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Koo YK, Choi SJ, Kwon SS, Myung J, Kim S, Park I, Chung HS. Effect of storage duration on outcome of patients receiving red blood cell in emergency department. Sci Rep 2024; 14:23463. [PMID: 39379435 PMCID: PMC11461482 DOI: 10.1038/s41598-024-74114-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 09/24/2024] [Indexed: 10/10/2024] Open
Abstract
The effect of the duration of red blood cell (RBC) storage on the outcomes of transfused patients remains controversial, and studies on patients in the emergency department (ED) are limited. This study aimed to determine the association between RBC storage duration and outcomes of patients receiving transfusions in the ED. For RBCs issued to patients in the ED between 2017 and 2022, the storage period of the RBC and data on the transfused patient were obtained. Patients were divided into fresh (≤ 7 days) and old (> 7 days) RBC groups, and the associations between storage duration, outcomes, and laboratory changes were evaluated. There was no significant difference in outcomes between the two groups in the 28-day mortality (adjusted odds ratio [OR] 0.91, 95% confidence interval [CI] 0.75-1.10, P = 0.320) and the length of stay (fresh 13.5 ± 18.1 vs. old 13.3 ± 19.8, P = 0.814). Regarding changes in laboratory test results, the increase in hemoglobin and hematocrit levels was not affected by the storage durations. The study revealed that transfusion of older RBCs is not associated with inferior outcomes or adverse clinical consequences when compared to that of fresh RBCs in patients in the ED.
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Affiliation(s)
- Yu-Kyung Koo
- Department of Laboratory Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei- ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Sol Ji Choi
- Department of Emergency Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei- ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Soon Sung Kwon
- Department of Laboratory Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei- ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
| | - Jinwoo Myung
- Department of Emergency Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei- ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
| | - Sinyoung Kim
- Department of Laboratory Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei- ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Incheol Park
- Department of Emergency Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei- ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hyun Soo Chung
- Department of Emergency Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei- ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
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2
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Assunta F, Matteo A, Séverine V, Guy S, Aurélien K, Oriana KP, Dominique J, Josette S, Olivier H, Jérome P, Philippe D. Feasibility and acceptability of a serious game to study the effects of environmental distractors on emergency room nurse triage accuracy: A pilot study. Int Emerg Nurs 2024; 76:101504. [PMID: 39159597 DOI: 10.1016/j.ienj.2024.101504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 07/12/2024] [Accepted: 08/08/2024] [Indexed: 08/21/2024]
Abstract
BACKGROUND Emergency triage, which involves complex decision-making under stress and time constraints, may suffer from inaccuracies due to workplace distractions. A serious game was developed to simulate the triage process and environment. A pilot study was undertaken to collect preliminary data on the effects of distractors on emergency nurse triage accuracy. METHOD A 2 × 2 factorial randomized controlled trial (RCT) was designed for the study. A sample of 70 emergency room nurses was randomly assigned to three experimental groups exposed to different distractors (noise, task interruptions, and both) and one control group. Nurses had two hours to complete a series of 20 clinical vignettes, in which they had to establish a chief complaint and assign an emergency level. RESULTS Fifty-five nurses completed approximately 15 vignettes each during the allotted time. No intergroup differences emerged in terms of triage performance. Nurses had a very favorable appreciation of the serious game focusing on triage. CONCLUSION The results show that both the structure of our study and the serious game can be used to carry out a future RCT on a larger scale. The lack of a distractor effect raises questions about the frequency and intensity required to find a significant impact on triage performance.
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Affiliation(s)
- Fiorentino Assunta
- La Source School of Nursing, HES-SO University of Applied Sciences and Arts Western Switzerland Lausanne, Switzerland.
| | - Antonini Matteo
- La Source School of Nursing, HES-SO University of Applied Sciences and Arts Western Switzerland Lausanne, Switzerland; HE Arc - HES-SO University of Applied Sciences and Arts Western Switzerland, Neuchâtel, Switzerland
| | - Vuilleumier Séverine
- La Source School of Nursing, HES-SO University of Applied Sciences and Arts Western Switzerland Lausanne, Switzerland
| | - Stotzer Guy
- La Source School of Nursing, HES-SO University of Applied Sciences and Arts Western Switzerland Lausanne, Switzerland
| | - Kollbrunner Aurélien
- La Source School of Nursing, HES-SO University of Applied Sciences and Arts Western Switzerland Lausanne, Switzerland
| | - Keserue Pittet Oriana
- La Source School of Nursing, HES-SO University of Applied Sciences and Arts Western Switzerland Lausanne, Switzerland
| | - Jaccard Dominique
- School of Management and Engineering Vaud, HES-SO University of Applied Sciences and Arts Western Switzerland Yverdon-les-Bains, Switzerland
| | - Simon Josette
- Emergency Department, Geneva University Hospital, Geneva, Switzerland
| | - Hugli Olivier
- Emergency Department, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Pasquier Jérome
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Delmas Philippe
- La Source School of Nursing, HES-SO University of Applied Sciences and Arts Western Switzerland Lausanne, Switzerland
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Ingielewicz A, Rychlik P, Sieminski M. Drinking from the Holy Grail-Does a Perfect Triage System Exist? And Where to Look for It? J Pers Med 2024; 14:590. [PMID: 38929811 PMCID: PMC11204574 DOI: 10.3390/jpm14060590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 05/23/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024] Open
Abstract
The Emergency Department (ED) is a facility meant to treat patients in need of medical assistance. The choice of triage system hugely impactsed the organization of any given ED and it is important to analyze them for their effectiveness. The goal of this review is to briefly describe selected triage systems in an attempt to find the perfect one. Papers published in PubMed from 1990 to 2022 were reviewed. The following terms were used for comparison: "ED" and "triage system". The papers contained data on the design and function of the triage system, its validation, and its performance. After studies comparing the distinct means of patient selection were reviewed, they were meant to be classified as either flawed or non-ideal. The validity of all the comparable segregation systems was similar. A possible solution would be to search for a new, measurable parameter for a more accurate risk estimation, which could be a game changer in terms of triage assessment. The dynamic development of artificial intelligence (AI) technologies has recently been observed. The authors of this study believe that the future segregation system should be a combination of the experience and intuition of trained healthcare professionals and modern technology (artificial intelligence).
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Affiliation(s)
- Anna Ingielewicz
- Department of Emergency Medicine, Faculty of Health Science, Medical University of Gdansk, Mariana Smoluchowskiego Street 17, 80-214 Gdansk, Poland;
- Emergency Department, Copernicus Hospital, Nowe Ogrody Street 1-6, 80-203 Gdansk, Poland
| | - Piotr Rychlik
- Emergency Department, Copernicus Hospital, Nowe Ogrody Street 1-6, 80-203 Gdansk, Poland
| | - Mariusz Sieminski
- Department of Emergency Medicine, Faculty of Health Science, Medical University of Gdansk, Mariana Smoluchowskiego Street 17, 80-214 Gdansk, Poland;
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Hall JN, Galaev R, Gavrilov M, Mondoux S. Development of a machine learning-based acuity score prediction model for virtual care settings. BMC Med Inform Decis Mak 2023; 23:200. [PMID: 37789357 PMCID: PMC10548626 DOI: 10.1186/s12911-023-02307-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 09/26/2023] [Indexed: 10/05/2023] Open
Abstract
OBJECTIVE Healthcare is increasingly digitized, yet remote and automated machine learning (ML) triage prediction systems for virtual urgent care use remain limited. The Canadian Triage and Acuity Scale (CTAS) is the gold standard triage tool for in-person care in Canada. The current work describes the development of a ML-based acuity score modelled after the CTAS system. METHODS The ML-based acuity score model was developed using 2,460,109 de-identified patient-level encounter records from three large healthcare organizations (Ontario, Canada). Data included presenting complaint, clinical modifiers, age, sex, and self-reported pain. 2,041,987 records were high acuity (CTAS 1-3) and 416,870 records were low acuity (CTAS 4-5). Five models were trained: decision tree, k-nearest neighbors, random forest, gradient boosting regressor, and neural net. The outcome variable of interest was the acuity score predicted by the ML system compared to the CTAS score assigned by the triage nurse. RESULTS Gradient boosting regressor demonstrated the greatest prediction accuracy. This final model was tuned toward up triaging to minimize patient risk if adopted into the clinical context. The algorithm predicted the same score in 47.4% of cases, and the same or more acute score in 95.0% of cases. CONCLUSIONS The ML algorithm shows reasonable predictive accuracy and high predictive safety and was developed using the largest dataset of its kind to date. Future work will involve conducting a pilot study to validate and prospectively assess reliability of the ML algorithm to assign acuity scores remotely.
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Affiliation(s)
- Justin N Hall
- Department of Emergency Services, C753, Sunnybrook Health Sciences Centre, Toronto, ON, M4N 3M5, Canada.
- Division of Emergency Medicine, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
| | | | | | - Shawn Mondoux
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Emergency Medicine, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
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5
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Song J, Kim S, Chung HS, Park I, Kwon SS, Myung J. Predictive indicators for determining red blood cell transfusion strategies in the emergency department. Eur J Emerg Med 2023; 30:260-266. [PMID: 37115971 DOI: 10.1097/mej.0000000000001032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
BACKGROUND AND IMPORTANCE Appropriate decision-making is critical for transfusions to prevent unnecessary adverse outcomes; however, transfusion in the emergency department (ED) can only be decided based on sparse evidence in a limited time window. OBJECTIVES This study aimed to identify factors associated with appropriate red blood cell (RBC) transfusion in the ED by analyzing retrospective data of patients who received transfusions at a single center. OUTCOME MEASURES AND ANALYSIS This study analyzed associations between transfusion appropriateness and sex, age, initial vital signs, an ED triage score [the Korean Triage and Acuity Scale (KTAS)], the length of stay, and the hemoglobin (Hb) concentration. MAIN RESULTS Of 10 490 transfusions, 10 109 were deemed appropriate, and 381 were considered inappropriate. A younger age ( P < 0.001) and a KTAS level of 3-5 ( P = 0.028) were associated with inappropriate transfusions, after adjusting for O 2 saturation and the Hb level. CONCLUSIONS In this single-center retrospective study, younger age and higher ED triage scores were associated with the appropriateness of RBC transfusions.
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Affiliation(s)
| | | | - Hyun Soo Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Incheol Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | | | - Jinwoo Myung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
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Chen YHJ, Lin CS, Lin C, Tsai DJ, Fang WH, Lee CC, Wang CH, Chen SJ. An AI-Enabled Dynamic Risk Stratification for Emergency Department Patients with ECG and CXR Integration. J Med Syst 2023; 47:81. [PMID: 37523102 DOI: 10.1007/s10916-023-01980-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/21/2023] [Indexed: 08/01/2023]
Abstract
Emergency department (ED) triage scale determines the priority of patient care and foretells the prognosis. However, the information retrieved from the initial assessment is limited, hindering the risk identification accuracy of triage. Therefore, we sought to develop a 'dynamic' triage system as secondary screening, using artificial intelligence (AI) techniques to integrate information from initial assessment data and subsequent examinations. This retrospective cohort study included 134,112 ED visits with at least one electrocardiography (ECG) and chest X-ray (CXR) in a medical center from 2012 to 2022. Additionally, an independent community hospital provided 45,614 ED visits as an external validation set. We trained an eXtreme gradient boosting (XGB) model using initial assessment data to predict all-cause mortality in 7 days. Two deep learning models (DLMs) using ECG and CXR were trained to stratify mortality risks. The dynamic triage levels were based on output from the XGB-triage and DLMs from ECG and CXR. During the internal and external validation, the area under the receiver operating characteristic curve (AUC) of the XGB-triage model was >0.866; furthermore, the AUCs of DLMs using ECG and CXR were >0.862 and >0.886, respectively. The dynamic triage scale provided a higher C-index (0.914-0.920 vs. 0.827-0.843) than the original one and demonstrated better predictive ability for 5-year mortality, 30-day ED revisit, and 30-day discharge. The AI-based risk scale provides a more accurate and dynamic stratification of mortality risk in ED patients, particularly in identifying patients who tend to be overlooked due to atypical symptoms.
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Affiliation(s)
| | - Chin-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center Taipei, Taipei, Taiwan
- Medical Technology Education Center, School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Chin Lin
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
- Medical Technology Education Center, School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Graduate Institutes of Life Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Dung-Jang Tsai
- Center for Artificial Intelligence and Internet of Things, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Department of Statistics and Information Science, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Wen-Hui Fang
- Center for Artificial Intelligence and Internet of Things, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Cheng Lee
- Medical Informatics Office, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Division of Colorectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Hung Wang
- Graduate Institutes of Life Sciences, National Defense Medical Center, Taipei, Taiwan
- Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Sy-Jou Chen
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, No.161, Sec. 6, Minquan E. Rd., Neihu Dist., Taipei City, 11490, Taiwan.
- Graduate Institute of Injury Prevention and Control, College of Public Health and Nutrition, Taipei Medical University, Taipei, Taiwan.
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7
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Picard C, Kleib M, Norris C, O'Rourke HM, Montgomery C, Douma M. The Use and Structure of Emergency Nurses' Triage Narrative Data: Scoping Review. JMIR Nurs 2023; 6:e41331. [PMID: 36637881 PMCID: PMC9883744 DOI: 10.2196/41331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 11/24/2022] [Accepted: 11/28/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Emergency departments use triage to ensure that patients with the highest level of acuity receive care quickly and safely. Triage is typically a nursing process that is documented as structured and unstructured (free text) data. Free-text triage narratives have been studied for specific conditions but never reviewed in a comprehensive manner. OBJECTIVE The objective of this paper was to identify and map the academic literature that examines triage narratives. The paper described the types of research conducted, identified gaps in the research, and determined where additional review may be warranted. METHODS We conducted a scoping review of unstructured triage narratives. We mapped the literature, described the use of triage narrative data, examined the information available on the form and structure of narratives, highlighted similarities among publications, and identified opportunities for future research. RESULTS We screened 18,074 studies published between 1990 and 2022 in CINAHL, MEDLINE, Embase, Cochrane, and ProQuest Central. We identified 0.53% (96/18,074) of studies that directly examined the use of triage nurses' narratives. More than 12 million visits were made to 2438 emergency departments included in the review. In total, 82% (79/96) of these studies were conducted in the United States (43/96, 45%), Australia (31/96, 32%), or Canada (5/96, 5%). Triage narratives were used for research and case identification, as input variables for predictive modeling, and for quality improvement. Overall, 31% (30/96) of the studies offered a description of the triage narrative, including a list of the keywords used (27/96, 28%) or more fulsome descriptions (such as word counts, character counts, abbreviation, etc; 7/96, 7%). We found limited use of reporting guidelines (8/96, 8%). CONCLUSIONS The breadth of the identified studies suggests that there is widespread routine collection and research use of triage narrative data. Despite the use of triage narratives as a source of data in studies, the narratives and nurses who generate them are poorly described in the literature, and data reporting is inconsistent. Additional research is needed to describe the structure of triage narratives, determine the best use of triage narratives, and improve the consistent use of triage-specific data reporting guidelines. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1136/bmjopen-2021-055132.
