Australasian Emergency Nursing Journal (2014) 17, 184—189
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/aenj
RESEARCH PAPER
A comparison of emergency triage scales in triaging poisoned patients Dushan Jayaweera, MBBS, FACEM a,b,c,f,∗ Satish Mitter, MBBS, FACEM a,b,c,f Andrew Grouse, MBBS, FACEM d Luke Strachan, BN, GradCertCCN, MNurs(NursPrac) b Margaret Murphy, BN, MHlthSc a David Douglass, BN, GradCertCCN b Liesel Gerlach, BN, MEmergNurs d Naren Gunja, MBBS, MSc, FACEM, FACMT a,b,c,e,f a
Emergency Department, Westmead Hospital, Sydney, Australia Emergency Department, Blacktown-Mt.Druitt Hospital, Sydney, Australia c Department of Clinical Pharmacology & Toxicology, Western Sydney LHD, Sydney, Australia d Emergency Department, Nepean Hospital, Sydney, Australia e Discipline of Emergency Medicine, Sydney Medical School, NSW, Australia f School of Medicine, University of Western Sydney, NSW, Australia b
Received 12 December 2013; received in revised form 14 May 2014; accepted 14 May 2014
KEYWORDS Emergency nursing; Poison control centres; Toxicology; Triage; Risk assessment
Summary Background: Triage of toxicology patients presents a challenge due to their complexity, underlying psychosocial issues, and additional pharmacological considerations. Two emergency department triage systems used in Australia, the Australasian Triage Scale (ATS) and the Manchester Triage System (MTS), were compared in triaging patients presenting with poisoning and envenoming. Methods: In this simulation-based study, 30 triage nurses from three hospitals were given 8 tabletop scenarios and asked to provide a triage category. 20 nurses from two hospitals using the ATS, and 10 nurses from a third hospital using the MTS, triaged 8 scenarios, grouped into
∗ Corresponding author at: Emergency Department, Westmead Hospital, Westmead, NSW 2145, Australia. Tel.: +61 2 9845 7607; fax: +61 2 9633 4296. E-mail address: [email protected] (D. Jayaweera).
http://dx.doi.org/10.1016/j.aenj.2014.05.004 1574-6267/© 2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
Toxicology triage study
185 ‘‘commonly encountered’’ (n = 4) and ‘‘rarely encountered’’ (n = 4). Triage systems and scenario groups were compared for median triage category and variance in scoring. Triage nurses also noted if they would seek help from toxicology services or the poisons information centre (PIC) for advice. Results: Overall, MTS nurses triaged all 8 scenarios with a lower acuity triage category, though statistically significant for only 3 scenarios. ATS nurses scored higher acuity triage category in all 4 ‘‘rare’’ highly toxic presentations, whereas MTS nurses scored higher acuity when vital signs were abnormal. MTS showed wider variance in triage scores in both scenario groups when compared to the ATS. Triage nurses without access to local toxicology services chose to contact PIC in most cases. Conclusions: When compared to the ATS, MTS gave a lower acuity triage score for all common and rarely encountered poisoning scenario groups, which included highly toxic ingestions that appear well at triage but may progress to severe poisoning. Triage nurses should refer to information on highly toxic exposures and envenomation guidelines during their triage risk assessment. © 2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
What is known • There is little published data on triage of the poisoned patient and no published studies comparing the Australian Triage Scale and the Manchester Triage Scale, in their risk assessment.
What this paper adds • This study compares the Australasian Triage Scale (ATS) and the Manchester triage system (MTS) in the assessment of patients presenting with toxicological scenarios. Triage nurses using ATS provided higher acuity triage scores compared with MTS nurses across all study scenarios. Emergency departments should carry additional information on highly toxic exposures and local envenomation guidelines for triage nurses.
