Algorithm-directed triage in a pediatric acute care facility: a retrospective study

Quality Metrics and Systems Transformation: Are We Advancing Alcohol and Drug Screening in Primary Care?

OBJECTIVE

To examine the influence of Oregon's coordinated care organizations (CCOs) and pay-for-performance incentive model on completion of screening and brief intervention (SBI) and utilization of substance use disorder (SUD) treatment services.

DATA SOURCES/STUDY SETTING

Secondary analysis of Medicaid encounter data from 2012 to 2015 and semiannual qualitative interviews with stakeholders in CCOs.

STUDY DESIGN

Longitudinal mixed-methods design with simultaneous data collection with equal importance.

DATA COLLECTION/EXTRACTION METHODS

Qualitative interviews were recorded, transcribed, and coded in ATLAS.ti. Quantitative data included Medicaid encounters 30 months prior to CCO implementation, a 6-month transition period, and 30 months following CCO implementation. Data were aggregated by half-year with analyses restricted to Medicaid recipients 18-64 years of age enrolled in a CCO, not eligible for Medicare coverage or Medicaid expansion.

PRINCIPAL FINDINGS

Quantitative analysis documented a significant increase in SBI rates coinciding with CCO implementation (0.1 to 4.6 percent). Completed SBI was not associated with increased initiation in treatment for SUD diagnoses. Qualitative analysis highlighted importance of aligning incentives, workflow redesign, and leadership to facilitate statewide SBI.

CONCLUSIONS

Results provide modest support for use of a performance metric to expand SBI in primary care. Future research should examine health reform efforts that increase initiation and engagement in SUD treatment.

Comparisons between Full-time and Part-time Pediatric Emergency Physicians in Pediatric Emergency Department

BACKGROUND

Pediatric emergency medicine is a young field that has established itself in recent decades. Many unanswered questions remain regarding how to deliver better pediatric emergency care. The implementation of full-time pediatric emergency physicians is a quality improvement strategy for child care in Taiwan. The aim of this study is to evaluate the quality of care under different physician coverage models in the pediatric emergency department (ED).

METHODS

The medical records of 132,398 patients visiting the pediatric ED of a tertiary care university hospital during January 2004 to December 2006 were retrospectively reviewed. Full-time pediatric emergency physicians are the group specializing in the pediatric emergency medicine, and they only work in the pediatric ED. Part-time pediatricians specializing in other subspecialties also can work an extra shift in the pediatric ED, with the majority working in their inpatient and outpatient services. We compared quality performance indicators, including: mortality rate, the 72-hour return visit rate, length of stay, admission rate, and the rate of being kept for observation between full-time and part-time pediatric emergency physicians.

RESULTS

An average of 3678 ± 125 [mean ± standard error (SE)] visits per month (with a range of 2487-6646) were observed. The trends in quality of care, observed monthly, indicated that the 72-hour return rate was 2-6% and length of stay in the ED decreased from 11.5 hours to 3.2 hours over the study period. The annual mortality rate within 48 hours of admission to the ED increased from 0.04% to 0.05% and then decreased to 0.02%, and the overall mortality rate dropped from 0.13% to 0.07%. Multivariate analyses indicated that there was no change in the 72-hour return visit rate for full-time pediatric emergency physicians; they were more likely to admit and keep patients for observation [odds ratio = 1.43 and odds ratio = 1.71, respectively], and these results were similar to those of senior physicians.

CONCLUSION

Full-time pediatric emergency physicians in the pediatric ED decreased the mortality rate and length of stay in the ED, but had no change in the 72-hour return visit rate. This pilot study shows that the quality of care in pediatric ED after the implementation of full-time pediatric emergency physicians needs further evaluation.

Two models for delivery of women's continence care: the step-wise continence team versus the traditional medical model

BACKGROUND

The current pyramidal system of health care delivery, in which subspecialized physicians with the most complete knowledge and expertise are difficult to access, is inefficient and ineffective at delivering the best care to the majority of patients. Urinary incontinence care exemplifies this problem. Patients can wait up to one year to see a urogynaecologist, regardless of the complexity of their problem. Many women who do not require subspecialized care could have their incontinence managed in a more timely fashion if they had access to education and conservative interventions via a new, more accessible model of care.