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Affiliation(s)
| | - Manal Kleib
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Colleen Norris
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | | | | | - Matthew Douma
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
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Rowe BH, Yang EH, Gaudet LA, Lowes J, Eliyahu L, Villa-Roel C, Beach J, Mrazik M, Cummings G, Voaklander D. Sports-Related Concussions in Adults Presenting to Canadian Emergency Departments. Clin J Sport Med 2022; 32:e469-e477. [PMID: 36083333 DOI: 10.1097/jsm.0000000000001005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 11/20/2021] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To document the occurrence and recovery outcomes of sports-related concussions (SRCs) presenting to the Emergency Department (ED) in a community-based sample. DESIGN A prospective observational cohort study was conducted in 3 Canadian hospitals. SETTING Emergency Department. PATIENTS Adults (≥17 years) presenting with a concussion to participating EDs with a Glasgow Coma Scale score ≥13 were recruited. INTERVENTIONS Patient demographics (eg, age and sex), clinical characteristics (eg, history of depression or anxiety), injury characteristics (eg, injury mechanisms and loss of consciousness and duration), and ED management and outcomes (eg, imaging, consultations, and ED length of stay) were collected. MAIN OUTCOME MEASURES Patients' self-reported persistent concussion symptoms, return to physical activity status, and health-related quality of life at 30 and 90 days after ED discharge. RESULTS Overall, 248 patients were enrolled, and 25% had a SRC. Patients with SRCs were younger and reported more physical activity before the event. Although most of the patients with SRCs returned to their normal physical activities at 30 days, postconcussive symptoms persisted in 40% at 90 days of follow-up. After adjustment, there was no significant association between SRCs and persistent symptoms; however, patients with concussion from motor vehicle collisions were more likely to have persistent symptoms. CONCLUSION Although physically active individuals may recover faster after a concussion, patients returning to their physical activities before full resolution of symptoms are at higher risk of persistent symptoms and further injury. Patient-clinician communications and tailored recommendations should be encouraged to guide appropriate acute management of concussions.
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Affiliation(s)
- Brian H Rowe
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Esther H Yang
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Lindsay A Gaudet
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Justin Lowes
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Leeor Eliyahu
- Department of Family Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Cristina Villa-Roel
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Jeremy Beach
- College of Physicians and Surgeons of Alberta, Edmonton, AB, Canada
- Division of Preventive Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada; and
| | - Martin Mrazik
- Department of Educational Psychology, Faculty of Education, University of Alberta, Edmonton, AB, Canada
| | - Garnet Cummings
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Donald Voaklander
- School of Public Health, University of Alberta, Edmonton, AB, Canada
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Sempere-González A, Llaneras-Artigues J, Pinal-Fernández I, Cañas-Ruano E, Orozco-Gálvez O, Domingo-Baldrich E, Michelena X, Meza B, García-Vives E, Gil-Vila A, Sarrapio-Lorenzo J, Romero-Ruperto S, Sanpedro-Jiménez F, Arranz-Betegón M, Fernández-Codina A. Radiography-based triage for COVID-19 in the Emergency Department in a Spanish cohort of patients. MEDICINA CLINICA (ENGLISH ED.) 2022; 158:466-471. [PMID: 35702721 PMCID: PMC9181762 DOI: 10.1016/j.medcle.2021.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/21/2021] [Indexed: 01/08/2023]
Abstract
Background Strategies to determine who could be safely discharged home from the Emergency Department (ED) in COVID-19 are needed to decongestion healthcare systems. Objectives To describe the outcomes of an ED triage system for non-severe patients with suspected COVID-19 and possible pneumonia based on chest X-ray (CXR) upon admission. Material and methods Retrospective, single-center study performed in Barcelona (Spain) during the COVID-19 peak in March-April 2020. Patients with COVID-19 symptoms and potential pneumonia, without respiratory insufficiency, with priority class IV-V (Andorran triage model) had a CXR upon admission. This approach tried to optimize resource use and to facilitate discharges. The results after adopting this organizational approach are reported. Results We included 834 patients, 53% were female. Most patients were white (66%) or Hispanic (27%). CXR showed pneumonia in 523 (62.7%). Compared to those without pneumonia, patients with pneumonia were older (55 vs 46.6 years old) and had a higher Charlson comorbidity index (1.9 vs 1.3). Patients with pneumonia were at a higher risk for a combined outcome of admission and/or death (91 vs 12%). Death rates tended to be numerically higher in the pneumonia group (10 vs 1). Among patients without pneumonia in the initial CXR, 10% reconsulted (40% of them with new pneumonia). Conclusion CXR identified pneumonia in a significant number of patients. Those without pneumonia were mostly discharged. Mortality among patients with an initially negative CXR was low. CXR triage for pneumonia in non-severe COVID-19 patients in the ED can be an effective strategy to optimize resource use.
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Affiliation(s)
| | | | - Iago Pinal-Fernández
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MA, USA
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Faculty of Health Sciences and Faculty of Computer Science, Multimedia and Telecommunications, Universitat Oberta de Catalunya, Barcelona, Spain
| | | | | | | | - Xabier Michelena
- Emergency Department, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Beatriz Meza
- Emergency Department, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Eloi García-Vives
- Emergency Department, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Albert Gil-Vila
- Emergency Department, University Hospital Vall d'Hebron, Barcelona, Spain
| | | | | | | | | | - Andreu Fernández-Codina
- Emergency Department, University Hospital Vall d'Hebron, Barcelona, Spain
- Rheumatology Division and General Internal Medicine Division-Windsor Campus, University of Western Ontario, London/Windsor, ON, Canada
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10
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Sempere-González A, Llaneras-Artigues J, Pinal-Fernández I, Cañas-Ruano E, Orozco-Gálvez O, Domingo-Baldrich E, Michelena X, Meza B, García-Vives E, Gil-Vila A, Sarrapio-Lorenzo J, Romero-Ruperto S, Sanpedro-Jiménez F, Arranz-Betegón M, Fernández-Codina A. Radiography-based triage for COVID-19 in the Emergency Department in a Spanish cohort of patients. Med Clin (Barc) 2022; 158:466-471. [PMID: 34256936 PMCID: PMC8206616 DOI: 10.1016/j.medcli.2021.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/20/2021] [Accepted: 05/21/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Strategies to determine who could be safely discharged home from the Emergency Department (ED) in COVID-19 are needed to decongestion healthcare systems. OBJECTIVES To describe the outcomes of an ED triage system for non-severe patients with suspected COVID-19 and possible pneumonia based on chest X-ray (CXR) upon admission. MATERIAL AND METHODS Retrospective, single-center study performed in Barcelona (Spain) during the COVID-19 peak in March-April 2020. Patients with COVID-19 symptoms and potential pneumonia, without respiratory insufficiency, with priority class IV-V (Andorran triage model) had a CXR upon admission. This approach tried to optimize resource use and to facilitate discharges. The results after adopting this organizational approach are reported. RESULTS We included 834 patients, 53% were female. Most patients were white (66%) or Hispanic (27%). CXR showed pneumonia in 523 (62.7%). Compared to those without pneumonia, patients with pneumonia were older (55 vs 46.6 years old) and had a higher Charlson comorbidity index (1.9 vs 1.3). Patients with pneumonia were at a higher risk for a combined outcome of admission and/or death (91 vs 12%). Death rates tended to be numerically higher in the pneumonia group (10 vs 1). Among patients without pneumonia in the initial CXR, 10% reconsulted (40% of them with new pneumonia). CONCLUSION CXR identified pneumonia in a significant number of patients. Those without pneumonia were mostly discharged. Mortality among patients with an initially negative CXR was low. CXR triage for pneumonia in non-severe COVID-19 patients in the ED can be an effective strategy to optimize resource use.
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Affiliation(s)
| | | | - Iago Pinal-Fernández
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MA, USA; Johns Hopkins University School of Medicine, Baltimore, MD, USA; Faculty of Health Sciences and Faculty of Computer Science, Multimedia and Telecommunications, Universitat Oberta de Catalunya, Barcelona, Spain
| | | | | | | | - Xabier Michelena
- Emergency Department, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Beatriz Meza
- Emergency Department, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Eloi García-Vives
- Emergency Department, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Albert Gil-Vila
- Emergency Department, University Hospital Vall d'Hebron, Barcelona, Spain
| | | | | | | | | | - Andreu Fernández-Codina
- Emergency Department, University Hospital Vall d'Hebron, Barcelona, Spain; Rheumatology Division and General Internal Medicine Division-Windsor Campus, University of Western Ontario, London/Windsor, ON, Canada.
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11
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Tsai DJ, Tsai SH, Chiang HH, Lee CC, Chen SJ. Development and Validation of an Artificial Intelligence Electrocardiogram Recommendation System in the Emergency Department. J Pers Med 2022; 12:jpm12050700. [PMID: 35629122 PMCID: PMC9143094 DOI: 10.3390/jpm12050700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 04/25/2022] [Accepted: 04/25/2022] [Indexed: 12/10/2022] Open
Abstract
The machine learning-assisted electrocardiogram (ECG) is increasingly recognized for its unprecedented capabilities in diagnosing and predicting cardiovascular diseases. Identifying the need for ECG examination early in emergency department (ED) triage is key to timely artificial intelligence-assisted analysis. We used machine learning to develop and validate a clinical decision support tool to predict ED triage patients’ need for ECG. Data from 301,658 ED visits from August 2017 to November 2020 in a tertiary hospital were divided into a development cohort, validation cohort, and two test cohorts that included admissions before and during the COVID-19 pandemic. Models were developed using logistic regression, decision tree, random forest, and XGBoost methods. Their areas under the receiver operating characteristic curves (AUCs), positive predictive values (PPVs), and negative predictive values (NPVs) were compared and validated. In the validation cohort, the AUCs were 0.887 for the XGBoost model, 0.885 for the logistic regression model, 0.878 for the random forest model, and 0.845 for the decision tree model. The XGBoost model was selected for subsequent application. In test cohort 1, the AUC was 0.891, with sensitivity of 0.812, specificity of 0.814, PPV of 0.708 and NPV of 0.886. In test cohort 2, the AUC was 0.885, with sensitivity of 0.816, specificity of 0.812, PPV of 0.659, and NPV of 0.908. In the cumulative incidence analysis, patients not receiving an ECG yet positively predicted by the model had significantly higher probability of receiving the examination within 48 h compared with those negatively predicted by the model. A machine learning model based on triage datasets was developed to predict ECG acquisition with high accuracy. The ECG recommendation can effectively predict whether patients presenting at ED triage will require an ECG, prompting subsequent analysis and decision-making in the ED.
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Affiliation(s)
- Dung-Jang Tsai
- Institute of Life Sciences, School of Public Health, National Defense Medical Center, Taipei 11499, Taiwan;
| | - Shih-Hung Tsai
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 11499, Taiwan;
| | - Hui-Hsun Chiang
- School of Nursing, National Defense Medical Center, Taipei 11499, Taiwan;
| | - Chia-Cheng Lee
- Planning and Management Office, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan;
| | - Sy-Jou Chen
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 11499, Taiwan;
- Correspondence:
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12
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Ha J, Jang K, An M. Development and validity of the Korea psychiatric triage algorithm. BMC Nurs 2021; 20:212. [PMID: 34706717 PMCID: PMC8549170 DOI: 10.1186/s12912-021-00738-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 10/17/2021] [Indexed: 12/29/2022] Open
Abstract
Background Psychiatric emergencies require timely intervention because of the risk of harm to individuals and society, including others. The aim of the present study was to test the content validity of a psychiatric triage algorithm developed for use in South Korea. Methods The initial algorithm was developed through systematic literature review. Its validity was then verified by 10 experts. Based on results of expert validity, the algorithm was modified and the final algorithm was developed. Results Its clinical validity was then verified by 37 emergency room nurses who had used triage. Four questions of expert validity results with a CVI of 0.8 or less were revised to reflect expert opinion. The usefulness, adequacy, and convenience of the final modified algorithm was 2.98 ~ 3.53. Conclusion After sufficiently validated by follow-up studies, it is expected that the use of psychiatric classification algorithms in emergency room nurses will not only improve the quality of care, but also can improve patient outcomes and experience.
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Affiliation(s)
- Jeongmin Ha
- Department of Nursing, Chung-Ang University, 84 Heukseok-ro , Dongjak-gu, Seoul, Republic of Korea
| | - Kyeongmin Jang
- Department of Nursing, Bucheon University, 56, Sosa-ro, Bucheon-si, Gyeonggi-do, Republic of Korea.
| | - Misuk An
- Heart Center, Chung-Ang University Hospital, 102, Heuseok-ro, Dongjak-gu, Seoul, 06973, Republic of Korea
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13
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Rowe BH, Yang EH, Gaudet LA, Eliyahu L, Junqueira DR, Beach J, Mrazik M, Cummings G, Voaklander D. Sex-based differences in outcomes for adult patients presenting to the emergency department with a concussion. J Neurosurg 2021; 136:264-273. [PMID: 34298511 DOI: 10.3171/2021.1.jns203753] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/04/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patients with concussion frequently present to the emergency department (ED). Studies of athletes and children indicate that concussion symptoms are often more severe and prolonged in females compared with males. Given infrequent study of concussion symptoms in the general adult population, the authors conducted a sex-based comparison of patients with concussion. METHODS Adults (≥ 17 years of age) presenting with concussion to one of three urban Canadian EDs were recruited. Discharged patients were contacted by telephone 30 and 90 days later to capture the extent of persistent postconcussion symptoms using the Rivermead Post Concussion Symptoms Questionnaire (RPQ). A multivariate logistic regression model for persistent symptoms that included biological sex was developed. RESULTS Overall, 250 patients were included; 131 (52%) were women, and the median age of women was significantly higher than that of men (40 vs 32 years). Women had higher RPQ scores at baseline (p < 0.001) and the 30-day follow-up (p = 0.001); this difference resolved by 90 days. The multivariate logistic regression identified that women, patients having a history of sleep disorder, and those presenting to the ED with concussions after a motor vehicle collision were more likely to experience persistent symptoms. CONCLUSIONS In a community concussion sample, inconsequential demographic differences existed between adult women and men on ED presentation. Based on self-reported and objective outcomes, work and daily activities may be more affected by concussion and persistent postconcussion symptoms for women than men. Further analysis of these differences is required to identify different treatment options and ensure adequate care and management of injury.
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Affiliation(s)
- Brian H Rowe
- Departments of1Emergency Medicine.,2School of Public Health; and
| | | | | | | | | | - Jeremy Beach
- 5College of Physicians and Surgeons of Alberta, Edmonton, Alberta, Canada.,6Division of Preventive Medicine, Faculty of Medicine & Dentistry
| | - Martin Mrazik
- 7Department of Educational Psychology, Faculty of Education, University of Alberta; and
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14
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Macri F, Niu BT, Erdelyi S, Mayo JR, Khosa F, Nicolaou S, Brubacher JR. Impact of 24/7 Onsite Emergency Radiology Staff Coverage on Emergency Department Workflow. Can Assoc Radiol J 2021; 73:249-258. [PMID: 34229465 DOI: 10.1177/08465371211023861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Assess the impact of 24/7/365 emergency trauma radiology (ETR) coverage on Emergency Department (ED) patient flow in an urban, quaternary-care teaching hospital. METHODS Patient ED visit and imaging information were extracted from the hospital patient care information system for 2008 to 2018. An interrupted time-series approach with a comparison group was used to study the impact of 24/7/365 ETR on average monthly ED length of stay (ED-LOS) and Emergency Physician to disposition time (EP-DISP). Linear regression models were fit with abrupt and permanent interrupts for 24/7/365 ETR, a coefficient for comparison series and a SARIMA error term; subgroup analyses were performed by patient arrival time, imaging type and chief complaint. RESULTS During the study period, there were 949,029 ED visits and 739,796 diagnostic tests. Following implementation of 24/7/365 coverage, we found a significant decrease in EP-DISP time for patients requiring only radiographs (-29 min;95%CI:-52,-6) and a significant increase in EP-DISP time for major trauma patients (46 min;95%CI:13,79). No significant change in patient throughput was observed during evening hours for any patient subgroup. For overnight patients, there was a reduction in EP-DISP for patients with symptoms consistent with stroke (-78 min;95%CI:-131,-24) and for high acuity patients who required imaging (-33 min;95%CI:-57,-10). Changes in ED-LOS followed a similar pattern. CONCLUSIONS At our institution, 24/7/365 in-house ETR staff radiology coverage was associated with improved ED flow for patients requiring only radiographs and for overnight stroke and high acuity patients. Major trauma patients spent more time in the ED, perhaps reflecting the required multidisciplinary management.
