今日の臨床サポート

トリアージ

著者: 東裕之 福井県立病院 救命救急センター

監修: 林寛之 福井大学医学部附属病院

著者校正/監修レビュー済:2021/04/21
参考ガイドライン:
  1. CDC:Guidelines for Field Triage of Injured Patients(2011)
  1. 日本救急医学会日本救急看護学会日本小児救急医学会日本臨床救急医学会:JTAS2017ガイドブック
  1. 日本外傷学会:外傷初期診療ガイドライン 改訂第5版
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
東裕之 : 特に申告事項無し[2021年]
監修:林寛之 : 講演料(メディカ出版),原稿料(羊土社)[2021年]

改訂のポイント:
  1. 定期レビューを行い、START法・SALT法のエビデンスについて加筆修正を行った。
  1. JTASガイドブックの更新に合わせて加筆修正を行った。

まとめ

まとめ  
  1. トリアージとは、重症度を評価し、適切な治療を適切な時間に受けるために行うもので、災害時だけでなく病院診察前にも行えるものである。
  1. 災害時では呼吸状態・脈・意識状態・歩行可能かどうかの項目で4段階に区分するSTART法が日本では一般的である[1]
  1. 8歳未満の小児に対してはJumpSTARTを使うことが多い。
  1. JumpSTARTでは、気道確保後の無呼吸に対して脈が触れれば人工呼吸を行うことが許されている。
  1. START法では小児と成人を分けなくてはいけないため、最近では区別しないSALT法が広まりつつある。
  1. 外傷の病院前トリアージではバイタルや受傷機転などを考慮し、適切な施設へ搬送することが求められる。
  1. 脳卒中が疑われる場合、CPSSを用いて評価を行って搬送を行う。
  1. 診察前トリアージを行うことで、優先的に緊急度の高い患者に対する配慮を保証できる。
  1. 診察前トリアージは来院10~15分以内に行い、緊急度を5段階に分けて評価を行う。
  1. 診察前トリアージは、第一印象の重症感・来院時主訴・バイタルサインなどに基づいて行う。
 
  1. トリアージ方法の正確性の比較
  1. START法・SALT法のトリアージを正確性などについて比較した。
  1. SALT法が52%の正確性であったのに対して、START法では36%であった。またアンダートリアージについてはSALT法が最も低く26%で、START法では57%と違いが出ている。オーバートリアージについてはSALT法が22%であったのに対してSTART法では7%となっている。
  1. 正確性という点ではSALT法が優れている結果となっている[2]
 
トリアージ方法の正確性の比較

SALT法が52%の正確性であったのに対して、START法では36%であった。またアンダートリアージについてはSALT法が最も低く26%で、START法では57%と違いが出ている。オーバートリアージについてはSALT法が22%であったのに対してSTART法では7%となっている。

出典

img1:  Comparing the Accuracy of Mass Casualty Triage Systems When Used in an Adult Population.
 
 Prehosp Emerg Care. 2019 Jul 31;:1-8. do・・・
 
各トリアージ方法でexpectant(灰/黒)症例の包含・除外の比較

SALT法では他の方法に比べて、expectant(灰/黒)症例に対しての正確性も高くなっている。

出典

img1:  Comparing the Accuracy of Mass Casualty Triage Systems When Used in an Adult Population.
 
