Impact of implementing five-level triage system on patients outcomes and resource utilization in the emergency department of Alexandria main university hospital

Figures & data

Figure 1. Study patients’ flow chart.

Table 1. Baseline patients’ characteristics in both studied groups.

	Group I (No = 9766)	Group II (No = 22936)	p value
Age (years): Range Mean ± S.D.	1.0–98.0 45.7 ± 22.7	1.0–96.0 45.8 ± 19.7	t = 0.24 0.624
Sex: Male Female	5161 (52.8%) 4605 (47.2%)	13435 (58.6%) 9501 (41.4%)	χ^2 = 19.66 0.001*
Mode of arrival: By Ambulance Ambulatory Private car	3707 (37.9%) 867 (8.9%) 5192 (53.2%)	8873 (38.7%) 1613 (7.0%) 12450 (54.3%)	χ^2 = 4.02 0.211
Initial presentation: Isolated trauma Poly trauma Surgical emergencies Medical emergencies	2051 (21.0%) 3027 (31.0%) 2149 (22.0%) 2539 (26.0%)	5622 (24.5%) 6811 (29.7%) 5108 (22.3%) 5395 (23.5%)	χ^2 = 7.22 0.107
Initial Code (ABCDE): 1 2 3 4 5	2928 (30.0%) 5154 (52.8%) 1684 (17.2%)--	3851 (16.7%) 1921 (8.4%) 1512 (6.6%) 7819 (34.1%) 7833 (34.2%)	0.001* (2 # 2,3= 0.001*) (3 # 4,5= 0.001*)
Final Code: Died 1 2 3 4 5	(ABCDE) 514 (5.26%) 3062 (31.35%) 2546 (26.07%) 3644 (37.31%)--	(NEWS) 336 (1.46%) 2486 (10.84%) 1418 (6.18%) 2578 (11.24%) 6959 (30.34%) 9159 (39.93%)	0.027* 0.001* (2 # 2,3= 0.011*) (3 # 4,5= 0.001*)
Time-to-clinical decision: Immediate < 30 minutes 30–60 minutes > 60 minutes	3516 (36.0%) 1563 (16.0%) 2442 (25.0%) 2245 (23.0%)	11835 (51.6%) 3899 (17.0%) 4450 (19.4%) 2752 (12.0%)	χ^2 = 89.25 0.001*
Differential diagnosis: 0–2 3–5 > 5	4590 (47.0%) 2930 (30.0%) 2246 (23.0%)	14564 (63.5%) 6124 (26.7%) 2248 (9.8%)	χ2=89.8 0.001*

Group I: 3-level triaging. Group II: 5-level triaging. Values are presented as number (No.), percentage (%), and mean ± standard deviation (SD). t: student t-test. χ²: Chi-square test. 2 # 2,3: comparison between code 2 in group I and both codes 2 and 3 in group II. 3 # 4,5: comparison between code 3 in group I and both codes 4 and 5 in group II. p: probability for comparing between both groups. *: significant differences from baseline p ≤ 0.05.

Table 2. Relation between initial and final codes of patients in both studied groups.

	Final Code	Initial code					χ^2 Test p value
		1	2	3	4	5
Group I	Died 1 2 3	275 (9.4%) 1683 (57.5%) 441 (15.1%) 529 (18.1%)	139 (2.7%) 1209 (23.5%) 1813 (35.2%) 1993 (38.7%)	100 (5.9%) 170 (10.1%) 292 (17.3%) 1122 (66.6%)	-	-	73.7 0.001*
Group II	Died 1 2 3 4 5	318 (8.3%) 2079 (54.0%) 602 (15.6%) 634 (16.5%) 190 (4.9%) 28 (0.7%)	18 (0.9%) 348 (18.1%) 719 (37.4%) 720 (37.5%) 83 (4.3%) 33 (1.7%)	0 (0.0%) 59 (3.9%) 92 (6.1%) 1098 (72.6%) 213 (14.1%) 50 (3.3%)	0 (0.0%) 0 (0.0%) 5 (0.1%) 125 (1.6%) 6426 (82.6%) 1263 (16.2%)	0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (0.0%) 47 (0.6%) 7785 (99.4%)	674.1 0.001*

Group I: 3-level triaging (initial and final codes were based on ABCDE approach). Group II: 5-level triaging (ABCDE-based initial and NEWS-based final codes). Values are presented as number (No.), and percentage (%). χ2: Chi-square test. p: probability for comparing between both groups. *: significant if p ≤ 0.05.

Table 3. Outcome measures in both studied groups.