Introduction Triage is an important tool for clinical decision making in the Emergency Department (ED). A triage system is the process by which a clinician assesses a patient’s clinical urgency. Urgency is determined according to the patient’s clinical condition and is used to determine the speed of intervention that is necessary to achieve an optimal outcome.1 Urgency is independent of the severity or complexity of an illness or injury. ED nursing staff require specific training to perform this vital role at the front end of the hospital and take years to perfect the ‘art’ of triaging. Australian triage nurses complete a national standardised triage-training programme based on the ‘‘Emergency Triage Education Kit’’ in order to perform this role.1 Triage of ED patients has evolved considerably over the last two decades. Since their inception, triage systems have continued to develop and be modified into ever more useful tools in early recognition of the acutely ill. Two common systems for triaging emergency patients are the
Australasian Triage Scale (ATS), utilised in the majority of Australian EDs, and the Manchester Triage System (MTS), utilised in the United Kingdom and some Australian EDs.2—5 The National Triage Scale (NTS) was implemented in 1993, becoming the first triage system to be used in all publicly funded EDs throughout Australia. In the late 1990s, the NTS underwent refinement and was subsequently renamed the ATS.1 At a similar time period, the MTS was jointly developed by the Royal College of Nursing Accident and Emergency Association and the British Association for Accident and Emergency Medicine. The MTS consists of 52 algorithms or flow charts that lead the triage nurse to a logical triage choice for almost any presenting complaint, and results in a five-point scale similar to that described by the ATS. From the very earliest use of these triage scales, a time limit for clinical assessment has been associated with each triage category—these time limits are shown in Table 1 comparing the two systems. The MTS has been modified for regionspecific envenoming presentations in the Australian context. Applying these systems to the poisoned patient, triage aims to rapidly assign treatment priority for a given overdose or envenomation. The existence of poisons information centres (PICs) within a healthcare system has significant implications on emergency triage presentations.6—8 The ability to filter the majority of trivial and minor exposures with out-ofhospital management selects higher acuity patients for ED
Table 1 Triage category
1 2 3 4 5 a
Comparison of ATS and MTS.3,4 Treatment acuity (maximum waiting time for medical assessment and treatment) ATS
MTSa
Immediate 10 min 30 min 60 min 120 min
Immediate 10 min 60 min 120 min 240 min
The MTS has been modified by the hospital in our study to match ATS waiting times.
186
D. Jayaweera et al.
presentation.9 PICs also play a key role in ambulance triage at the scene as well as in ambulance control systems that decide on transportation of potentially poisoned patients. ED triage nurses may also choose to contact a PIC during or
Table 2
at the completion of triage in order to modify risk stratification. Poisoned and envenomed patients are a challenging cohort when it comes to triage. Specific pharmacological
Study scenarios.
Group
Scenario
Details
Common presentations
A: Supratherapeutic paracetamol
A 48-year-old man with knee pain presents with vomiting. He has been taking 2 tablets of Panadeine every 2 h for the last 12 h. He has vomited twice — clear fluid in vomitus. His last Panadeine tablet was 2.5 h ago. He is currently pain free, sitting on a chair and no longer nauseated. He has arthritis in his knee after a previous work injury; he denies other medical problems. His vital signs are HR 84, RR 14, BP 118/66, Sats 96% on room air A 63-year-old woman with a history of trigeminal neuralgia self-presents with an accidental overdose of her regular medication. She has inadvertently mixed her regular prednisone with amitriptyline. This morning she took 4 tablets of amitriptyline 25 mg each and 1 tablet of prednisone 5 mg, instead of the other way around. She appears well and coherent, but anxious. Her observations are HR 112, RR 18, BP 136/78, Sats 98% on room air A 4-year old girl is brought in by her mother after being ‘‘bitten by a bug’’ in the garden. Mum heard her screaming while playing in the backyard an hour ago. They have noticed more red-back spiders in their backyard over the last few months. The child is now comfortable in her mum’s lap and does not appear to be in pain. There is a small red welt on the R leg above the ankle; there is no obvious swelling. Her obs are HR 100, RR 18, Sats 99% on room air A 22-year-old male is brought in by ambulance with palpitations that he noticed after waking up this morning. He was at a party last night and bought some ‘‘eccies’’ from a friend — he had 2 tablets last night along with some alcohol. He appears anxious but co-operative. The Ambulance rhythm strip shows sinus tachycardia at 110 beats per minute. His