THE GLOBALIZATION OF CTAS –
DEBUNKING THE MYTHS
Presenter: Michael J Bullard MD
Professor, Department of
Emergency Medicine
University of Alberta
CAEP rep CTAS NWG
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Relationship with commercial interests: None
INTRODUCTION
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Nationally, questioning the value of triage and the application
of CTAS has become a hot button item over the last few years
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Much of this has arisen out of Lean processing work and the
desire to eliminate “non value add” activities
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At the same time internationally interest in adopting or
adapting CTAS to meet their country’s needs continues to
grow
Let’s synthesize some of these concerns and activities
OBJECTIVES
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Address several triage/CTAS myths
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Review research support for CTAS reliability, validity and
usability
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focusing on eCTAS
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Outline out international partnerships and the benefits
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Summary and ‘update’ plans
RATIONALE BEHIND CTAS
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A national standard to assist triage nurse prioritization
Support improved patient care and safety
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Important role of 2nd order (Special modifiers)
Increase triage reliability and validity
Provide ability to capture and compare patient presentation type
& acuity/risk by site, by region, and track performance indicators
National benchmarking
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partner with the Canadian Institute of Health Information (CIHI) and their
National Ambulatory Care Reporting System (NACRS) to align and help
define each others needs
MYTH #1
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Triage is not a value add for the patient, an unnecessary
waste of time
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Assuming we can readily identify ‘nearly dying patients’
Currently for the busiest 15 EDs In Alberta & ‘CIHI reporting’ BC EDs
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Time to physician (PIA) Median
90th%ile
CTAS level 2
30-45 mins
1-2 hours
CTAS level 3,4,5
1-2 hours
3-6 hours
All levels (BC)
1 hour
2+ hours
With no triage, for all ‘non dying patients’ the median wait time would be 1-2 hours
One clear value is patient safety and the ability to identify and expedite care
for the sickest patients and others at risk
MYTH #2
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Anyone can triage
While computerized clinical decision support in IT systems or on
smart phones can assist ‘nurses’ correctly assign a CTAS acuity
score ……..
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Experienced, trained triage nurses based on clinical
judgment will “uptriage” 5-10% of the time
Resource limited sites may need to utilize LPNs or EMS
providers but nurses should see all CTAS ≥3 patients
MYTH #3
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Triage takes too long!
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Triage is to “prioritize patients based on acuity and risk” and stream them to
the most appropriate care area”
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CTAS is our preferred tool to help make rapid decisions based selecting the
key complaint and the highest priority modifier to assign an acuity score.
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Triage is not the place for system based data collection, med reconciliation or
other time costly activities
This process takes seconds to minutes
Nurses required to triage to, and have responsibility for, the waiting room will
add a nursing assessment component, however, this is not triage. This is a
negative impact of crowding
MYTH #4
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Triage data is primarily for administrators
CTAS acuity, presenting complaint, age, EMS transport, and
disposition are 5 important case mix measures collected in ED to
help advocate for resources & counter arguments of patient misuse
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In future adding complexity measures such as the Charlson Co-morbidity index
linked to key diagnoses will allow us to further advocate for ED needs
Current Accreditation standards for Canadian EDs require:
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Evidence of a safe and effective triage process
The assignment of a CTAS acuity score
CTAS EVOLUTION
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CAEP Triage and Acuity Scale – Canada
1995
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CTAS – Canada (CAEP, NENA, AMUQ )
1999
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Paediatric CTAS (above + CPS, SRPC)
2001
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CEDIS Complaint list (+ revision)
2003 & 2008
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Adult CTAS revision
2004
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Prehospital CTAS variably introduced
2006
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Internationalization begins
Adult & Paediatric CTAS revisions
2006
2008
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Agree to 4-year revision cycle
2012
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CTAS 2013 Update published
2014
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Work underway for 2016 Update
2016-17
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WHY THE INTERNATIONAL INTEREST
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Hierarchal design suitable for computerization and clinical
decision support is attractive
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CTAS publications, support documents and contact
information readily available on CAEP website
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We have processes in place for collaborative agreements
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Research support for CTAS is robust
CTAS SUPPORT APPLICATIONS
CTAS RESEARCH using eCDSS
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Reliability
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Nurse-to-nurse & site-to -site consistency
Validity
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Predicting resource utilization differences, and ED outcomes
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Not designed to predict in hospital outcomes!
