Comparison of validity of Korean triage and acuity scale levels assessed by triage nurse in real-time and by retrospectively applying strict systemic inflammatory response syndrome criteria in patients with fever

The strict application of vital signs has substantial risk of over-triage. Therefore, this study assessed the predictive value of Korean Triage and Acuity Scale (KTAS) level calculated using strict Systemic Inflammatory Response Syndrome (SIRS) criteria versus that evaluated by a verified triage nurse (TN). The study is based on a retrospective observational cohort of a single-center emergency department (ED) from 01 May 2018 to 30 April 2019. Study subjects were patients aged ≥18 years with fever. Intensive care unit admission rate or death in ED (IADE) and general ward admission rate according to two differently defined KTAS levels were compared by receiver operating characteristic curve and logistic regression. A total of 2322 patients were included. In comparing the area under the curves (AUCs) of TN- and SIRS-KTAS, TN-KTAS’ predictive power for IADE (0.802) was higher than that of SIRS-KTAS (0.7440, p = 0.0489). The odds ratio of level 3 for IADE (1.35) was not significantly different from that of level 4 in SIRS-KTAS (p = 0.5429). In KTAS, the severity of illness in patients was more accurately predicted by the triage nurse’s decision based on clinical experience than the strict application of SIRS criteria with only vital signs.

Emergency service; Triage; Systemic inflammatory response syndrome; Patient acuity; Patient safety; Hospitalization

[1] Iserson KV. Ethics, personal responsibility and the pandemic: a new triage paradigm. The Journal of Emergency Medicine. 2022; 62: 508–512.

[2] Ennis JS, Riggan KA, Nguyen NV, Kramer DB, Smith AK, Sulmasy DP, et al. Triage procedures for critical care resource allocation during scarcity. JAMA Network Open. 2023; 6: e2329688.

[3] Heslin SM, Viccellio P. Overcrowding, triage, and care rationing. Urban Emergency Medicine (pp. 184–190). 1st edition. Cambridge University Press: United of Kingdom. 2023.

[4] AlShatarat M, Rayan A, Eshah NF, Baqeas MH, Jaber MJ, ALBashtawy M. Triage knowledge and practice and associated factors among emergency department nurses. SAGE Open Nursing. 2022; 8: 237796082211305.

[5] Park J, Lim T. Korean triage and acuity scale (KTAS). Journal of The Korean Society of Emergency Medicine. 2017; 28: 547–551.

[6] Beveridge R. The Canadian emergency department triage and acuity scale: a new and critical element in health care reform. Journal of Emergency Medicine. 1998; 16: 507–511.

[7] Gando S, Shiraishi A, Abe T, Kushimoto S, Mayumi T, Fujishima S, et al. The SIRS criteria have better performance for predicting infection than qSOFA scores in the emergency department. Scientific Reports. 2020; 10: 8095.

[8] Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest. 1992; 101: 1644–1655.

[9] Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Medicine. 2021; 47: 1181–1247.

[10] Sun J, Chung H, Jang H, Kim S, Lee Y, Park J. Validation of systemic inflammatory response syndrome criteria without white blood cell count in Korean triage and acuity scale. Journal of The Korean Society of Emergency Medicine. 2019; 30: 232–238.

[11] Lee B, Kim DK, Park JD, Kwak YH. Clinical considerations when applying vital signs in pediatric Korean triage and acuity scale. Journal of Korean Medical Science. 2017; 32: 1702.

[12] Moon S-H, Shim JL, Park K-S, Park CS. Triage accuracy and causes of mistriage using the Korean triage and acuity scale. PLOS ONE. 2019; 14: e0216972.

[13] Levis-Elmelech T, Schwartz D, Bitan Y. The effect of emergency department nurse experience on triage decision making. Human Factors in Healthcare. 2022; 2: 100015.

[14] Hwang S, Shin S. Factors affecting triage competence among emergency room nurses: a cross‐sectional study. Journal of Clinical Nursing. 2023; 32: 3589–3598.

[15] Lee JY, Oh SH, Peck EH, Lee JM, Park KN, Kim SH, et al. The validity of the Canadian triage and acuity scale in predicting resource utilization and the need for immediate life-saving interventions in elderly emergency department patients. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2011; 19: 68.

[16] Usman OA, Usman AA, Ward MA. Comparison of SIRS, qSOFA, and NEWS for the early identification of sepsis in the Emergency Department. The American Journal of Emergency Medicine. 2019; 37: 1490–1497.

[17] Oduncu AF, Kıyan GS, Yalçınlı S. Comparison of qSOFA, SIRS, and NEWS scoring systems for diagnosis, mortality, and morbidity of sepsis in emergency department. The American Journal of Emergency Medicine. 2021; 48: 54–59.

[18] Ruangsomboon O, Boonmee P, Limsuwat C, Chakorn T, Monsomboon A. The utility of the rapid emergency medicine score (REMS) compared with SIRS, qSOFA and NEWS for predicting in-hospital mortality among patients with suspicion of sepsis in an emergency department. BMC Emergency Medicine. 2021; 21: 2.

[19] Wang C, Xu R, Zeng Y, Zhao Y, Hu X. A comparison of qSOFA, SIRS and NEWS in predicting the accuracy of mortality in patients with suspected sepsis: a meta-analysis. PLOS ONE. 2022; 17: e0266755.