Triage Performance in Emergency Medicine: A Systematic Review

Area of Science:

• Emergency Medicine
• Health Services Research
• Clinical Informatics

Background:

• Emergency department (ED) triage systems are critical for prioritizing patient care.
• Existing literature on ED triage shows diverse study designs and outcome assessments.
• A need exists for standardized performance comparisons across different triage systems.

Purpose of the Study:

• To synthesize ED triage literature using a comparative framework.
• To benchmark performance of widely adopted triage systems based on clinical outcomes and reliability.
• To identify areas for improvement in ED patient assessment and acuity assignment.

Main Methods:

• Systematic literature search of PubMed, EMBASE, Scopus, and Web of Science through 2016.
• Cataloging and comparison of five major ED triage scales: Australian Triage Scale, Canadian Triage and Acuity Scale, Emergency Severity Index, Manchester Triage Scale, and South African Triage Scale.
• Analysis of studies for performance in identifying mortality, critical illness, hospitalization, and interrater reliability, adhering to PRISMA guidelines.

Main Results:

• 182 studies met eligibility criteria; 50 provided sufficient data for comparative analysis.
• Most studied scales (Canadian Triage and Acuity Scale, Emergency Severity Index, Manchester Triage Scale) showed similar performance.
• High sensitivity (>90%) for ED mortality was reported, but low sensitivity (<80%) for critical illness and delayed death.
• Sensitivity varied significantly by condition (e.g., low for sepsis, higher for STEMI).
• 3-45% of hospitalized patients were undertriaged (low acuity).
• Interrater reliability (κ) was variable, with only 11 of 42 studies reporting κ > 0.8.

Conclusions:

• A significant number of critically ill or deceased ED patients were not assigned high acuity during triage.
• Current ED triage systems have limitations in accurately identifying patients at high risk for adverse outcomes.
• There is a clear opportunity to enhance interrater reliability and improve triage performance for better patient safety.