A consensus-based process to define standard national data elements for a Canadian emergency department information system

The Use and Structure of Emergency Nurses' Triage Narrative Data: Scoping Review

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.

Emergency nurses' triage narrative data, their uses and structure: a scoping review protocol

INTRODUCTION

The first clinical interaction most patients have in the emergency department occurs during triage. An unstructured narrative is generated during triage and is the first source of in-hospital documentation. These narratives capture the patient's reported reason for the visit and the initial assessment and offer significantly more nuanced descriptions of the patient's complaints than fixed field data. Previous research demonstrated these data are useful for predicting important clinical outcomes. Previous reviews examined these narratives in combination or isolation with other free-text sources, but used restricted searches and are becoming outdated. Furthermore, there are no reviews focused solely on nurses' (the primary collectors of these data) narratives.

METHODS AND ANALYSIS

Using the Arksey and O'Malley scoping review framework and PRISMA-ScR reporting guidelines, we will perform structured searches of CINAHL, Ovid MEDLINE, ProQuest Central, Ovid Embase and Cochrane Library (via Wiley). Additionally, we will forward citation searches of all included studies. No geographical or study design exclusion criteria will be used. Studies examining disaster triage, published before 1990, and non-English language literature will be excluded. Data will be managed using online management tools; extracted data will be independently confirmed by a separate reviewer using prepiloted extraction forms. Cohen's kappa will be used to examine inter-rater agreement on pilot and final screening. Quantitative data will be expressed using measures of range and central tendency, counts, proportions and percentages, as appropriate. Qualitative data will be narrative summaries of the authors' primary findings.

PATIENT AND PUBLIC INVOLVEMENT

No patients involved.

ETHICS AND DISSEMINATION

No ethics approval is required. Findings will be submitted to peer-reviewed conferences and journals. Results will be disseminated using individual and institutional social media platforms.

Development and validation of an automated emergency department-based syndromic surveillance system to enhance public health surveillance in Yukon: a lower-resourced and remote setting

BACKGROUND

Automated Emergency Department syndromic surveillance systems (ED-SyS) are useful tools in routine surveillance activities and during mass gathering events to rapidly detect public health threats. To improve the existing surveillance infrastructure in a lower-resourced rural/remote setting and enhance monitoring during an upcoming mass gathering event, an automated low-cost and low-resources ED-SyS was developed and validated in Yukon, Canada.

METHODS

Syndromes of interest were identified in consultation with the local public health authorities. For each syndrome, case definitions were developed using published resources and expert elicitation. Natural language processing algorithms were then written using Stata LP 15.1 (Texas, USA) to detect syndromic cases from three different fields (e.g., triage notes; chief complaint; discharge diagnosis), comprising of free-text and standardized codes. Validation was conducted using data from 19,082 visits between October 1, 2018 to April 30, 2019. The National Ambulatory Care Reporting System (NACRS) records were used as a reference for the inclusion of International Classification of Disease, 10th edition (ICD-10) diagnosis codes. The automatic identification of cases was then manually validated by two raters and results were used to calculate positive predicted values for each syndrome and identify improvements to the detection algorithms.

RESULTS

A daily secure file transfer of Yukon's Meditech ED-Tracker system data and an aberration detection plan was set up. A total of six syndromes were originally identified for the syndromic surveillance system (e.g., Gastrointestinal, Influenza-like-Illness, Mumps, Neurological Infections, Rash, Respiratory), with an additional syndrome added to assist in detecting potential cases of COVID-19. The positive predictive value for the automated detection of each syndrome ranged from 48.8-89.5% to 62.5-94.1% after implementing improvements identified during validation. As expected, no records were flagged for COVID-19 from our validation dataset.

CONCLUSIONS

The development and validation of automated ED-SyS in lower-resourced settings can be achieved without sophisticated platforms, intensive resources, time or costs. Validation is an important step for measuring the accuracy of syndromic surveillance, and ensuring it performs adequately in a local context. The use of three different fields and integration of both free-text and structured fields improved case detection.

