The reliability of the Australasian Triage Scale: a meta-analysis

doi:10.5847/wjem.j.1920-8642.2015.02.002

Abstract

Abstract:

BACKGROUND: Although the Australasian Triage Scale (ATS) has been developed two decades ago, its reliability has not been defined; therefore, we present a meta-analyis of the reliability of the ATS in order to reveal to what extent the ATS is reliable.
DATA SOURCES: Electronic databases were searched to March 2014. The included studies were those that reported samples size, reliability coefficients, and adequate description of the ATS reliability assessment. The guidelines for reporting reliability and agreement studies (GRRAS) were used. Two reviewers independently examined abstracts and extracted data. The effect size was obtained by the z-transformation of reliability coefficients. Data were pooled with random-effects models, and meta-regression was done based on the method of moment's estimator.
RESULTS: Six studies were included in this study at last. Pooled coefficient for the ATS was substantial 0.428 (95%CI 0.340-0.509). The rate of mis-triage was less than fifty percent. The agreement upon the adult version is higher than the pediatric version.
CONCLUSION: The ATS has shown an acceptable level of overall reliability in the emergency department, but it needs more development to reach an almost perfect agreement.

Key words: Triage, Emergency treatment, Algorithm, Reliability and validity, Meta-analysis

Mohsen Ebrahimi, Abbas Heydari, Reza Mazlom, Amir Mirhaghi. The reliability of the Australasian Triage Scale: a meta-analysis[J]. World Journal of Emergency Medicine, 2015, 6(2): 94-99.

