suPARcharging triage – Empowering clinical decisions
Triage in the Emergency Department
Initial triaging in the Emergency Department is one of the most critical steps in securing good patient outcomes. All around the world, clinicians have different methods to assess the risk stratification of patients in hospitals to categorise the urgency and need for care.
Triage involves a complex decision-making process carried out by specially trained nurses, technicians, and doctors based on vital signs, complaints, respiratory rate, oxygen saturation in blood, pulse, level of consciousness, blood pressure, age, and body temperature15.
Internationally, there is no consensus on the protocol used for the decision-making process. Therefore, specific regions have adopted several triage scales that guide healthcare professionals in their clinical decision-making.
Risk Scoring Systems for Triage
Limitations of conventional triage
Conventional triage processes carried out by visual and physical examinations have the following limitations:
- A study found that the experience and training of individual nurses18 significantly influenced clinical triage efficiency. This results in high variability. Since conventional triages are not based on objective measurements, they can be influenced by personal bias and cultural differences.
- Triage stratifications based on visible vital signs may ineffectively diagnose penetrating injuries and blunt trauma. More mistakes are likely to be made if the patient is unconscious and unable to communicate their symptoms.
Even widely used triage protocols like the Manchester Triage system were found to lead to several cases of sub and super-triage (under and over-classification of severity)19. Errors in categorisation were seen mostly in cases of patients presenting chest pain, resulting in long waiting times and ineffective treatment20. A meta-analysis study in Great Britain found that triage decisions made in most hospitals across the country were based on insufficient evidence, resulting in repeated re-admissions and increased mortality15.
The prognostic biomarker suPAR is a data-based scientific tool that empowers healthcare professionals to make quick and correct triage decisions across diseases. Implementing suPAR in triage, improves patient outcomes and reduces healthcare costs44,54.
suPARnostic products are approved for all the major chemical analysers, fit existing hospital laboratory workflows and delivers results in less than 20 mins.
How to interpret suPAR results
suPAR level < 4 ng/mL
Supports patient discharge
suPAR level > 6 ng/mL
Supports patient hospitalisation
Soluble urokinase plasminogen activator (suPAR) may be of exceptionally high value in triage in the Emergency Department due to the high degree of unspecificity. A randomised controlled study showed that patients with measured suPAR levels and those with suPAR levels within the acceptable norms were more often discharged early. On average, patients evaluated with suPAR measures stayed 6,5 hours shorter in the hospital compared to the control group without suPAR measurement44.
High plasma suPAR levels have been associated with increased severity and mortality in COVID-1956, 57, HIV35, sepsis28, tuberculosis36 , malaria37, auto-immune diseases, Streptococcus pneumonia bacteremia, cancer38, Alzheimer’s39, cardiovascular diseases40, organ failure, neoplastic and pregnancy relation conditions, and type 2 diabetes mellitus41. High plasma concentrations of suPAR have also been associated with more extended hospital stays45, 46.
The most commonly used inflammatory biomarker is C-reactive protein measured using high-sensitivity (hsCRP) assays. Elevated CRP levels have also been linked to cancer, CVD, and all-cause mortality4.
Interestingly, suPAR outperforms CRP in prognosing a range of diseases. Additionally, suPAR is linked to a biochemical pathway more closely associated with organ damage than CRP and is therefore poised to be more sensitive40. Moreover, although troponins are the preferred biomarker in CVD prognosis, troponin levels rise only 2-6 ng/mL after a myocardial infarction (MI) event, and measurements at the 1st and 3rd hour are needed to determine MI. In contrast, a one-time test of suPAR is sufficient to rule out severe disease44.
The Charlson Comorbidity score predicts the annual mortality of a patient with a range of co-morbid diseases such as heart disease, diabetes, HIV, cancer, etc. The inclusion of suPAR in the Charlson algorithm contributed to a better prediction of disease severity42.
Fever is a fairly common presenting symptom in hospitals. But, it can be easily misdiagnosed due to its highly variable etiology. In such cases, there is a need for an objective biomarker that would accurately reflect the severity and magnitude of the infection43. suPAR is an ideal candidate due to its highly nonspecific nature. Low plasma levels can be used to identify patients with a good prognosis which enables early discharge. In Denmark, suPAR based stratification helped reduce ED overcrowding without any adverse effects on mortality or morbidity44.
The use of suPAR for triage in hospitals has been researched. Some of the essential findings from clinical studies are listed below:
- A study published in 2019 in the Scandinavian Journal of Trauma, Resuscitation, and Emergency Medicine studied the effectiveness of suPAR in grouping patients into high and low risk after they arrive in the Emergency Department (ED). The study’s findings revealed that measurement of suPAR in the triage process can allow more accurate identification of ED patients at risk54.
- Another study from 2019 published in the Journal of Family Medicine and Primary Care found that suPAR can be reliably used in the emergency department for triage and prognostic assessment of patients55.