Original contribution
Medical Emergency Triage and Treatment System (METTS): A New Protocol in Primary Triage and Secondary Priority Decision in Emergency Medicine

https://doi.org/10.1016/j.jemermed.2008.04.003Get rights and content

Abstract

Background: In many Emergency Department (ED) triage scoring systems, vital signs are not included as an assessment parameter. Objectives: To evaluate the validity of a new protocol for Emergency Medicine in a large cohort of patients referred to in-hospital care. Methods: From January 1 to June 30, 2006, 22,934 patients were admitted to the ED at Sahlgrenska University Hospital. Of those, 8695 were referred to in-hospital care and included in the study. A new five-level triage tool, combining vital signs, symptoms, and signs in the triage decision, was used. A small control of the inter-rater disagreement was also performed in 132 parallel, single-blinded observations. Results: Fifty percent of the patients were admitted by ambulance and the other 50% by walk-in. Hospital stay was significantly (p < 0.001) longer in those admitted by ambulance (9.3 ± 14 days) as compared with walk-in patients (6.2 ± 10 days). In-hospital mortality incidence was higher (8.1%) in patients admitted by ambulance, as compared with walk-in patients (2.4%). Hospital stay and in-hospital mortality increased with higher level of priority. In the highest priority groups, 32–53% of the patients were downgraded to a lower priority level after primary treatment. Conclusion: In the present study, the METTS protocol was shown to be a reliable triage method and a sensitive tool for secondary re-evaluation of the patient in the ED.

Introduction

Early identification of critically ill patients and stratification into priority levels on admission to the Emergency Department (ED) is very important for the quality and safety of Emergency Medicine. In most EDs, triage assessments are made close to admittance. There are several reports on different methods of triage in the ED; in Sweden, triage has been introduced in most Emergency Departments during recent years (1, 2, 3). Previously, scoring systems—including physiological parameters—to predict mortality have been described, but in most triage methods used in EDs, vital signs or laboratory parameters are not included as standard assessments (1, 2, 3, 4, 5). However, vital signs have been reported to be of importance and superior for predicting mortality and stratifying critically ill patients (5). Vital signs have also been shown to be of importance in detecting high-risk hospital inpatients (6). The safety of triage systems is related to the ability to detect the critically ill and not fail to detect those who deteriorate during the ED stay (7). This safety has to be balanced with the resource implications of over-triage.

At the ED of Sahlgrenska University Hospital, we developed and introduced a new protocol including a triage algorithm combining vital signs, chief complaints, symptoms, and signs to give the priority level. The aim of the present study was to evaluate the new triage algorithm used in our Accident and Emergency Department in patients referred from the ED to in-hospital care.

Section snippets

Methods and Material

Sahlgrenska University Hospital, with 48,000 annual visits to its Accident and Emergency Department, serves as an urban, academic teaching hospital. In the present retrospective study, 22,934 adult patients were admitted to the ED from January 1 through June 30, 2006. Of these, 38% (n = 8695) had an in-hospital stay and 14,239 patients were discharged from the ED. Only in-hospital patients were included in the present study. A small number of patients admitted to the ED, by helicopter (n = 45)

Results

There was a significantly (p < 0.001) higher percentage of male patients (54%) as compared with females (46%) in this cohort. Males were significantly older than females, whereas no significant difference was found in length of hospital stay or in-hospital mortality between males and females (Table 1).

Approximately 50% were admitted by walk-in and 50% by pre-hospital services. Age was significantly higher and hospital stay longer in patients admitted by ambulance as compared with those admitted

Discussion

In the present study, it was shown that the METTS protocol includes a sensitive triage algorithm to find those with high or low medical risk in the ED. The aim with this new protocol was to establish a higher sensitivity to identify the level of acuity and stratify patients into one of five priority levels close to admittance. It is clear that the priority level in METTS, based on the combination of vital parameters, symptoms, and signs, is closely related to in-hospital mortality and hospital

Conclusions

We believe that our protocol for early detection of organ failure and follow-up during ED stay can increase the medical safety and lower the mortality of the ED population.

We did also find that the METTS triage method is a sensitive tool to find those in need of immediate medical attention, and for early detection of those with deterioration during the ED stay. This gives us a reliable and validated protocol for both triage and follow-up management in the ED.

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