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Pre-hospital triage is critical for resource-allocation and patient-outcomes. This study aimed to assess the sensitivity (SN) of updated 2021 Field Triage Guidelines (FTGs) and trauma center activation criteria (TAC) related to Need for Trauma Intervention (NFTI). Data were collected to identify FTGs Red Criteria (RC) and Yellow Criteria (YC) and NFTI: pRBC within 4 ​h, operating room within 90 ​min, interventional radiology, ICU length-of-stay ≥3 days, mechanical ventilation within 3 days, or death within 60 ​h. SN was analyzed for RC and TAC. Lastly, logistic regressions assessed covariates associated with under-triage (UT). 319 patients were included. SN of RC and TAC were 79 ​% and 77 ​%, respectively. Regression analysis showed UT by RC and TAC was associated with blunt mechanism. FTGs did not meet ACS goals of ≤5 ​% UT and ≤35 ​% OT with blunt mechanism being associated with UT.

The geriatric triage protocol at the study institution was modified from SBP <90 mmHg to SBP <110 mmHg and then to SBP <100 mmHg. The purpose of this study is to evaluate the impact of adjusting geriatric triage protocols on patient outcomes. A single-center retrospective review was conducted on trauma patients 65 years or older. Three study periods with different geriatric specific trauma team activation (TTA) protocols (Group 1-SBP<90 mmHg; Group 2-SBP<110 mmHg; Group 3-SBP<100 mmHg) were compared. 2016 patients were included. There were no differences in mortality rates or need for trauma intervention (NFTI) rates among the three groups. The SBP <100 mmHg and SBP <110 mmHg groups had similar under-triage rates. The NFTI over-triage rate in the SBP <100 mmHg group was lower than the SBP <110 mmHg group. Using SBP <100 mmHg threshold for TTA criteria in geriatric trauma patients improves over-triage without leading to under-triage. •Using a threshold of SBP <100 mmHg for TTA criteria is safe in geriatric trauma patients.•Trauma activation thresholds of SBP <100 mmHg and SBP <110 mmHg have similar under-triage rates.•A SBP <110 mmHg threshold is associated with a higher rate of over-triage.

Objective This study aimed to identify independent predictors of under-triage among patients with non-traumatic acute abdominal pain (NAAP) and quantify their impact on emergency department length of stay (EDLOS). Methods A multicenter retrospective study was conducted at three tertiary hospitals in China from December 2023 to May 2024, enrolling 769 patients with NAAP. Data collected included patient demographics, environmental factors, nurse characteristics, and clinical presentations. Binary logistic regression was employed to identify risk factors for under-triage, and multivariate linear regression was used to assess its association with EDLOS. Results The incidence of under-triage was 16.38% (126/769). Multivariate analysis revealed that a history of hyperlipidemia (OR = 7.944), scleral icterus (OR = 5.731), persistent pain (OR = 4.116), and advanced age (OR = 2.447) were significant independent risk factors for under-triage (all P  < 0.05). Conversely, higher nursing seniority (Senior Nurse: OR = 0.295; Charge Nurse: OR = 0.311) served as a protective factor. Furthermore, under-triage independently predicted operational inefficiency, prolonging EDLOS by approximately 310 min (B = 309.765, P  < 0.001) after adjustment for confounders. Conclusion This multicenter study demonstrates that under-triage in NAAP is associated with patient age, history of hyperlipidemia, higher nurse professional titles, and abdominal pain characteristics. Under-triage significantly prolongs EDLOS. These findings provide a foundation for understanding and mitigating under-triage through competency-based training and risk-stratified assessment protocols in emergency departments.

