The ACT and the ADJUST framework: Layering structured detection and clinical judgment in emergency department triage

Background Emergency department (ED) triage must balance rapid detection of critical illness with efficient use of limited resources. We evaluated the Adaptive Clinical Triage (ACT) model—a deliberately lean, nurse-led approach integrating predefined NEWS2 thresholds, symptom-urgency flags, and a discretionary concern override. We also examined ADJUST (Adaptive Judgment of Urgency and Streaming), a semi-structured physician reassessment incorporating early streaming where capacity allows. Methods We performed a retrospective cohort study of 53,645 ED encounters (1 Sept 2023–1 Apr 2025). ACT and ADJUST data were extracted from the electronic trackboard. The primary outcome was intensive care unit (ICU) admission within 24 hours, analyzed as a pragmatic proxy for high acuity. Sensitivity and specificity for ACT were calculated for Red triage assignments and stratified by transfer timing (≤ 2 h, ≤ 4 h, ≤ 6 h). A secondary analysis of paired ACT–ADJUST encounters examined how physician reassessment reclassified acuity. Results Among 46,895 encounters with ACT documentation, sensitivity for ICU admission within 24 hours was 81.2% (95% CI 76.8–85.6) and specificity 85.9% (85.6–86.3). Sensitivity reached 95.2% for ICU transfers within 2 hours and decreased gradually with longer transfer times, indicating strong early detection of critical illness. In 42,881 paired encounters, ACT and ADJUST agreed in 51%. ADJUST improved specificity (96.2%) but reduced sensitivity (64.5%), consistent with its role as a contextual refinement rather than a primary detection layer. Conclusion ACT provides a straightforward, standardized framework that maintains high early sensitivity through structured physiological and symptom-based triggers. ADJUST, when applied, enhances specificity and facilitates early streaming, reflecting its value as a contextual complement to ACT. Together they illustrate how layered triage can combine standardized safety with adaptable clinical judgment. Future studies should examine generalizability across diverse ED environments.