Rapid Emergency Triage and Treatment System (RETTS): Guide to the Swedish Triage System
Imagine walking into an emergency department (ED)—the air is filled with a mix of urgency and uncertainty. Nurses and doctors swiftly move from one patient to another, making split-second decisions that can mean the difference between life and death. In the midst of this chaos, a systematic approach is crucial for ensuring that each patient receives the care they need, when they need it. This is where the Rapid Emergency Triage and Treatment System (RETTS) comes into play. Developed in Sweden, RETTS is a triage system that combines vital signs with emergency symptoms and signs to provide a comprehensive assessment of a patient's condition. In this article, we will delve into the origins, applications, and effectiveness of RETTS, exploring how it has revolutionized emergency medical care.
The Development and Evolution of RETTS
The Rapid Emergency Triage and Treatment System (RETTS) was developed at Sahlgrenska University Hospital, Sweden. Initially known as the Medical Emergency Triage and Treatment System (METTS), RETTS has evolved over the years to become one of the most widely used triage systems in Sweden and other Scandinavian countries123. The system was designed to address the need for a standardized approach to emergency triage, ensuring that patients are prioritized based on the severity of their condition.
Key Milestones in the Development of RETTS
Initial Development: RETTS was first developed at Sahlgrenska University Hospital, Sweden, as a response to the need for a more structured and efficient triage system. The initial version, known as METTS, laid the foundation for what would become RETTS12.
Pediatric Version (RETTS-p): A pediatric version of RETTS, known as RETTS-p, was later developed to address the unique needs of pediatric patients. This version has been increasingly used internationally and includes specific criteria for assessing children's vital parameters and emergency signs and symptoms (ESS)41.
International Adaptation: An English online version of RETTS was developed, making the system internationally available. This adaptation has allowed RETTS to be used in various countries, aligning it with more established triage systems15.
Continuous Updates: RETTS has undergone continuous updates and improvements to enhance its effectiveness and reliability. These updates have included adjustments to the criteria for assessing vital parameters and emergency signs and symptoms3.
The RETTS Triage Process
The RETTS triage process involves a systematic evaluation of a patient's condition based on vital parameters (VPs) and emergency signs and symptoms (ESS). This dual approach ensures that both objective measurements and subjective observations are considered in the triage decision. The process can be broken down into several key steps:
1. Assessment of Vital Parameters
Vital parameters, or VPs, are objective measurements that provide crucial information about a patient's physiological status. In RETTS, the following VPs are assessed:
Airway: The patency and protection of the airway are evaluated to ensure adequate ventilation.
Respiratory Rate: The number of breaths per minute is measured to assess respiratory function.
Oxygen Saturation: The level of oxygen in the blood is measured using a pulse oximeter.
Heart Rate: The number of heartbeats per minute is measured to assess cardiac function.
Alertness Level: The level of consciousness is evaluated using the Glasgow Coma Scale.
Temperature: Body temperature is measured to detect fever or hypothermia41.
2. Evaluation of Emergency Signs and Symptoms
Emergency signs and symptoms (ESS) are subjective observations that provide additional information about a patient's condition. In RETTS, ESS algorithms cover a wide range of pediatric complaints, with 42 algorithms available for different symptoms41. For example, a patient presenting with abdominal pain would be evaluated using the abdominal pain ESS algorithm, which includes recommendations for initial evaluation and treatment.
3. Assignment of Triage Priority Levels
Based on the assessment of VPs and ESS, patients are assigned one of five triage priority levels. These levels determine the urgency with which a patient should be seen by a medical doctor:
Applications and Effectiveness of RETTS
RETTS has been widely adopted in Sweden and other Scandinavian countries, demonstrating its effectiveness in various emergency care settings. The system's structured approach ensures consistency in decision-making, reducing the variability in triage assessments among healthcare professionals2.
1. Pediatric Emergency Departments
In pediatric emergency departments (PEDs), RETTS-p has been shown to be a reliable triage system. Studies have found a high degree of inter- and intrarater reliability, indicating that nurses consistently agree on the triage priority levels assigned to patients415. This consistency is crucial in pediatric settings, where the accurate assessment of a child's condition can be challenging due to their unique physiological and developmental characteristics. For example, in a study conducted at St. Olav’s University Hospital in Norway, RETTS-p was used to assign triage priority levels to patients based on clinical signs and symptoms evaluations and vital parameter measurements. The study found a very high inter- and intrarater reliability, confirming the system's effectiveness in pediatric settings41.
2. Adult Emergency Departments
In adult emergency departments, RETTS has been shown to prioritize patients to higher triage levels, ensuring that those with the most urgent needs receive immediate medical care. However, this prioritization has also led to challenges in identifying true high-risk patients and increased waiting times for these patients67. For instance, a study comparing RETTS with the novel WEst coast System for Triage (WEST) found that RETTS prioritized patients to higher triage levels more frequently than WEST. This difference was attributed to the inclusion of high heart rate or high respiratory rate as criteria for higher triage levels in RETTS67.