Background and Objectives: Triage systems help provide the right care at the right time for patients presenting to emergency departments (EDs). Triage systems are generally used to subdivide patients into three to five categories according to the system used, and their performance must be carefully monitored to ensure the best care for patients. Materials and Methods: We examined ED accesses in the context of 4-level (4LT) and 5-level triage systems (5LT), implemented from 1 January 2014 to 31 December 2020. This study assessed the effects of a 5LT on wait times and under-triage (UT) and over-triage (OT). We also examined how 5LT and 4LT systems reflected actual patient acuity by correlating triage codes with severity codes at discharge. Other outcomes included the impact of crowding indices and 5LT system function during the COVID-19 pandemic in the study populations. Results: We evaluated 423,257 ED presentations. Visits to the ED by more fragile and seriously ill individuals increased, with a progressive increase in crowding. The length of stay (LOS), exit block, boarding, and processing times increased, reflecting a net raise in throughput and output factors, with a consequent lengthening of wait times. The decreased UT trend was observed after implementing the 5LT system. Conversely, a slight rise in OT was reported, although this did not affect the medium-high-intensity care area. Conclusions: Introducing a 5LT improved ED performance and patient care.

Background Cancer-related emergencies are a significant challenge for healthcare systems globally, including Jordan. Effective triage is critical in ensuring timely and accurate prioritization of care, especially for surgical cancer patients requiring urgent intervention. However, under-triage—misclassification of high-acuity patients into lower urgency categories—can lead to significant delays and worsened outcomes. Despite the recognized importance of accurate triage, limited research has evaluated its impact on cancer patients in Jordan, particularly those requiring surgical care. Objectives This study aimed to evaluate the timeliness and prioritization of care for cancer patients admitted through the emergency department (ED) in Jordan. The specific objectives were to examine the association between under-triage and treatment delays and assess its impact on key outcomes, including time to physician assessment, time to treatment, and hospital length of stay. Methods A retrospective cohort design was used to analyze data from 481 cancer patients admitted through the ED in four governmental hospitals across Jordan. Two cohorts were established: surgical cancer patients requiring emergency interventions and non-surgical cancer patients presenting with other oncological emergencies. Triage accuracy was assessed using the Canadian Triage and Acuity Scale (CTAS), and under-triage was identified when patients requiring high urgency care (CTAS I-III) were misclassified into lower urgency categories (CTAS IV-V). Data were collected from electronic health records and analyzed using multiple linear regression to evaluate the association between under-triage and treatment outcomes. Results The majority of patients were elderly, with a mean age of 62.6 years (± 10.7), and a significant proportion presented with advanced-stage cancer (83.4% in stages III and IV). Surgical patients frequently exhibited severe symptoms such as acute pain (51.6%) and respiratory discomfort (41.1%). Under-triage rates were 44.1% for surgical patients and 39.4% for non-surgical patients. Among surgical patients, under-triage significantly delayed time to physician assessment (β = 34.9 min, p  < 0.001) and time to treatment (β = 68.0 min, p  < 0.001). For non-surgical patients, under-triage delays were even greater, with prolonged physician assessment times (β = 48.6 min, p  < 0.001) and ED length of stay (β = 7.3 h, p  < 0.001). Both cohorts experienced significant increases in hospital length of stay (surgical: β = 3.2 days, p  = 0.008; non-surgical: β = 3.2 days, p  < 0.001). Conclusion Under-triage in Jordanian EDs is strongly associated with significant delays in care for both surgical and non-surgical cancer patients, highlighting systemic gaps in acuity recognition and triage processes. These findings underscore the need for targeted interventions to improve triage accuracy, particularly through oncology-specific training and the integration of evidence-based tools like SIRS criteria. Enhancing ED processes for cancer patients is crucial to reducing delays, optimizing resource allocation, and improving clinical outcomes in this vulnerable population. Clinical trial number Not applicable.