 Prehosp Emerg Care. 2019 Jul 31;:1-8. do・・・

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文献 

著者: Courtney H McKee, Robert W Heffernan, Brian D Willenbring, Richard B Schwartz, J Marc Liu, M Riccardo Colella, E Brooke Lerner
雑誌名: Prehosp Emerg Care. 2019 Jul 31;:1-8. doi: 10.1080/10903127.2019.1641579. Epub 2019 Jul 31.
Abstract/Text Objective: To use a previously published criterion standard to compare the accuracy of 4 different mass casualty triage systems (Sort, Assess, Lifesaving Interventions, Treatment/Transport [SALT], Simple Triage and Rapid Treatment [START], Triage Sieve, and CareFlight) when used in an emergency department-based adult population. Methods: We performed a prospective, observational study of a convenience sample of adults aged 18 years or older presenting to a single tertiary care hospital emergency department. A co-investigator with prior emergency medical services (EMS) experience observed each subject's initial triage in the emergency department and recorded all data points necessary to assign a triage category using each of the 4 mass casualty triage systems being studied. Subjects' medical records were reviewed after their discharge from the hospital to assign the "correct" triage category using the criterion standard. The 4 mass casualty triage system assignments were then compared to the "correct" assignment. Descriptive statistics were used to compare accuracy and over- and under-triage rates for each triage system. Results: A total of 125 subjects were included in the study. Of those, 53% were male and 59% were transported by private vehicle. When compared to the criterion standard definitions, SALT was found to have the highest accuracy rate (52%; 95% CI 43-60) compared to START (36%; 95% CI 28-44), CareFlight (36%; 95% CI 28-44), and TriageSieve (37%; 95% CI 28-45). SALT also had the lowest under-triage rate (26%; 95% CI 19-34) compared to START (57%; 95% CI 48-66), CareFlight (58%; 95% CI 49-66), and TriageSieve (58%; 95% CI 49-66). SALT had the highest over-triage rate (22%; 95% CI 14-29) compared to START (7%; 95% CI 3-12), CareFlight (6%; 95% CI 2-11) and TriageSieve (6%; 95% CI 2-11). Conclusion: We found that SALT triage most often correctly triaged adult emergency department patients when compared to a previously published criterion standard. While there are no target under- and over-triage rates that have been published for mass casualty triage, all 4 systems had relatively high rates of under-triage.

PMID 31287350  Prehosp Emerg Care. 2019 Jul 31;:1-8. doi: 10.1080/1090・・・
著者: Christopher A Kahn, Carl H Schultz, Ken T Miller, Craig L Anderson
雑誌名: Ann Emerg Med. 2009 Sep;54(3):424-30, 430.e1. doi: 10.1016/j.annemergmed.2008.12.035. Epub 2009 Feb 5.
Abstract/Text STUDY OBJECTIVE: The mass casualty triage system known as simple triage and rapid treatment (START) has been widely used in the United States since the 1980s. However, no outcomes assessment has been conducted after a disaster to determine whether assigned triage levels match patients' actual clinical status. Researchers hypothesize that START achieves at least 90% sensitivity and specificity for each triage level and ensures that the most critical patients are transported first to area hospitals.
METHODS: The performance of START was evaluated at a train crash disaster in 2003. Patient field triage categories and scene times were obtained from county reports. Patient medical records were then reviewed at all receiving hospitals. Victim arrival times were obtained and correct triage categories determined a priori using a combination of the modified Baxt criteria and hospital admission. Field and outcomes-based triage categories were compared, defining the appropriateness of each triage assignment.
RESULTS: Investigators reviewed 148 records at 14 receiving hospitals. Field triage designations comprised 22 red (immediate), 68 yellow (delayed), and 58 green (minor) patients. Outcomes-based designations found 2 red, 26 yellow, and 120 green patients. Seventy-nine patients were overtriaged, 3 were undertriaged, and 66 patients' outcomes matched their triage level. No triage level met both the 90% sensitivity and 90% specificity requirement set forth in the hypothesis, although red was 100% sensitive (95% confidence interval [CI] 16% to 100%) and green was 89.3% specific (95% CI 72% to 98%). The Obuchowski statistic was 0.81, meaning that victims from a higher-acuity outcome group had an 81% chance of assignment to a higher-acuity triage category. The median arrival time for red patients was more than 1 hour earlier than the other patients.
CONCLUSION: This analysis demonstrates poor agreement between triage levels assigned by START at a train crash and a priori outcomes criteria for each level. START ensured acceptable levels of undertriage (100% red sensitivity and 89% green specificity) but incorporated a substantial amount of overtriage. START proved useful in prioritizing transport of the most critical patients to area hospitals first.