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Affiliation(s)
- Francesco Macri
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada.,Department of Radiology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bonnie T Niu
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada.,Department of Radiology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shannon Erdelyi
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - John R Mayo
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada.,Department of Radiology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Faisal Khosa
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada.,Department of Radiology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Savvas Nicolaou
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada.,Department of Radiology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeffrey R Brubacher
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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15
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Russell B, Philip J, Wawryk O, Vogrin S, Burchell J, Collins A, Le B, Brand C, Hudson P, Sundararajan V. Validation of the responding to urgency of need in palliative care (RUN-PC) triage tool. Palliat Med 2021; 35:759-767. [PMID: 33478366 DOI: 10.1177/0269216320986730] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The Responding to Urgency of Need in Palliative Care (RUN-PC) Triage Tool is a novel, evidence-based tool by which specialist palliative care services can manage waiting lists and workflow by prioritising access to care for those patients with the most pressing needs in an equitable, efficient and transparent manner. AIM This study aimed to establish the intra- and inter-rater reliability, and convergent validity of the RUN-PC Triage Tool and generate recommended response times. DESIGN An online survey of palliative care intake officers applying the RUN-PC Triage Tool to a series of 49 real clinical vignettes was assessed against a reference standard: a postal survey of expert palliative care clinicians ranking the same vignettes in order of urgency. SETTING/PARTICIPANTS Intake officers (n = 28) with a minimum of 2 years palliative care experience and expert clinicians (n = 32) with a minimum of 10 years palliative care experience were recruited from inpatient, hospital consultation and community palliative care services across metropolitan and regional Victoria, Australia. RESULTS The RUN-PC Triage Tool has good intra- and inter-rater reliability in inpatient, hospital consultation and community palliative care settings (Intraclass Correlation Coefficients ranged from 0.61 to 0.74), and moderate to good correlation to expert opinion used as a reference standard (Kendall's Tau rank correlation coefficients ranged from 0.68 to 0.83). CONCLUSION The RUN-PC Triage Tool appears to be a reliable and valid tool for the prioritisation of patients referred to specialist inpatient, hospital consultation and community palliative care services.
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Affiliation(s)
- Bethany Russell
- Palliative Nexus Research Group, University of Melbourne and St Vincent's Hospital Melbourne, VIC, Australia.,Department of Palliative Care, St Vincent's Hospital Melbourne, VIC, Australia
| | - Jennifer Philip
- Palliative Nexus Research Group, University of Melbourne and St Vincent's Hospital Melbourne, VIC, Australia.,Department of Palliative Care, St Vincent's Hospital Melbourne, VIC, Australia.,Victorian Comprehensive Cancer Centre, Melbourne, VIC, Australia.,Department of Palliative Care, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Olivia Wawryk
- Palliative Nexus Research Group, University of Melbourne and St Vincent's Hospital Melbourne, VIC, Australia.,Department of Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Sara Vogrin
- Department of Medicine, St Vincent's Hospital Melbourne and University of Melbourne, Melbourne, VIC, Australia
| | - Jodie Burchell
- Department of Medicine, St Vincent's Hospital Melbourne and University of Melbourne, Melbourne, VIC, Australia
| | - Anna Collins
- Palliative Nexus Research Group, University of Melbourne and St Vincent's Hospital Melbourne, VIC, Australia
| | - Brian Le
- Victorian Comprehensive Cancer Centre, Melbourne, VIC, Australia.,Department of Palliative Care, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Caroline Brand
- Melbourne EpiCentre, University of Melbourne and Melbourne Health, Melbourne, VIC, Australia.,Department of Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Peter Hudson
- Centre for Palliative Care, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia.,End-of-life Care Research Group, Vrije University, Brussels, Belgium.,School of Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Vijaya Sundararajan
- Department of Public Health, La Trobe University, Melbourne, VIC, Australia.,Department of Medicine, St Vincent's Hospital Melbourne and University of Melbourne, Melbourne, VIC, Australia
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16
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Sember M, Donley C, Eggleston M. Implementation of a Provider in Triage and Its Effect on Left without Being Seen Rate at a Community Trauma Center. Open Access Emerg Med 2021; 13:137-141. [PMID: 33824606 PMCID: PMC8018550 DOI: 10.2147/oaem.s296001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 03/09/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Emergency department (ED) overcrowding is a nationally recognized problem and multiple strategies have been proposed and implemented with varying levels of success. It has caused patients to present to the ED but leave without being seen (LWBS). These patients suffer delayed diagnosis, delayed treatment, and ultimately increased morbidity and mortality. In efforts to decrease the number of patients who leave without being seen, one proposed solution is to place a provider in triage to evaluate these patients at the initial point of contact. Methods A retrospective chart review was conducted on patient’s presenting to the Emergency Department from October through January for the years 2013 through 2017. A list of all patient dispositions for each study month was analyzed and compared for the 4 consecutive years with the implementation of an Advanced Practice Provider (APP) in triage. Results A total of 2162 patients dispositioned as LWBS during the entire study period of October 2013 through January 2017 were enrolled in the analysis. After implementation of a provider in triage, there was a 39% overall decrease (95% CI 0.005) in patients who left the ED before completion of treatment. There was a 69% reduction (95% CI 0.005) in patients who left before seeing the provider in triage. After seeing the provider, we saw an 83% reduction (95% CI<0.001) in LWBS. Overall, our initial LWBS rate was found to be 5%, and after implementation of a provider in triage that rate decreased to 1%. Discussion The addition of a provider in triage decreased our LWBS rate from 5% to 1%. The addition of a provider in triage also helped identify sick patients in the waiting room and helped facilitate more rapid assessment of ED patients on arrival.
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Affiliation(s)
- Maria Sember
- Department of Emergency Medicine, Mercy Health Youngstown Hospital, Youngstown, OH, USA
| | - Chad Donley
- Department of Emergency Medicine, Mercy Health Youngstown Hospital, Youngstown, OH, USA
| | - Matthew Eggleston
- Department of Emergency Medicine, Mercy Health Youngstown Hospital, Youngstown, OH, USA
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17
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Delmas P, Fiorentino A, Antonini M, Vuilleumier S, Stotzer G, Kollbrunner A, Jaccard D, Hulaas J, Rutschmann O, Simon J, Hugli O, Gilart de Keranflec'h C, Pasquier J. Effects of environmental distractors on nurse emergency triage accuracy: a pilot study protocol. Pilot Feasibility Stud 2020; 6:171. [PMID: 33292718 PMCID: PMC7648299 DOI: 10.1186/s40814-020-00717-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 10/27/2020] [Indexed: 11/30/2022] Open
Abstract
Background The clinical decisions of emergency department triage nurses need to be of the highest accuracy. However, studies have found repeatedly that these nurses over- or underestimate the severity of patient health conditions. This has major consequences for patient safety and patient flow management. Workplace distractors such as noise and task interruptions have been pointed to as factors that might explain this inaccuracy. The use of a serious game reproducing the work environment during triage affords the opportunity to explore the impact of these distractors on nurse emergency triage accuracy, in a safe setting. Methods/design A pilot study with a factorial design will be carried out to test the acceptability and feasibility of a serious game developed specifically to simulate the triage process in emergency departments and to explore the primary effects of distractors on nurse emergency triage accuracy. Eighty emergency nurses will be randomized into four groups: three groups exposed to different distractors (A, noise; B, task interruptions; C, noise and task interruptions) and one control group. All nurses will have to complete 20 clinical vignettes within 2 h. For each vignette, a gold standard assessment will be determined by experts. Pre-tests will be conducted with clinicians and certified emergency nurses to evaluate the appeal of the serious game. Discussion Study results will inform the design of large-scale investigations and will help identify teaching, training, and research areas that require further development.
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Affiliation(s)
- Philippe Delmas
- La Source School of Nursing, University of Applied Sciences and Arts Western Switzerland (HES-SO), Lausanne, Switzerland.
| | - Assunta Fiorentino
- La Source School of Nursing, University of Applied Sciences and Arts Western Switzerland (HES-SO), Lausanne, Switzerland
| | - Matteo Antonini
- La Source School of Nursing, University of Applied Sciences and Arts Western Switzerland (HES-SO), Lausanne, Switzerland
| | - Séverine Vuilleumier
- La Source School of Nursing, University of Applied Sciences and Arts Western Switzerland (HES-SO), Lausanne, Switzerland
| | - Guy Stotzer
- La Source School of Nursing, University of Applied Sciences and Arts Western Switzerland (HES-SO), Lausanne, Switzerland
| | - Aurélien Kollbrunner
- La Source School of Nursing, University of Applied Sciences and Arts Western Switzerland (HES-SO), Lausanne, Switzerland
| | - Dominique Jaccard
- School of Management and Engineering Vaud, Yverdon-les-Bains, Switzerland
| | - Jarle Hulaas
- School of Management and Engineering Vaud, Yverdon-les-Bains, Switzerland
| | | | - Josette Simon
- Emergency Department, Geneva University Hospital, Geneva, Switzerland
| | - Olivier Hugli
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Charlotte Gilart de Keranflec'h
- School of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland (HES-SO), Lausanne, Switzerland
| | - Jérome Pasquier
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
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18
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Daş M, Bardakci O, Siddikoglu D, Akdur G, Yilmaz MC, Akdur O, Beyazit Y. Prognostic performance of peripheral perfusion index and shock index combined with ESI to predict hospital outcome. Am J Emerg Med 2020; 38:2055-2059. [PMID: 33142174 DOI: 10.1016/j.ajem.2020.06.084] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/18/2020] [Accepted: 06/29/2020] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Peripheral perfusion index (PPI) and shock index (SI) are considered valuable predictors of hospital outcome and mortality in various operative and intensive care settings. In the present study, we evaluated the prognostic capabilities of these parameters for performing emergency department (ED) triage, as represented by the emergency severity index (ESI). METHODS This prospective cross-sectional study included 367 patients aged older than 18 years who visited the ED of a tertiary referral hospital. The ESI triage levels with PPI, SI, and other basic vital sign parameters were recorded for each patient. The hospital outcome of the patients at the end of the ED period, such as discharge, admission to the hospital and death were recorded. RESULTS A total of 367 patients (M/F: 178/189) admitted to the ED were categorized according to ESI and included in the study. A decrease in diastolic BP, SpO2 and PPI increased the likelihood of hospitalization and 30-day mortality. Based on univariate analysis, a significant improvement in performance was found by using age, diastolic BP, mean arterial pressure, SpO2, SI and PPI in terms of predicting high acuity level patients (ESI < 3). In the multivariable analysis only SpO2 and PPI were found to predict ESI < 3 patients. CONCLUSION Peripheral perfusion index and SI as novel triage instruments might provide useful information for predicting hospital admission and mortality in ED patients. The addition of these parameters to existing triage instruments such as ESI could enhance the triage specificity in unselected patients admitted to ED.
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Affiliation(s)
- Murat Daş
- Department of Emergency Medicine, Faculty of Medicine, Çanakkale Onsekiz Mart University, 17020 Çanakkale, Turkey
| | - Okan Bardakci
- Department of Emergency Medicine, Faculty of Medicine, Çanakkale Onsekiz Mart University, 17020 Çanakkale, Turkey.
| | - Duygu Siddikoglu
- Department of Biostatistic, Faculty of Medicine, Çanakkale Onsekiz Mart University, 17020 Çanakkale, Turkey
| | - Gökhan Akdur
- Department of Emergency Medicine, Faculty of Medicine, Çanakkale Onsekiz Mart University, 17020 Çanakkale, Turkey
| | - Musa Caner Yilmaz
- Department of Emergency Medicine, Faculty of Medicine, Çanakkale Onsekiz Mart University, 17020 Çanakkale, Turkey
| | - Okhan Akdur
- Department of Emergency Medicine, Faculty of Medicine, Çanakkale Onsekiz Mart University, 17020 Çanakkale, Turkey
| | - Yavuz Beyazit
- Department of Internal Medicine, Faculty of Medicine, Çanakkale Onsekiz Mart University, 17020 Çanakkale, Turkey
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McLeod SL, Thompson C, Borgundvaag B, Thabane L, Ovens H, Scott S, Ahmed T, Grewal K, McCarron J, Filsinger B, Mittmann N, Worster A, Agoritsas T, Bullard M, Guyatt G. Consistency of triage scores by presenting complaint pre- and post-implementation of a real-time electronic triage decision support tool. J Am Coll Emerg Physicians Open 2020; 1:747-756. [PMID: 33145515 PMCID: PMC7593433 DOI: 10.1002/emp2.12062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 03/18/2020] [Accepted: 03/19/2020] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE eCTAS is a real-time electronic decision-support tool designed to standardize the application of the Canadian Triage and Acuity Scale (CTAS). This study addresses the variability of CTAS score distributions across institutions pre- and post-eCTAS implementation. METHODS We used population-based administrative data from 2016-2018 from all emergency departments (EDs) that had implemented eCTAS for 9 months. Following a 3-month stabilization period, we compared 6 months post-eCTAS data to the same 6 months the previous year (pre-eCTAS). We included triage encounters of adult (≥17 years) patients who presented with 1 of 16 pre-specified, high-volume complaints. For each ED, consistency was calculated as the absolute difference in CTAS distribution compared to the average of all included EDs for each presenting complaint. Pre-eCTAS and post-eCTAS change scores were compared using a paired-samples t-test. We also assessed if eCTAS modifiers were associated with triage consistency. RESULTS There were 363,214 (183,231 pre-eCTAS, 179,983 post-eCTAS) triage encounters included from 35 EDs. Triage scores were more consistent (P < 0.05) post-eCTAS for 6 (37.5%) presenting complaints: chest pain (cardiac features), extremity weakness/symptoms of cerebrovascular accident, fever, shortness of breath, syncope, and hyperglycemia. Triage consistency was similar pre- and post-eCTAS for altered level of consciousness, anxiety/situational crisis, confusion, depression/suicidal/deliberate self-harm, general weakness, head injury, palpitations, seizure, substance misuse/intoxication, and vertigo. Use of eCTAS modifiers was associated with increased triage consistency. CONCLUSIONS eCTAS increased triage consistency across many, but not all, high-volume presenting complaints. Modifier use was associated with increased triage consistency, particularly for non-specific complaints such as fever and general weakness.