Background Little is known about the effect of under triage on early mortality in trauma in a pediatric population. Our objective is to describe the effect of under triage on 24-h mortality after major pediatric trauma in a regional trauma system. Methods This cohort study was conducted from January 2009 to December 2017. Data were obtained from the registry of the Northern French Alps Trauma System. The network guidelines triage pediatric trauma patients according to an algorithm shared with adult patients. Under triage was defined by the number of pediatric trauma patients that required specialized trauma care transported to a non-level I pediatric trauma center on the total number of injured patients with critical resource use. The effect of under triage on 24-h mortality was assessed with inverse probability treatment weighting (IPTW) and a propensity score (Ps) matching analysis. Results A total of 1143 pediatric patients were included (mean [SD], age 10 [5] years), mainly after a blunt trauma (1130 [99%]). Of the children, 402 (35%) had an ISS higher than 15 and 547 (48%) required specialized trauma care. Nineteen (1.7%) patients died within 24 h. Under triage rate was 33% based on the need of specialized trauma care. Under triage of children requiring specialized trauma care increased the risk of death in IPTW (risk difference 6.0 [95% CI 1.3–10.7]) and Ps matching analyses (risk difference 3.1 [95% CI 0.8–5.4]). Conclusions In a regional inclusive trauma system, under triage increased the risk of early death after pediatric major trauma.

Since the 1950's there has been a proliferation of standardized emergency department triage tools worldwide [4,5]. [...]there are no data to support simulated vignettes as a proxies for real patients who present to emergency departments for care [14]. [...]we are failing to provide accurate data for policy makers to reach important decisions on triage tool use and implementation [7]. 1 P.A. Maningas, The Soterion rapid triage system: evaluation of inter-rater reliability and validity, J Emerg Med, Vol. 30, Iss. 4, 2006, 461-469 2 P. Tanabe, Refining emergency severity index triage criteria, Acad Emerg Med, Vol. 12, Iss. 6, 2005, 497-501 3 I. Robertson-Steel, Evolution of triage systems, Emerg Med J, Vol. 23, Iss. 2, 2006, 154-155 4 M. Christ, Modern triage in the emergency department, Dtsch Arztebl Int, Vol. 107, Iss. 50, 2010, 892-898 5 N. Gilboy, D. Travers, R. Wuerz, Re-evaluating triage in the new millennium: a comprehensive look at the need for standardization and quality, J Emerg Nurs, Vol. 25, Iss. 6, 1999, 468-473 6 M. Twomey, The South African triage scale (adult version) provides valid acuity ratings when used by doctors and enrolled nursing assistants, African Journal for Emergency Medicine, Vol. 2, 2012, 3-12 7 C.M. Fernandes, J Emerg Nurs, Vol. 31, 2005 8 N. Farrohknia, Emergency department triage scales and their components: a systematic review of the scientific evidence, Scand J Trauma Resusc Emerg Med, Vol. 19, 2011, 42 9 R.C. Wuerz, Reliability and validity of a new five-level triage instrument, Acad Emerg Med, Vol. 7,...

Elderly patients, when they present to the emergency department (ED) or are admitted to the hospital, are at higher risk of adverse outcomes such as higher mortality and longer hospital stays. This is mainly due to their age and their increased fragility. In order to minimize this already increased risk, adequate triage is of foremost importance for fragile geriatric (>75 years old) patients who present to the ED. The admissions of elderly patients from 1 January 2014 to 31 December 2020 were examined, taking into consideration the presence of two different triage systems, a 4-level (4LT) and a 5-level (5LT) triage system. This study analyzes the difference in wait times and under- (UT) and over-triage (OT) in geriatric and general populations with two different triage models. Another outcome of this study was the analysis of the impact of crowding and its variables on the triage system during the COVID-19 pandemic. A total of 423,257 ED presentations were included. An increase in admissions of geriatric, more fragile, and seriously ill individuals was observed, and a progressive increase in crowding was simultaneously detected. Geriatric patients, when presenting to the emergency department, are subject to the problems of UT and OT in both a 4LT system and a 5LT system. Several indicators and variables of crowding increased, with a net increase in throughput and output factors, notably the length of stay (LOS), exit block, boarding, and processing times. This in turn led to an increase in wait times and an increase in UT in the geriatric population. It has indeed been shown that an increase in crowding results in an increased risk of UT, and this is especially true for 4LT compared to 5LT systems. When observing the pandemic period, an increase in admissions of older and more serious patients was observed. However, in the pandemic period, a general reduction in waiting times was observed, as well as an increase in crowding indices and intrahospital mortality. This study demonstrates how introducing a 5LT system enables better flow and patient care in an ED. Avoiding UT of geriatric patients, however, remains a challenge in EDs.

