Chang Gung University (fund number EMRPD1B0351, EMRPD1C0301, EMRPD1D0911, EMRPD1E1691, EMRPD1H0371 and EMRPD1H0551).

  • Competing interests None declared.

  • Ethics approval The study was approved by the Institutional Review Board (IRB) of the study institution (review #102–6071C).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.