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Affiliation(s)
- Shelley L. McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health SystemTorontoOntarioCanada
- Division of Emergency MedicineDepartment of Family and Community MedicineUniversity of TorontoTorontoOntarioCanada
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonOntarioCanada
| | - Cameron Thompson
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health SystemTorontoOntarioCanada
| | - Bjug Borgundvaag
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health SystemTorontoOntarioCanada
- Division of Emergency MedicineDepartment of Family and Community MedicineUniversity of TorontoTorontoOntarioCanada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonOntarioCanada
| | - Howard Ovens
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health SystemTorontoOntarioCanada
- Division of Emergency MedicineDepartment of Family and Community MedicineUniversity of TorontoTorontoOntarioCanada
| | - Steve Scott
- Ontario Health (Cancer Care Ontario)Ministry of HealthTorontoOntarioCanada
| | - Tamer Ahmed
- Ontario Health (Cancer Care Ontario)Ministry of HealthTorontoOntarioCanada
| | - Keerat Grewal
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health SystemTorontoOntarioCanada
| | - Joy McCarron
- Ontario Health (Cancer Care Ontario)Ministry of HealthTorontoOntarioCanada
| | - Brooke Filsinger
- Ontario Health (Cancer Care Ontario)Ministry of HealthTorontoOntarioCanada
| | - Nicole Mittmann
- Ontario Health (Cancer Care Ontario)Ministry of HealthTorontoOntarioCanada
- Sunnybrook Research InstituteTorontoOntarioCanada
| | - Andrew Worster
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonOntarioCanada
- Division of Emergency MedicineDepartment of MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonOntarioCanada
- Division of General Internal Medicine and Division of Clinical EpidemiologyUniversity Hospitals of GenevaGenevaSwitzerland
| | - Michael Bullard
- Department of Emergency MedicineUniversity of AlbertaEdmontonAlbertaCanada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonOntarioCanada
- Department of MedicineMcMaster UniversityHamiltonOntarioCanada
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20
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Lam RPK, Kwok SL, Chaang VK, Chen L, Lau EHY, Chan KL. Performance of a three-level triage scale in live triage encounters in an emergency department in Hong Kong. Int J Emerg Med 2020; 13:28. [PMID: 32522272 PMCID: PMC7288528 DOI: 10.1186/s12245-020-00288-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 05/26/2020] [Indexed: 11/17/2022] Open
Abstract
Background Despite its continued use in many low-volume emergency departments (EDs), 3-level triage systems have not been extensively studied, especially on live triage cases. We have modified from the Australasian Triage Scale and developed a 3-level triage scale, and sought to evaluate its validity, reliability, and over- and under-triage rates in real patient encounters in our setting. Method This was a cross-sectional study in a single ED with 24,000 attendances per year. At triage, each patient was simultaneously assessed by a triage nurse, an adjudicator (the “criterion standard”), and a study nurse independently. Predictive validity was determined by comparing clinical outcomes, such as hospitalization, across triage levels. The discriminating performance of the triage tool in identifying patients requiring earlier medical attention was determined. Inter-observer reliability between the triage nurse and criterion standard, and across providers were determined using kappa statistics. Results In total, 453 triage ratings of 151 triage cases, involving 17 ED triage nurses and 57 nurse pairs, were analysed. The proportion of hospital admission significantly increased with a higher triage rating. The performance of the scale in identifying patients requiring earlier medical attention was as follows: sensitivity, 68.2% (95% CI 45.1–86.1%); specificity, 99.2% (95% CI 95.8–100%); positive predictive value, 93.8% (95% CI 67.6–99.1%); and negative predictive value, 94.8% (95% CI 90.8–97.1%). The over-triage and under-triage rates were 0.7% and 4.6%, respectively. Agreement between the triage nurse and criterion standard was substantial (quadratic-weighted kappa = 0.76, 95% CI, 0.60–0.92, p < 0.001), so was the agreement across nurses (quadratic-weighted kappa = 0.81, 95% CI 0.65–0.97, p < 0.001). Conclusions The 3-level triage system appears to have good validity and reasonable reliability in a low-volume ED setting. Further studies comparing 3-level and prevailing 5-level triage scales in live triage encounters and different ED settings are warranted.
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Affiliation(s)
- Rex Pui Kin Lam
- 24-hour Outpatient and Emergency Department, Gleneagles Hong Kong Hospital, 1 Nam Fung Path, Wong Chuk Hang, Hong Kong Special Administrative Region, China. .,Emergency Medicine Unit, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Room 514, 5/F, William MW Mong Block, 21 Sassoon Road, Pokfulam, Hong Kong Special Administrative Region, China.
| | - Shing Lam Kwok
- 24-hour Outpatient and Emergency Department, Gleneagles Hong Kong Hospital, 1 Nam Fung Path, Wong Chuk Hang, Hong Kong Special Administrative Region, China.,Present address: 24-hour Urgent Care Center, Tseun Wan Adventist Hospital, 199 Tseun King Circuit, Tseun Wan New Territories, Hong Kong
| | - Vi Ka Chaang
- Emergency Medicine Unit, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Room 514, 5/F, William MW Mong Block, 21 Sassoon Road, Pokfulam, Hong Kong Special Administrative Region, China
| | - Lujie Chen
- Emergency Medicine Unit, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Room 514, 5/F, William MW Mong Block, 21 Sassoon Road, Pokfulam, Hong Kong Special Administrative Region, China
| | - Eric Ho Yin Lau
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 2/F, Patrick Mansion Building, 7 Sassoon Road, Pokfulam, Hong Kong Special Administrative Region, China
| | - Kin Ling Chan
- 24-hour Outpatient and Emergency Department, Gleneagles Hong Kong Hospital, 1 Nam Fung Path, Wong Chuk Hang, Hong Kong Special Administrative Region, China
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Decision aid for early identification of acute underlying illness in emergency department patients with atrial fibrillation or flutter. CAN J EMERG MED 2020; 22:301-308. [PMID: 31856926 DOI: 10.1017/cem.2019.454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Emergency department (ED) patients with atrial fibrillation or flutter (AFF) with underlying occult condition such as sepsis or heart failure, and who are managed with rate or rhythm control, have poor prognoses. Such conditions may not be easy to identify early in the ED evaluation when critical treatment decisions are made. We sought to develop a simple decision aid to quickly identify undifferentiated ED AFF patients who are at high risk of acute underlying illness. METHODS We collected consecutive ED patients with electrocardiogram-proven AFF over a 1-year period and performed a chart review to ascertain demographics, comorbidities, and investigations. The primary outcome was having an acute underlying illness according to prespecified criteria. We used logistic regression to identify factors associated with the primary outcome, and developed criteria to identify those with an underlying illness at presentation. RESULTS Of 1,083 consecutive undifferentiated ED AFF patients, 400 (36.9%) had an acute underlying illness; they were older with more comorbidities. Modeling demonstrated that three predictors (ambulance arrival; chief complaint of chest pain, dyspnea, or weakness; CHA2DS2-VASc score greater than 2) identified 93% of patients with acute underlying illness (95% confidence interval [CI], 91-96%) with 54% (95% CI, 50-58%) specificity. The decision aid missed 28 patients; (7.0%) simple blood tests and chest radiography identified all within an hour of presentation. CONCLUSIONS In ED patients with undifferentiated AFF, this simple predictive model rapidly differentiates patients at risk of acute underlying illness, who will likely merit investigations before AFF-specific therapy.
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Effectiveness of nurse-initiated X-ray for emergency department patients with distal limb injuries: a systematic review. Eur J Emerg Med 2019; 26:314-322. [DOI: 10.1097/mej.0000000000000604] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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23
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McLeod SL, McCarron J, Ahmed T, Grewal K, Mittmann N, Scott S, Ovens H, Garay J, Bullard M, Rowe BH, Dreyer J, Borgundvaag B. Interrater Reliability, Accuracy, and Triage Time Pre- and Post-implementation of a Real-Time Electronic Triage Decision-Support Tool. Ann Emerg Med 2019; 75:524-531. [PMID: 31564379 DOI: 10.1016/j.annemergmed.2019.07.048] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/24/2019] [Accepted: 07/30/2019] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE The electronic Canadian Triage and Acuity Scale (eCTAS) is a real-time electronic triage decision-support tool designed to improve patient safety and quality of care by standardizing the application of the Canadian Triage and Acuity Scale (CTAS). The objective of this study is to determine interrater agreement of triage scores pre- and post-implementation of eCTAS. METHODS This was a prospective, observational study conducted in 7 emergency departments (EDs), selected to represent a mix of triage documentation practices, hospital types, and patient volumes. A provincial CTAS auditor observed triage nurses in the ED pre- and post-implementation of eCTAS and assigned an independent CTAS score in real time. Research assistants independently recorded triage time. Interrater agreement was estimated with κ statistics with 95% confidence intervals (CIs). RESULTS A total of 1,491 individual triage assessments (752 pre-eCTAS, 739 post-implementation) were audited during 42 7-hour triage shifts (21 pre-eCTAS, 21 post-implementation). Exact modal agreement was achieved for 567 patients (75.4%) pre-eCTAS compared with 685 patients (92.7%) triaged with eCTAS. With the auditor's CTAS score as the reference, eCTAS significantly reduced the number of patients over-triaged (12.0% versus 5.1%; Δ 6.9; 95% CI 4.0 to 9.7) and under-triaged (12.6% versus 2.2%; Δ 10.4; 95% CI 7.9 to 13.2). Interrater agreement was higher with eCTAS (unweighted κ 0.89 versus 0.63; quadratic-weighted κ 0.93 versus 0.79). Median triage time was 312 seconds (n=3,808 patients) pre-eCTAS and 347 seconds (n=3,489 patients) with eCTAS (Δ 35 seconds; 95% CI 29 to 40 seconds). CONCLUSION A standardized, electronic approach to performing triage assessments improves both interrater agreement and data accuracy without substantially increasing triage time.
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Affiliation(s)
- Shelley L McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada; Department of Family and Community Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Joy McCarron
- Cancer Care Ontario, Ministry of Health and Long-Term Care, Toronto, Ontario, Canada
| | - Tamer Ahmed
- Cancer Care Ontario, Ministry of Health and Long-Term Care, Toronto, Ontario, Canada
| | - Keerat Grewal
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Nicole Mittmann
- Cancer Care Ontario, Ministry of Health and Long-Term Care, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Steve Scott
- Cancer Care Ontario, Ministry of Health and Long-Term Care, Toronto, Ontario, Canada
| | - Howard Ovens
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada; Department of Family and Community Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jason Garay
- Cancer Care Ontario, Ministry of Health and Long-Term Care, Toronto, Ontario, Canada
| | - Michael Bullard
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada; School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Jonathan Dreyer
- Division of Emergency Medicine, The University of Western Ontario, London, Ontario, Canada
| | - Bjug Borgundvaag
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada; Department of Family and Community Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
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Wang L, Homayra F, Pearce LA, Panagiotoglou D, McKendry R, Barrios R, Mitton C, Nosyk B. Identifying mental health and substance use disorders using emergency department and hospital records: a population-based retrospective cohort study of diagnostic concordance and disease attribution. BMJ Open 2019; 9:e030530. [PMID: 31300509 PMCID: PMC6629422 DOI: 10.1136/bmjopen-2019-030530] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Administrative data are increasingly being used for surveillance and monitoring of mental health and substance use disorders (MHSUD) across Canada. However, the validity of the diagnostic codes specific to MHSUD is unknown in emergency departments (EDs). Our objective was to determine the concordance, and individual-level and hospital-level factors associated with concordance, between diagnosis codes assigned in ED and at discharge from hospital for MHSUD-related conditions. DESIGN Population-based retrospective cohort study. SETTING EDs and hospitals within Vancouver Coastal Health Authority (VCH), British Columbia, Canada. PARTICIPANTS 16 926 individuals who were admitted into a VCH hospital following an ED visit from 1 April 2009 to 31 March 2017, contributing to 48 116 pairs of ED and hospital discharge diagnoses. PRIMARY AND SECONDARY OUTCOME MEASURES We examined concordance in identifying MHSUD between the primary discharge diagnosis codes based on the International Statistical Classification of Diseases, 9th and 10th Revisions (Canada) assigned in the ED and those assigned in the hospital among all ED visits resulting in a hospital admission. We calculated the percent overall agreement, positive agreement, negative agreement and Cohen's kappa coefficient. We performed multiple regression analyses to identify factors independently associated with discordance. RESULTS We found a high level of concordance for broad categories of MH conditions (overall agreement=0.89, positive agreement=0.74 and kappa=0.67), and a fair level of concordance for SUDs (overall agreement=0.89, positive agreement=0.31 and kappa=0.27). SUDs were less likely to be indicated as the primary cause in ED as opposed to in hospital (3.8% vs 11.7%). In multiple regression analyses, ED visits occurring during holidays, weekends and overnight (21:00-8:59 hours) were associated with increased odds of discordance in identifying MH conditions (adjusted OR 1.47, 95% CI 1.11 to 1.93; 1.27, 95% CI 1.16 to 1.40; 1.30, 95% CI 1.19 to 1.42, respectively). CONCLUSIONS ED data could be used to improve surveillance and monitoring of MHSUD. Future efforts are needed to improve screening for individuals with MHSUD and subsequently connect them to treatment and follow-up care.
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Affiliation(s)
- Linwei Wang
- Epidemiology and Population Health Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Fahmida Homayra
- Epidemiology and Population Health Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Lindsay A Pearce
- Epidemiology and Population Health Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Dimitra Panagiotoglou
- Epidemiology and Population Health Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Rachael McKendry
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Rolando Barrios
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Craig Mitton
- Centre for Clinical Epidemiology and Evaluation, University of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- Epidemiology and Population Health Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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Mackay MH, Ratner PA, Veenstra G, Scheuermeyer FX, Grubisic M, Ramanathan K, Murray C, Humphries KH. Racism Is Not a Factor in Door-to-electrocardiogram Times of Patients With Symptoms of Acute Coronary Syndrome: A Prospective, Observational Study. Acad Emerg Med 2019; 26:491-500. [PMID: 30222233 PMCID: PMC6563064 DOI: 10.1111/acem.13569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/07/2018] [Accepted: 09/11/2018] [Indexed: 12/03/2022]
Abstract
Background Investigators have identified important racial identity/ethnicity‐based differences in some aspects of acute coronary syndrome (ACS) care and outcomes (time to presentation, symptoms, receipt of coronary angiography/revascularization, repeat revascularization, mortality). Patient‐based differences such as pathophysiology and treatment‐seeking behavior account only partly for these outcome differences. We sought to investigate whether there are racial identity/ethnicity‐based variations in the initial emergency department (ED) triage and care of patients with suspected ACS in Canadian hospitals. Methods We prospectively enrolled ED patients with suspected ACS from one university‐affiliated and two community hospitals. Trained research assistants administered a standardized interview to gather data on symptoms, treatment‐seeking patterns, and self‐reported racial/ethnic identity: “white,” South Asian” (SA), “Asian,” or “Other.” Clinical parameters were obtained through chart review. The primary outcome was door‐to‐electrocardiogram (D2ECG) time. ECG times were log‐transformed and two linear regression models, controlling for important demographic, system, and clinical factors, were fit. Results Of 448 participants, 214 (48%) reported white identity, 115 (26%) SA, 83 (19%) Asian, and 36 (8%) “Other.” Asian respondents were younger and more likely to report initial discomfort as “low” and be accompanied by family; respondents identifying as “Other” were more likely to report initial discomfort as “high.” There was no difference in D2ECG time between white participants and all other groups, but there were statistically significant differences by sex: women had longer D2ECG times than men. Exploring more specific racial identities revealed similar findings: no significant differences between the white, SA, Asian, and other groups, while sex (women had 13.4% [95% confidence interval, 0.81%–27.57%] longer D2ECG times) remained statistically significantly different in the adjusted models. Conclusion Although racial/ethnicity‐based differences in aspects of ACS care have been previously identified, we found no differences in the current study of early ED care in a Canadian urban setting. However, female patients experience longer D2ECG times, and this may be a target for process improvements.