PMID 19195739  Ann Emerg Med. 2009 Sep;54(3):424-30, 430.e1. doi: 10.1・・・
著者: D Michael Navin, William J Sacco, Thomas B McCord
雑誌名: Ann Emerg Med. 2010 Jun;55(6):579-80; author reply 580-1. doi: 10.1016/j.annemergmed.2009.11.031.
Abstract/Text
PMID 20494228  Ann Emerg Med. 2010 Jun;55(6):579-80; author reply 580-・・・
著者: Stefano Badiali, Aimone Giugni, Lucia Marcis
雑誌名: Disaster Med Public Health Prep. 2017 Jun;11(3):305-309. doi: 10.1017/dmp.2016.151. Epub 2017 Jan 9.
Abstract/Text OBJECTIVE: START (Simple Triage and Rapid Treatment) triage is a tool that is available even to nonmedical rescue personnel in case of a disaster or mass casualty incident (MCI). In Italy, no data are available on whether application of the START protocol could improve patient outcomes during a disaster or MCI. We aimed to address whether "last-minute" START training of nonmedical personnel during a disaster or MCI would result in more effective triage of patients.
METHODS: In this case-control study, 400 nonmedical ambulance crew members were randomly assigned to a non-START or a START group (200 per group). The START group received last-minute START training. Each group examined 6000 patients, obtained from the Emergo Train System (ETS Italy, Bologna, Italy) victims database, and assigned patients a triage code (black-red-yellow-green) along with a reason for the assignment. Each rescuer triaged 30 patients within a 30-minute time frame. Results were analyzed according to Fisher's exact test for a P value<0.01. Under- and over-triage ratios were analyzed as well.
RESULTS: The START group completed the evaluations in 15 minutes, whereas the non-START group took 30 minutes. The START group correctly triaged 94.2% of their patients, as opposed to 59.83% of the non-START group (P<0.01). Under- and over-triage were, respectively, 2.73% and 3.08% for the START group versus 13.67% and 26.5% for the non-START group. The non-START group had 458 "preventable deaths" on 6000 cases because of incorrect triage, whereas the START group had 91.
CONCLUSIONS: Even a "last-minute" training on the START triage protocol allows nonmedical personnel to better identify and triage the victims of a disaster or MCI, resulting in more effective and efficient medical intervention. (Disaster Med Public Health Preparedness. 2017;11:305-309).

PMID 28065200  Disaster Med Public Health Prep. 2017 Jun;11(3):305-309・・・
著者: Lou E Romig
雑誌名: JEMS. 2002 Jul;27(7):52-8, 60-3.
Abstract/Text No matter how well we plan and train, every MCI is an exercise in gaining control over chaos. Emotions can sometimes get in the way. An MCI with pediatric victims is an additional emotional challenge that must be met by using objective tools so we can avoid needless mistakes in medical judgment. JumpSTART, used in conjunction with an adult triage tool such as START, can help to ensure that we not only meet the needs of all our MCI victims, but also address our own needs to provide the very best care for the children we encounter.

PMID 12141119  JEMS. 2002 Jul;27(7):52-8, 60-3.
著者: L A Wallis, S Carley
雑誌名: Emerg Med J. 2006 Jun;23(6):475-8. doi: 10.1136/emj.2005.032672.
Abstract/Text OBJECTIVES: To determine the sensitivity and specificity of paediatric major incident triage scores. The Paediatric Triage Tape (PTT), Careflight, Simple Triage and Rapid Treatment (START), and JumpSTART systems were tested.
METHODS: In total, 3461 children presenting to a South African emergency department with trauma were scored using the four different methods. The sensitivity and specificity of the four scores was calculated against the Injury Severity Score (ISS), New ISS (NISS), and a modification of the Garner criteria (a measure of need for urgent clinical intervention). We also performed a Bayesian analysis of the scores against three different types of major incident.
RESULTS: None of the tools showed high sensitivity and specificity. Overall, the Careflight score had the best performance in terms of sensitivity and specificity. The performance of the PTT was very similar. In contrast, the JumpSTART and START scores had very low sensitivities, which meant that they failed to identify patients with serious injury, and would have missed the majority of seriously injured casualties in the models of major incidents.
CONCLUSION: The Careflight or PTT methods of triage should be used in paediatric major incidents in preference to the jumpSTART or START methods.

PMID 16714518  Emerg Med J. 2006 Jun;23(6):475-8. doi: 10.1136/emj.200・・・
著者: L A Wallis, S Carley
雑誌名: Emerg Med J. 2006 Jan;23(1):47-50. doi: 10.1136/emj.2005.024893.
Abstract/Text INTRODUCTION: The Paediatric Triage Tape (PTT) is an easy to use major incident primary triage tool, based upon a modification of the Triage Sieve. The purpose of this study was to prospectively validate the PTT for use in paediatric major incidents.
METHODS: A database of children presenting the Trauma Unit of the Red Cross Children's Hospital, Cape Town, was developed over a nine month period. Each child was triaged using the PTT, and had an Injury Severity Score (ISS) calculated. Additionally, the New Injury Severity Score (NISS) was calculated, and the presence of interventions that may occur to the children ("Garner criteria") was documented. The sensitivity, specificity, overtriage, and undertriage rates were calculated.
RESULTS: 3461 children were entered into the database. For identifying children with an ISS of over 15, the PTT had a sensitivity of 37.8%, specificity of 98.6%, overtriage rate of 38.8%, and an undertriage rate of 3.5%. Against the NISS and Garner criteria, the results were comparable.
CONCLUSION: The PTT has poor sensitivity at identifying immediate priority children by these criteria. Specificity (the ability to identify non-T1 patients) is excellent, and the overtriage and undertriage rates are within the range deemed unavoidable by the American College of Surgeons.