The way from pen and paper to electronic documentation in a German emergency department

Background

Some of the advantages of implementing electronic emergency department information systems (EDIS) are improvements in data availability and simplification of statistical evaluations of emergency department (ED) treatments. However, for multi-center evaluations, standardized documentation is necessary. The AKTIN project (“National Emergency Department Register: Improvement of Health Services Research in Acute Medicine in Germany”) has used the “German Emergency Department Medical Record” (GEDMR) published by the German Interdisciplinary Association of Intensive and Emergency Care as the documentation standard for its national data registry.

Methods

Until March 2016 the documentation standard in ED was the pen-and-paper version of the GEDMR. In April 2016 we implemented the GEDMR in a timeline-based EDIS. Related to this, we compared the availability of structured treatment information of traumatological patients between pen-and-paper-based and electronic documentation, with special focus on the treatment time.

Results

All 796 data fields of the 6 modules (basic data, severe trauma, patient surveillance, anesthesia, council, neurology) were adapted for use with the existing EDIS configuration by a physician working regularly in the ED. Electronic implementation increased availability of structured anamnesis and treatment information. However, treatment time was increased in electronic documentation both immediately (2:12 ± 0:04 h; n = 2907) and 6 months after implementation (2:18 ± 0:03 h; n = 4778) compared to the pen-and-paper group (1:43 ± 0:02 h; n = 2523; p < 0.001).

Conclusions

We successfully implemented standardized documentation in an EDIS. The availability of structured treatment information was improved, but treatment time was also increased. Thus, further work is necessary to improve input time.

Quality of patient information in emergency department

PURPOSE

Data comprise one of the key resources currently used in organizations. High-quality data are those that are appropriate for use by the customer. The quality of data is a key factor in determining the level of healthcare in hospitals, and its improvement leads to an improved quality of health and treatment and ultimately increases patient satisfaction. The purpose of this paper is to assess the quality of emergency patients' information in a hospital information system.

DESIGN/METHODOLOGY/APPROACH

This cross-sectional study was conducted on 385 randomly selected records of patients admitted to the emergency department of Shahid Beheshti Hospital in Kashan, Iran, in 2016. Data on five dimensions of quality, including accuracy, accessibility, timeliness, completeness and definition, were collected using a researcher-made checklist and were then analyzed in SPSS. The results are presented using descriptive statistics, such as frequency distribution and percentage.

FINDINGS

The overall quality of emergency patients' information in the hospital information system was 86 percent, and the dimensions of quality scored 87.7 percent for accuracy, 86.8 percent for completeness, 83.9 percent for timeliness, 79 percent for definition and 62.1 percent for accessibility.

ORIGINALITY/VALUE

Increasing the quality of patient information at emergency departments can lead to improvements in the timely diagnosis and management of diseases and patient and personnel satisfaction, and reduce hospital costs.

Tracking progress in suicide prevention in Indigenous communities: a challenge for public health surveillance in Canada

Indigenous peoples in Canada experience disproportionate rates of suicide compared to non-Indigenous populations. Indigenous communities and organizations have designed local and regional approaches to prevention, and the federal government has developed a national suicide prevention framework. However, public health systems continue to face challenges in monitoring the population burden of suicide and suicidal behaviour. National health data systems lack Indigenous identifiers, do not capture data from some regions, and do not routinely engage Indigenous communities in data governance. These challenges hamper efforts to detect changes in population-level outcomes and assess the impact of suicide prevention activities. Consequently, this limits the ability to achieve public health prevention goals and reduce suicide rates and rate inequities.

This paper provides a critical analysis of the challenges related to suicide surveillance in Canada and assesses the strengths and limitations of existing data infrastructure for monitoring outcomes in Indigenous communities. To better understand these challenges, we discuss the policy context for suicide surveillance and examine the survey and administrative data sources that are commonly used in public health surveillance. We then review recent data on the epidemiology of suicide and suicidal behaviour among Indigenous populations, and identify challenges related to national surveillance.

