EVALUATION OF THE IMPLEMENTATION OF A REAL TIME ELECTRONIC TRIAGE DECISION-SUPPORT TOOL (eCTAS) IN ONTARIO EMERGENCY DEPARTMENTS

Abstract

Triage is a fundamental process for the safe and efficient management of patients where health care demands exceed available emergency department (ED) resources. The Canadian Triage and Acuity Scale (CTAS) is the standard used in all Canadian and many international EDs to aid in safely determining the priority by which patients should be assessed. The scale delineates 5 levels of acuity: level 1 (resuscitation), level 2 (emergent), level 3 (urgent), level 4 (less urgent) and level 5 (non-urgent).

Many provincial governments use CTAS as an administrative metric to estimate patient care requirements, compare ED performance, and estimate ED physician staffing needs. Despite its clinical and administrative importance, the process by which CTAS scores are derived is highly variable. eCTAS is a real-time electronic decision-support tool designed to standardize the application CTAS guidelines.

This dissertation includes three scientific papers that describe the evaluation of the provincial implementation of eCTAS in hospital EDs across Ontario. This thesis first describes the results from a prospective, observational study of nearly 1,500 triage encounters from sevens EDs that found that a standardized, electronic approach to performing triage assessments improves both interrater agreement and data accuracy compared to each hospital’s previous triage process, without substantially increasing triage time.

We then present our findings from a study exploring the consistency of CTAS score distributions across 35 hospital EDs pre and post-eCTAS implementation for 16 high-volume presenting complaints, and describe the association between use of eCTAS clinical modifiers and triage consistency. We found that compared to the previous triage process, eCTAS increased triage consistency across many, but not all, high-volume presenting complaints. Modifier use was associated with increased triage consistency, particularly for non-specific complaints such as fever and general weakness.

The third paper includes data from 354,176 triage encounters from 31 EDs and describes a change in the distribution of triage scores (from higher to lower acuity) that is likely due to eCTAS implementation. It also explores the possible impact of eCTAS implementation on the ED metrics of hospital admission, left without being seen, and time from triage to physician initial assessment, finding low quality evidence of minimal if any impact of eCTAS on these outcomes. Finally, this thesis concludes with suggestions for future research in this area.