PMID 16373803  Emerg Med J. 2006 Jan;23(1):47-50. doi: 10.1136/emj.200・・・
著者: Ilene Claudius, Amy H Kaji, Genevieve Santillanes, Mark X Cicero, J Joelle Donofrio, Marianne Gausche-Hill, Saranya Srinivasan, Todd P Chang
雑誌名: Prehosp Disaster Med. 2015 Oct;30(5):457-60. doi: 10.1017/S1049023X15005002. Epub 2015 Sep 1.
Abstract/Text INTRODUCTION: Using the pediatric version of the Simple Triage and Rapid Treatment (JumpSTART) algorithm for the triage of pediatric patients in a mass-casualty incident (MCI) requires assessing the results of each step and determining whether to move to the next appropriate action. Inappropriate application can lead to performance of unnecessary actions or failure to perform necessary actions. Hypothesis/Problem To report overall accuracy and time required for triage, and to assess if the performance of unnecessary steps, or failure to perform required steps, in the triage algorithm was associated with inaccuracy of triage designation or increased time to reach a triage decision.
METHODS: Medical students participated in an MCI drill in which they triaged both live actors portraying patients and computer-based simulated patients to the four triage levels: minor, delayed, immediate, and expectant. Their performance was timed and compared to intended triage designations and a priori determined critical actions.
RESULTS: Thirty-three students completed 363 scenarios. The overall accuracy was 85.7% and overall mean time to assign a triage designation was 70.4 seconds, with decreasing times as triage acuity level decreased. In over one-half of cases, the student omitted at least one action and/or performed at least one action that was not required. Each unnecessary action increased time to triage by a mean of 8.4 seconds and each omitted action increased time to triage by a mean of 5.5 seconds. Discussion Increasing triage level, performance of inappropriate actions, and omission of recommended actions were all associated with increasing time to perform triage.

PMID 26323610  Prehosp Disaster Med. 2015 Oct;30(5):457-60. doi: 10.10・・・
著者: E Brooke Lerner, Richard B Schwartz, Phillip L Coule, Eric S Weinstein, David C Cone, Richard C Hunt, Scott M Sasser, J Marc Liu, Nikiah G Nudell, Ian S Wedmore, Jeffrey Hammond, Eileen M Bulger, Jeffrey P Salomone, Teri L Sanddal, David Markenson, Robert E O'Connor
雑誌名: Disaster Med Public Health Prep. 2008 Sep;2 Suppl 1:S25-34. doi: 10.1097/DMP.0b013e318182194e.
Abstract/Text Mass casualty triage is a critical skill. Although many systems exist to guide providers in making triage decisions, there is little scientific evidence available to demonstrate that any of the available systems have been validated. Furthermore, in the United States there is little consistency from one jurisdiction to the next in the application of mass casualty triage methodology. There are no nationally agreed upon categories or color designations. This review reports on a consensus committee process used to evaluate and compare commonly used triage systems, and to develop a proposed national mass casualty triage guideline. The proposed guideline, entitled SALT (sort, assess, life-saving interventions, treatment and/or transport) triage, was developed based on the best available science and consensus opinion. It incorporates aspects from all of the existing triage systems to create a single overarching guide for unifying the mass casualty triage process across the United States.

PMID 18769263  Disaster Med Public Health Prep. 2008 Sep;2 Suppl 1:S25・・・
著者: E Brooke Lerner, David C Cone, Eric S Weinstein, Richard B Schwartz, Phillip L Coule, Michael Cronin, Ian S Wedmore, Eileen M Bulger, Deborah Ann Mulligan, Raymond E Swienton, Scott M Sasser, Umair A Shah, Leonard J Weireter, Teri L Sanddal, Julio Lairet, David Markenson, Lou Romig, Gregg Lord, Jeffrey Salomone, Robert O'Connor, Richard C Hunt
雑誌名: Disaster Med Public Health Prep. 2011 Jun;5(2):129-37. doi: 10.1001/dmp.2011.39.
Abstract/Text Mass casualty triage is the process of prioritizing multiple victims when resources are not sufficient to treat everyone immediately. No national guideline for mass casualty triage exists in the United States. The lack of a national guideline has resulted in variability in triage processes, tags, and nomenclature. This variability has the potential to inject confusion and miscommunication into the disaster incident, particularly when multiple jurisdictions are involved. The Model Uniform Core Criteria for Mass Casualty Triage were developed to be a national guideline for mass casualty triage to ensure interoperability and standardization when responding to a mass casualty incident. The Core Criteria consist of 4 categories: general considerations, global sorting, lifesaving interventions, and individual assessment of triage category. The criteria within each of these categories were developed by a workgroup of experts representing national stakeholder organizations who used the best available science and, when necessary, consensus opinion. This article describes how the Model Uniform Core Criteria for Mass Casualty Triage were developed.