Nor is it an “independent” workload measure
Usability
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Can be applied with ease & efficiency
IMPLEMENTATION RESEARCH
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Study
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6 weeks: 9 nurses with median experience of 11 years in ED &
7 years of triage experience
2/3 were novice PC users
Results
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Expert computer users faster initially, but both groups comfortable with
the application & reported no negative impact on nurse-patient
relationship or on triage time
3-hour training adequate
Nurses chose to override only 5.5% of the time
Suggested need for greater complaint specificity
eTRIAGE LEARNING CURVE
Difference of 2.4 sec
2.8
2.7
2.6
Min. 2.5
2.4
2.3
2.2
Paper
1st 2 wks
Last 2 wks
Modality
RELIABILITY RESEARCH
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Blinded Adult triage study
• Study Design: 2 different nurses scored the same patient based
independent blinded assessments
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Blinded Paediatric triage study
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Dong et al 2008, using electronic triage: w 0.65
Gravel et al 2012, IRR was good: w 0.74
Concurrent Observation Study
• Study Design: 2 different nurses scored the same patient based on the
same nurse/patient interaction
Grafstein 2005, using electronic triage: w 0.75
Worster 2007, paper based direct observation IRR 0.9 using G-theory, where
>0.7 is considered good
• Ng et al 2010, using electronic triage: w 0.87
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 agreement: ≥0.8 excellent; 0.6-0.79 good; 0.4-0.59 moderate
VALIDITY RESEARCH
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Jiminez, et al. CJEM 2003; strong relationship between
admission & deaths; & lab & DI utilization
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Spence et al. CAEP 2004; resource use increases from 5 - 1 but
variable utilization rates by complaint
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Gravel et al. CJEM 2008; stepwize increase CTAS 5 to 1 in
admission rates: 1%/2%/14%/37%/63% (p <0.001); also good
correlation between triage levels and ED LOS and admit to
PICU (p < 0.001
Dong et al. AEM 2007; significant increase in admission rates,
consults and CT scan ordering by acuity
RESEARCH RESULTS: VALIDITY
Odds Ratio compared to CTAS 3
Consult
CT Scan
Admission
6
5
4
3
2
1
0.5
0.4
0.3
0.2
0.1
1
2
3
4
5
1
2
3
CTAS
4
5
1
2
3
4
5
ED HOSPITAL COSTS BY TRIAGE SCORE
500000
Cost ($CDN)
100000
10000
1000
100
10
CTAS
n=
1
2
3
4
5
254
3212
12933
11149
1976
CURRENT INTERNATIONAL PARTNERS
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Taiwan
2006
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Trinidad and Tobago
2008
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Japan, Turks and Caicos
2009
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Costa Rica, Korea, Hungary
2012
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Barbados
2013
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Saudi Arabia, Oman
2015
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Portugal (Paeds CTAS)
later 2015
TAIWAN (TTAS)
JAPAN (JTAS)
HEAT STROKE ADDITION
SAUDI INSTRUCTORS
SUMMARY
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With current 1+ hour waits in most EDs for undifferentiated patients, a
failure to apply a proven triage strategy will put many patients at risk
CTAS is a tool developed by physicians and nurses and refined
based on feedback and adherence to evidence-based standards
of care
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International partnerships are great opportunities to share and also
learn from the challenges and approaches of others
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Apart from standard research many novel approaches to the use of
CTAS data at home and abroad will help pave future directions
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CTAS data combined with resource utilization, patient dispositions,
age and sex demographics, and complexity provide valuable site,
regional, and national analytics opportunity for informed planning
THANK YOU
ANY QUESTIONS?