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Reducing Mis-triage in Emergency Departments (RemEDy): Protocol for Improving Triage Accuracy Through Real-time
Serena Sibilio1, Bastiaan Van Grootven1,2, Annette Christine Mettler3
1Department of Public Health, Institute of Nursing Science, Faculty of Medicine, University of Basel, Basel, Basel-City, Switzerland.
Background:
Mis-triage represents a global concern, with reported rates ranging from 15% to 33%. Understanding its causes and contributing factors is essential for ensuring patient safety. Currently, available studies have mainly focused on evaluating triage systems rather than investigating the human factors affecting triage performance. A major limitation in triage evaluation studies is the lack of standardized criteria to assess patient acuity and the absence of a clear consensus on how to measure triage accuracy. Most studies rely on retrospective data, which often fail to capture real-life clinical complexity. Therefore, the underlying causes and consequences of mis-triage remain partially understood.
Objective:
This study aims to improve triage by defining the optimal triage evaluation process and identifying clinician-, patient-, and system-level factors that compromise its accuracy and safety.
Methods:
Reducing Mis-Triage in Emergency Departments (RemEDy) will be a 4-phase, mixed methods project conducted across 7 Swiss emergency departments. The first phase will focus on developing a standardized triage evaluation instrument, combining evidence from a scoping review of triage evaluation processes, workshops with triage clinicians using design thinking methodology, and a modified Research and Development-University of California Delphi involving international experts and patient representatives. The second phase will prospectively implement this instrument in real time within a multicenter observational cohort study to evaluate triage performance; quantify mis-triage; and identify predictors at the patient level (eg, demographics), clinician level (eg, training), and system level (eg, crowding and length of stay). The third phase will focus on designing and validating an artificial intelligence-based decision support tool, applying multimodal models that integrate real-time triage data to enhance acuity prediction and minimize human error. The fourth phase will develop and evaluate a targeted training program, guided by the Capability, Opportunity, Motivation, and Behavior model, to strengthen triage accuracy and mitigate cognitive biases.
Results:
The project was funded by the Swiss National Science Foundation in March 2025 (grant 10004535). At submission, the scoping review is ongoing and expected to be completed in early 2026. Development and piloting of the triage evaluation instrument will take place in 2026. A multicenter cohort study is planned between October 2026 and June 2027. The intervention study is scheduled between October 2027 and December 2028. Final results are expected in 2029.
Conclusions:
The RemEDy project addresses key limitations of current triage research, including the lack of standardized evaluation methods. By combining expert and clinician consensus; real-time assessment; and multilevel analysis of patient-, clinician-, and emergency department-level factors, RemEDy is expected to provide a more comprehensive understanding of mis-triage and its causes. RemEDy will establish a novel framework for real-time triage evaluation and inform the development of targeted training programs with the potential to improve triage accuracy, safety, and equity.
International Registered Report Identifier (Irrid):
PRR1-10.2196/92264.
