Journal of Neurology

, Volume 266, Issue 11, pp 2685–2698 | Cite as

Development and validation of the Heidelberg Neurological Triage System (HEINTS)

  • Hanna M. Oßwald
  • Linda Harenberg
  • Hannah Jaschonek
  • Sibu Mundiyanapurath
  • Jan C. Purrucker
  • Geraldine Rauch
  • Peter A. Ringleb
  • Simon NagelEmail author
Original Communication



Neurological syndromes are underrepresented in existing triage systems which are not validated for neurological patients; therefore, we developed and validated the new Heidelberg Neurological Triage System (HEINTS) in a prospective, single-center observational study.


Patients were triaged according to the new triage system by nurses and physicians (stage 1) as well as trained nurses (stage 2). In stage 1, all patients presenting to the neurological emergency room (ER) were triaged by nurses and physicians. In stage 2, three specially trained nurses triaged patients according to HEINTS. The main outcomes comprised interrater agreement between nurses’ and physicians’ triage (stage 1), sensitivity and specificity to detect emergencies (stages 1 and 2), and improvement in triage quality as a result of training (stage 2), as well as correlation of HEINTS with hospital admissions and resource utilization.


In stage 1 (n = 2423 patients), sensitivity and specificity to detect neurological emergencies were 84.2% (SD 0.8%) and 85.4% (SD 0.8%) for nurses, as well as 92.4% (SD 0.6%) and 84.1% (SD 0.9%) for physicians, respectively. The interrater-reliability between nurses and physicians in stage 1 was moderate [Cohen’s kappa 0.44, standard deviation (SD) 0.02]. In stage 2 (n = 506 patients), sensitivity of trained nurses increased to 94.3% (SD 1.0%), while specificity decreased to 74.8% (SD 1.9%). Correlation of HEINTS triage with hospital admission and resource utilization in both stages was highly significant.


HEINTS predicted hospital admissions and resource utilization. Agreement between nurses and physicians was moderate. HEINTS, applied by physicians and by nurses after training, reliably detected neurological emergencies.


Triage Neurological emergency Emergency room 



We thank all our nurses’ and physicians’ staff for their participation and support in realizing this study. Special thanks goes to Ann-Christin Butke, Lena Kleebauer and Ulrike Weiß for their dedication to the project.

Compliance with ethical standards

Conflicts of interest

Dr. Oßwald, Mrs. Harenberg, Dr. Jaschonek, Dr. Mundiyanapurath, and Prof. Rauch have nothing to disclose. Dr. Purrucker reports personal fees from BMS Pfizer, Boehringer Ingelheim and Akcea, outside the submitted work. Dr. Ringleb reports personal fees from Bayer, BMS Pfizer, Boehringer Ingelheim, Grants from Deutsche Forschungsgemeinschaft, outside the submitted work. Dr. Nagel reports personal fees from Brainomix, BMS Pfizer, Boehringer Ingelheim and Medtronic, outside the submitted work.

Ethical standards

The study was approved by the institutional review board.

Informed consent

Written informed consent was obtained from the participants (nurses, nurse assistants and physicians working in the emergency room). Patients’ consent was waived.


