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Updated:
3 October, 2024
This section describes the principles of triage in an emergency department according to RETTS. RETTS is a system that prioritizes patient care based on vital functions, focusing on the patient's medical risks and needs.
Triage
Most triage or decision support systems include some form of primary sorting of patients with varying needs for emergency care. The division is based on different scales indicating the estimated/assessed current medical risk of waiting for a medical evaluation by a doctor or medical intervention.
The RETTS decision support system contains both a triage module and a module aimed at providing recommendations on how care processes should be managed from a medical safety perspective. The medical responsibility for diagnosis and treatment lies with the individual and the medical authority in each given situation.
Vital Parameter Algorithm
The triage module in RETTS consists of several steps, the first being to obtain an objective picture of the patient’s condition through a direct medical physical examination using an algorithm designed to capture signs of failure in one or more organ systems. This is called the vital parameter algorithm (VP) in RETTS and aims to provide an overview of A+B breathing and C, circulation functions, D, consciousness level (CNS), and also E, body temperature.
Measurement, assessment, and control of VP should be performed simultaneously while obtaining a structured history based on the patient’s primary and main reason for seeking care. In addition to a brief history of the current reason for seeking care, the history is supplemented with a number of yes/no questions regarding conditions with known increased co-morbidity, such as known cardiovascular disease, diabetes, kidney failure, liver failure, etc. These conditions are each part of what is called the Charlson’s comorbidity index, meaning that if the patient brings these diagnoses/conditions into emergency care, they have a higher risk of both morbidity and mortality than those without these diagnoses/conditions. The idea is that this process forms the basis for structured documentation.
RETTS Score
In RETTS VP, since 2019, there is also a scoring system (RETTS Score) included, which, together with the priority color, also provides a score that differentiates patients within each color more clearly. RETTS Score can also be used within the hospital’s departments. Other systems do not differ significantly from RETTS VP. It is especially important in the priority groups where the most critically ill patients are placed. RETTS Score indicates medical complexity, while the medical priority color or level indicates the individual medical risk present. One can imagine a situation where there are 12 patients in the emergency room with an Orange priority. Often, a problem arises regarding how capacity should be distributed within that priority group. In such cases, the score is used to secondary prioritize systematically based on the highest score. All with Orange priority have the same priority and similar medical risk, but sometimes they differ slightly in terms of medical complexity.
ESS (Emergency Symptoms and Signs)
The second step in the RETTS decision support system involves reasons for seeking care based on symptoms and clinical signs. All reasons for seeking care are also classified as ICD-10 codes (International Statistical Classification of Diseases and Related Health Problems). The reasons for seeking care are gathered into algorithms or ESS (Emergency Symptoms and Signs) that contain one or more reasons for seeking care according to ICD 10, intended to assist in gathering the history and observing clinical signs such as ECG, chills, rashes, injuries, or vegetative signs (cold sweats, nausea, etc.). Each ESS algorithm includes different symptoms and clinical signs graded or other important information that provides guidance on what RETTS recommends and what should be the correct priority level, expressed as a color in RETTS.
The recommended priority in ESS should be weighed and combined with the priority indicated by VP, and the sum of objective and more subjective observations gives the final priority, along with the evaluator’s own experience and competence, which forms the third step, a review step. The algorithm, VP, or ESS, which gives the highest priority, becomes the final priority.
In RETTS, ESS and VP algorithms are available for children, adults, and pregnant women. They address both psychiatric and somatic conditions regardless of age group.
Prioritization
Prioritization in RETTS is based solely on the patient’s medical risk and need and is unrelated to the order of care or time to doctor, X-ray, or other interventions. The priority level should be seen as a recommendation to the user to provide emergency care immediately or if the patient, without medical risk, can wait until capacity is available. In RETTS, no timeframes are specified for how long a patient with a certain priority can wait for a doctor or intervention. Ideally, all patients should be treated immediately, but in practice, this is obviously impossible, as variations in inflow often do not align with available capacity. In practice, this means that if existing capacity is utilized 100% at any given time, there is always some form of capacity shortage or a queue that must be managed by the organization deciding on capacity.
RETTS
In RETTS, two levels of medical availability are indicated: “emergency care immediately” or “can wait,” but without RETTS specifying a recommended waiting time in minutes. The reason for the RETTS recommendation is based on validations in the form of observational studies conducted on the METTS/RETTS system, but also the fact that if a waiting time/lead time in minutes is indicated, it tends to be met or exceeded. RETTS also specifies what is recommended for immediate actions and what type of logistics should be used. In the validations conducted, there is a correlation between priority according to RETTS and the need for inpatient care. However, it should be emphasized that this relationship should not be used as a basis for deciding that all patients with red/orange priority should be hospitalized and that all patients with yellow or green priority do not have an absolute medical need for inpatient care or the resources and expertise of the emergency department and ambulance service.