PMID 21685309  Disaster Med Public Health Prep. 2011 Jun;5(2):129-37. ・・・
著者: D Michael Navin, William J Sacco
雑誌名: Disaster Med Public Health Prep. 2010 Mar;4(1):10-2; author reply 12.
Abstract/Text
PMID 20389186  Disaster Med Public Health Prep. 2010 Mar;4(1):10-2; au・・・
著者: Scott M Sasser, Richard C Hunt, Mark Faul, David Sugerman, William S Pearson, Theresa Dulski, Marlena M Wald, Gregory J Jurkovich, Craig D Newgard, E Brooke Lerner, Centers for Disease Control and Prevention (CDC)
雑誌名: MMWR Recomm Rep. 2012 Jan 13;61(RR-1):1-20.
Abstract/Text In the United States, injury is the leading cause of death for persons aged 1-44 years. In 2008, approximately 30 million injuries were serious enough to require the injured person to visit a hospital emergency department (ED); 5.4 million (18%) of these injured patients were transported by Emergency Medical Services (EMS). On arrival at the scene of an injury, the EMS provider must determine the severity of injury, initiate management of the patient's injuries, and decide the most appropriate destination hospital for the individual patient. These destination decisions are made through a process known as "field triage," which involves an assessment not only of the physiology and anatomy of injury but also of the mechanism of the injury and special patient and system considerations. Since 1986, the American College of Surgeons Committee on Trauma (ACS-COT) has provided guidance for the field triage process through its "Field Triage Decision Scheme." This guidance was updated with each version of the decision scheme (published in 1986, 1990, 1993, and 1999). In 2005, CDC, with financial support from the National Highway Traffic Safety Administration, collaborated with ACS-COT to convene the initial meetings of the National Expert Panel on Field Triage (the Panel) to revise the decision scheme; the revised version was published in 2006 by ACS-COT (American College of Surgeons. Resources for the optimal care of the injured patient: 2006. Chicago, IL: American College of Surgeons; 2006). In 2009, CDC published a detailed description of the scientific rationale for revising the field triage criteria (CDC. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage. MMWR 2009;58[No. RR-1]). In 2011, CDC reconvened the Panel to review the 2006 Guidelines in the context of recently published literature, assess the experiences of states and local communities working to implement the Guidelines, and recommend any needed changes or modifications to the Guidelines. This report describes the dissemination and impact of the 2006 Guidelines; outlines the methodology used by the Panel for its 2011 review; explains the revisions and modifications to the physiologic, anatomic, mechanism-of-injury, and special considerations criteria; updates the schematic of the 2006 Guidelines; and provides the rationale used by the Panel for these changes. This report is intended to help prehospital-care providers in their daily duties recognize individual injured patients who are most likely to benefit from specialized trauma center resources and is not intended as a mass casualty or disaster triage tool. The Panel anticipates a review of these Guidelines approximately every 5 years.