vital signs at triage are HR 116, RR 14, BP 126/84 A 45-year-old man with a background of depression is brought in by ambulance after ingesting a pesticide in his home. He admitted to ambulance officers on scene that he drank half a bottle of Nufarm termite killer about 1 h ago. He vomited several times and on route to the hospital, he had a generalised seizure in the ambulance. The Ambulance officer gave 5 mg IM midazolam after which he has not had any seizures. On exam, he is diaphoretic and incontinent of urine. His vital signs as per the Ambulance officers are HR 56, BP 92/60, RR 10, Sats 100% (on NRB oxygen), blood glucose level 6.2 mmol/L, GCS E2V3M5 = 10. A 6-year-old autistic child is brought in by her grandmother after finding her with an empty bottle of Ferrogradumet. The bottle was purchased yesterday and contained about 30 tablets. The child had been playing in the bedroom unsupervised for around 15 min. The grandmother noted that there were some tablets on the floor, but did not count them as she panicked. The girl is alert and behaving normally as per her grandmother. Her vital signs are HR 94, RR 18, Sats 99% on room air, weight 25 kg. A 25-year-old male presents an hour after accidentally ingesting a mouthful of blue-coloured weed killer. He picked up an unlabeled bottle thinking it was a sports drink. He has mild epigastric discomfort and has vomited once. He appears well and his vital signs are HR 86, RR 16, Sats 98% on room air, GCS 15 A 58-year-old male presents after deliberate ingestion of 30 tablets of Cardizem CD 240 mg, 2 h ago after an argument with his wife. He is brought in by his brother and is regretful of his actions; he is co-operative and agrees to stay for treatment. He has a background of hypertension. His vital signs are HR 76, RR 14, BP 128/68, Sats 99% on room air, GCS 15
D: TCA medication error
F: Red-back spider bite
H: Ecstasy
Rare presentations
B: Organophosphate
C: Iron
E: Paraquat
G: Calcium channel blocker
Toxicology triage study and/or toxicological knowledge may be required to triage this group of patients. To date, we have not identified any studies looking into the triage of this particular cohort of patients and the unique challenge posed by their multifaceted presentations. Our objective was to compare the two triaging systems, ATS and the MTS used by three Western Sydney hospitals, in scoring scenarios of poisoned and envenomed patients. The existence of two triage systems within our local health services allowed for an assessment of the varying practices and whether front end streaming of poisoned patients was dependent on the triage system used. This study attempted to answer the question ‘‘does using different triaging systems affect the urgency assigned to toxicology patients?’’ The study was not designed or aimed at ascertaining which system was superior, but rather whether there were differences in assigned urgency based on triaging method.
187 Table 3
Results.
Scenario
ATS score Median (IQR)
MTS score Median (IQR)
M—W test P value
A (Common) D (Common) F (Common) H (Common) B (Rare) C (Rare) E (Rare) G (Rare)
3.0 2.5 3.0 3.0 1.0 2.0 2.0 2.0
3.0 3.0 4.0 3.0 2.0 3.0 2.5 2.0
0.082 0.001
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/aenj
RESEARCH PAPER
A comparison of emergency triage scales in triaging poisoned patients Dushan Jayaweera, MBBS, FACEM a,b,c,f,∗ Satish Mitter, MBBS, FACEM a,b,c,f Andrew Grouse, MBBS, FACEM d Luke Strachan, BN, GradCertCCN, MNurs(NursPrac) b Margaret Murphy, BN, MHlthSc a David Douglass, BN, GradCertCCN b Liesel Gerlach, BN, MEmergNurs d Naren Gunja, MBBS, MSc, FACEM, FACMT a,b,c,e,f a
Emergency Department, Westmead Hospital, Sydney, Australia Emergency Department, Blacktown-Mt.Druitt Hospital, Sydney, Australia c Department of Clinical Pharmacology & Toxicology, Western Sydney LHD, Sydney, Australia d Emergency Department, Nepean Hospital, Sydney, Australia e Discipline of Emergency Medicine, Sydney Medical School, NSW, Australia f School of Medicine, University of Western Sydney, NSW, Australia b
Received 12 December 2013; received in revised form 14 May 2014; accepted 14 May 2014
KEYWORDS Emergency nursing; Poison control centres; Toxicology; Triage; Risk assessment
Summary Background: Triage of toxicology patients presents a challenge due to their complexity, underlying psychosocial issues, and additional pharmacological considerations. Two emergency department triage systems used in Australia, the Australasian Triage Scale (ATS) and the Manchester Triage System (MTS), were compared in triaging patients presenting with poisoning and envenoming. Methods: In this simulation-based study, 30 triage nurses from three hospitals were given 8 tabletop scenarios and asked to provide a triage category. 20 nurses from two hospitals using the ATS, and 10 nurses from a third hospital using the MTS, triaged 8 scenarios, grouped into
∗ Corresponding author at: Emergency Department, Westmead Hospital, Westmead, NSW 2145, Australia. Tel.: +61 2 9845 7607; fax: +61 2 9633 4296. E-mail address: [email protected] (D. Jayaweera).