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Affiliation(s)
- Martha H. Mackay
- University of British Columbia Vancouver British Columbia Canada
- BC Centre for Improved Cardiovascular Health Vancouver British Columbia Canada
- Centre for Health Evaluation and Outcomes Sciences Vancouver British Columbia Canada
| | - Pamela A. Ratner
- University of British Columbia Vancouver British Columbia Canada
| | - Gerry Veenstra
- University of British Columbia Vancouver British Columbia Canada
| | | | - Maja Grubisic
- BC Centre for Improved Cardiovascular Health Vancouver British Columbia Canada
| | | | - Craig Murray
- Fraser Health Authority Surrey British Columbia Canada
| | - Karin H. Humphries
- University of British Columbia Vancouver British Columbia Canada
- BC Centre for Improved Cardiovascular Health Vancouver British Columbia Canada
- Centre for Health Evaluation and Outcomes Sciences Vancouver British Columbia Canada
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Frequent emergency department use and mortality in patients with substance and opioid use in Alberta: A population-based retrospective cohort study. CAN J EMERG MED 2019; 21:482-491. [PMID: 30983561 DOI: 10.1017/cem.2019.15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES In the current opioid epidemic, identifying high-risk patients among those with substance and opioid use may prevent deaths. The objective of this study was to determine whether frequent emergency department (ED) use and degree of frequent use are associated with mortality among ED patients with substance and opioid use. METHODS This cohort study used linked population-based ED (National Ambulatory Care Reporting System) and mortality data from Alberta. All adults ≥ 18 years with substance or opioid use-related visits based on diagnostic codes from April 1, 2012, to March 31, 2013, were included (n = 16,389). Frequent use was defined by ≥ 5 visits in the previous year. Outcomes were unadjusted and adjusted (for age, sex, income) mortality within 90 days (primary), and 30 days, 365 days, and 2 years (secondary). To examine degree, frequent use was subcategorized into 5-10, 11-15, 16-20, and > 20 visits. RESULTS Frequent users were older, lower income, and made lower acuity visits than non-frequent users. Frequent users with substance use had higher mortality at 365 days (hazard ratio [HR] 1.36 [1.04, 1.77]) and 2 years (HR 1.32 [1.04, 1.67]), but not at 90 or 30 days. Mortality did not differ for frequent users with opioid use overall. By degree, patients with substance use and > 20 visits/year and with opioid use and 16-20 visits/year demonstrated a higher 365-day and 2-year mortality. CONCLUSIONS Among patients with substance use, frequent ED use and extremely frequent use (> 20 visits/year) were associated with long-term but not short-term mortality. These findings suggest a role for targeted screening and preventive intervention.
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Choi H, Ok JS, An SY. [Evaluation of Validity of the Korean Triage and Acuity Scale]. J Korean Acad Nurs 2019; 49:26-35. [PMID: 30837440 DOI: 10.4040/jkan.2019.49.1.26] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 12/20/2018] [Accepted: 12/24/2018] [Indexed: 11/09/2022]
Abstract
PURPOSE The aim of this study was to identify the predictive validity of the Korean Triage and Acuity Scale (KTAS). METHODS This methodological study used data from National Emergency Department Information System for 2016. The KTAS disposition and emergency treatment results for emergency patients aged 15 years and older were analyzed to evaluate its predictive validity through its sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS In case of death in the emergency department, or where the intensive care unit admission was considered an emergency, the sensitivity, specificity, positive predictive value, and negative predictive value of the KTAS were 0.916, 0.581, 0.097, and 0.993, respectively. In case of death in the emergency department, or where the intensive or non-intensive care unit admission was considered an emergency, the sensitivity, specificity, and positive predictive value, and negative predictive value were 0.700, 0.642, 0.391, and 0.867, respectively. CONCLUSION The results of this study showed that the KTAS had high sensitivity but low specificity. It is necessary to constantly review and revise the KTAS level classification because it still results in a few errors of under and over-triage. Nevertheless, this study is meaningful in that it was an evaluation of the KTAS for the total cases of adult patients who sought help at regional and local emergency medical centers in 2016.
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Affiliation(s)
- Heejung Choi
- Department of Nursing, Konkuk University, Cheongju, Korea
| | - Jong Sun Ok
- Department of Nursing, Konkuk University, Cheongju, Korea
| | - Soo Young An
- Department of Emergency Department, Konkuk University Medical Center, Seoul, Korea.
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Do physicians and nurses agree on triage levels in the emergency department? A meta-analysis. Notf Rett Med 2019. [DOI: 10.1007/s10049-019-0580-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Zibrowski E, Shepherd L, Sedig K, Booth R, Gibson C. Easier and Faster Is Not Always Better: Grounded Theory of the Impact of Large-Scale System Transformation on the Clinical Work of Emergency Medicine Nurses and Physicians. JMIR Hum Factors 2018; 5:e11013. [PMID: 30545817 PMCID: PMC6315245 DOI: 10.2196/11013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/23/2018] [Accepted: 09/04/2018] [Indexed: 12/04/2022] Open
Abstract
Background The effectiveness of Lean Thinking as a quality improvement method for health care has been contested due, in part, to our limited contextual understanding of how it affects the working conditions and clinical workflow of nurses and physicians. Although there are some initial indications, arising from prevalence surveys and interviews, that Lean may intensify work performed within medical environments, the evidence base still requires detailed descriptions of the changes that were actually introduced to individuals’ clinical workflow and how these changes impacted health care professionals. Objective The aim of this study was to explore ways in which a Lean intervention may impact the clinical work of emergency medicine nurses and physicians. Methods We used a realist grounded theory approach to explore the clinical work of nurses and physicians practicing in 2 emergency medicine departments from a single teaching hospital in Canada. The hospital has 1000 beds with 128,000 emergency department (ED) visits annually. In 2013, both sites began a large-scale, Lean-driven system transformation of their practice environments. In-person interviews were iteratively conducted with health care professionals from July to December 2017. Information from transcripts was coded into categories and compared with existing codes. With repeated review of transcripts and evolving coding, we organized categories into themes. Data collection continued to theoretical sufficiency. Results A total of 15 emergency medicine nurses and 5 physicians were interviewed. Of these, 18 individuals had practiced for at least 10 years. Our grounded theory involved 3 themes: (1) organization of our clinical work, (2) pushed pace in the front cell, and (3) the toll this all takes on us. Although the intervention was supposed to make the EDs work easier, faster, and better, the participants in our study indicated that the changes made had the opposite impact. Nurses and physicians described ways in which the reconfigured EDs disrupted their established practice routines and resulted in the intensification of their work. Participants also identified indications of deskilling of nurses’ work and how the new push-forward model of patient care had detrimental impacts on their physical, cognitive, and emotional well-being. Conclusions To our knowledge, this is the first study to describe the impact of Lean health care on the working conditions and actual work of emergency medicine nurses and physicians. We theorize that rather than support health care professionals in their management of the complexities that characterize emergency medicine, the physical and process-based changes introduced by the Lean intervention acted to further complicate their working environment. We have illuminated some unintended consequences associated with accelerating patient flow on the clinical workflow and perceived well-being of health care professionals. We identify some areas for reconsideration by the departments and put forward ideas for future research.
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Affiliation(s)
- Elaine Zibrowski
- Health Information Science, Faculty of Information & Media Sciences, University of Western Ontario, London, ON, Canada
| | - Lisa Shepherd
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
| | - Kamran Sedig
- Department of Computer Science, University of Western Ontario, London, ON, Canada.,Faculty of Information & Media Sciences, University of Western Ontario, London, ON, Canada
| | - Richard Booth
- Arthur Labatt Family School of Nursing, University of Western Ontario, London, ON, Canada
| | - Candace Gibson
- Pathology & Laboratory Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
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Alsabbagh MW, Houle SKD. The proportion, conditions, and predictors of emergency department visits that can be potentially managed by pharmacists with expanded scope of practice. Res Social Adm Pharm 2018; 15:1289-1297. [PMID: 30545614 DOI: 10.1016/j.sapharm.2018.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 12/06/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pharmacists have been shown to be beneficial for inclusion in emergency department (ED) services; however, little has been done to assess these benefits with pharmacists having even wider scopes of practice, including limited prescribing authority. OBJECTIVES The aims of this study were to determine the proportion of ED visits that can potentially be managed by pharmacists, the most prevalent conditions within these cases, and the factors associated with patients presenting with such cases to the ED. METHODS This was a retrospective quantitative cohort study using administrative databases from 2010 to 2017. Among all unscheduled ED visits in Ontario, all visits with a Family Practice Sensitive Condition and Canadian Triage and Acuity Scale score of IV or V were identified, in addition to conditions that can be managed by pharmacists with expanded scope. Logistic regression was performed to identify determinants of having a potentially pharmacist-manageable condition. RESULTS Of 34,550,020 ED visits identified, 12.4% (n = 4,293,807) were considered FPSC with CTAS IV or V. Of these, 1,494,887 (34.8%) were for conditions considered to be potentially manageable by pharmacists, representing 4.3% of all ED visits. The most frequent diagnoses observed were: acute pharyngitis, conjunctivitis, rash and other nonspecific skin eruption, otitis externa, cough, acute sinusitis, and dermatitis. Female gender, having a family physician or presenting with a CTAS of IV were associated with higher odds of presenting to the ED, while increased age and income were associated with lower odds. CONCLUSIONS Under an expanded scope, pharmacists could potentially have managed nearly 1.5 million cases presenting to the ED over the study period. The introduction of ED-based or community pharmacists practicing under an expanded scope may have a positive impact on overcrowding in EDs.
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Affiliation(s)
- Mhd Wasem Alsabbagh
- School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, N2G 1C5, ON, Canada; Ontario Pharmacy Evidence Network (OPEN), School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, N2G 1C5, ON, Canada. https://uwaterloo.ca/pharmacy/people-profiles/wasem-alsabbagh
| | - Sherilyn K D Houle
- School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, N2G 1C5, ON, Canada; Ontario Pharmacy Evidence Network (OPEN), School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, N2G 1C5, ON, Canada
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Hinson JS, Martinez DA, Cabral S, George K, Whalen M, Hansoti B, Levin S. Triage Performance in Emergency Medicine: A Systematic Review. Ann Emerg Med 2018; 74:140-152. [PMID: 30470513 DOI: 10.1016/j.annemergmed.2018.09.022] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/11/2018] [Accepted: 09/21/2018] [Indexed: 12/12/2022]
Abstract
STUDY OBJECTIVE Rapid growth in emergency department (ED) triage literature has been accompanied by diversity in study design, methodology, and outcome assessment. We aim to synthesize existing ED triage literature by using a framework that enables performance comparisons and benchmarking across triage systems, with respect to clinical outcomes and reliability. METHODS PubMed, EMBASE, Scopus, and Web of Science were systematically searched for studies of adult ED triage systems through 2016. Studies evaluating triage systems with evidence of widespread adoption (Australian Triage Scale, Canadian Triage and Acuity Scale, Emergency Severity Index, Manchester Triage Scale, and South African Triage Scale) were cataloged and compared for performance in identifying patients at risk for mortality, critical illness and hospitalization, and interrater reliability. This study was performed and reported in adherence to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. RESULTS A total of 6,160 publications were identified, with 182 meeting eligibility criteria and 50 with sufficient data for inclusion in comparative analysis. The Canadian Triage and Acuity Scale (32 studies), Emergency Severity Index (43), and Manchester Triage Scale (38) were the most frequently studied triage scales, and all demonstrated similar performance. Most studies (6 of 8) reported high sensitivity (>90%) of triage scales for identifying patients with ED mortality as high acuity at triage. However, sensitivity was low (<80%) for identification of patients who had critical illness outcomes and those who died within days of the ED visit or during the index hospitalization. Sensitivity varied by critical illness and was lower for severe sepsis (36% to 74%), pulmonary embolism (54%), and non-ST-segment elevation myocardial infarction (44% to 85%) compared with ST-segment elevation myocardial infarction (56% to 92%) and general outcomes of ICU admission (58% to 100%) and lifesaving intervention (77% to 98%). Some proportion of hospitalized patients (3% to 45%) were triaged to low acuity (level 4 to 5) in all studies. Reliability measures (κ) were variable across evaluations, with only a minority (11 of 42) reporting κ above 0.8. CONCLUSION We found that a substantial proportion of ED patients who die postencounter or are critically ill are not designated as high acuity at triage. Opportunity to improve interrater reliability and triage performance in identifying patients at risk of adverse outcome exists.
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Affiliation(s)
- Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Diego A Martinez
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephanie Cabral
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Kevin George
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD
| | - Madeleine Whalen
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Whiting School of Engineering, Johns Hopkins University, Baltimore, MD
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Brubacher JR, Shih Y, Weng JT, Verma R, Evans D, Grafstein E. Low-impact strategy for capturing better emergency department injury surveillance data. Inj Prev 2018; 25:507-513. [PMID: 30337353 DOI: 10.1136/injuryprev-2018-042958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 09/10/2018] [Accepted: 09/16/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Injury prevention should be informed by timely surveillance data. Unfortunately, most injury surveillance only captures patients with severe injuries and is not available in real time, hampering prevention efforts. We aimed to develop and pilot a simple injury surveillance strategy that can be integrated into routine emergency department (ED) workflow to collect more robust mechanism of injury information at time of visit for all injured ED patients with minimal impact on workflow. METHODS We reviewed ED injury surveillance systems and considered ED workflow. Forms were developed to collect injury-related information on ED patients and refined to address workload concerns raised by key stakeholders. Research assistants observed ED staff as they registered injured patients and noted the time required to collect data and any ambiguities or concerns encountered. Interobserver agreement was recorded. RESULTS Injury surveillance questions were based on a modification of the International Classification of External Causes of Injury. Research assistants observed 222 injured patients being admitted by registration clerks. The mean time required to complete the surveillance form was 64.9 s (95% CI 59.9 s to 69.9 s) for paper-based forms (120 cases) and 44.5 s (95% CI 41.7s to 47.4s) with direct electronic data entry (102 cases). Interobserver agreement (26 cases) was 100% for intent (kappa=1.0) of injury and 96% for mechanism of injury (kappa=0.74). CONCLUSIONS We report a simple injury surveillance strategy that ED staff can use to collect meaningful injury data in real time with minimal impact on workflow. This strategy can be adapted to enhance regional injury surveillance efforts.
