A Study On Optimization Of Emergency Electronic Triage System Based On Canadian Triage And Acuity Scale

BackgroundEmergency medicine in China started relatively late,with obvious regional differences.There is no unified triage tool in China’s mainland for a long time.In recent years,with reference to foreign standards,hospitals have gradually tried to establish triage standards with their own conditions,and establish information triage system according to the standards.However,the triage standard is not unified,and the information system needs to be standardized and improved.How to establish an efficient,sensitive and feasible electronic triage system is still an urgent problem to be solved.The existing electronic triage system in our hospital is based on the 2012 Canadian Triage and Acuity Scale(CTAS)and Taiwan Triage and Acuity scale(TTAS)as reference.However,there are some problems such as incomplete chief complaint parameters,complicated selection of triage basis,single variable decision-making classification and low specificity.ObjectivesThis subject is applied research.According to the principles of scientificity,feasibility and practicability,the preliminary emergency triage system(hereinafter referred to as"existing electronic triage system")in a hospital was tested,evaluated and optimized to achieve the purpose of further improving the sensitivity and specificity of the existing electronic triage system.Contents and Methods(1)Through cross-sectional study,the existing electronic triage system was tested and evaluated retrospectively.14787 cases of emergency patients from 2019.3～2019.5 were selected as the research objects by convenient sampling method.The inclusion criteria:Adult emergency patients aged over 14 years;exclusion criteria:(1)Burn patients;(2)Trauma patients;(3)Hospitalized death patients;(4)Refused to collect vital signs;(5)Incomplete information collection caused by automatic leaving hospital.All patients were triaged by the existing electronic triage system.The effectiveness of existing electronic triage system was evaluated by specificity,sensitivity and Area Under Curve(AUC).In order to evaluate the reliability of the existing electronic triage system,six medical staffs used the system to triage 30 cases.Weighted Kappa coefficient was used test the consistency with"Expert Triage",and Kendall W coefficient was used to test the consistency among 6 triage personnel."Expert Triage"refers to the results obtained by two deputy chief Emergency Physicians using the existing electronic triage system.If there is any difference,the third deputy director and the superior doctor will participate in the discussion to determine the final level.(2)Translated Canadian Emergency Information System(CEDIS)to add the chief complaint parameters of the existing electronic triage system,and the chief complaint code consistent with CEDIS was used.According to Brislin’s improved back translation model II,the translation of CEDIS Presenting Complaint List was formed.On this basis,expert correspondence(n=20)was conducted to evaluate the evaluation basis,the importance of chief complaint items to emergency department,the correlation between items and classification,and familiarity.To clarify the accuracy of the translation and the importance of each chief complaint item in emergency department,so as to lay the foundation of main complaint variable for subsequent construction of triage level prediction model.(3)Combined with the 2016 CTAS and 2018 Chinese Triage Expert Consensus,the existing electronic triage system was supplemented and revised,and the revised emergency triage standard(chief complaint and objective indicators)was formed.After that,10978 cases of emergency patients were included as the research objects,and the subjective and objective indexes listed in the revised emergency triage standard were used as the research variables,and a three-step Logistic regression model was used to construct the model for predicting triage level:(1)The patients were divided into mild patients(level III/IV)and severe patients(level I/II)by using the binary Logistic regression model;(2)The patients with mild symptoms were classified by another binary Logistic regression prediction model into level III and IV.(3)The third binary Logistic model was used to distinguish level I and II.ROC curve was used to evaluate the prediction efficiency of the model under different combinations of variables.(4)Using 10978 cases of emergency patients as the database,10-fold cross validation was used to test the effectiveness of the model;weighted Kappa coefficient was used to compare the consistency of triage result of 30 standard cases by medical staff with different age,length of emergency service and professional title,and the reliability of triage system was tested;the correlation between the predictive levels and hospitalization rate,ICU admission rate and mortality were compared to test the validity of the optimized triage system.Results:(1)The specificity,sensitivity and AUC of the existing electronic triage system were67.03%,87.8%and 0.848.The weighted Kappa coefficient between the triage results of medical staffs and the“Gold Standard”was 0.844(P<0.001),and the Kendall W coefficient was 0.871(P<0.001).(2)The Chinese Presenting Complaint List contains 15 categories and 165 items.In this study,the recovery rate of two rounds of expert consultation was 100%;the authority coefficient was 0.833,0.883,and the coefficient of variation was 0.489 and0.442;Kendall W coefficient was 0.856(χ~2=2926.12,P<0.001)and 0.858(χ~2=2917.47,P<0.001)respectively.The total Cronbachαof the list was 0.977,and the content validity of expert consultation was S-CVI=0.56.(3)14 variables were included in the mild(level III/IV)-severe(level I/II)prediction model,the Youden index was 0.8375,the sensitivity was 84.26%,the specificity was99.49%,AUC was 0.9693;9 variables were included in the prediction model of level I-II,the Youden index was 0.9643,the sensitivity was 95.18%,and the specificity was98.03%,the AUC was 0.9643;14 variables were included in the prediction model of level III-IV,the sensitivity,specificity and AUC of the model were 94.44%,92.63%and 0.9331 respectively.It is suggested that the prediction efficiency of the model is high.(4)The weighted Kappa coefficient between the results of medical staffs and the“Gold Standard”was 0.79(P<0.001),and the Kendall W coefficient among staffs was 0.88(P<0.001).There were significant differences in mortality,hospitalization rate and ICU admission rate between mild(level III/IV)and severe(level I/II)(P<0.001).There was significant difference in mortality between level I and level II(P<0.001),and level I was higher than level II.There was no significant difference between level III and level IV(P>0.05).It is suggested that the reliability and validity of the revised triage standard are good.Conclusion:The optimized electronic triage system can comprehensively collect triage information of patients and accurately predict the triage level of emergency patients.Compared with the existing electronic emergency electronic triage system,the effectiveness and specificity of the prediction level have been greatly improved.The users are not affected by age,education background,professional title and so on,and the consistency is good.The triage standard has good reliability and validity and achieves the optimization purpose.