  1. 1.
    McHugh M, Tanabe P, McClelland M, Khare RK (2012) More patients are triaged using the Emergency Severity Index than any other triage acuity system in the United States. Acad Emerg Med 19:106–109CrossRefGoogle Scholar
  2. 2.
    Mackway-Jones K, Marsden J, Windle J (2013) Emergency triage. Blackwell Publishing Ltd, HobokenCrossRefGoogle Scholar
  3. 3.
    Christ M, Bingisser R, Nickel CH (2016) Emergency triage. An overview. Dtsch Med Wochenschr 141:329–335CrossRefGoogle Scholar
  4. 4.
    Gumbinger C, Reuter B, Stock C et al (2014) Time to treatment with recombinant tissue plasminogen activator and outcome of stroke in clinical practice: retrospective analysis of hospital quality assurance data with comparison with results from randomised clinical trials. BMJ 348:g3429CrossRefGoogle Scholar
  5. 5.
    Ohwaki K, Yano E, Nagashima H, Hirata M, Nakagomi T, Tamura A (2004) Blood pressure management in acute intracerebral hemorrhage: relationship between elevated blood pressure and hematoma enlargement. Stroke 35:1364–1367CrossRefGoogle Scholar
  6. 6.
    Trinka E, Cock H, Hesdorffer D et al (2015) A definition and classification of status epilepticus—report of the ILAE task force on classification of status epilepticus. Epilepsia 56:1515–1523CrossRefGoogle Scholar
  7. 7.
    Auburtin M, Wolff M, Charpentier J et al (2006) Detrimental role of delayed antibiotic administration and penicillin-nonsusceptible strains in adult intensive care unit patients with pneumococcal meningitis: the PNEUMOREA prospective multicenter study. Crit Care Med 34:2758–2765CrossRefGoogle Scholar
  8. 8.
    Steiner D, Renetseder F, Kutz A et al (2016) Performance of the Manchester Triage System in adult medical emergency patients: a prospective cohort study. J Emerg Med 50:678–689CrossRefGoogle Scholar
  9. 9.
    Wallesch C (2007) Organisation of Emergency services in German university and general hospitals—neurological aspects. Aktuelle Neurologie 34(7):416–421CrossRefGoogle Scholar
  10. 10.
    Christ M, Grossmann F, Winter D, Bingisser R, Platz E (2010) Modern triage in the emergency department. Dtsch Arztebl Int 107:892–898PubMedPubMedCentralGoogle Scholar
  11. 11.
    Parenti N, Reggiani ML, Iannone P, Percudani D, Dowding D (2014) A systematic review on the validity and reliability of an emergency department triage scale, the Manchester Triage System. Int J Nurs Stud 51:1062–1069CrossRefGoogle Scholar
  12. 12.
    Zachariasse JM, Seiger N, Rood PP et al (2017) Validity of the Manchester Triage System in emergency care: a prospective observational study. PLoS ONE 12:e0170811CrossRefGoogle Scholar
  13. 13.
    Kuriyama A, Urushidani S, Nakayama T (2017) Five-level emergency triage systems: variation in assessment of validity. Emerg Med J 34:703–710CrossRefGoogle Scholar
  14. 14.
    van Veen M, Steyerberg EW, Ruige M et al (2008) Manchester triage system in paediatric emergency care: prospective observational study. BMJ 337:a1501CrossRefGoogle Scholar
  15. 15.
    Platts-Mills TF, Travers D, Biese K et al (2010) Accuracy of the Emergency Severity Index triage instrument for identifying elder emergency department patients receiving an immediate life-saving intervention. Acad Emerg Med 17:238–243CrossRefGoogle Scholar
  16. 16.
    Storm-Versloot MN, Ubbink DT, Kappelhof J, Luitse JS (2011) Comparison of an informally structured triage system, the Emergency Severity Index, and the Manchester Triage System to distinguish patient priority in the emergency department. Acad Emerg Med 18:822–829CrossRefGoogle Scholar
  17. 17.
    Grossmann FF, Zumbrunn T, Frauchiger A, Delport K, Bingisser R, Nickel CH (2012) At risk of undertriage? Testing the performance and accuracy of the emergency severity index in older emergency department patients. Ann Emerg Med 60(317–25):e3Google Scholar
  18. 18.
    Travers DA, Waller AE, Bowling JM, Flowers D, Tintinalli J (2002) Five-level triage system more effective than three-level in tertiary emergency department. J Emerg Nurs 28:395–400CrossRefGoogle Scholar
  19. 19.
    Uscher-Pines L, Pines J, Kellermann A, Gillen E, Mehrotra A (2013) Emergency department visits for nonurgent conditions: systematic literature review. Am J Manag Care 19:47–59PubMedPubMedCentralGoogle Scholar
  20. 20.
