Triage is sorting patients based on acuity in order to manage care in the emergency department (ED) {Mirhaghi, 2017 #60}(1). Medical institutes are trying to develop triage scales compatible with their own culture of care. A triage scale must be precise and comprehensive enough to guide triage nurses and eliminate uncertainty

Ebrahimi, Mohsen

Mirhaghi, Amir

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Emergency. 2018; 6 (1): e60LETTER TO EDITORRegression to Middle Effect May Threaten Validity ofTriage Scales; a Letter to EditorAmir Mirhaghi1∗, Mohsen Ebrahimi21. Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.2. Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.Received: September 2018; Accepted: October 2018; Published online: 18 November 2018Cite this article as: Regression to Middle Effect May Threaten Validity of Triage Scales; a Letter to Editor. Emergency. 2018; 6(1): e60.Dear Editor;Triage is sorting patients based on acuity in order to man-age care in the emergency department (ED) (1). Medical in-stitutes are trying to develop triage scales compatible withtheir own culture of care. A triage scale must be precise andcomprehensive enough to guide triage nurses and eliminateuncertainty. It is vital to address the potential pitfalls of thenew triage scales to enhance their reliability and validity. Per-forming a validation study in other institutes provides a greatopportunity for medical institutes to learn from each other.One of the newly described triage scales is the Korean Triageand Acuity Scale (KTAS) in South Korea (2). It has been im-plemented since 2015 and is a five-level system that classi-fies patients using a combination of variables, including vitalsigns and chief complaints.Triage nurses are likely to triage more conservatively whenapplying ambiguous triage scales. They try to avoid takingrisks as much as possible in clinically ambiguous situations,therefore choosing the mid-point of Likert scale to mitigateany unfavorable consequences (middle effect). Their errorremains as low as possible when they choose triage level 3.Triage level 3 is a safe category because it fits a significantportion of incoming patients and it differs only one level fromtriage level 2 or 4 in case of wrong selection. A recent paperon the validity of KTAS showed that regression to middle ef-fect may occur (2).Almost six percent of the intensive care unit (ICU) patientswere assigned to triage level 4 and 5 (2). Even if the fairly highproportion of the ICU patients (30.69%) being allocated tolevel 3 can be overlooked, triage nurses categorizing patientswho will be admitted to ICU in level 4 or 5 is not tolerable (2).∗Corresponding Author: Amir Mirhaghi; Department of Medical-SurgicalNursing, School of Nursing and Midwifery, Doktorha Crossroad, Mashhad,Razavi Khorasan, Iran. Postcode: 9137913199 Tel: 0098 51 38591511 Fax: 009851 38539775 Email: mirhaghi@mail.comTherefore, it has to be said that 6% of the ICU patients suf-fer from under-triage in this subgroup, which deserves fur-ther analysis. Almost 59% percent of the general ward (GW)patients were assigned to triage level 3. This implies thattriage nurses have mostly assigned GW patients to the triagelevel 3, which is the most appropriate triage level for pa-tients who need admission to GWs. Choosing level 3 is themost compatible with patients’ acuity in GWs. Almost 58%of discharged (DC) patients from the ED were assigned to thetriage level 3, while 35% were placed in level 4 and 5. Thisshows that a large proportion of DC patients were assignedto level 3, implying that the KTAS is not sensitive enough toassign low-risk patients to level 4 or 5.Overall, a high proportion of level 3 patients in all three sub-groups shows that triage nurses had a great tendency to as-sign patients to level 3, implying that regression to the mid-dle effect took place. Regression to the midpoint of a 5-pointscale is reported in literature too (3). It is safe for nurses toregress to the middle in case of uncertainty. Kim et al. alsoshowed that 41.6% of patients were assigned to level 3 by theKTAS compared with 38.4% for the emergency severity index(ESI) (4). However, KTAS is more effective than 3-level triagescale, more revisions are needed and further studies are rec-ommended to improve its reliability and validity. In addition,patient influx in level 3 results in other parts of the ED re-maining unused. This issue could not be tolerated in the EDbecause all ED resources must be consumed conscientiouslyas much as possible to reduce overcrowding.1. Appendix1.1. AcknowledgementsNone.1.2. Author’s contributionAll authors met the four criteria for authorship contributionbased on the recommendations of the international com-This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).Downloaded from: www.jemerg.comA. Mirhaghi et al. 2mittee of medical journal editors.Authors’ ORCIDsAmir Mirhaghi: 0000-0002-4482-1156Mohsen Ebrahimi: 0000-0003-2168-84761.3. Conflict of interestNone.1.4. Funding and supportNone.References1. Mirhaghi A, Ebrahimi M. The Australasian Triage ScaleLevel 5 Criteria may Need to be Revised. Emergency.2017;5(1):e51.2. Kwon H, Kim YJ, Jo YH, Lee JH, Lee JH, Kim J, et al. The Ko-rean Triage and Acuity Scale: associations with admission,disposition, mortality and length of stay in the emergencydepartment. International Journal for Quality in HealthCare. 2018:mzy184-mzy.3. Kulas JT, Stachowski AA. Middle category endorsement inodd-numbered Likert response scales: Associated itemcharacteristics, cognitive demands, and preferred mean-ings. Journal of Research in Personality. 2009;43(3):489-93.4. Kim JH, Kim JW, Kim SY, Hong DY, Park SO, Baek KJ, et al.Validation of the Korean Triage and Acuity Scale compareto triage by emergency severity index for emergency adultpatient: preliminary study in a tertiary hospital emer-gency medical center. Journal of the Korean Society ofEmergency Medicine. 2016;27(5):436-41.This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).Downloaded from: www.jemerg.com

Regression to Middle Effect May Threaten Validity of Triage Scales; a Letter to Editor

Amir Mirhaghi

Mohsen Ebrahimi

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Regression to Middle Effect May Threaten Validity of Triage Scales; a Letter to Editor

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