METHODS

We studied a modification of urinary incontinence care that departed from the traditional methods of care delivery in two distinct ways. First, patients were permitted to refer themselves directly to the specialty care team. Second, standardized questionnaires and evaluation tools facilitated assessment and management of the patients by a continence educator and nurses, without direct contact between patient and physician. This step-wise model of care was compared with the traditional method of care delivery (medical model), in which the management of all patients was provided by a physician.

RESULTS

Two hundred thirty-two women participated in this study: 154 in the step-wise arm and 78 in the medical model arm. Neither the demographics nor the pre-treatment incontinence severity of the two groups differed significantly. Patients in both groups showed significant improvement in all measures of urinary incontinence after treatment. Patients in the self-referral model experienced significantly better resolution of stress incontinence and irritated bladder symptoms. Their quality of life was also significantly better and their treatment satisfaction higher.

CONCLUSION

The step-wise model of care delivery involving a continence advisor and nurses was as effective in the management of urinary incontinence as the traditional medical model.

The use of the soterion rapid triage system in children presenting to the Emergency Department

There has been a recent move toward the adoption of five-level triage systems in the United States. However, there have been no studies in this country that have critically evaluated the use of these systems in children. The purpose of this study was to evaluate the reliability and validity of a new five-level triage system, the Soterion Rapid Triage System, for stratifying acuity levels in children under the age of 13 years. The study was conducted in a 389-bed Level II mixed adult and pediatric Trauma Center that experiences approximately 12,000 patient visits/year of children under the age of 13 years. We performed a prospective evaluation of the system's reliability using the weighted kappa statistical method (n = 117) and a retrospective evaluation of the system's validity through an analysis of all patients under the age of 13 years triaged with the system over an 8-month period (n = 7077). The system's validity was measured by in-hospital admission rate, Emergency Department length of stay, hospital charges, and Current Procedural Terminology (CPT) Codes 99281-99285. The inter-rater reliability as measured by the weighted kappa was 0.90 (95% confidence interval 0.83-0.96), with 92% exact agreement between nurses in the triage level assigned. The in-hospital admission rates for patients triaged as Level 1 Immediate-Level 5 Non-Urgent were 38%, 18%, 9%, 1.5% and 0.4%, respectively (p < 0.0001). The mean total hospital charges for each of the five triage levels were $2673, $1563, $1112, $477, and $258, respectively (p < 0.0001). Similarly, there were significant differences in the means for laboratory and pharmacy charges, Emergency Department lengths of stay, and CPT Codes. This report represents the first study in this country on the effectiveness of a five-level triage system in children. We have demonstrated that the Soterion Rapid Triage System possesses high inter-rater reliability and validity when used to triage children younger than 13 years of age.

Adverse outcomes of managed care gatekeeping

OBJECTIVES

To determine whether telephone preauthorization for reimbursement of ED care (medical "gate-keeping") by managed care organizations (MCOs) is associated with adverse outcomes.

METHODS

A structured review was performed of case reports solicited during 1994 and 1995 with possible adverse outcomes related to managed care gatekeeping. Gatekeeping was defined as the requirement imposed by an MCO that ED staff contact on-call gatekeepers (i.e., clinical or nonclinical MCO personnel) to request preauthorization for ED treatment (a requirement that such MCOs enforce by refusing payment for the ED care unless preauthorization is obtained). Cases in which gatekeeper denial of preauthorization occurred were sought. Two physicians agreed on patient eligibility and classification criteria, then independently, retrospectively classified case reports identified as MCO ED payment denials into 1 of 4 categories: 1) adverse outcome; 2) patient placed at increased risk of death or disability; 3) "near miss" (emergency physicians prevented adverse outcome by caring for patient despite denial); and 4) none of the above.

RESULTS

Of the 143 cases reviewed, 29 reports represented MCO ED payment denial. Of these 29 eligible cases, there were 4 (14%) patients with adverse outcomes, 4 (14%) patients placed at increased risk, and 21 (72%) near misses. All of the 29 cases came from different EDs, representing 9 different states, with the majority from California. Adverse outcomes included respiratory failure from fulminant meningococcemia, hypovolemic syncope from ruptured ectopic pregnancy, hypovolemic arrest from vascular fibroid hemorrhage necessitating emergency hysterectomy, and prolonged postoperative course following ruptured duodenal ulcer. Patients placed at increased risk were diagnosed as having epiglottitis, myocardial infarction, ruptured ectopic pregnancy, and delayed treatment of hip septic arthritis. Near misses included diagnoses of ectopic pregnancy (n = 2), pneumothorax (n = 2), alcohol withdrawal seizures and pancreatitis necessitating intensive care unit admission, appendicitis, bacterial meningitis, cerebrovascular accident, cryptococal meningitis in immuno comprised host, endocarditis, incarerated inguinal hernia, meningocococemia, meninoccocal meningitis, peritonsillar abscess, pneumococcal meningitis, ruptured abdominal aortic aneurysm, shock from gastrointestinal bleeding, small bowel obstruction, schizophrenic crisis resulting in psychiatric hospitalization, suicidal depression resulting in psychiatric hospitalization, and unstable angina.