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References 29

1	Mirhaghi A, Kooshiar H, Esmaeili H, Ebrahimi M. Outcomes for Emergency Severity Index Triage implementation in the Emergency Department. J Clin Diagn Res 2015; 9: OC04-OC07. doi: 10.7860/JCDR/2015/11791.5737 pmid: 26023578
2	Dilley SJ, Standen P. Victorian nurses demonstrate concordance in the application of the National Triage Scale. Emerg Med 1998; 10:12-18.
3	Fernandes CM, Wuerz R, Clark S, Djurdjev O. How reliable is emergency department triage?. Ann Emerg Med 1999; 34:141-147. pmid: 10424913
4	Crellin DJ, Johnston L. Poor agreement in application of the Australasian Triage Scale to paediatric emergency department presentations. Contemp Nurse 2003; 15:48-60. doi: 10.5172/conu.15.1-2.48 pmid: 14649508
5	Considine J, LeVasseur SA, Villanueva E. The Australasian Triage Scale: examining emergency department nurses' performance using computer and paper scenarios. Ann Emerg Med 2004; 44:516-523.
6	Gerdtz MF, Bucknall TK. Influence of task properties and subjectivity on consistency of triage: a simulation study. J Adv Nurs 2007; 58:180-190. pmid: 17445021
7	Gerdtz MF, Collins M, Chu M, Grant A, Tchernomoroff R, Pollard C, et al. Optimizing triage consistency in Australian emergency departments: the Emergency Triage Education Kit. Emerg Med Australas 2008; 20:250-259. doi: 10.1111/j.1742-6723.2008.01089.x pmid: 18462405
8	Gerdtz M, Considine J, Sands N, Stewart C, Crellin D, Pollock W, et al. Emergency triage education kit. Department of Health and Ageing, Canberra. 2007; 19.
9	Andersson A, Omberg M, Svedlund M. Triage in the emergency department—a qualitative study of the factors which nurses consider when making decisions. Nurs Crit Care 2006; 11:136-145. doi: 10.1111/j.1362-1017.2006.00162.x pmid: 16719019
10	Mirhaghi A, Heydari A, Mazlom R, Hasanzadeh F. Reliability of the Emergency Severity Index Meta-analysis. Sultan Qaboos University Med J 2015; 15:67-73.
11	Farrohknia N, Castrén M, Ehrenberg A, Lind L, Oredsson S, Jonsson H, et al. Emergency department triage scales and their components: a systematic review of the scientific evidence. Scand J Trauma Resusc Emerg Med 2011; 19:42. pmid: 21718476
12	Göransson K, Ehrenberg A, Marklund B, Ehnfors M. Accuracy and concordance of nurses in emergency department triage. Scand J Caring Sci 2005; 19:432-438. pmid: 16324070
13	Sim J, Wright CC. The kappa statistic in reliability studies: Use, interpretation, and sample size requirements. Phys Ther 2005; 85:257-268.
14	van der Wulp I, van Stel HF. Calculating kappas from adjusted data improved the comparability of the reliability of triage systems: a comparative study. J Clin Epidemiol 2010; 63: 1256-1263. Epub 2010/05/01. pmid: 20430580
15	Viera A, Garrett J. Understanding interobserver agreement: the kappa statistic. Fam Med 2005; 37:360-363.
16	Petitti D. Meta-analysis, decision analysis, and cost effectiveness analysis. New York, NY: Oxford University Press; 1994; 69.
17	Christ M, Grossmann F, Winter D, Bingisser R, Platz E. Modern triage in the emergency department. Dtsch Arztebl Int 2010; 107:892-898. doi: 10.3238/arztebl.2010.0892 pmid: 21246025
18	Kottner J, Audige L, Brorson S, Donner A, Gajewski BJ, Hróbjartsson A, et al. Guidelines for reporting reliability and agreement studies (GRRAS) were proposed. Int J Nurs Stud 2011; 48: 661-671. Epub 2011 Apr 23. pmid: 21514934
19	Julius S, Wright CC. The kappa statistic in reliability studies: use, interpretation, and sample size requirements. Phys Ther 2005; 85:257-268. pmid: 15733050
20	Rettew DC, Lynch AD, Achenbach TM, Dumenci L, Ivanova MY. Meta-analyses of agreement between diagnoses made from clinical evaluations and standardized diagnostic interviews. Int J Methods Psychiatr Res 2009; 18:169-184. pmid: 19701924
21	Hedges LV, Olkin I. Statistical methods for meta-analysis. Academic Press; 1985; 76-81.
22	Rosenthal R. Meta-analytic procedures for social research. SAGE Publications; 1991; 43-89.
23	Chen H, Manning AK, Dupuis J. A method of moments estimator for random effect multivariate meta-analysis. Biometrics 2012; 68:1278-1284. doi: 10.1111/j.1541-0420.2012.01761.x pmid: 22551393
24	Riley RD, Higgins JPT, Deeks JJ. Interpretation of random effects meta-analyses. BMJ 2011; 342:d549. doi: 10.1136/bmj.d549 pmid: 21310794
25	Le May A, Mulhall A, Alexander C. Bridging the research-practice gap: exploring the research cultures of practitioners and managers. J Adv Nurs 1998; 28:428-437. pmid: 9725742
26	Alpert EA, Lipsky AM, Hertz D, Rieck J, Or J. Simulated evaluation of two triage scales in an emergency department in Israel. Eur J Emerg Med 2013; 20:431-434.
27	Eliasziw M, Young SL, Woodbury MG, Fryday-Field K. Statistical methodology for the concurrent assessment of interrater and intrarater reliability: using goniometric measurements as an example. Phys Ther 1994; 74:777-788. doi: 10.1093/ptj/74.8.777 pmid: 8047565
28	Hogan TP, Benjamin A, Brezinski KL. Reliability methods: A note on the frequency of use of various types. Educational and Psychological Measurement 2000; 60:523-531.
29	Parenti N, Bacchi Reggiani ML, Sangiorgi D, Serventi V, Sarli L. Effect of a triage course on quality of rating triage codes in a group of university nursing students:a before-after observational study. World J Emerg Med 2013; 4:20-25. pmid: 25215088

Studies	Patient	Participants^*	Instrument	Methods^**	Statistics^***	Country
Dilley et al^[2] 1998	Adult	NN	Scenario	Inter	Κuw (0.25)	Australia
Fernandes CMB et al^[3]1999	Adult Adult	NN NN	Scenario Scenario	Intra Inter	Kuw (0.75) Kuw (0.66)	Australia
Crellin et al^[4] 2003	Adult	NN	Scenario	Inter	Κuw (0.21)	Australia
Considine et al^[5] 2004	Adult Pediatrics	NN NN	Scenario Scenario	Inter Inter	Κuw (0.43) Κuw (0.40)	Australia
Gerdtz et al^[6] 2007	Adult	NN	Scenario	Inter	Κuw (0.38)	Australia
Gerdtz et al^[7] 2008	Adult	NN	Scenario	Inter	Κuw (0.41)	Australia

ED raters decisions	ED raters decisions by ATS category					Total
ED raters decisions	1	2	3	4	5	Total
1	357 (7.74)*	61	5	0	1	424
2	275	452 (9.80)	166	6	1	900
3	26	144	887 (19.22)	279	64	1 400
4	2	2	255	890 (19.29)	372	1 521
5	0	0	5	144	220 (4.77)	369
Total	660	659	1 318	1 319	658	4 614 (100.00)

Independent variable	B	SE_b	P value
Distance from origin	0.00004	0.00001	0.0000
Publication date	-0.00193	0.00704	0.76219

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