Background Telephone consultation and triage are used to limit the workload on emergency departments. Lack of visual cues and clinical tests put telephone consultations to a disadvantage compared to face-to-face consultations increasing the risk of under-triage. Under-triage occurs in telephone triage; however why under-triage happens is not explored yet. The aim of the study was to describe situations of under-triage in context, to assess the quality of under-triaged calls, and to identify communication patterns contributing to under-triage in a regional OOH service in the capital region of Denmark. Methods Explanatory simultaneous mixed method with thematic analysis and descriptive statistics was chosen. The study was carried out in an Out-Of-Hours service (OOH) in the Capital Region of Denmark, Copenhagen. Under-triage was defined as Potentially Under-Triaged Calls (PUTC) by specific criteria to an OOH Hotline, and identification by integration of three databases: Medical Hotline database, Emergency number database, including the Ambulance database, and electronic patient records. Distribution of PUTC were carried out using ICD-10 codes to identify diagnosis and main themes identified by qualitative analysis of audio recorded under-triaged calls. Study period was October 15 th to November 30 th 2014. Results Three hundred twenty seven PUTC were identified, representing 0.04% of all calls ( n  = 937.056) to the OOH. Distribution of PUTC according to diagnoses was: digestive (24%), circulatory (19%), respiratory (15%) and all others (42%). Thematic analysis of the voice logs suggested that inadequate communication and non-normative symptom description contributed to under-triage. Discussion The incidence of potentially under-triage is low (0.04%). However, the over-representation of digestive, circulatory, and respiratory diagnoses might suggest that under-triage is related to inadequate symptom description. We recommend that caller and call-handler collaborate systematically on problem identification and negotiate non-normative symptom description. Conclusion The incidence of under-triage is low (0.04%). However, the over-representation of digestive, circulatory, and respiratory diagnoses might suggest that under-triage is related to inadequate symptom description. We recommend that caller and call-handler collaborate systematically on problem identification and negotiate non-normative symptom description.

Under-triage is a major threat when admitting patients at the Intermediate Care Unit (IMCU). This study aims to identify risk factors and predict early deterioration of IMCU admissions, to reduce the risk of under-triage. This retrospective cohort study included all admissions to the mixed-surgical stand-alone IMCU of a tertiary referral hospital (2001–2015). Variables included were age, sex, admission indication, admitting specialty, re-admission, and nursing interventions. Early clinical deterioration was defined as ICU transfer or death ≤24 h of admission. Multinomial and logistic regression analyses were performed to identify risk factors and obtain predictions, for several frequently encountered subgroups. A total of 9103 admissions were included, of which 350 (3.8%) early deteriorated. Patients admitted for hemodynamic and respiratory instability had a high risk of early deterioration (OR 16.3 (CI 4.5-59.1)), probability 47.1%. Patients admitted with respiratory insufficiency and active diuresis or complicated sepsis had a high probability of early deterioration (≥29% and ≥26% respectively). The model had an optimism-corrected c-statistic of 0.79 (IQR 0.78-0.80). Patients with combined hemodynamic and respiratory instability should not be admitted to the IMCU. Patients with respiratory insufficiency and active diuresis, or complicated sepsis require close monitoring. •The presented nomogram can be used to assess the probability of early clinical deterioration•Patients with hemodynamic and respiratory instability should be admitted at the ICU•IMCU Patients with respiratory insufficiency and active diuresis, or complicated sepsis require close monitoring