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Affiliation(s)
- Jeffrey R Brubacher
- Department of Emergency Medicine, University of British Columbia, c/o Vancouver General Hospital Emergency Research Office, Vancouver, British Columbia, Canada
| | - Yuda Shih
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jian Ting Weng
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rahul Verma
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - David Evans
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Grafstein
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Kim JJ, Kwok ESH, Cook OG, Calder LA. Characterizing Highly Frequent Users of a Large Canadian Urban Emergency Department. West J Emerg Med 2018; 19:926-933. [PMID: 30429923 PMCID: PMC6225932 DOI: 10.5811/westjem.2018.9.39369] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 09/10/2018] [Accepted: 09/24/2018] [Indexed: 11/23/2022] Open
Abstract
Introduction Highly frequent users (HFU) of the emergency department (ED) are a poorly defined population. This study describes patient and visit characteristics for Canadian ED HFU and patient subgroups with mental illness, substance misuse, or ≥ 30 yearly ED visits. Methods We reviewed health records from a random selection of adult patients whose visit frequency comprised the 99th percentile of yearly ED visits to The Ottawa Hospital. We excluded scheduled repeat ED assessments. We collected the following: 1) patient characteristics – age, sex, and comorbidities; and 2) ED visit characteristics – diagnosis category, length of stay, presentation time, consultation services, and final disposition. Two reviewers collected data, and we performed an inter-rater review to measure agreement. Results We analyzed 3,164 ED visits for 261 patients in all subgroups overall. Within the HFU random selection, mean age was 53.4 ± 1.3, and 55.6% were female. Most patients had a fixed address (88.9%), and family physician (87.2%). Top ED diagnoses included musculoskeletal pain (9.6%), alcohol intoxication (8.5%), and abdominal pain (8.4%). Allied health (social work, geriatric emergency medicine, or community care access centre) was consulted for 5.9% of visits. In 52.7% of these cases, allied health services were not available at the time of presentation. Conclusion HFU are a complex population who represent a marked proportion of annual ED visits. Our data indicate that there are opportunities to improve the current approaches to care. Future work examining ED-based screening and multi-disciplinary approaches for HFU may help reduce frequent ED presentations, and better serve this vulnerable population.
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Affiliation(s)
- Julie J Kim
- University of Ottawa, Department of Emergency Medicine, Ottawa, Ontario, Canada
| | - Edmund S H Kwok
- University of Ottawa, Department of Emergency Medicine, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Olivia G Cook
- University of Ottawa, Department of Undergraduate Medicine, Ottawa, Ontario, Canada
| | - Lisa A Calder
- University of Ottawa, Department of Emergency Medicine, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Humphries KH, Gao M, Lee MK, Izadnegahdar M, Holmes DT, Scheuermeyer FX, Mackay M, Mattman A, Grafstein E. Sex Differences in Cardiac Troponin Testing in Patients Presenting to the Emergency Department with Chest Pain. J Womens Health (Larchmt) 2018; 27:1327-1334. [PMID: 30010472 DOI: 10.1089/jwh.2017.6812] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Elevated cardiac troponin (cTn), with signs/symptoms of ischemia, is a key element in a diagnosis of myocardial infarction (MI). Underdiagnosis of MI in women has been attributed to atypical symptoms, inconsistent ECG findings, and less diagnostic testing. We sought to determine if there are sex differences in cTn testing following presentation to the emergency department (ED) with a chief complaint of ischemic chest pain (CP) and if presentation affects diagnostic assessment. METHODS All adults presenting to six hospital EDs in the Vancouver, Canada with a chief complaint of ischemic CP from 2009 to 2013 were included. The highest cTn level within 24 hours of ED presentation was used. CP was classified into cardiac- or respiratory dominant based on standard Canadian Emergency Department Triage and Acuity Scale coding. Chi-square testing was used to test for sex differences in CP categories and cTn testing within 24 hours. Logistic regression models were used to examine the association between sex, cTn testing, and CP categories. RESULTS Of 27,063 patients with ischemic CP, cardiac presentation was more common in men than women, irrespective of age. Among cardiac CP, 24.7% of men were <50 years compared to 18.2% of women; however, more women (19.9%) than men (11.6%) were >80 years. Overall, women were 1.8% less likely to have cTn testing; in patients <50 years, testing was markedly lower in women compared to men [odds ratio, OR (95% confidence intervals, CI) 0.78 (0.70-0.87)]. The odds of cardiac catheterization within 90 days of ED presentation were lower in women [OR, (95% CI) 0.52 (0.44-0.63)]. Even with cardiac CP, 17.7% of women versus 32.7% of men had cardiac catheterization. CONCLUSIONS In men and women presenting to the ED with ischemic CP, cTn testing overall is similar except among young women under 50 years old, where it is markedly lower. Women undergo less cardiac catheterization, irrespective of CP type.
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Affiliation(s)
- Karin H Humphries
- 1 Division of Cardiology, University of British Columbia , Vancouver, British Columbia, Canada .,2 BC Centre for Improved Cardiovascular Health Vancouver, British Columbia, Canada
| | - Min Gao
- 2 BC Centre for Improved Cardiovascular Health Vancouver, British Columbia, Canada
| | - May K Lee
- 2 BC Centre for Improved Cardiovascular Health Vancouver, British Columbia, Canada
| | - Mona Izadnegahdar
- 2 BC Centre for Improved Cardiovascular Health Vancouver, British Columbia, Canada
| | - Daniel T Holmes
- 3 Department of Pathology and Lab Medicine, University of British Columbia , Vancouver, British Columbia, Canada
| | - Frank X Scheuermeyer
- 4 Department of Emergency Medicine, University of British Columbia , Vancouver, British Columbia, Canada
| | - Martha Mackay
- 5 School of Nursing, University of British Columbia , Vancouver, British Columbia, Canada
| | - Andre Mattman
- 3 Department of Pathology and Lab Medicine, University of British Columbia , Vancouver, British Columbia, Canada
| | - Eric Grafstein
- 4 Department of Emergency Medicine, University of British Columbia , Vancouver, British Columbia, Canada
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Bakewell F, Addleman S, Dickinson G, Thiruganasambandamoorthy V. Use of the emergency department by refugees under the Interim Federal Health Program: A health records review. PLoS One 2018; 13:e0197282. [PMID: 29746538 PMCID: PMC5945039 DOI: 10.1371/journal.pone.0197282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 04/29/2018] [Indexed: 11/23/2022] Open
Abstract
Introduction In June 2012, the federal government made cuts to the Interim Federal Health (IFH) Program that reduced or eliminated health insurance for refugee claimants in Canada. The purpose of this study was to examine the effect of the cuts on emergency department (ED) use among patients claiming IFH benefits. Methods We conducted a health records review at two tertiary care EDs in Ottawa. We reviewed all ED visits where an IFH claim was made at triage, for 18 months before and 18 months after the changes to the program on June 30, 2012 (2011–2013). Claims made before and after the cuts were compared in terms of basic demographics, chief presenting complaints, acuity, diagnosis, presence of primary care, and financial status of the claim. Bivariate or multivariate logistic regression analysis was performed to yield odds ratios (OR) with 95% confidence intervals. Results There were a total of 612 IFH claims made in the ED from 2011–2013. The demographic characteristics, acuity of presentation and discharge diagnoses were similar during both the before and after periods. Overall, 28.6% fewer claims were made under the IFH program after the cuts. Of the claims made, significantly more were rejected after the cuts than before (13.7% after vs. 3.9% before, adjusted OR 4.28, 95% CI: 2.18–8.40; p<0.05). The majority (75.0%) of rejected claims have not been paid by patients. Fewer patients after the cuts indicated that they had a family physician (20.4% after vs. 30% before, unadjusted OR 1.67, 95% CI: 1.14–2.44; p<0.05) yet a higher proportion of patients without a family physician were still advised to follow up with their family doctor during the after period (67.2% after vs. 41.8% before, unadjusted OR 2.85, 95% CI: 1.45–5.62; p<0.05). Conclusion A higher proportion of both rejected and subsequently unpaid claims after the IFH cuts in June 2012, as demonstrated in the logistic regression analysis in this health records review, represents a potential barrier to emergency medical care, as well as a new financial burden to be shouldered by patients and hospitals. A reduction in IFH claims in the ED and a reduction in the number of patients with access to a family physician also suggests inadequate primary care for this population, yet this was not reflected in the follow-up advice offered by ED physicians to patients.
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Affiliation(s)
- Francis Bakewell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- * E-mail:
| | - Sarah Addleman
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Garth Dickinson
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
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Chan TM, Mercuri M, Van Dewark K, Sherbino J, Schwartz A, Norman G, Lineberry M. Managing Multiplicity: Conceptualizing Physician Cognition in Multipatient Environments. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:786-793. [PMID: 29210754 DOI: 10.1097/acm.0000000000002081] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE Emergency physicians (EPs) regularly manage multiple patients simultaneously, often making time-sensitive decisions around priorities for multiple patients. Few studies have explored physician cognition in multipatient scenarios. The authors sought to develop a conceptual framework to describe how EPs think in busy, multipatient environments. METHOD From July 2014 to May 2015, a qualitative study was conducted at McMaster University, using a think-aloud protocol to examine how 10 attending EPs and 10 junior residents made decisions in multipatient environments. Participants engaged in the think-aloud exercise for five different simulated multipatient scenarios. Transcripts from recorded interviews were analyzed inductively, with an iterative process involving two independent coders, and compared between attendings and residents. RESULTS The attending EPs and junior residents used similar processes to prioritize patients in these multipatient scenarios. The think-aloud processes demonstrated a similar process used by almost all participants. The cognitive task of patient prioritization consisted of three components: a brief overview of the entire cohort of patients to determine a general strategy; an individual chart review, whereby the participant created a functional patient story from information available in a file (i.e., vitals, brief clinical history); and creation of a relative priority list. Compared with residents, the attendings were better able to construct deeper and more complex patient stories. CONCLUSIONS The authors propose a conceptual framework for how EPs prioritize care for multiple patients in complex environments. This study may be useful to teachers who train physicians to function more efficiently in busy clinical environments.
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Affiliation(s)
- Teresa M Chan
- T.M. Chan is assistant professor, Division of Emergency Medicine, Department of Medicine, Michael G. DeGroote School of Medicine, program director, Clinician Educator Area of Focused Competence program, and adjunct scientist, McMaster Education Research, Innovation and Theory (MERIT), McMaster University, Hamilton, Ontario, Canada; ORCID: 0000-0001-6104-462X. M. Mercuri is assistant professor, Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada. K. Van Dewark is clinical instructor, Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada. J. Sherbino is associate professor, Division of Emergency Medicine, Department of Medicine, Michael G. DeGroote School of Medicine, and assistant dean of education research, and director, McMaster Education Research, Innovation, and Theory (MERIT), McMaster University, Hamilton, Ontario, Canada. A. Schwartz is Michael Reese Endowed Professor of Medical Education, associate head, Department of Medical Education, and research professor, Department of Pediatrics, College of Medicine, University of Illinois at Chicago; ORCID: 0000-0003-3809-6637. G. Norman is professor emeritus, Department of Clinical Epidemiology Biostatistics, and founding member, Program for Education Research and Development, and scientist, McMaster Education Research, Innovation and Theory (MERIT), McMaster University, Hamilton, Ontario, Canada. M. Lineberry is director, Simulation Research, Assessment, and Outcomes, Zamierowski Institute for Experiential Learning, and assistant professor, Department of Health Policy and Management, University of Kansas Medical Center, Kansas City, Kansas
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Humphries KH, Lee MK, Izadnegahdar M, Gao M, Holmes DT, Scheuermeyer FX, Mackay M, Mattman A, Grafstein E. Sex Differences in Diagnoses, Treatment, and Outcomes for Emergency Department Patients With Chest Pain and Elevated Cardiac Troponin. Acad Emerg Med 2018; 25:413-424. [PMID: 29274187 DOI: 10.1111/acem.13371] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 12/15/2017] [Accepted: 12/18/2017] [Indexed: 12/25/2022]
Abstract
OBJECTIVE While sex differences in the treatment and outcomes of subjects with acute coronary syndromes are well documented, little is known about the impact of cardiac troponin (cTn) levels obtained in the emergency department (ED) on the observed sex differences. We sought to determine whether cTn levels by chest pain features modify sex differences in diagnosis, treatment, and outcomes in patients presenting with chest pain suggestive of ischemia. METHODS All adults presenting to two hospitals in Vancouver, Canada, between May 2008 and March 2013 with ischemic chest pain and with cTn testing were included in the study. Outcomes were obtained through data linkage with population-based administrative data sets, including Vital Statistics (death), Discharge Abstract Database (hospitalizations), and PharmaNet (medications). Cumulative event rates for the composite major adverse cardiac event (MACE) endpoint (death, myocardial infarction [MI], incident admission for heart failure or for angina requiring diagnostic catheterization or revascularization) were estimated for each sex and cTn level using the Kaplan-Meier method; Cox models were used to estimate hazard ratios and 95% confidence interval (CIs) for 1-year MACE and 7-day catheterization. Logistic models were used to estimate odds ratios (ORs) and 95% CI for 90-day medication use. RESULTS Over the 5-year study period, 25,539 patients presented to the ED with chest pain of which 7,272 (2,933 females and 4,339 males) met the inclusion criteria. Among patients with chest pain with cardiac features/history and cTn > 99th percentile, females were less likely to be diagnosed with MI (46.4% vs. 57.5%). Females in the cTnI > 99th percentile group had the worst outcomes with a 1-year MACE rate of 22.7% (95% CI = 18.5-27.7) versus 18.8% (95% CI = 16.2-21.6), although this difference was attenuated and not statistically significant after adjustment for baseline differences. Overall, females underwent fewer diagnostic catheterizations than males within 7 days of admission to the ED. Even when cTn was above the 99th percentile and the chest pain was cardiac in nature, 48.4% of females underwent a diagnostic catheterization compared to 64.3% of males (p < 0.001). Within 90 days of discharge, females were less likely to use the evidence-based cardiac medications. The most striking sex differences were noted when cTnI levels were > 99th percentile and when the chest pain was cardiac in nature; males filled 25% more prescriptions for statins than their female counterparts. Adjustment for baseline differences did not attenuate this difference. CONCLUSIONS Sex differences in diagnosis and treatment after presentation to the ED with chest pain are not explained by differences in chest pain features or levels of cTn. Even when females have cardiac chest pain and cTn levels > 99th percentile, they are less likely to be diagnosed with MI, less likely to undergo diagnostic cardiac catheterization within 7 days, and less likely to use evidence-based cardiac medications, but they have the highest 1-year MACE rate. The higher MACE rate appears to be driven by the higher burden of comorbid conditions.