To enhance capacity for suicide surveillance, we propose strategies to better track progress in Indigenous suicide prevention. Specifically, we recommend establishing an independent community and scientific governing council, integrating Indigenous identifiers into population health datasets, increasing geographic coverage, improving suicide data quality, comprehensiveness, and timeliness, and developing a platform for making suicide data accessible to all stakeholders. Overall, the strategies we propose can build on the strengths of the existing national suicide surveillance system by adopting a collaborative and inclusive governance model that recognizes the stake Indigenous communities have in suicide prevention.

Sex Differences in Diagnoses, Treatment, and Outcomes for Emergency Department Patients With Chest Pain and Elevated Cardiac Troponin

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.

CAEP 2014 Academic symposium: "How to make research succeed in your department: How to fund your research program"

OBJECTIVE

We sought to gather a comprehensive list of funding strategies and opportunities for emergency medicine (EM) centres across Canada, and make recommendations on how to successfully fund all levels of research activity, including research projects, staff salaries, infrastructure, and researcher stipends.

METHODS

We formed an expert panel consisting of volunteers recognized nationally for their scholarly work in EM. First, we conducted interviews with academic leaders and researchers to obtain a description of their local funding strategies using a standardized open-ended questionnaire. Panelists then identified emerging funding models. Second, we listed funding opportunities and initiatives at the provincial, national, and international levels. Finally, we used an iterative consensus-based approach to derive pragmatic recommendations after incorporating comments and suggestions from participants at an academic symposium.

RESULTS

Our review of funding strategies identified four funding models: 1) investigator dependent model, 2) practice plan, 3) generous benefactor, and 4) mixed funding. Recommendations in this document include approaches for research contributors and producers (seven recommendations), for local academic leaders (five recommendations), and for national organizations, such as the Canadian Association of Emergency Physicians (CAEP) (three recommendations).

CONCLUSIONS

Funding for research in EM varies across Canada and is largely insecure. We offer recommendations to help facilitate funding for large and small projects, for salary support, and for local and national leaders to advance EM research. We believe that these recommendations will increase funding for all levels of EM research activity, including research projects, staff salaries, infrastructure, and researcher stipends.

Reliability of the Canadian Triage and Acuity Scale: interrater and intrarater agreement from a community and an academic emergency department

OBJECTIVES

The Canadian Triage and Acuity Scale (CTAS) is a five-level triage tool that is used to help prioritize the order in which emergency department (ED) patients should be seen. The objectives of this study were to determine the interrater and intrarater agreement of the 2008 CTAS guideline revisions by triage nurses and to compare agreement between triage nurses working in a small community ED and an academic ED.

METHODS

Seventy-eight triage nurses assigned CTAS scores and free-text presenting complaints for 10 paper-based case scenarios. For five scenarios, the CTAS score should have remained unchanged from previous guidelines, whereas the other five scenarios should have been triaged differently based on the 2008 CTAS first-order modifiers. Thirty-three participants repeated the questionnaire 90 days later, and intrarater agreement was measured.

RESULTS

There was a higher level of agreement (κ  =  0.73; 95% CI 0.68-0.79) for the five case scenarios, which relied on the older 2004 guidelines compared to the scenarios where the 2008 guidelines would have suggested a different triage level (κ  =  0.50; 95% CI 0.42-0.59). For the 10 case scenarios analyzed, the free-text presenting complaints matched the Canadian Emergency Department Information System (CEDIS) list 90.1% of the time (κ  =  0.80; 95% CI 0.76-0.84).

CONCLUSION

The reliability of CTAS scoring by academic and community ED nurses was relatively good; however, the application of the 2008 CTAS revisions appears less reliable than the 2004 CTAS guidelines. These results may be useful to develop educational materials to strengthen reliability and validity for triage scoring using the 2008 CTAS guideline revisions.

[Quality management in emergency departments: Lack of uniform standards for fact-based controlling]

BACKGROUND

The general high occupancy of emergency departments during the winter months of 2014/2015 outlined deficits in health politics. Whether on the regional, province, or federal level, verifiable and accepted figures to enable in depth analysis and fact-based controlling of emergency care systems are lacking.