PMID 22237112  MMWR Recomm Rep. 2012 Jan 13;61(RR-1):1-20.
著者: R U Kothari, A Pancioli, T Liu, T Brott, J Broderick
雑誌名: Ann Emerg Med. 1999 Apr;33(4):373-8.
Abstract/Text STUDY OBJECTIVE: The Cincinnati Prehospital Stroke Scale (CPSS) is a 3-item scale based on a simplification of the National Institutes of Health (NIH) Stroke Scale. When performed by a physician, it has a high sensitivity and specificity in identifying patients with stroke who are candidates for thrombolysis. The objective of this study was to validate and verify the reproducibility of the CPSS when used by prehospital providers.
METHODS: The CPSS was performed and scored by a physician certified in the use of the NIH Stroke Scale (gold standard). Simultaneously, a group of 4 paramedics and EMTs scored the same patient.
RESULTS: A total of 860 scales were completed on a convenience sample of 171 patients from the emergency department and neurology inpatient service. Of these patients, 49 had a diagnosis of stroke or transient ischemic attack. High reproducibility was observed among prehospital providers for total score (intraclass correlation coefficient [rI],.89; 95% confidence interval [CI],.87 to.92) and for each scale item: arm weakness, speech, and facial droop (.91,.84, and.75, respectively). There was excellent intraclass correlation between the physician and the prehospital providers for total score (rI,.92; 95% CI,.89 to.93) and for the specific items of the scale (.91,.87, and.78, respectively). Observation by the physician of an abnormality in any 1 of the 3 stroke scale items had a sensitivity of 66% and specificity of 87% in identifying a stroke patient. The sensitivity was 88% for identification of patients with anterior circulation strokes.
CONCLUSION: The CPSS has excellent reproducibility among prehospital personnel and physicians. It has good validity in identifying patients with stroke who are candidates for thrombolytic therapy, especially those with anterior circulation stroke.

PMID 10092713  Ann Emerg Med. 1999 Apr;33(4):373-8.
著者: Daniel M Frendl, David G Strauss, B Kevin Underhill, Larry B Goldstein
雑誌名: Stroke. 2009 Mar;40(3):754-6. doi: 10.1161/STROKEAHA.108.531285. Epub 2008 Dec 31.
Abstract/Text BACKGROUND AND PURPOSE: The Cincinnati Prehospital Stroke Scale (CPSS) is recommended for emergency medical services use in identifying patients with stroke. Data evaluating its performance in the field are limited. We assessed the impact of training and use of the CPSS on the accuracy of paramedics' stroke patient identification and on-scene time.
METHODS: A 1-hour interactive educational presentation on the use of the CPSS was conducted for paramedics transporting patients to an academic medical center. Patients with stroke/transient ischemic attack (TIA) were identified retrospectively from paramedic records and were compared with the hospital's prospective stroke registry for the year before and after the training.
RESULTS: There were 154 patients with suspected stroke/transient ischemic attack identified (56% women, 53% white, 44% black, mean age 67+/-16 years). There was no difference in paramedics' use of the CPSS (37.5% versus 23.8%, P=0.123) or accuracy of stroke/TIA patient identification (40.5% versus 38.9%, P=0.859) before and after training. Of responsive patients identified by paramedics as having a stroke/TIA, 57% had an abnormality in at least one CPSS item with no effect on on-scene time (17+/-6 minutes with a normal versus 18+/-6 minutes with an abnormal CPSS, P=0.492). Those with a final diagnosis of stroke/TIA (n=61, 40%) more frequently had at least one abnormal CPSS item (70% versus 30%, P=0.008, sensitivity 0.71, specificity 0.52) with 49% of patients with an abnormality having a discharge diagnosis of stroke/TIA.
CONCLUSIONS: Paramedic training in the CPSS, or its use, had no impact on the accuracy of their identification of patients with stroke/TIA or on-scene time.

PMID 19118240  Stroke. 2009 Mar;40(3):754-6. doi: 10.1161/STROKEAHA.10・・・
著者: Janet E Bray, Kelly Coughlan, Bill Barger, Chris Bladin
雑誌名: Stroke. 2010 Jul;41(7):1363-6. doi: 10.1161/STROKEAHA.109.571836. Epub 2010 Jun 10.
Abstract/Text BACKGROUND AND PURPOSE: Recent evidence suggests the Cincinnati Prehospital Stroke Scale is ineffectively used and lacks sensitivity and specificity. Melbourne (Australia) paramedics have been using the Melbourne Ambulance Stroke Screen (MASS) since 2005. The aim of this study was to review the real-world use of MASS 3 years after city wide implementation.
METHODS: Two groups of consecutively admitted patients to an Australian hospital between January and May 2008 were used: (1) patients for whom paramedics performed MASS; and (2) patients with a discharge diagnosis of stroke or transient ischemic attack. Use of MASS was examined for all transports and for patients diagnosed with stroke or transient ischemic attack. The sensitivity and specificity of paramedic diagnosis, MASS, and Cincinnati Prehospital Stroke Scale were calculated. Paramedic diagnosis of stroke among patients with stroke was statistically compared with those obtained immediately post-MASS implementation in 2002.
RESULTS: For the study period, MASS was performed for 850 (16%) of 5286 emergency transports, including 199 of 207 (96%) patients with confirmed stroke and transient ischemic attack. In patients in whom MASS was performed (n=850), the sensitivity of paramedic diagnosis of stroke (93%, 95% CI: 88% to 96%) was higher than the MASS (83%, 95% CI: 77% to 88%, P=0.003) and equivalent to Cincinnati Prehospital Stroke Scale (88%, 95% CI: 83% to 92%, P=0.120), whereas the specificity of the paramedic diagnosis of stroke (87%, 95% CI: 84% to 89%) was equivalent to MASS (86%, 95% CI: 83% to 88%, P=0.687) and higher than Cincinnati Prehospital Stroke Scale (79%, 95% CI: 75% to 82%, P<0.001). The initial improvement in stroke paramedic diagnosis seen in 2002 (94%, 95% CI: 86% to 98%) was sustained in 2008 (89%, 95% CI: 84% to 94%, P=0.19).
CONCLUSIONS: In our experience, paramedics have successfully incorporated MASS into the assessment of neurologically compromised patients. The initial improvement to the paramedics' diagnosis of stroke with MASS was sustained 3 years after city wide implementation.

