Assessing severity, immediacy, and ideal setting in ED patients: a pilot study on interrater reliability

Performance of the rapid triage conducted by nurses at the emergency entrance

Objective:

to compare the performance of the rapid triage conducted by nurses at the emergency entrance and of the Manchester Triage System (MTS) in identifying the priority level of care for patients with spontaneous demand and predicting variables related to hospitalization.

Method:

a cross-sectional study carried out in an Emergency Department (ED) of a university hospital in São Paulo. The priority levels established in the rapid triage performed by nurses were high priority (patients of spontaneous demand directed to the emergency room) or low priority (those referred to the institution’s usual flow). Diagnostic accuracy measures were calculated to assess the performance of the indexes.

Results:

of the 173 patients (52.0% female, with mean age of 60.4 ± 21.2 years old) evaluated, it was observed that rapid triage was more inclusive for high priority and had better sensitivity and worse specificity than the MTS. The probability of non-severe patients being admitted to the emergency observation unit was lower due to the rapid triage. For the prediction of the other variables, the systems presented unsatisfactory results.

Conclusion:

the nurses overestimated the classification of patients as high priority, and rapid triage performed better than MTS in predicting admission to the emergency observation unit.

Ambulance transport to the emergency department: A patient-selected signal of acuity and its effect on resource provision

OBJECTIVE

To determine whether ambulance arrival to the emergency department has remained an unidentified signal of perceived medical acuity. Informed by economic signaling theory, does arrival via ambulance affect resource utilization given varying levels of patient acuity?

METHODS

The analysis examined a nationally representative sample of de-identified emergency department patient encounters from 2011 to 2015, gathered from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Multivariate logistic regression analysis was employed using regional and time-fixed effects. The provision of twenty diagnostic and imaging services was analyzed. Patient encounters were also categorized into five acuity-levels.

RESULTS

Drawing from the NHAMCS dataset, 98,888 emergency department records were analyzed, weighted to represent 504.5 million estimated emergency department patient encounters. Findings suggest that patients transported to the hospital via ambulance are more likely than those who arrive by other means to receive 19 of the 20 analyzed diagnostic testing and imaging services. Furthermore, when analyzed by acuity-level, the disparity of service provision is the greatest among low-acuity patients, where medical complaints are argued to be the most subjective.

CONCLUSIONS

The results are consistent with the notion that emergency department medical providers readily accept ambulance transport as a valid signal of patient acuity, regardless of true acuity level. Consequently, patients transported to the hospital via ambulance may be receiving a disproportionate amount of medical resources in an increasingly cost-conscious environment.