OBJECTS

As the first step, reasons for the current situation are outlined in order to developed concrete recommendations for individual hospitals.

METHODS

This work is based on a selective literature search with focus on quality management, ratio driven management, and process management within emergency departments as well as personal experience with implementation of a key ratio system in a German maximum care hospital.

RESULTS AND CONCLUSION

The insufficient integration of emergencies into the DRG systematic, the role as gatekeeper between inpatient and outpatient care sector, the decentralized organization of emergency departments in many hospitals, and the inconsistent representation within the medical societies can be mentioned as reasons for the lack of key ratio systems. In addition to the important role within treatment procedures, emergency departments also have an immense economic importance. Consequently, the management of individual hospitals should promote implementation of key ratio systems to enable controlling of emergency care processes. Thereby the perspectives finance, employees, processes as well as partners and patients should be equally considered. Within the process perspective, milestones could be used to enable detailed controlling of treatment procedures. An implementation of key ratio systems without IT support is not feasible; thus, existing digital data should be used and future data analysis should already be considered during implementation of new IT systems.

Development of the Canadian Emergency Department Diagnosis Shortlist

Objective:

Managers of emergency departments (EDs), governments and researchers would benefit from reliable data sets that characterize use of EDs. Although Canadian ED lists for chief complaints and triage acuity exist, no such list exists for diagnosis classification. This study was aimed at developing a standardized Canadian Emergency Department Diagnosis Shortlist (CED-DxS), as a subset of the full International Classification of Diseases, 10th revision, with Canadian Enhancement (ICD-10-CA).

Methods:

Emergency physicians from across Canada participated in the revision of the ICD-10-CA through 2 rounds of the modified Delphi method. We randomly assigned chapters from the ICD-10-CA (approximately 3000 diagnoses) to reviewers, who rated the importance of including each diagnosis in the ED-specific diagnosis list. If 80% or more of the reviewers agreed on the importance of a diagnosis, it was retained for the final revision. The retained diagnoses were further aggregated and adjusted, thus creating the CED-DxS.

Results:

Of the 83 reviewers, 76% were emergency medicine (EM)–trained physicians with an average of 12 years of experience in EM, and 92% were affiliated with a university teaching hospital. The modified Delphi process and further adjustments resulted in the creation of the CED-DxS, containing 837 items. The chapter with the largest number of retained diagnoses was injury and poisoning (n= 292), followed by gastrointestinal (n= 59), musculoskeletal (n= 55) and infectious disease (n= 42). Chapters with the lowest number retained were neoplasm (n= 18) and pregnancy (n= 12).

Conclusion:

We report the creation of the uniform CED-DxS, tailored for Canadian EDs. The addition of ED diagnoses to existing standardized parameters for the ED will contribute to homogeneity of data across the country.

Standard for improving emergency information interoperability: the HL7 data elements for emergency department systems

BACKGROUND

Emergency departments in the United States service over 130 million visits per year. The demands for information from these visits require interoperable data exchange standards. While multiple data exchange specifications are in use, none have undergone rigorous standards review. This paper describes the creation and balloting of the Health Level Seven (HL7) Data Elements for Emergency Department Systems (DEEDS).

METHODS

Existing data exchange specifications were collected and organized into categories reflecting the workflow of emergency care. The concepts were then mapped to existing standards for vocabulary, data types, and the HL7 information model. The HL7 community then processed the specification through the normal balloting process addressing all comments and concerns. The resulting specification was then submitted for publication as an HL7 informational standard.

RESULTS

The resulting specification contains 525 concepts related to emergency care required for operations and reporting to external agencies. An additional 200 of the most commonly ordered laboratory tests were included. Each concept was given a unique identifier and mapped to Logical Observation Identifiers, Names, and Codes (LOINC). HL7 standard data types were applied.

DISCUSSION

The HL7 DEEDS specification represents the first set of common ED related data elements to undergo rigorous standards development. The availability of this standard will contribute to improved interoperability of emergency care data.

Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain

Objectives:

Current guidelines emphasize that emergency department (ED) patients at low risk for potential ischemic chest pain cannot be discharged without extensive investigations or hospitalization to minimize the risk of missing acute coronary syndrome (ACS). We sought to derive and validate a prediction rule that permitted 20 to 30% of ED patients without ACS safely to be discharged within 2 hours without further provocative cardiac testing.

Methods:

This prospective cohort study enrolled 1,669 chest pain patients in two blocks in 2000–2003 (development cohort) and 2006 (validation cohort). The primary outcome was 30-day ACS diagnosis. A recursive partitioning model incorporated reliable and predictive cardiac risk factors, pain characteristics, electrocardiographic findings, and cardiac biomarker results.

Results:

In the derivation cohort, 165 of 763 patients (21.6%) had a 30-day ACS diagnosis. The derived prediction rule was 100.0% sensitive and 18.6% specific. In the validation cohort, 119 of 906 patients (13.1%) had ACS, and the prediction rule was 99.2% sensitive (95% CI 95.4–100.0) and 23.4% specific (95% CI 20.6–26.5). Patients have a very low ACS risk if arrival and 2-hour troponin levels are normal, the initial electrocardiogram is nonischemic, there is no history of ACS or nitrate use, age is &lt; 50 years, and defined pain characteristics are met. The validation of the rule was limited by the lack of consistency in data capture, incomplete follow-up, and lack of evaluation of the accuracy, comfort, and clinical sensibility of this clinical decision rule.

Conclusion:

The Vancouver Chest Pain Rule may identify a cohort of ED chest pain patients who can be safely discharged within 2 hours without provocative cardiac testing. Further validation across other centres with consistent application and comprehensive and uniform follow-up of all eligible and enrolled patients, in addition to measuring and reporting the accuracy of and comfort level with applying the rule and the clinical sensibility, should be completed prior to adoption and implementation.

[National data set "emergency department": development, structure and approval by the Deutsche Interdisziplinäre Vereinigung für Intensivmedizin und Notfallmedizin]

BACKGROUND

The Deutsche Interdisziplinäre Vereinigung für Intensivmedizin und Notfallmedizin (DIVI) is divided into sections one of which is the "Sektion Notaufnahmeprotokoll" (emergency department protocol section) founded in 2007. The main task was to create a national data set for the documentation of patients in emergency departments (ED).

MATERIAL AND METHODS

In order to create such a data set a careful look was taken at the current state of documentation in many different hospitals throughout Germany. In addition, existing registries and international requirements were also taken into consideration. The content of the dataset "ED documentation" was developed in interdisciplinary and interprofessional expert rounds.

RESULTS

The dataset "ED documentation" forms the first basis for documentation in German EDs. The modular data set contains 676 fields and covers all relevant information of the whole clinical process in the ED. Legal issues as well as several aspects for internal and external quality management are also included. For this reason the data of several German quality registries (e.g. TraumaRegister DGU® of the German Society of Trauma Surgery) are part of the data set. Furthermore, the data set forms the basis for several financial and billing aspects. A set of six forms was created in accordance with the developed modular data set. In 2010 the data set was approved by the executive committee of the DIVI. Several German medical associations (e.g. German Association for Emergency Medicine/Deutsche Gesellschaft Interdisziplinäre Notfall- und Akutmedizin, DGINA) recommend its use. Currently 80 hospitals are using the data set.

CONCLUSION

Beside the ability to exchange information the presented data set is the basis for internal and external quality assessment in the ED even if most of the available scoring and benchmarking tools are not validated for the German medical system. Implementing an ED register in Germany which is planned in the future, could close this gap.

