Reliability and validity of the four-level Chinese emergency triage scale in mainland China: A multicenter assessment

An effective emergency triage system is lacking in mainland China. The Chinese Emergency Triage Scale (CETS) was developed based on vital complaints and vital parameters, according to Chinese data.The aim of this study was to assess the reliability and validity of the CETS by emergency department (ED) nurses in eight EDs in mainland China.A cross-sectional multi-center study was conducted.Eight EDs in the eastern, western, northern, and central areas of mainland China.A total of 51 ED nurses and 8000 active ED patients participated in the study between May and September 2018 in eight EDs.Standardized triage scenarios and active patients were assigned to nurses who used the CETS for evaluative purposes. Accuracy was defined by concordance with the key for the scenarios and was calculated as percentages. Inter-rater reliability was measured by weighted κ to compare the triage nurse's rating with the research nurse's acuity level for each patient. The triage time and clinical outcome of 1000 active patients per site also were collected. The criterion-related validity of the CETS was evaluated; criteria included ED mortality, number of patients discharged, and admission to ICU or general ward. The relationship between the CETS acuity levels triaged by the research nurse and four possible outcomes was assessed with a cross-classification table, using a chi-square test. The ability of the CETS to predict ED mortality was assessed via the receiver-operating characteristic (ROC) area under the curve (AUC).Mean pooled accuracy from all sites was 89.4% (95% CI = 86.9%-91.8%), and the proportion of over-triage slightly exceeded under-triage (6.5% vs. 4.1%). There was no difference in accuracy between sites or according to nurse experience. Inter-rater reliability values for triage nurses and research nurses were 0.96 (95% CI = 0.95-0.97), based on the quadratic weight κ. Trauma cases were assigned to triage with greater accuracy than were nontrauma cases, both for the scenarios and for active patients. The average triage time of ED nurses in all sites was 151.5 ± 26.3 s, using the computer-based triage instrument. The chi-square test showed that there was a significant difference in triage time between the CETS levels (p < 0.001). The AUC was 0.968 (95% CI = 0.958-0.979).The CETS is a reliable system for ED triage and can promote rapid and effective triage in mainland China.