What is it about?
When patients arrive at an emergency department, staff must quickly decide who is most likely to be seriously ill and who can safely wait. This first sorting step is called triage. Getting it right matters: missing a critically ill patient is dangerous, but flagging too many people as urgent ties up staff and equipment that other patients need. At Vestfold Hospital Trust, we use a triage system built in two steps. First, a nurse applies a simple, standardised checklist called ACT, which combines vital-sign scores, a list of warning symptoms, and the option to escalate on gut feeling. Second, a doctor reviews the case using a tool called ADJUST, taking into account the patient's development, treatment response, goals of care, and the department's workload. We looked back at 53,651 emergency visits over 19 months and asked how well each step identified the patients who ended up in intensive care within 24 hours. The nurse step caught more of these patients but also flagged many who were not critically ill. The doctor step flagged far fewer patients overall, so it was more precise, but it missed more of the intensive care patients, including one in five whom the nurses had correctly marked as most urgent. The two steps therefore pull in different directions. Whether combining them improves patient safety and department flow still needs to be tested in a prospective study.
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Why is it important?
Most studies of emergency triage ask whether nurses or doctors are better at spotting the sickest patients. We asked a different question: what happens when both do it, one after the other? Our hospital has run exactly that setup for years, so we could look at what the doctors changed about the nurses' assessments, how often, in which direction, and how fast. The answer turned out to be a useful warning. Doctors ruled out a lot of patients who were never seriously ill, which frees up staff and beds. But they also downgraded one in five patients who ended up in intensive care and whom the nurses had correctly flagged. Both of those things happen at once, and both are worth knowing about. This is a live issue. Emergency departments are crowded and short-staffed, and many are adding a doctor to the triage step to cope. Our results show what that gains and what it may cost, and make the case for testing it properly before it spreads further.
Perspectives
I joined this project at the analysis stage, and what struck me most was that the data were already there, clean, structured, and easy to pull. The emergency department at Vestfold Hospital Trust records its triage decisions in Flyttavla, a trackboard system built in-house, and extracting nearly 47,000 encounters from it was a matter of a query rather than a project of its own. That is not the usual experience. Triage happens in the noisiest few minutes of a patient's hospital stay, and the reason it could be studied here at all is that colleagues built structured documentation into the daily workflow years before anyone thought to analyse it. Much of what we can eventually ask of clinical data is settled at that stage, by people who are not thinking about research when they make those decisions. Working with a dataset this well curated made the analysis straightforward and made it obvious how much is lost in the settings where it isn't.
Bjørn-Jostein Singstad
Akershus University Hospital
Read the Original
This page is a summary of: ACT and ADJUST: Evaluating a Layered Emergency Triage Model Integrating Structured Scoring and Physician Judgment, June 2025, Springer Science + Business Media,
DOI: 10.21203/rs.3.rs-6951401/v1.
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