Validation of the Cipto Triage Method: A Single-Centre Study from Indonesia

Abstract

Purpose

A national referral hospital in Indonesia developed a three-category triage acuity method called the Cipto Triage Method (CTM) for emergency departments (ED) in developing countries. This was a validation study to assess the performance of the triage method.

Methods

This cohort, retrospective, single-centre study was conducted in the ED of Cipto Mangunkusumo Hospital that receives approximately 30,000 patient visits per year. The ED medical records throughout the year 2017 were randomly selected as the study sample. Completely written forms of triage and ED initial assessment were included in this study. Validation of the CTM decision was done by using expert panel opinion as reference standard, and also using surrogate conditions such as patient outcome for hospital admission and in-hospital mortality.

Results

There were 1348 samples assigned to the following three categories: resuscitation (14.9%), urgent (63.8%) and non-urgent (21.3%). Overall accuracy was more than 80%, positive predictive value and negative predictive value for resuscitation category were 99% (95% confidence interval [CI], 96.5–99.9) and 96.9% (95% CI, 95.7−97.8), respectively. Resuscitation category had a relative risk (RR) for admission of 1.341 (95% CI, 1.259–1.429) and a RR for mortality of 4.294 (95% CI, 3.180–5.799). Undertriage increases the risk of mortality compared to correct triage (RR, 3.1; 95% CI, 2.11–4.54).

Conclusion

CTM has a good criterion and construct validity; it is also easy to understand and can accommodate a simple ED design in the majority of hospitals in Indonesia.

Keywords:

• triage
• emergency department
• validation

Abbreviations

ATS, Australian Triage Scale; AUC, Area Under the Curve; CI, Confidence Interval; CMH, Cipto Mangunkusumo Hospital; CTAS, Canadian Triage and Acuity Scale; CTM, Cipto Triage Method; ED, Emergency Department; ESI, Emergency Severity Index; ICU, Intensive Care Unit; LR, Likelihood Ratio; MTS, Manchester Triage Scale; NPV, Negative Predictive Value; PPV, Positive Predictive Value; RR, Relative Risk; SATS, South African Triage Scale.

Ethics and Consent Statement

We certify the data presentation has complied with the policy of the journal of ethical consent and approved by local ethical committee from the Universitas Indonesia and Research Unit of Cipto Mangunkusumo Hospital. Consent to participate is not applicable because no human subject involved.

Author Contributions

Hadiki Habib planned the study and submitted the study and responsible for the overall content. Septo Sulistio, Imamul Aziz Albar, and Radi Muharris Mulyana conducted a panel judgement evaluation, Nova Yundiarto conducted a sample selection and data analysis. All authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; gave final approval of the version to be published; and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest in this work.