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Affiliation(s)
- Karin H. Humphries
- Division of Cardiology; University of British Columbia; Vancouver BC Canada
- BC Centre for Improved Cardiovascular Health; Vancouver BC Canada
- Centre for Health Evaluation and Outcomes Sciences; Vancouver BC Canada
| | - May K. Lee
- Division of Cardiology; University of British Columbia; Vancouver BC Canada
- BC Centre for Improved Cardiovascular Health; Vancouver BC Canada
| | - Mona Izadnegahdar
- Division of Cardiology; University of British Columbia; Vancouver BC Canada
- BC Centre for Improved Cardiovascular Health; Vancouver BC Canada
| | - Min Gao
- BC Centre for Improved Cardiovascular Health; Vancouver BC Canada
| | - Daniel T. Holmes
- Division of Endocrinology; University of British Columbia; Vancouver BC Canada
| | - Frank X. Scheuermeyer
- Department of Emergency Medicine; University of British Columbia; Vancouver BC Canada
| | - Martha Mackay
- School of Nursing; University of British Columbia; Vancouver BC Canada
- BC Centre for Improved Cardiovascular Health; Vancouver BC Canada
- Centre for Health Evaluation and Outcomes Sciences; Vancouver BC Canada
| | - Andre Mattman
- Department of Pathology and Lab Medicine; University of British Columbia; Vancouver BC Canada
| | - Eric Grafstein
- Department of Emergency Medicine; University of British Columbia; Vancouver BC Canada
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Dalwai M, Tayler-Smith K, Twomey M, Nasim M, Popal AQ, Haqdost WH, Gayraud O, Cheréstal S, Wallis L, Valles P. Inter-rater and intrarater reliability of the South African Triage Scale in low-resource settings of Haiti and Afghanistan. Emerg Med J 2018; 35:379-383. [PMID: 29549171 PMCID: PMC5969337 DOI: 10.1136/emermed-2017-207062] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 02/06/2018] [Accepted: 02/13/2018] [Indexed: 11/15/2022]
Abstract
Objective The South African Triage Scale (SATS) has demonstrated good validity in the EDs of Médecins Sans Frontières (MSF)-supported sites in Afghanistan and Haiti; however, corresponding reliability in these settings has not yet been reported on. This study set out to assess the inter-rater and intrarater reliability of the SATS in four MSF-supported EDs in Afghanistan and Haiti (two trauma-only EDs and two mixed (including both medical and trauma cases) EDs). Methods Under classroom conditions between December 2013 and February 2014, ED nurses at each site assigned triage ratings to a set of context-specific vignettes (written case reports of ED patients). Inter-rater reliability was assessed by comparing triage ratings among nurses; intrarater reliability was assessed by asking the nurses to retriage 10 random vignettes from the original set and comparing these duplicate ratings. Inter-rater reliability was calculated using the unweighted kappa, linearly weighted kappa and quadratically weighted kappa (QWK) statistics, and the intraclass correlation coefficient (ICC). Intrarater reliability was calculated according to the percentage of exact agreement and the percentage of agreement allowing for one level of discrepancy in triage ratings. The correlation between years of nursing experience and reliability of the SATS was assessed based on comparison of ICCs and the respective 95% CIs. Results A total of 67 nurses agreed to participate in the study: In Afghanistan there were 19 nurses from Kunduz Trauma Centre and nine from Ahmed Shah Baba; in Haiti, there were 20 nurses from Martissant Emergency Centre and 19 from Tabarre Surgical and Trauma Centre. Inter-rater agreement was moderate across all sites (ICC range: 0.50–0.60; QWK range: 0.50–0.59) apart from the trauma ED in Haiti where it was moderate to substantial (ICC: 0.58; QWK: 0.61). Intrarater agreement was similar across the four sites (68%–74% exact agreement); when allowing for a one-level discrepancy in triage ratings, intrarater reliability was near perfect across all sites (96%–99%). No significant correlation was found between years of nursing experience and reliability. Conclusion The SATS has moderate reliability in different EDs in Afghanistan and Haiti. These findings, together with concurrent findings showing that the SATS has good validity in the same settings, provide evidence to suggest that SATS is suitable in trauma-only and mixed EDs in low-resource settings.
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Affiliation(s)
- Mohammed Dalwai
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa.,Medical Department, Médecins Sans Frontières, Operational Centre Brussels, Brussels, Belgium
| | - Katie Tayler-Smith
- Operational Research Unit Luxembourg, Médecins Sans Frontières, Luxembourg City, Luxembourg
| | - Michèle Twomey
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Masood Nasim
- Medical Department, Médecins Sans Frontières, Kabul, Afghanistan
| | | | | | - Olivia Gayraud
- Medical Department, Médecins Sans Frontières, Port au Prince, Haiti
| | - Sophia Cheréstal
- Medical Department, Médecins Sans Frontières, Port au Prince, Haiti
| | | | - Pola Valles
- Medical Department, Médecins Sans Frontières, Operational Centre Brussels, Brussels, Belgium
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Characteristics and outcomes of older emergency department patients assigned a low acuity triage score. CAN J EMERG MED 2018; 20:762-769. [DOI: 10.1017/cem.2018.17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjectiveAlthough older patients are a high-risk population in the emergency department (ED), little is known about those identified as “less acute” at triage. We aimed to describe the outcomes of patients ages 65 years and older who receive low acuity triage scores.MethodsThis health records review assessed ED patients who were ages 65 years and above or ages 40 to 55 years (controls) who received a Canadian Triage Acuity Scale score of 4 or 5. Data collected included patient demographics, ED management, disposition, and a return visit or hospital admission at 14 days. Data were analysed descriptively and chi-square testing performed. A pre-planned stratified analysis of patients ages 65 to 74, 75 to 84, and 85 and older was conducted.ResultsThree hundred fifty older patients with a mean age of 76.5 years and 150 control patients were included. Most patients presented with musculoskeletal or skin complaints and were triaged to the ambulatory care area. Older patients were significantly more likely than controls to be admitted on the index visit (5.0% v. 0.3%, p=0.016) and on re-presentation (4.0% v. 0.7%, p=0.045). In a subgroup analysis, patients ages 85 years and above were most likely to be admitted (8.9%, p=0.003).ConclusionsOlder patients who present to the ED with issues labelled as “less acute” at triage are 16 times more likely to be admitted than younger controls. Patients ages 85 years and up are the primary drivers of this higher admission rate. Our study indicates that even “low acuity” elders presenting to the ED are at risk for re-presentation and admission within 14 days.
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Chowdhury S, Nicol AJ, Moydien MR, Navsaria PH, Montoya-Pelaez LF. Is case triaging a useful tool for emergency surgeries? A review of 106 trauma surgery cases at a level 1 trauma center in South Africa. World J Emerg Surg 2018; 13:4. [PMID: 29410701 PMCID: PMC5781325 DOI: 10.1186/s13017-018-0166-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 01/18/2018] [Indexed: 11/10/2022] Open
Abstract
Background The optimal timing for emergency surgical interventions and implementation of protocols for trauma surgery is insufficient in the literature. The Groote Schuur emergency surgery triage (GSEST) system, based on Cape Triaging Score (CTS), is followed at Groote Schuur Hospital (GSH) for triaging emergency surgical cases including trauma cases. The study aimed to look at the effect of delay in surgery after scheduling based on the GSEST system has an impact on outcome in terms of postoperative complications and death. Methods Prospective audit of patients presenting to GSH trauma center following penetrating or blunt chest, abdominal, neck and peripheral vascular trauma who underwent surgery over a 4-month period was performed. Post-operative complications were graded according to Clavien-Dindo classification of surgical complications. Results One-hundred six patients underwent surgery during the study period. One-hundred two (96.2%) cases were related to penetrating trauma. Stab wounds comprised 71 (67%) and gunshot wounds (GSW) 31 (29.2%) cases. Of the 106 cases, 6, 47, 40, and 13 patients were booked as red, orange, yellow, and green, respectively. The median delay for green, yellow, and orange cases was within the expected time. The red patients took unexpectedly longer (median delay 48 min, IQR 35-60 min). Thirty-one (29.3%) patients developed postoperative complications. Among the booked red, orange, yellow, and green cases, postoperative complications developed in 3, 18, 9, and 1 cases, respectively. Only two (1.9%) postoperative deaths were documented during the study period. There was no statistically significant association between operative triage and post-operative complications (p = 0.074). Conclusion Surgical case categorization has been shown to be useful in prioritizing emergency trauma surgical cases in a resource constraint high-volume trauma center.
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Affiliation(s)
- Sharfuddin Chowdhury
- 1Consultant and head of Trauma Surgery, King Saud Medical City, 7790 Al-Imam Abdul Aziz Ibn Muhammad Ibn Saud, Ulaishah, Riyadh, 12746 Kingdom of Saudi Arabia
| | - Andrew John Nicol
- 2Head and Director of Trauma Centre, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | | | - Pradeep Harkison Navsaria
- 4Deputy Director of Trauma Centre, Groote Schuur Hospital, and University of Cape Town, Cape Town, South Africa
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Hinson JS, Martinez DA, Schmitz PSK, Toerper M, Radu D, Scheulen J, Stewart de Ramirez SA, Levin S. Accuracy of emergency department triage using the Emergency Severity Index and independent predictors of under-triage and over-triage in Brazil: a retrospective cohort analysis. Int J Emerg Med 2018; 11:3. [PMID: 29335793 PMCID: PMC5768578 DOI: 10.1186/s12245-017-0161-8] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 12/26/2017] [Indexed: 11/29/2022] Open
Abstract
Background Emergency department (ED) triage is performed to prioritize care for patients with critical and time-sensitive illness. Triage errors create opportunity for increased morbidity and mortality. Here, we sought to measure the frequency of under- and over-triage of patients by nurses using the Emergency Severity Index (ESI) in Brazil and to identify factors independently associated with each. Methods This was a single-center retrospective cohort study. The accuracy of initial ESI score assignment was determined by comparison with a score entered at the close of each ED encounter by treating physicians with full knowledge of actual resource utilization, disposition, and acute outcomes. Chi-square analysis was used to validate this surrogate gold standard, via comparison of associations with disposition and clinical outcomes. Independent predictors of under- and over-triage were identified by multivariate logistic regression. Results Initial ESI-determined triage score was classified as inaccurate for 16,426 of 96,071 patient encounters. Under-triage was associated with a significantly higher rate of admission and critical outcome, while over-triage was associated with a lower rate of both. A number of factors identifiable at time of presentation including advanced age, bradycardia, tachycardia, hypoxia, hyperthermia, and several specific chief complaints (i.e., neurologic complaints, chest pain, shortness of breath) were identified as independent predictors of under-triage, while other chief complaints (i.e., hypertension and allergic complaints) were independent predictors of over-triage. Conclusions Despite rigorous and ongoing training of ESI users, a large number of patients in this cohort were under- or over-triaged. Advanced age, vital sign derangements, and specific chief complaints—all subject to limited guidance by the ESI algorithm—were particularly under-appreciated.
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Affiliation(s)
- Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 801 Smith Avenue, Davis Building, Suite 3220, Baltimore, MD, 21209, USA.
| | - Diego A Martinez
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 801 Smith Avenue, Davis Building, Suite 3220, Baltimore, MD, 21209, USA.,Department of Operations Integration, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Paulo S K Schmitz
- Emergency Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Matthew Toerper
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 801 Smith Avenue, Davis Building, Suite 3220, Baltimore, MD, 21209, USA.,Department of Operations Integration, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Danieli Radu
- Emergency Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - James Scheulen
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 801 Smith Avenue, Davis Building, Suite 3220, Baltimore, MD, 21209, USA
| | - Sarah A Stewart de Ramirez
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 801 Smith Avenue, Davis Building, Suite 3220, Baltimore, MD, 21209, USA
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 801 Smith Avenue, Davis Building, Suite 3220, Baltimore, MD, 21209, USA.,Department of Operations Integration, Johns Hopkins Hospital, Baltimore, MD, USA.,Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA.,Systems Institute, Johns Hopkins University, Baltimore, MD, USA
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Urbanoski K, Cheng J, Rehm J, Kurdyak P. Frequent use of emergency departments for mental and substance use disorders. Emerg Med J 2018; 35:220-225. [DOI: 10.1136/emermed-2015-205554] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 11/27/2017] [Accepted: 12/19/2017] [Indexed: 11/03/2022]
Abstract
ObjectivesWe described the population of people who frequently use ED for mental disorders, delineating differences by the number of visits for substance use disorders (SUDs), and predicted the receipt of follow-up services and 2-year mortality by the level of ED use for SUD.MethodsThis retrospective observational study included all Ontario residents 15 years and older who had five or more ED visits during any 12-month period from 2010 to 2012 (n=263 346). The study involved a secondary analysis of administrative health databases capturing emergency, hospital and ambulatory care. Frequent ED users for mental disorders (n=5416) were grouped into nested categories based on the number of ED visits for SUD. Logistic regression was used to examine group differences in the receipt of follow-up services and mortality, controlling for sociodemographics, comorbidities and past service use.ResultsThe majority of frequent ED users for mental disorders had at least one ED visit for SUD, most commonly involving alcohol. Relative to people with no visits for SUD, those with ED visits for SUD were older and more likely to be men (Ps <0.001). As the number of ED visits for SUD increased, the likelihood of receiving follow-up care, particularly specialist mental healthcare, declined while 2-year mortality steadily increased (Ps <0.001). These associations remained after controlling for comorbidities and past service use.ConclusionsFindings highlight disparities in the receipt of specialist care based on use of ED services for SUD, coupled with a greater mortality risk. There is a need for policies and procedures to help address unmet needs for care and to connect members of this vulnerable subgroup with services that are better able to support recovery and improve survival.
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Dechamps M, Castanares-Zapatero D, Manara A. Combination of clinical and ECG criteria may increase validity of triage scales: authors' reply. Intern Emerg Med 2017; 12:1333-1334. [PMID: 28150087 DOI: 10.1007/s11739-017-1617-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 01/24/2017] [Indexed: 10/20/2022]
Affiliation(s)
- Melanie Dechamps
- Emergency Department,Cliniques Universitaires Saint Luc, Université Catholique de Louvain, 1200, Brussels, Belgium.
- Intensive Care UnitCliniques Universitaires Saint Luc, Université Catholique de Louvain, 1200, Brussels, Belgium.
| | - Diego Castanares-Zapatero
- Intensive Care UnitCliniques Universitaires Saint Luc, Université Catholique de Louvain, 1200, Brussels, Belgium
| | - Alessandro Manara
- Emergency Department,Cliniques Universitaires Saint Luc, Université Catholique de Louvain, 1200, Brussels, Belgium
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Kristensen M, Iversen AKS, Gerds TA, Østervig R, Linnet JD, Barfod C, Lange KHW, Sölétormos G, Forberg JL, Eugen-Olsen J, Rasmussen LS, Schou M, Køber L, Iversen K. Routine blood tests are associated with short term mortality and can improve emergency department triage: a cohort study of >12,000 patients. Scand J Trauma Resusc Emerg Med 2017; 25:115. [PMID: 29179764 PMCID: PMC5704435 DOI: 10.1186/s13049-017-0458-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 11/17/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prioritization of acutely ill patients in the Emergency Department remains a challenge. We aimed to evaluate whether routine blood tests can predict mortality in unselected patients in an emergency department and to compare risk prediction with a formalized triage algorithm. METHODS A prospective observational cohort study of 12,661 consecutive admissions to the Emergency Department of Nordsjælland University Hospital during two separate periods in 2010 (primary cohort, n = 6279) and 2013 (validation cohort, n = 6383). Patients were triaged in five categories by a formalized triage algorithm. All patients with a full routine biochemical screening (albumin, creatinine, c-reactive protein, haemoglobin, lactate dehydrogenase, leukocyte count, potassium, and sodium) taken at triage were included. Information about vital status was collected from the Danish Central Office of Civil registration. Multiple logistic regressions were used to predict 30-day mortality. Validation was performed by applying the regression models on the 2013 validation cohort. RESULTS Thirty-day mortality was 5.3%. The routine blood tests had a significantly stronger discriminative value on 30-day mortality compared to the formalized triage (AUC 88.1 [85.7;90.5] vs. 63.4 [59.1;67.5], p < 0.01). Risk stratification by routine blood tests was able to identify a larger number of low risk patients (n = 2100, 30-day mortality 0.1% [95% CI 0.0;0.3%]) compared to formalized triage (n = 1591, 2.8% [95% CI 2.0;3.6%]), p < 0.01. CONCLUSIONS Routine blood tests were strongly associated with 30-day mortality in acutely ill patients and discriminatory ability was significantly higher than with a formalized triage algorithm. Thus routine blood tests allowed an improved risk stratification of patients presenting in an emergency department.