Chief complaint-based performance measures: a new focus for acute care quality measurement

Performance measures are increasingly important to guide meaningful quality improvement efforts and value-based reimbursement. Populations included in most current hospital performance measures are defined by recorded diagnoses using International Classification of Diseases, Ninth Revision codes in administrative claims data. Although the diagnosis-centric approach allows the assessment of disease-specific quality, it fails to measure one of the primary functions of emergency department (ED) care, which involves diagnosing, risk stratifying, and treating patients' potentially life-threatening conditions according to symptoms (ie, chief complaints). In this article, we propose chief complaint-based quality measures as a means to enhance the evaluation of quality and value in emergency care. We discuss the potential benefits of chief complaint-based measures, describe opportunities to mitigate challenges, propose an example measure set, and present several recommendations to advance this paradigm in ED-based performance measurement.

Validation of the new diagnosis grouping system for pediatric emergency department visits using the International Classification of Diseases, 10th Revision

OBJECTIVE

A clinically sensible diagnosis grouping system (DGS) is needed for describing pediatric emergency diagnoses for research, medical resource preparedness, and making national policy for pediatric emergency medical care. The Pediatric Emergency Care Applied Research Network (PECARN) developed the DGS successfully. We developed the modified PECARN DGS based on the different pediatric population of South Korea and validated the system to obtain the accurate and comparable epidemiologic data of pediatric emergent conditions of the selected population.

METHODS

The data source used to develop and validate the modified PECARN DGS was the National Emergency Department Information System of South Korea, which was coded by the International Classification of Diseases, 10th Revision (ICD-10) code system. To develop the modified DGS based on ICD-10 code, we matched the selected ICD-10 codes with those of the PECARN DGS by the General Equivalence Mappings (GEMs). After converting ICD-10 codes to ICD-9 codes by GEMs, we matched ICD-9 codes into PECARN DGS categories using the matrix developed by PECARN group. Lastly, we conducted the expert panel survey using Delphi method for the remaining diagnosis codes that were not matched.

RESULTS

A total of 1879 ICD-10 codes were used in development of the modified DGS. After 1078 (57.4%) of 1879 ICD-10 codes were assigned to the modified DGS by GEM and PECARN conversion tools, investigators assigned each of the remaining 801 codes (42.6%) to DGS subgroups by 2 rounds of electronic Delphi surveys. And we assigned the remaining 29 codes (4%) into the modified DGS at the second expert consensus meeting. The modified DGS accounts for 98.7% and 95.2% of diagnoses of the 2008 and 2009 National Emergency Department Information System data set. This modified DGS also exhibited strong construct validity using the concepts of age, sex, site of care, and seasons. This also reflected the 2009 outbreak of H1N1 influenza in Korea.

CONCLUSIONS

We developed and validated clinically feasible and sensible DGS system for describing pediatric emergent conditions in Korea. The modified PECARN DGS showed good comprehensiveness and demonstrated reliable construct validity. This modified DGS based on PECARN DGS framework may be effectively implemented for research, reporting, and resource planning in pediatric emergency system of South Korea.

A method for reviewing the accuracy and reliability of a five-level triage process (canadian triage and acuity scale) in a community emergency department setting: building the crowding measurement infrastructure

Objectives. Triage data are widely used to evaluate patient flow, disease severity, and emergency department (ED) workload, factors used in ED crowding evaluation and management. We defined an indicator-based methodology that can be easily used to review the accuracy of Canadian Triage and Acuity Scale (CTAS) performance. Methods. A trained nurse reviewer (NR) retrospectively triaged two separate month's ED charts relative to a set of clinical indicators based on CTAS Chief Complaints. Interobserver reliability and accuracy were compared using Kappa and comparative statistics. Results. There were 2838 patients in Trial 1 and 3091 in Trial 2. The rate of inconsistent triage was 14% and 16% (Kappa 0.596 and 0.604). Clinical Indicators “pain scale, chest pain, musculoskeletal injury, respiratory illness, and headache” captured 68% and 62% of visits. Conclusions. We have demonstrated a system to measure the levels of process accuracy and reliability for triage over time. We identified five key clinical indicators which captured over 60% of visits. A simple method for quality review uses a small set of indicators, capturing a majority of cases. Performance consistency and data collection using indicators may be important areas to direct training efforts.