http://dx.doi.org/10.1016/j.aenj.2014.05.004 1574-6267/© 2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
Toxicology triage study
185 ‘‘commonly encountered’’ (n = 4) and ‘‘rarely encountered’’ (n = 4). Triage systems and scenario groups were compared for median triage category and variance in scoring. Triage nurses also noted if they would seek help from toxicology services or the poisons information centre (PIC) for advice. Results: Overall, MTS nurses triaged all 8 scenarios with a lower acuity triage category, though statistically significant for only 3 scenarios. ATS nurses scored higher acuity triage category in all 4 ‘‘rare’’ highly toxic presentations, whereas MTS nurses scored higher acuity when vital signs were abnormal. MTS showed wider variance in triage scores in both scenario groups when compared to the ATS. Triage nurses without access to local toxicology services chose to contact PIC in most cases. Conclusions: When compared to the ATS, MTS gave a lower acuity triage score for all common and rarely encountered poisoning scenario groups, which included highly toxic ingestions that appear well at triage but may progress to severe poisoning. Triage nurses should refer to information on highly toxic exposures and envenomation guidelines during their triage risk assessment. © 2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
What is known • There is little published data on triage of the poisoned patient and no published studies comparing the Australian Triage Scale and the Manchester Triage Scale, in their risk assessment.
What this paper adds • This study compares the Australasian Triage Scale (ATS) and the Manchester triage system (MTS) in the assessment of patients presenting with toxicological scenarios. Triage nurses using ATS provided higher acuity triage scores compared with MTS nurses across all study scenarios. Emergency departments should carry additional information on highly toxic exposures and local envenomation guidelines for triage nurses.
Introduction Triage is an important tool for clinical decision making in the Emergency Department (ED). A triage system is the process by which a clinician assesses a patient’s clinical urgency. Urgency is determined according to the patient’s clinical condition and is used to determine the speed of intervention that is necessary to achieve an optimal outcome.1 Urgency is independent of the severity or complexity of an illness or injury. ED nursing staff require specific training to perform this vital role at the front end of the hospital and take years to perfect the ‘art’ of triaging. Australian triage nurses complete a national standardised triage-training programme based on the ‘‘Emergency Triage Education Kit’’ in order to perform this role.1 Triage of ED patients has evolved considerably over the last two decades. Since their inception, triage systems have continued to develop and be modified into ever more useful tools in early recognition of the acutely ill. Two common systems for triaging emergency patients are the
Australasian Triage Scale (ATS), utilised in the majority of Australian EDs, and the Manchester Triage System (MTS), utilised in the United Kingdom and some Australian EDs.2—5 The National Triage Scale (NTS) was implemented in 1993, becoming the first triage system to be used in all publicly funded EDs throughout Australia. In the late 1990s, the NTS underwent refinement and was subsequently renamed the ATS.1 At a similar time period, the MTS was jointly developed by the Royal College of Nursing Accident and Emergency Association and the British Association for Accident and Emergency Medicine. The MTS consists of 52 algorithms or flow charts that lead the triage nurse to a logical triage choice for almost any presenting complaint, and results in a five-point scale similar to that described by the ATS. From the very earliest use of these triage scales, a time limit for clinical assessment has been associated with each triage category—these time limits are shown in Table 1 comparing the two systems. The MTS has been modified for regionspecific envenoming presentations in the Australian context. Applying these systems to the poisoned patient, triage aims to rapidly assign treatment priority for a given overdose or envenomation. The existence of poisons information centres (PICs) within a healthcare system has significant implications on emergency triage presentations.6—8 The ability to filter the majority of trivial and minor exposures with out-ofhospital management selects higher acuity patients for ED
Table 1 Triage category
1 2 3 4 5 a
Comparison of ATS and MTS.3,4 Treatment acuity (maximum waiting time for medical assessment and treatment) ATS
MTSa
Immediate 10 min 30 min 60 min 120 min
Immediate 10 min 60 min 120 min 240 min
The MTS has been modified by the hospital in our study to match ATS waiting times.
186
D. Jayaweera et al.
presentation.9 PICs also play a key role in ambulance triage at the scene as well as in ambulance control systems that decide on transportation of potentially poisoned patients. ED triage nurses may also choose to contact a PIC during or
Table 2
at the completion of triage in order to modify risk stratification. Poisoned and envenomed patients are a challenging cohort when it comes to triage. Specific pharmacological
Study scenarios.