    Berchet C (2015) Emergency care services: trends, drivers and interventions to manage the demand. OECD Health Working Papers, no. 83. OECD Publishing, ParisGoogle Scholar
  21. 21.
    Harenberg L, Osswald HM, Jaschonek H, Nagel S (2019) Self-assessment of treatment urgency on presentation to a neurological emergency department: results of a patient survey. Nervenarzt 90:175–182CrossRefGoogle Scholar
  22. 22.
    Gilboy NTT, Travers D, Rosenau AM (2011) Emergency Severity Index (ESI): a triage tool for emergency department care, version 4. implementation handbook, 2012nd edn. Agency for Healthcare Research and Quality, RockvilleGoogle Scholar
  23. 23.
    Gill JM, Reese CLT, Diamond JJ (1996) Disagreement among health care professionals about the urgent care needs of emergency department patients. Ann Emerg Med 28:474–479CrossRefGoogle Scholar
  24. 24.
    Graff I, Goldschmidt B, Glien P et al (2014) The German Version of the Manchester Triage System and its quality criteria—first assessment of validity and reliability. PLoS ONE 9:e88995CrossRefGoogle Scholar
  25. 25.
    Twomey M, Wallis LA, Myers JE (2007) Limitations in validating emergency department triage scales. Emerg Med J 24:477–479CrossRefGoogle Scholar
  26. 26.
    Baumann MR, Strout TD (2007) Triage of geriatric patients in the emergency department: validity and survival with the Emergency Severity Index. Ann Emerg Med 49:234–240CrossRefGoogle Scholar
  27. 27.
    Grossmann FF, Nickel CH, Christ M, Schneider K, Spirig R, Bingisser R (2011) Transporting clinical tools to new settings: cultural adaptation and validation of the Emergency Severity Index in German. Ann Emerg Med 57:257–264CrossRefGoogle Scholar
  28. 28.
    Eitel DR, Travers DA, Rosenau AM, Gilboy N, Wuerz RC (2003) The emergency severity index triage algorithm version 2 is reliable and valid. Acad Emerg Med 10:1070–1080CrossRefGoogle Scholar
  29. 29.
    Wuerz R (2001) Emergency severity index triage category is associated with six-month survival. ESI Triage Study Group. Acad Emerg Med 8:61–64CrossRefGoogle Scholar
  30. 30.
    Wuerz RC, Milne LW, Eitel DR, Travers D, Gilboy N (2000) Reliability and validity of a new five-level triage instrument. Acad Emerg Med 7:236–242CrossRefGoogle Scholar
  31. 31.
    Worster A, Fernandes CM, Eva K, Upadhye S (2007) Predictive validity comparison of two five-level triage acuity scales. Eur J Emerg Med 14:188–192CrossRefGoogle Scholar
  32. 32.
    Brosinski CM, Riddell AJ, Valdez S (2017) Improving triage accuracy: a staff development approach. Clin Nurse Spec 31:145–148CrossRefGoogle Scholar
  33. 33.
    Ebrahimi M, Mirhaghi A, Mazlom R, Heydari A, Nassehi A, Jafari M (2016) The role descriptions of triage nurse in emergency department: a Delphi study. Scientifica (Cairo) 2016:5269815Google Scholar
  34. 34.
    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174CrossRefGoogle Scholar
  35. 35.
    Bambi S, Ruggeri M, Sansolino S et al (2016) Emergency department triage performance timing. A regional multicenter descriptive study in Italy. Int Emerg Nurs 29:32–37CrossRefGoogle Scholar
  36. 36.
    Hay E, Bekerman L, Rosenberg G, Peled R (2001) Quality assurance of nurse triage: consistency of results over three years. Am J Emerg Med 19:113–117CrossRefGoogle Scholar
  37. 37.
    Azzopardi M, Cauchi M, Cutajar K, Ellul R, Mallia-Azzopardi C, Grech V (2011) A time and motion study of patients presenting at the accident and emergency department at Mater Dei Hospital. BMC Res Notes 4:421CrossRefGoogle Scholar
  38. 38.
    Clifford-Brown J, Challen K, Ryan B (2010) What happens at triage: a naturalistic observational study. Emerg Med J 27:931–933CrossRefGoogle Scholar
  39. 39.
    Nogueira RG, Jadhav AP, Haussen DC et al (2018) Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. N Engl J Med 378:11–21CrossRefGoogle Scholar
  40. 40.
    Albers GW (2018) Endovascular thrombectomy in patients with large infarctions: reasons for restraint. Lancet Neurol 17:836–837CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of NeurologyHeidelberg University HospitalHeidelbergGermany
  2. 2.Institute of Medical Biometry and InformaticsHeidelberg University HospitalHeidelbergGermany
  3. 3.Institute of Biometry and Clinical EpidemiologyCharité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of HealthBerlinGermany

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