It is important that the entire care chain works with the same standard and that the system is followed, creating a chain of trust and confidence in RETTS within the organization. We have therefore postulated that the person performing the assessment process and evaluating the patient always does so correctly based on the conditions and data available at the time of assessment. Subsequent levels of care or handlers can always make a new assessment if they believe that the current condition deviates from the initial assessment, which may also have changed over time. It is important to remind that staff and doctors in the emergency department always have a personal medical responsibility to assess the reasonableness of the RETTS recommendation.
The Importance of Physiological Parameters in RETTS
The VP algorithm is based on previously known concepts such as ABCDE and has been used in various ways in healthcare for a long time. VP are all dynamic parameters, meaning that it is not only the individual measurement value that provides direct information about the condition, but the change in measurement values over time is just as important.
A = Airways
This section assesses whether the patient has any form of airway obstruction, which may present as stridor or other symptoms and signs of airway obstruction. Stridor is an uncommon condition in adult emergency care but much more common in pediatric emergency care, where airway infections often result in stridorous breathing. If signs of airway obstruction are found, the patient, regardless of age, is prioritized RED in RETTS until examined by a doctor who can choose to downgrade the priority if the examination shows no risk of airway obstruction.
B = Breathing
This part of the VP algorithm assesses both respiratory rate (breaths per minute) and oxygen saturation measured by pulse oximetry.
C = Circulation
VP circulation consists of several parameters, with heart rate and blood pressure being the objective VPs measured in RETTS. Peripheral circulation is a more subjective parameter that should be assessed but is not listed as an objective parameter in the VP algorithm.
D = Disability (Consciousness)
Consciousness is a clear VP that is relatively easy to determine and monitor in both adults and children. In Sweden, three scales are used: RLS (Reaction Level Scale), GCS (Glasgow Coma Scale), and ACVPU. All are suitable for use in RETTS, and regarding D, traditions vary between emergency departments and between prehospital and hospital care. In this VP, there is a very clear boundary between unconscious and conscious patients in terms of the risk of complications and death. In RETTS, unconsciousness is always RED, i.e., >3 in RLS, <8 in GCS, or P&U in ACVPU.
E = Environment or Exposure (Body Temperature)
This variable is important in certain conditions to identify patients with both high and low body temperatures. Body temperature is very rarely a decisive VP in RETTS for adult patients.
RETTS Process Levels
RETTS includes five process levels: blue, green, yellow, orange, and red, in increasing order of priority and severity, expressed as the risk of death and/or the need for emergency care immediately or within a reasonable time. The RETTS system also specifies how the patient should be managed in the emergency process in terms of monitoring and the degree of proximity and supervision required by healthcare personnel.
- RED is classified as an immediate life threat and means “emergency care immediately.”
- ORANGE is classified as a potential life threat and means “emergency care immediately.”
- YELLOW is classified as not life-threatening but requires emergency care within a reasonable time, “can wait,” based solely on the fact that the patient can wait without apparent medical risk.
- GREEN is classified as not life-threatening but requires care within a reasonable time, “can wait,” based solely on the fact that the patient can wait without apparent medical risk.
- BLUE classifies patients with a very limited acute need for emergency care at the time of seeking care and who present with minor medical problems that can sometimes be resolved with a healthcare intervention or referred directly to another level of care.
Algorithm for Vital Parameters in RETTS
RETTS Emergency Record
RETTS T-journal
NEWS
The NEWS Scoring System
| Physiological parameter | |||||||
|---|---|---|---|---|---|---|---|
| 3 | 2 | 1 | 0 | 1 | 2 | 3 | |
| Respiration rate (per minute) | ≤8 | 9–11 | 12–20 | 21–24 | ≥25 | ||
| SpO2 Scale 1 (%) | ≤91 | 92–93 | 94–95 | ≥96 | |||
| SpO2 Scale 2 (%) | ≤83 | 84–85 | 86–87 | 88–92 ≥93 on air | 93–94 on oxygen | 95–96 on oxygen | ≥97 on oxygen |
| Air or oxygen? | Oxygen | Air | |||||
| Systolic blood pressure (mmHg) | ≤90 | 91–100 | 101–110 | 111–219 | ≥220 | ||
| Pulse (per minute) | ≤40 | 41–50 | 51–90 | 91–110 | 111–130 | ≥131 | |
| Consciousness | Alert | * CVPU | |||||
| Temperature (°C) | ≤35.0° | 35.1–36.0° | 36.1–38.0° | 38.1–39.0° | ≥39.1° | ||
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