Group
Scenario
Details
Common presentations
A: Supratherapeutic paracetamol
A 48-year-old man with knee pain presents with vomiting. He has been taking 2 tablets of Panadeine every 2 h for the last 12 h. He has vomited twice — clear fluid in vomitus. His last Panadeine tablet was 2.5 h ago. He is currently pain free, sitting on a chair and no longer nauseated. He has arthritis in his knee after a previous work injury; he denies other medical problems. His vital signs are HR 84, RR 14, BP 118/66, Sats 96% on room air A 63-year-old woman with a history of trigeminal neuralgia self-presents with an accidental overdose of her regular medication. She has inadvertently mixed her regular prednisone with amitriptyline. This morning she took 4 tablets of amitriptyline 25 mg each and 1 tablet of prednisone 5 mg, instead of the other way around. She appears well and coherent, but anxious. Her observations are HR 112, RR 18, BP 136/78, Sats 98% on room air A 4-year old girl is brought in by her mother after being ‘‘bitten by a bug’’ in the garden. Mum heard her screaming while playing in the backyard an hour ago. They have noticed more red-back spiders in their backyard over the last few months. The child is now comfortable in her mum’s lap and does not appear to be in pain. There is a small red welt on the R leg above the ankle; there is no obvious swelling. Her obs are HR 100, RR 18, Sats 99% on room air A 22-year-old male is brought in by ambulance with palpitations that he noticed after waking up this morning. He was at a party last night and bought some ‘‘eccies’’ from a friend — he had 2 tablets last night along with some alcohol. He appears anxious but co-operative. The Ambulance rhythm strip shows sinus tachycardia at 110 beats per minute. His vital signs at triage are HR 116, RR 14, BP 126/84 A 45-year-old man with a background of depression is brought in by ambulance after ingesting a pesticide in his home. He admitted to ambulance officers on scene that he drank half a bottle of Nufarm termite killer about 1 h ago. He vomited several times and on route to the hospital, he had a generalised seizure in the ambulance. The Ambulance officer gave 5 mg IM midazolam after which he has not had any seizures. On exam, he is diaphoretic and incontinent of urine. His vital signs as per the Ambulance officers are HR 56, BP 92/60, RR 10, Sats 100% (on NRB oxygen), blood glucose level 6.2 mmol/L, GCS E2V3M5 = 10. A 6-year-old autistic child is brought in by her grandmother after finding her with an empty bottle of Ferrogradumet. The bottle was purchased yesterday and contained about 30 tablets. The child had been playing in the bedroom unsupervised for around 15 min. The grandmother noted that there were some tablets on the floor, but did not count them as she panicked. The girl is alert and behaving normally as per her grandmother. Her vital signs are HR 94, RR 18, Sats 99% on room air, weight 25 kg. A 25-year-old male presents an hour after accidentally ingesting a mouthful of blue-coloured weed killer. He picked up an unlabeled bottle thinking it was a sports drink. He has mild epigastric discomfort and has vomited once. He appears well and his vital signs are HR 86, RR 16, Sats 98% on room air, GCS 15 A 58-year-old male presents after deliberate ingestion of 30 tablets of Cardizem CD 240 mg, 2 h ago after an argument with his wife. He is brought in by his brother and is regretful of his actions; he is co-operative and agrees to stay for treatment. He has a background of hypertension. His vital signs are HR 76, RR 14, BP 128/68, Sats 99% on room air, GCS 15
D: TCA medication error
F: Red-back spider bite
H: Ecstasy
Rare presentations
B: Organophosphate
C: Iron
E: Paraquat
G: Calcium channel blocker
Toxicology triage study and/or toxicological knowledge may be required to triage this group of patients. To date, we have not identified any studies looking into the triage of this particular cohort of patients and the unique challenge posed by their multifaceted presentations. Our objective was to compare the two triaging systems, ATS and the MTS used by three Western Sydney hospitals, in scoring scenarios of poisoned and envenomed patients. The existence of two triage systems within our local health services allowed for an assessment of the varying practices and whether front end streaming of poisoned patients was dependent on the triage system used. This study attempted to answer the question ‘‘does using different triaging systems affect the urgency assigned to toxicology patients?’’ The study was not designed or aimed at ascertaining which system was superior, but rather whether there were differences in assigned urgency based on triaging method.
187 Table 3
Results.
Scenario
ATS score Median (IQR)
MTS score Median (IQR)
M—W test P value
A (Common) D (Common) F (Common) H (Common) B (Rare) C (Rare) E (Rare) G (Rare)
3.0 2.5 3.0 3.0 1.0 2.0 2.0 2.0
3.0 3.0 4.0 3.0 2.0 3.0 2.5 2.0
0.082 0.001