Toward vocabulary control for chief complaint

The chief complaint (CC) is the data element that documents the patient's reason for visiting the emergency department (ED). The need for a CC vocabulary has been acknowledged at national meetings and in multiple publications, but to our knowledge no groups have specifically focused on the requirements and development plans for a CC vocabulary. The national consensus meeting "Towards Vocabulary Control for Chief Complaint" was convened to identify the potential uses for ED CC and to develop the framework for CC vocabulary control. The 10-point consensus recommendations for action were 1) begin to develop a controlled vocabulary for CC, 2) obtain funding, 3) establish an infrastructure, 4) work with standards organizations, 5) address CC vocabulary characteristics for all user communities, 6) create a collection of CC for research, 7) identify the best candidate vocabulary for ED CCs, 8) conduct vocabulary validation studies, 9) establish beta test sites, and 10) plan publicity and marketing for the vocabulary.

Data collection on patients in emergency departments in Canada

OBJECTIVE

Relatively little is known about the ability of Canadian emergency departments (EDs) and the federal, provincial and territorial governments to quantify ED activity. The objectives of this study were to determine the use of electronic patient data in Canadian EDs, the accessibility of provincial data on ED visits, and to identify the data elements and current methods of ED information system (EDIS) data collection nationally.

METHODS

Surveys were conducted of the following 3 groups: 1) all ED directors of Canadian hospitals located in communities of >10,000 people, 2) all electronic EDIS vendors, and 3) representatives from the ministries of health from 13 provincial and territorial jurisdictions who had knowledge of ED data collection.

RESULTS

Of the 243 ED directors contacted, 158 completed the survey (65% response rate) and 39% of those reported using an electronic EDIS. All 11 EDIS vendor representatives responded. Most of the vendors provide a similar package of basic EDIS options, with add-on features. All 13 provincial or territorial government representatives completed the survey. Nine (69%) provinces and territories collect ED data, however the source of this information varies. Five provinces and territories collect triage data, and 3 have a comprehensive, jurisdiction-wide, population-based ED database. Thirty-nine percent of EDs in larger Canadian communities track patients using electronic methods. A variety of EDIS vendor options are available and used in Canada.

CONCLUSION

The wide variation in methods and in data collected presents serious barriers to meaningful comparison of ED services across the country. It is little wonder that the majority of information regarding ED overcrowding in Canada is anecdotal, when the collection of this critical health information is so variable. There is an urgent need to place the collection of ED information on the provincial and national agenda and to ensure that the collection of this information consistent, comprehensive and mandatory.

Current political issues facing emergency medicine in Canada

Health care in Canada is universal, accessible, transferable and publicly funded. Each of Canada's provinces has the responsibility for health care funding and delivery through its ministry of health, controlled by the governing provincial party and overseen by a Minister of Health. The Federal Government is responsible for ensuring the provinces conform to the spirit and regulations within the Canada Health Act and for broad programme funding, through the federal Minister of Health. As such, access to emergency health services is available to all Canadians free of direct charge. Some aspects of health care are the direct responsibility of citizens, such as ambulance services, medications (for those who can afford them), and 'non-essential' services. For most Canadians, however, care for acute illness and injury is provided without barriers in EDs while generalists such as family physicians and paediatricians provide primary care.

The Canadian Triage and Acuity Scale: A Canadian perspective on emergency department triage

The Canadian Triage and Acuity Scale has received widespread acceptance in Canada as a reliable and valid tool for emergency department triage. The importance of accurate triage becomes more apparent as emergency department volumes increase, and resources shrink. The need to ensure that those patients requiring more urgent care receive care first is the basis for all triage scales. Through the Canadian Triage and Acuity Scale National Working Group, the scale became the recommended triage tool for Canadian emergency departments. Work has been done on the interrater reliability of Canadian Triage and Acuity Scale among health care providers. There is a need to further assess the validity of the scale. This scale has now been applied in the out of hospital setting by paramedics and is being used in measurements of emergency physician workload. The future may see an electronic triage tool develop for emergency department use to reduce variability in its application. The Canadian Triage and Acuity Scale has become an integral component of Canadian emergency departments.