PMID 20538702  Stroke. 2010 Jul;41(7):1363-6. doi: 10.1161/STROKEAHA.1・・・
著者: C S Kidwell, S Starkman, M Eckstein, K Weems, J L Saver
雑誌名: Stroke. 2000 Jan;31(1):71-6.
Abstract/Text BACKGROUND AND PURPOSE: Reliable identification of stroke patients in the field by prehospital personnel could expedite delivery of acute stroke therapy. The Los Angeles Prehospital Stroke Screen (LAPSS) is a 1-page instrument designed to allow prehospital personnel to rapidly identify acute stroke patients in the field. We performed a prospective, in-the-field validation study of the LAPSS.
METHODS: Paramedics assigned to 3 University of California at Los Angeles-based advanced life support units were trained and certified in use of the LAPSS. Over 7 months, paramedics completed the LAPSS on noncomatose, nontrauma patients with complaints suggestive of neurological disease. LAPSS form stroke identification results were compared with emergency department and final hospital discharge diagnoses. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and likelihood ratios were calculated for LAPSS identification of ischemic stroke, currently symptomatic transient ischemic attack, and intracerebral hemorrhage.
RESULTS: Of a total of 1298 runs, 34% were for nontraumatic, noncomatose neurologically relevant complaints. Thirty-six of these patients (3% of all transports) had a final diagnosis of acute symptomatic cerebrovascular disease (21 ischemic strokes, 7 transient ischemic attacks, and 8 intracerebral hemorrhages). LAPSS forms were completed on 206 patients. Paramedic performance when completing the LAPSS demonstrated sensitivity of 91% (95% CI, 76% to 98%), specificity of 97% (95% CI, 93% to 99%), positive predictive value of 86% (95% CI, 70% to 95%), and negative predictive value of 98% (95% CI, 95% to 99%). With correction for the 4 documentation errors, positive predictive value increased to 97% (95% CI, 84% to 99%).
CONCLUSIONS: The LAPSS allows prehospital personnel to identify patients with acute cerebral ischemia and intracerebral hemorrhage with a high degree of sensitivity and specificity.

PMID 10625718  Stroke. 2000 Jan;31(1):71-6.
著者: Shari J Welch, Steven J Davidson
雑誌名: Ann Emerg Med. 2011 Aug;58(2):143-4. doi: 10.1016/j.annemergmed.2011.04.017. Epub 2011 May 20.
Abstract/Text
PMID 21601312  Ann Emerg Med. 2011 Aug;58(2):143-4. doi: 10.1016/j.ann・・・
著者: Jocelyn Gravel, Serge Gouin, Ran D Goldman, Martin H Osmond, Eleanor Fitzpatrick, Kathy Boutis, Chantal Guimont, Gary Joubert, Kelly Millar, Sarah Curtis, Douglas Sinclair, Devendra Amre
雑誌名: Ann Emerg Med. 2012 Jul;60(1):71-7.e3. doi: 10.1016/j.annemergmed.2011.12.004. Epub 2012 Feb 2.
Abstract/Text STUDY OBJECTIVE: The aims of the study are to measure both the interrater agreement of nurses using the Canadian Triage and Acuity Scale in children and the validity of the scale as measured by the correlation between triage level and proxy markers of severity.
METHODS: This was a prospective multicenter study of the reliability and construct validity of the Canadian Triage and Acuity Scale in 9 tertiary care pediatric emergency departments (EDs) across Canada during 2009 to 2010. Participants were a sample of children initially triaged as Canadian Triage and Acuity Scale level 2 (emergency) to level 5 (nonurgent). Participants were recruited immediately after their initial triage to undergo a second triage assessment by the research nurse. Both triages were performed blinded to the other. The primary outcome measures were the interrater agreement between the 2 nurses and the association between triage level and hospitalization. Secondary outcome measures were the association between triage level and health resource use and length of stay in the ED.
RESULTS: A total of 1,564 patients were approached and 1,464 consented. The overall interrater agreement was good, as demonstrated by a quadratic weighted κ score of 0.74 (95% confidence interval 0.71 to 0.76). Hospitalization proportions were 30%, 8.3%, 2.3%, and 2.2% for patients triaged at levels 2, 3, 4, and 5, respectively. There was also a strong association between triage levels and use of health care resources and length of stay.
CONCLUSION: The Canadian Triage and Acuity Scale demonstrates a good interrater agreement between nurses across multiple pediatric EDs and is a valid triage tool, as demonstrated by its good association with markers of severity.