3. Educational Interventions
Educational interventions have been used to improve the reliability of RETTS application. A study involving specialist nurse students in ambulance and emergency care found that an educational intervention using paper-based scenarios resulted in moderate agreement about the final levels of triage. This suggests that targeted educational interventions can enhance the accuracy of RETTS application8.
Challenges and Limitations of RETTS
Despite its widespread use and demonstrated effectiveness, RETTS is not without its challenges and limitations. One of the primary limitations is the potential for overtriage, where patients are assigned a higher triage priority level than necessary. This can lead to increased waiting times for true high-risk patients and strain on emergency department resources67.
Additionally, the assessment of vital signs criteria in RETTS-A Red priority has been found to be ambiguous, potentially threatening the association between patient acuity and fatal outcome9. This ambiguity can make it difficult for healthcare professionals to accurately assess a patient's condition and assign the appropriate triage priority level.
Comparison with Other Triage Systems
Several other triage systems are used in emergency departments worldwide, each with its unique strengths and weaknesses. Comparing RETTS with these systems can provide valuable insights into its relative effectiveness:
1. Emergency Severity Index (ESI)
The Emergency Severity Index (ESI) is a widely used triage system in the United States. ESI assigns patients to one of five triage levels based on the severity of their condition and the expected resource needs. Unlike RETTS, ESI does not rely on specific vital parameter measurements but instead focuses on the expected resource needs and the severity of the patient's condition.
2. Canadia Triage and Acuity Scale (CTAS)
The Canadian Triage and Acuity Scale (CTAS) is another commonly used triage system. CTAS assigns patients to one of five triage levels based on their presenting complaint and the severity of their condition. Similar to RETTS, CTAS considers both vital parameter measurements and emergency signs and symptoms in the triage decision.
3. Manchester Triage System (MTS)
The Manchester Triage System (MTS) is used primarily in the United Kingdom. MTS assigns patients to one of five triage levels based on their presenting complaint and the severity of their condition. MTS uses a flowchart-based approach to guide the triage decision, considering both vital parameter measurements and emergency signs and symptoms.
4. WEst coast System for Triage (WEST)
The WEst coast System for Triage (WEST) is a novel triage system that has been compared with RETTS in recent studies. WEST assigns patients to one of five triage levels based on their presenting complaint and the severity of their condition. Unlike RETTS, WEST does not rely on specific vital parameter measurements but instead focuses on the patient's chief complaint and the expected resource needs67.
Conclusion
The Rapid Emergency Triage and Treatment System (RETTS) is a comprehensive and effective triage system that combines vital signs with emergency symptoms and signs to provide a structured approach to emergency medical care. Developed in Sweden and widely used in Scandinavian countries, RETTS has demonstrated its effectiveness in various emergency care settings, particularly in pediatric emergency departments. However, like all triage systems, RETTS has its challenges and limitations, including the potential for overtriage and ambiguity in the assessment of vital signs criteria. As emergency medical care continues to evolve, ongoing research and development will be crucial in refining and improving triage systems like RETTS to ensure the best possible outcomes for patients.
FAQ Section
1. What is the Rapid Emergency Triage and Treatment System (RETTS)? RETTS is a Swedish triage system that combines vital signs with emergency symptoms and signs to provide a comprehensive assessment of a patient's condition in emergency departments.
2. Where was RETTS developed? RETTS was developed at Sahlgrenska University Hospital, Sweden.
3. What are the key components of the RETTS triage process? The RETTS triage process involves the assessment of vital parameters (VPs) and emergency signs and symptoms (ESS), followed by the assignment of triage priority levels based on these assessments.
4. How are patients prioritized in RETTS? Patients are prioritized based on the severity of their condition, as determined by the assessment of VPs and ESS. They are assigned one of five triage priority levels: Red (Immediate), Orange (Very urgent), Yellow (Urgent), Green (Standard), and Blue (Non-urgent).
5. What is RETTS-p? RETTS-p is the pediatric version of RETTS, designed to address the unique needs of pediatric patients. It includes specific criteria for assessing children's vital parameters and emergency signs and symptoms.
6. How effective is RETTS in pediatric emergency departments? Studies have shown that RETTS-p is a reliable triage system in pediatric emergency departments, with a high degree of inter- and intrarater reliability among nurses.
7. What are some challenges associated with RETTS? Challenges associated with RETTS include the potential for overtriage, increased waiting times for high-risk patients, and ambiguity in the assessment of vital signs criteria.
8. How does RETTS compare to other triage systems? RETTS is similar to other triage systems like ESI, CTAS, and MTS in that it assigns patients to triage levels based on the severity of their condition. However, RETTS uniquely combines vital parameter measurements with emergency signs and symptoms in the triage decision.
9. What educational interventions have been used to improve the reliability of RETTS application? Educational interventions involving paper-based scenarios have been used to improve the reliability of RETTS application, resulting in moderate agreement about the final levels of triage.
10. How has RETTS been adapted for international use? An English online version of RETTS has been developed, making the system internationally available and aligning it with more established triage systems.