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Systematic review

Triagesystems for emergency medical services – pre-hospital and at hospital admission

The emergency medical services (EMS) cover initiatives and services established to provide essential medical assistance in situations of acute illness.

The emergency medical services (EMS) cover initiatives and services established to provide essential medical assistance in situations of acute illness.


Key message

Background

The emergency medical services (EMS) cover initiatives and services established to provide essential medical assistance in situations of acute illness. Methods for systematic prioritizing of patients according to how urgent they need care, including the triage of requests on acute medical treatment, are established in Norway. However, the triage systems applied differ between the different settings of the EMS and also between regions.

Commission

The Norwegian Knowledge Centre for the Health Services was asked by the South-Eastern Norway Regional Health Authority Trade Group for Emergency Wards and Pre Hospital Services to review available research on effects of triage for use in the EMS, and with special attention to pre-hospital services.

We searched for systematic reviews, randomized controlled trials,  controlled studies, and interrupted time series on:

  • Effects of triage systems used in the prehospital setting of the EMS. To assess the effectiveness of triage systems and also to determine if one triage system is more effective than the other regarding health outcomes, patient safety, patient satisfaction, satisfaction with the use of the triage system, the use of resources, goal achievement, and to evaluate the quality of the information exchange between the different settings of the EMS (for example the quality of documentation).
  • Effects of using the same triage system in two or more settings of the EMS.

Main results

There is an evidence gap regarding the effects of prehospital triage and the effects of using the same triage system in two or more settings of the EMS.

Summary

Background

Methods for systematic prioritizing of patients according to how urgent they need care, triage, are adopted both in hospitals and in the pre-hospital setting in Norway. Different triage systems are implemented in the different settings of the emergency medical services (EMS) and between Regional Health Authorities. Research that evaluates the effect of different triage systems might influence the choice of which triage system to apply.  

In 2010, the Swedish Council on Health Technology Assessment systematically reviewed literature on the effect of triage systems in the hospital setting (1). Their report included evaluation of triage systems for use in somatic adult patients. The report concluded that the safety of triage systems may be evaluated based on the achieved degree of success in separating patients with different need for acute care. Patients with less acute need for care as assessed by triage seemed to be less likely to die within short time compared to patients whose need for acute care was higher as assessed with the same triage system. The authors indicated that there is a lack of scientific documentation concerning triage in the emergency department. Triage in the pre-hospital setting was not evaluated, nor was the effects of using the same triage system in two or more settings of the EMS.

The Norwegian Knowledge Centre for the Health Services was asked by the South-Eastern Norway Regional Health Authority Trade Group for Emergency Wards and Pre Hospital Services to review available research on effects of triage for use in the EMS with special attention to pre-hospital services.

This systematic review aims to identify and critically review literature that evaluates the effect of triage systems used in the pre-hospital setting. Another objective is to evaluate research that assesses effects of using the same triage system in two or more settings of the EMS.

Method

We conducted a systematic literature search in June 2011 in the following databases:

  • MEDLINE
  • Cinahl
  • EMBASE
  • PsycINFO
  • Cochrane Database of Systematic Reviews
  • Cochrane Central Register of Controlled Trials (CENTRAL)
  • British nursing index (BNI)
  • DARE via CRD and HTA via CRD

We applied no restrictions considering publication language. We also contacted experts in Norway.

Two persons independently read titles and abstracts to identify possibly relevant articles. We evaluated the relevance of selected articles based on our inclusion criteria:

  • Population : All patients or consultations regarding the need for acute/immediate medical help or treatment.
  • Intervention : The use of one triagesystem in the prehospital setting. The use of the same triagesystem in more than one element of the acute chain.
  • Comparison: The use of no or another triagesystem in the prehospital setting. The use of no or another triagesystem in the acute chain.
  • Outcomes : Health outcomes (mortality, morbidity), patient safety (for example undertriage), patient satisfaction (for example related to the results of the treatment or expectations), job-satisfaction with the triage system among health workers (for example related to coping and/or motivation), the use of resources (for example  overtriage), to what degree triage was completed (goal achieve-ment), to evaluate the quality of the information exchange between the  different settings of the emergency medical services (for example the quality of documentation).
  • Study design: Systematic reviews of high quality, randomized controlled trials, non- randomized controlled studies, controlled before-and- after studies and interrupted time series.

Results

The literature search identified 9216 unique references, whereof 120 publications were read in full text. Only one systematic review was included for further judgment. However, we assessed the methodological quality of the systematic review to be of low quality and not suitable for inclusion. Thus, none of the identified articles fulfilled our inclusion criteria concerning the question dealing with effects of pre- hospital triage systems, nor for the question dealing with effects of using the same triage system in two or more settings of the EMS.

Discussion

There is an evidence gap of research to assess the effects of prehospital triage and the effects of using the same triage system in two or more settings of the EMS. We conducted a systematic literature search in many databases, and we read many articles in full text. Nevertheless, we identified no relevant evidence from systematic reviews, randomised controlled trials, controlled studies or interrupted time series on the effects of triage systems within somatic acute medicine, for evaluation of paediatric patients, psychiatric patients, for trauma triage, triage in catastrophes, or for telephone triage. 

Conclusion

There is a lack of evidence on the effects of pre-hospital triage and the effects of using the same triage system in two or more settings of the EMS.

Therefore, we cannot conclude whether the usage of triage is effective, and we cannot tell the size of a potential effect.

We need well planned controlled studies of the effects of out of hospital triage systems. 

 

    About this publication

  • Year: 2011
  • By: Norwegian Knowledge Centre for the Health Services
  • Authors Lidal IB, Holte HH, Gundersen MW.
  • ISSN (digital): 1890-1298
  • ISBN (digital): 978-82-8121-440-8