Emergency Department Triage in Sweden : Occurrence, Validity, Reliability and Registered Nurses' Experiences

Abstract: Aim: The overall aim was to explore Emergency Department triage in Swedenthrough a specific focus on the Swedish triage system, RETTS© and RegisteredNurses’ experience of triage.Methods: Study I was a cross-sectional, prospective, national survey. Fiftyone(75%) EDs completed a digital questionnaire about triage and triage relatedwork. Study II was longitudinal, retrospective, register-based. In total 74,845patient ED visits were extracted, two annual cohorts from two EDs. Study IIIwas cross-sectional, 28 RNs from two EDs allocated triage levels on 46authentic patient scenarios. Study IV was descriptive, inductive, based on semistructuredinterviews with 14 RNs representing different parts of Sweden andlevels of hospitals. Descriptive (I, II, III), inferential (II), kappa statics (III), andinductive content analyses (IV) were applied.Results: Triage is firmly implemented in Swedish EDs and the Swedish triagesystem, RETTS© is the most commonly applied system but with variation on howRETTS© is applied or taught. RETTS© demonstrated no statistically significantdifference between the annual upgrades regarding ten-day and 72-hour mortality,but for admission to intensive care unit (ICU). Statistically significant differencewas demonstrated for mortality when data was adjusted for gender, age andcomorbidity. There was a statistically significant difference between the triagelevels for all outcomes. An inability to distinguish between stable/unstable patientwas demonstrated when 21/46 scenarios were triaged over this boundary. RETTS©reliability was moderate with κ=0.562. Furthermore, the RNs experience of triagewas described as A Balancing Act of an Ambiguous Assignment, a movementbetween uncomplicated and complex assessments performed with visible andimplicit prerequisites and in time perspectives that is both unpredictable andpredictable.Conclusion: Triage is performed in the majority of Swedish EDs and RETTS© isthe most commonly applied triage system, however, without a unanimous approach.The annual upgrade of RETTS© do not improve the ability to identify risk for shorttermmortality, but for admission to ICU. Furthermore, RETTS© reliability wasmoderate, and the RNs considered triage as a balancing act, a performance that hasto result in a safe assessment of the patient’s needs.