Copyright © 2012. Published by Mosby, Inc.
PMID 22305329  Ann Emerg Med. 2012 Jul;60(1):71-7.e3. doi: 10.1016/j.a・・・
著者: Serge Gouin, Jocelyn Gravel, Devendra K Amre, Sylvie Bergeron
雑誌名: Am J Emerg Med. 2005 May;23(3):243-7.
Abstract/Text The aim of this study was to compare the performance of the Paediatric Canadian Triage and Acuity Scale (Paed CTAS) to a previous triage tool with respect to the percentage of admissions, the diagnostic and therapeutic interventions, and the mean pediatric risk of admission (PRISA) score in a pediatric tertiary center emergency department. Data were prospectively collected for 4 months before the Paed CTAS introduction (PRE group) and for 4 months after its implementation (Paed CTAS group). Both groups were similar in chief complaints, distribution of triage levels, and mean PRISA score. In the Paed CTAS group, more patients were triaged in the higher acuity levels (53% vs 36%, P < .05), but the percentage of admission for these patients was comparatively lower (13% vs 27%, P<.05). The ability to predict admission was greater for the PRE tool as compared to the Paed CTAS tool (AUC: 0.82 vs 0.69, P=.001). The ability to predict requirements for interventions such as blood culture and intravenous fluid bolus was similar for both triage tools.

PMID 15915392  Am J Emerg Med. 2005 May;23(3):243-7.
著者: Kanokwan Aeimchanbanjong, Uthen Pandee
雑誌名: World J Emerg Med. 2017;8(3):223-227. doi: 10.5847/wjem.j.1920-8642.2017.03.010.
Abstract/Text BACKGROUND: Triage system in children seems to be more challenging compared to adults because of their different response to physiological and psychosocial stressors. This study aimed to determine the best triage system in the pediatric emergency department.
METHODS: This was a prospective observational study. This study was divided into two phases. The first phase determined the inter-rater reliability of five triage systems: Manchester Triage System (MTS), Emergency Severity Index (ESI) version 4, Pediatric Canadian Triage and Acuity Scale (CTAS), Australasian Triage Scale (ATS), and Ramathibodi Triage System (RTS) by triage nurses and pediatric residents. In the second phase, to analyze the validity of each triage system, patients were categorized as two groups, i.e., high acuity patients (triage level 1, 2) and low acuity patients (triage level 3, 4, and 5). Then we compared the triage acuity with actual admission.
RESULTS: In phase I, RTS illustrated almost perfect inter-rater reliability with kappa of 1.0 (P<0.01). ESI and CTAS illustrated good inter-rater reliability with kappa of 0.8-0.9 (P<0.01). Meanwhile, ATS and MTS illustrated moderate to good inter-rater reliability with kappa of 0.5-0.7 (P<0.01). In phase II, we included 1 041 participants with average age of 4.7±4.2 years, of which 55% were male and 45% were female. In addition 32% of the participants had underlying diseases, and 123 (11.8%) patients were admitted. We found that ESI illustrated the most appropriate predicting ability for admission with sensitivity of 52%, specificity of 81%, and AUC 0.78 (95%CI 0.74-0.81).
CONCLUSION: RTS illustrated almost perfect inter-rater reliability. Meanwhile, ESI and CTAS illustrated good inter-rater reliability. Finally, ESI illustrated the appropriate validity for triage system.

PMID 28680520  World J Emerg Med. 2017;8(3):223-227. doi: 10.5847/wjem・・・

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