CONCLUSION

Adverse outcomes occur with MCO gatekeeping, Although the present study cannot ascertain whether this is a frequent event or a rare one, the safety of MCO gatekeeping deserves further study.

Does a physician visual assessment change triage?

A prospective comparative trial was conducted to determine the effect of a physician's visual assessment of emergency patients on triage categorization and ability at triage to predict admission. The setting was a university, county, referral center and residency training site. Participants were a consecutive sample of emergency department patients presenting between the times of 0700 and 2300 hours for 5 weeks. All patients were assigned a triage category by an emergency nurse (RN) who saw the patient and by an emergency physician (EP) who had the option of performing a visual assessment. Triage categorization was compared for interobserver agreement (Kappa [kappa] statistic) and by ability to predict admission (MacNemar's test). A total of 3,949 patients was entered. The patients that physicians visually assessed were triaged by nurses as more ill (P < .001). For triage categories visualized by the EP compared with RN categorization, interobserver agreement was 59.8%, kappa = .21. For triage categories not visualized by EP compared with RN categorization, interobserver agreement was 67.9%, kappa = .45 (P < .001). Sensitivity of EPs to predict admission is as follows: all RN triage, 41.3; not seen by EP, 54.9; seen by EP, 69.3. Specificity is as follows: all RN triage, 93.7; not seen by EP, 88.5, seen by EP, 83.9. When physician visual assessment was done, agreement between physicians and nurses decreased by more than half. Physicians who included visual assessment in patient triage were less likely to agree with RN categorization. A visual assessment by the physician improved the sensitivity for predicting admission with an only small cost in specificity.

Refusing care to emergency department of patients: evaluation of published triage guidelines

STUDY OBJECTIVE

To determine whether a set of published triage guidelines identifies patients who can safely be refused emergency department care.

DESIGN

Historical cohort study.

SETTING

A public hospital ED.

TYPE OF PARTICIPANTS

All patients triaged during a one-week period who were not in the most acute triage category.

MEASUREMENTS

Two ED nurses, blinded to the study hypothesis, reviewed each triage sheet to determine whether the case met the published guidelines for refusing care. In addition, each ED record was reviewed for appropriateness; a visit was considered appropriate only if predetermined, explicit criteria were met and an emergency physician agreed that a 24-hour delay in care might have worsened the patient's outcome.

MAIN RESULTS

Of the 106 patients who would have been refused care according to the triage guidelines, 35 (33%) had appropriate visits. Four were hospitalized.

CONCLUSION

When tested in our patient population, the triage guidelines were not sufficiently sensitive to identify patients who needed ED care. Broad application of these guidelines may jeopardize the health of some patients.

Computerized algorithm-directed triage in the emergency department

A retrospective audit was conducted evaluating the effectiveness of the computerized algorithm-directed triage at Brooke Army Medical Center. A total of 98,086 charts were reviewed. From this, 58,282 patients were given dispositions to our acute care clinic and the remainder to the emergency department. Of these, 733 patients (1.2%) were retriaged from the acute care clinic to the ED. Based on these data, we conclude that the computerized algorithm-directed triage, using minimally trained personnel, appears to be an effective system.

Computerized triage of pediatric patients: automated triage algorithms

Pediatric triage algorithms which were prospectively and retrospectively validated in a pediatric acute care facility serve as the basis for the development of a simplified pediatric triage checklist. This checklist is used by minimally trained nonprofessionals to assign safely the care urgency categories of the chief complaints of pediatric "walk-in" patients. This article describes the background of the pediatric triage checklist and its adaptation to a computerized triage system. This system not only allows for safe triage, but also creates a mechanism for rapid, organized retrieval of data from individual and group patient triage encounters that is useful for the study and planning of health care delivery.