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Affiliation(s)
- Michael Kristensen
- Department of Emergency Medicine, Sjællands Universitetshospital Køge, Køge, Denmark.,Department of Cardiology, Endocrinology and Nephrology, Nordsjællands Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anne Kristine Servais Iversen
- Department of Cardiology, Endocrinology and Nephrology, Nordsjællands Hospital, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Cardiology, Herlev Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Rebecca Østervig
- Department of Cardiology, Endocrinology and Nephrology, Nordsjællands Hospital, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Cardiology, Herlev Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jakob Danker Linnet
- Department of Anaesthesia, Sjællands Universitetshospital Køge, Køge, Denmark
| | - Charlotte Barfod
- Department of Anaesthesia, Centre of Head and Orthopaedics Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Jakob Lundager Forberg
- Department of Prehospital and In-Hospital Emergency Medicine - Helsingborg Hospital, Helsingborg, Sweden
| | - Jesper Eugen-Olsen
- Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark
| | - Lars Simon Rasmussen
- Department of Anaesthesia, Centre of Head and Orthopaedics Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Endocrinology and Nephrology, Nordsjællands Hospital, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Cardiology, Herlev Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Iversen
- Department of Cardiology, Endocrinology and Nephrology, Nordsjællands Hospital, Copenhagen University Hospital, Copenhagen, Denmark. .,Department of Cardiology, Herlev Hospital, Copenhagen University Hospital, Copenhagen, Denmark.
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Nishi FA, de Oliveira Motta Maia F, de Souza Santos I, de Almeida Lopes Monteiro da Cruz D. Assessing sensitivity and specificity of the Manchester Triage System in the evaluation of acute coronary syndrome in adult patients in emergency care: a systematic review. JBI DATABASE OF SYSTEMATIC REVIEWS AND IMPLEMENTATION REPORTS 2017; 15:1747-1761. [PMID: 28628525 DOI: 10.11124/jbisrir-2016-003139] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Triage is the first assessment and sorting process used to prioritize patients arriving in the emergency department (ED). As a triage tool, the Manchester Triage System (MTS) must have a high sensitivity to minimize the occurrence of under-triage, but must not compromise specificity to avoid the occurrence of overtriage. Sensitivity and specificity of the MTS can be calculated using the frequency of appropriately assigned clinical priority levels for patients presenting to the ED. However, although there are well established criteria for the prioritization of patients with suspected acute coronary syndrome (ACS), several studies have reported difficulties when evaluating patients with this condition. OBJECTIVE The objective of this review was to synthesize the best available evidence on assessing the sensitivity and specificity of the MTS for screening high-level priority adult patients presenting to the ED with ACS. METHOD The current review considered studies that evaluated the use of the MTS in the risk classification of adult patients in the ED. In this review, studies that investigated the priority level, as established by the MTS to screen patients under suspicion of ACS or the sensitivity and specificity of the MTS, for screening patients before the medical diagnosis of ACS were included. This review included both experimental and epidemiological study designs. RESULTS The results were presented in a narrative synthesis. Six studies were appraised by the independent reviewers. All appraised studies enrolled a consecutive or random sample of patients and presented an overall moderate methodological quality, and all of them were included in this review. A total of 54,176 participants were included in the six studies. All studies were retrospective. Studies included in this review varied in content and data reporting. Only two studies reported sensitivity and specificity values or all the necessary data to calculate sensitivity and specificity. The remaining four studies presented either a sensitivity analysis or the number of true positives and false negatives. However, these four studies were conducted considering only data from patients diagnosed with ACS. Sensitivity values were relatively uniform among the studies: 0.70-0.80. A specificity of 0.59 was reported in the study including only patients with non-traumatic chest pain. On the other hand, in the study that included patients with any complaint, the specificity of MTS to screen patients with ACS was 0.97. CONCLUSION The current review demonstrates that the MTS has a moderate sensitivity to evaluate patients with ACS. This may compromise time to treatment in the ED, an important variable in the prognosis of ACS. Atypical presentation of ACS, or high specificity, may also explain the moderate sensitivity demonstrated in this review. However, because of minimal data, it is not possible to confirm this hypothesis. It is difficult to determine the acceptable level of sensitivity or specificity to ensure that a certain triage system is safe.
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Affiliation(s)
- Fernanda Ayache Nishi
- 1University Hospital, University of São Paulo, São Paulo, Brazil 2The Brazilian Centre for Evidence-Informed Healthcare: a Joanna Briggs Institute Centre of Excellence, São Paulo, Brazil 3School of Medicine, University of São Paulo, São Paulo, Brazil 4School of Nursing, University of São Paulo, São Paulo, Brazil
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Veit-Rubin N, Brossard P, Gayet-Ageron A, Montandon CY, Simon J, Irion O, Rutschmann OT, Martinez de Tejada B. Validation of an emergency triage scale for obstetrics and gynaecology: a prospective study. BJOG 2017; 124:1867-1873. [PMID: 28294509 DOI: 10.1111/1471-0528.14535] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the reliability of a four-level triage scale for obstetrics and gynaecology emergencies and to explore the factors associated with an optimal triage. DESIGN Thirty clinical vignettes presenting the most frequent indications for obstetrics and gynaecology emergency consultations were evaluated twice using a computerised simulator. SETTING The study was performed at the emergency unit of obstetrics and gynaecology at the Geneva University Hospitals. SAMPLE The vignettes were submitted to nurses and midwives. METHODS We assessed inter- and intra-rater reliability and agreement using a two-way mixed-effects intra-class correlation (ICC). We also performed a generalised linear mixed model to evaluate factors associated triage correctness. MAIN OUTCOME MEASURES Triage acuity. RESULTS We obtained a total of 1191 evaluations. Inter-rater reliability was good (ICC 0.748; 95% CI 0.633-0.858) and intra-rater reliability was almost perfect (ICC 0.812; 95% CI 0.726-0.889). We observed a wide variability: the mean number of questions varied from 6.9 to 18.9 across individuals and from 8.4 to 16.9 across vignettes. Triage acuity was underestimated in 12.4% of cases and overestimated in 9.3%. Undertriage occurred less frequently for gynaecology compared with obstetric vignettes [odds ratio (OR) 0.45; 95% CI 0.23-0.91; P = 0.035] and decreased with the number of questions asked (OR 0.94; 95% CI 0.88-0.99; P = 0.047). Certification in obstetrics and gynaecology emergencies was an independent factor for the avoidance of undertriage (OR 0.35; 95% CI 0.17-0.70; P = 0.003). CONCLUSION The four-level triage scale is a valid and reliable tool for the integrated emergency management of obstetrics and gynaecology patients. TWEETABLE ABSTRACT The Swiss Emergency Triage Scale is a valid and reliable tool for obstetrics and gynaecology emergency triage.
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Affiliation(s)
- N Veit-Rubin
- Department of Gynaecology and Obstetrics, Lausanne University Hospital and Faculty of Medicine, Lausanne, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Department of Obstetrics and Gynaecology, Medical University Vienna, Vienna, Austria
| | - P Brossard
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Department of Gynaecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - A Gayet-Ageron
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.,CRC & Division of Clinical Epidemiology, Department of Health and Community Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - C-Y Montandon
- Department of Gynaecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - J Simon
- Nursing Department, Geneva University Hospitals, Geneva, Switzerland
| | - O Irion
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Department of Gynaecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - O T Rutschmann
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Department of Primary Care, Community and Emergency Medicine, Division of Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - B Martinez de Tejada
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Department of Gynaecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
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Yuksen C, Sawatmongkornkul S, Suttabuth S, Sawanyawisuth K, Sittichanbuncha Y. Emergency severity index compared with 4-level triage at the emergency department of Ramathibodi University Hospital. ASIAN BIOMED 2017. [DOI: 10.5372/1905-7415.1002.477] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Emergency department (ED) triage is important for categorizing and prioritizing patients. Effective triage may assist in crowd reduction in the ED and appropriate patient management. There are several systems, including the 5-level Emergency Severity Index (ESI) and the 4-level Ramathibodi-nurse triage. Currently, there are limited data by which to compare the 5- versus 4-level triage; particularly on health outcomes, such as length of stay in the ED, mortality, and resource needs.
Objective
To compare the accuracy of 5- and 4-level triage in an ED.
Method
This observational study was conducted on a cross-section of patients in the ED at Ramathibodi Hospital of Mahidol University, Bangkok, Thailand. Eligible patients were those who visited the ED and were evaluated by ESI and nurse triage. Each evaluation was blinded to the results of the other. Discrimination performance between the 5- and 4-level triage was compared by using the area under a receiver operating characteristic (ROC) curve and concordance statistic for prediction of life saving intervention. Net reclassification improvement (NRI) of the 5-level ESI over the 4-level triage was performed.
Result
Study criteria were met by 520 patients. The areas under the ROC curves of the ESI and nurse triage on life-saving intervention were 92.2% (95% confidence intervals were 87.3%, 96.9%) and 81.3% (95% CI 75.2%, 87.3%), respectively. Areas under the ROC curve differed significantly (P < 0.001). The overall reclassification improvement was 42.4%.
Conclusion
The 5-level emergency severity index was more accurate than the 4-level triage in terms of lifesaving intervention.
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Affiliation(s)
- Chaiyaporn Yuksen
- Department of Emergency Medicine , Faculty of Medicine, Ramathibodi Hospital , Mahidol University , Bangkok 10400 , Thailand
| | - Sorravit Sawatmongkornkul
- Department of Emergency Medicine , Faculty of Medicine, Ramathibodi Hospital , Mahidol University , Bangkok 10400 , Thailand
| | - Supakrid Suttabuth
- Department of Emergency Medicine , Faculty of Medicine, Ramathibodi Hospital , Mahidol University , Bangkok 10400 , Thailand
| | - Kittisak Sawanyawisuth
- Department of Medicine , Faculty of Medicine , Khon Kaen University , Khon Kaen 40002 , Thailand
- Research Center in Back , Neck, Other Joint Pain and Human Performance (BNOJPH) , Khon Kaen University , Khon Kaen 40002 , Thailand
| | - Yuwares Sittichanbuncha
- Department of Emergency Medicine , Faculty of Medicine, Ramathibodi Hospital , Mahidol University , Bangkok 10400 , Thailand
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Paramedics assessing Elders at Risk for Independence Loss (PERIL): Derivation, Reliability and Comparative Effectiveness of a Clinical Prediction Rule. CAN J EMERG MED 2017; 18:121-32. [PMID: 26988720 DOI: 10.1017/cem.2016.14] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES We conducted a program of research to derive and test the reliability of a clinical prediction rule to identify high-risk older adults using paramedics' observations. METHODS We developed the Paramedics assessing Elders at Risk of Independence Loss (PERIL) checklist of 43 yes or no questions, including the Identifying Seniors at Risk (ISAR) tool items. We trained 1,185 paramedics from three Ontario services to use this checklist, and assessed inter-observer reliability in a convenience sample. The primary outcome, return to the ED, hospitalization, or death within one month was assessed using provincial databases. We derived a prediction rule using multivariable logistic regression. RESULTS We enrolled 1,065 subjects, of which 764 (71.7%) had complete data. Inter-observer reliability was good or excellent for 40/43 questions. We derived a four-item rule: 1) "Problems in the home contributing to adverse outcomes?" (OR 1.43); 2) "Called 911 in the last 30 days?" (OR 1.72); 3) male (OR 1.38) and 4) lacks social support (OR 1.4). The PERIL rule performed better than a proxy measure of clinical judgment (AUC 0.62 vs. 0.56, p=0.02) and adherence was better for PERIL than for ISAR. CONCLUSIONS The four-item PERIL rule has good inter-observer reliability and adherence, and had advantages compared to a proxy measure of clinical judgment. The ISAR is an acceptable alternative, but adherence may be lower. If future research validates the PERIL rule, it could be used by emergency physicians and paramedic services to target preventative interventions for seniors identified as high-risk.
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Mochizuki K, Shintani R, Mori K, Sato T, Sakaguchi O, Takeshige K, Nitta K, Imamura H. Importance of respiratory rate for the prediction of clinical deterioration after emergency department discharge: a single-center, case-control study. Acute Med Surg 2016; 4:172-178. [PMID: 29123857 PMCID: PMC5667270 DOI: 10.1002/ams2.252] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 09/07/2016] [Indexed: 01/16/2023] Open
Abstract
Aim The purpose of the present study was to investigate the predictors of clinical deterioration soon after emergency department (ED) discharge. Methods We undertook a case–control study using the ED database of the Nagano Municipal Hospital (Nagano, Japan) from January 2012 to December 2013. We selected adult patients with medical conditions who revisited the ED with deterioration within 2 days of ED discharge (deterioration group). The deterioration group was compared with a control group. Results During the study period, 15,724 adult medical patients were discharged from the ED. Of these, 170 patients revisited the ED because of clinical deterioration within 2 days. Among the initial vital signs, respiratory rate was less frequently recorded than other vital signs (P < 0.001 versus all other vital signs in each group). The frequency of recording each vital sign did not differ significantly between the groups. Overall, patients in the deterioration group had significantly higher respiratory rates than those in the control group (21 ± 5/min versus 18 ± 5/min, respectively; P = 0.002). A binary logistic regression analysis revealed that respiratory rate was an independent risk factor for clinical deterioration (unadjusted odds ratio, 1.15; 95% confidence interval, 1.04−1.26; adjusted odds ratio, 1.15; 95% confidence interval, 1.01−1.29). Conclusions An increased respiratory rate is a predictor of early clinical deterioration after ED discharge. Vital signs, especially respiratory rate, should be carefully evaluated when making decisions about patient disposition in the ED.
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Affiliation(s)
- Katsunori Mochizuki
- Department of Emergency and Critical Care Medicine Shinshu University School of Medicine Matsumoto Japan
| | - Ryosuke Shintani
- Department of Emergency Medicine Nagano Municipal Hospital Nagano Japan
| | - Kotaro Mori
- Department of Emergency and Critical Care Medicine Shinshu University School of Medicine Matsumoto Japan
| | - Takahisa Sato
- Department of Emergency Medicine Nagano Municipal Hospital Nagano Japan
| | - Osamu Sakaguchi
- Department of Emergency Medicine Nagano Municipal Hospital Nagano Japan
| | - Kanako Takeshige
- Department of Emergency and Critical Care Medicine Shinshu University School of Medicine Matsumoto Japan
| | - Kenichi Nitta
- Department of Emergency and Critical Care Medicine Shinshu University School of Medicine Matsumoto Japan
| | - Hiroshi Imamura
- Department of Emergency and Critical Care Medicine Shinshu University School of Medicine Matsumoto Japan
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Jatoba A, Burns CM, Vidal MCR, Carvalho PVR. Designing for Risk Assessment Systems for Patient Triage in Primary Health Care: A Literature Review. JMIR Hum Factors 2016; 3:e21. [PMID: 27528543 PMCID: PMC5004057 DOI: 10.2196/humanfactors.5083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 10/22/2015] [Accepted: 07/07/2016] [Indexed: 11/13/2022] Open
Abstract
Background This literature review covers original journal papers published between 2011 and 2015. These papers review the current status of research on the application of human factors and ergonomics in risk assessment systems’ design to cope with the complexity, singularity, and danger in patient triage in primary health care. Objective This paper presents a systematic literature review that aims to identify, analyze, and interpret the application of available evidence from human factors and ergonomics to the design of tools, devices, and work processes to support risk assessment in the context of health care. Methods Electronic search was performed on 7 bibliographic databases of health sciences, engineering, and computer sciences disciplines. The quality and suitability of primary studies were evaluated, and selected papers were classified according to 4 classes of outcomes. Results A total of 1845 papers were retrieved by the initial search, culminating in 16 selected for data extraction after the application of inclusion and exclusion criteria and quality and suitability evaluation. Conclusions Results point out that the study of the implications of the lack of understanding about real work performance in designing for risk assessment in health care is very specific, little explored, and mostly focused on the development of tools.
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Affiliation(s)
- Alessandro Jatoba
- Fundação Oswaldo Cruz, Centro de Estudos Estratégicos, Rio de Janeiro, Brazil.
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