	Group I (No = 9766)	Group II (No = 22936)	χ2 Test p value
ED mortality Disposition: ICU admission In-hospital admission Home discharge	514 (5.26%) 2666 (27.3%) 5899 (60.44%) 687 (7.0%)	336 (1.46%) 5321 (23.2%) 14321 (62.44%) 2958 (12.9%)	0.027* 0.036* 0.031* 0.021*
Resources utilization: Consultations: Range Mean ± S.D. Lab. Investigations: No lab. investigations Range Mean ± S.D. Rad. Investigations: No rad. investigations Range Mean ± S.D. ED treatment categories: No treatments Range Mean ± S.D. ER interventions: No interventions Range Mean ± S.D.	0.0–5.0 1.86 ± 0.93 173 (1.8%) 0.0–8.0 3.92 ± 1.96 1296 (13.3%) 0.0–6.0 1.72 ± 0.91 171 (1.8%) 0–4 1.82 ± 1.23 1667 (17.1%) 0.0–6.0 1.51 ± 1.17	0.0–5.0 1.67 ± 0.91 5922 (25.8%) 0.0–8.0 3.03 ± 2.42 6023 (26.3%) 0.0–6.0 1.11 ± 0.85 4772 (20.8%) 0–4 1.21 ± 1.08 6394 (27.9%) 0.0–6.0 0.89 ± 0.80	χ2=38.5 0.01* 0.001* χ2=6.11 0.013* 0.006* χ2=8.71 0.001* 0.001* χ2=57.91 0.001* 0.005* χ2=34.79 0.001*
ED LOS (minutes): Range Mean ± S.D. Median	10.0–720.0 170.1 ±88.7 190.0	10.0–420.0 72 ± 109.8 88.0	U = 84.1 0.0001*

Group I:3-level triaging. Group II:5-level triaging. Lab.: laboratory (ECG, CBC, RBS, renal function tests, electrolytes, arterial blood gases, coagulation profile, and cardiac enzymes). Rad.: radiological (X-Rays, ultrasound, echocardiography, computerized tomography studies, and magnetic resonance imaging). Treatment categories: blood products, I.V fluids, I.V drugs, and others. Interventions: CPR, cardiac, airway, circulatory, drainage, and minor surgical interventions. ED LOS: emergency department length of stay. Values are presented as range, mean ± standard deviation (SD), median, number (No.), and percentage (%). χ2: Chi-square test. U-test: Mann-Whitney U-test. p: probability for comparing between both groups. *: significant if p ≤ 0.05.

Table 4. Multivariate logistic regression analysis for predictors of ED mortality.

	Standardized B Coefficients	Odds ratio	95.0% C.I.	p value
Type of triaging: Three-level Five-level	0.506	2.20 1	1.130–4.11	0.004*
Age	0.231	1.01	0.57–1.76	0.566
Sex: Male Female	0.205	1.010 1	0.35–1.11	0.584
Mode of arrival: Ambulance Ambulatory Private car	0.084	1.62 1 1.10	0.85–3.08 0.63–1.83	0.089
Initial presentation: Isolated trauma Poly trauma Surgical emergencies Medical emergencies	0.241	1 1.03 1.14 1.92	0.68–2.22 0.43–2.02 0.71–3.68	0.261 0.115 0.021*
Initial Code: 1 2 (2–3) 3 (4–5)	0.106	2.33 1.15 1	1.16–5.22 0.76–2.00	0.005* 0.172
Time-to-decision: Immediate < 30 minutes 30–60 minutes > 60 minutes	0.108	1 1.10 1.21 2.27	0.66–1.85 0.513–2.00 0.96–4.62	0.223 0.107 0.007*
No. of D.D.: 0–2 3–5 >5	0.207	1 1.02 2.33	0.62–1.72 1.21–4.87	0.236 0.008*
No. of consultations	0.0712	0.96	0.33–1.06	0.074
No. of laboratories	0.128	1.02	0.56–2.02	0.069
No. of radiologies	0.233	1.07	0.76–1.52	0.231
No. of treatments	0.224	0.87	0.656–1.57	0.229
No. of interventions	0.405	1.94	0.917–3.26	0.015*
ED LOS (in minutes)	0.062	2.31	1.41–4.67	0.008*

ED mortality was the dependent continuous variable versus discharge, hospital, and ICU admission. The overall model was significant (Chi-square test = 64.0 and p = 0.0001). No.: number. D.D: differential diagnoses. ED LOS: emergency department length of stay. C.I.: confidence interval. *: significant differences from baseline p (probability) ≤ 0.05.