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Rashidi F, Simbar M, Safari S, Kiani Z. The design of an Obstetric Telephone Triage Guideline (OTTG): a mixed method study. BMC Womens Health 2024; 24:246. [PMID: 38637803 PMCID: PMC11025151 DOI: 10.1186/s12905-024-03076-1] [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: 04/25/2023] [Accepted: 04/04/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Clarifying the dimensions and characteristics of obstetric telephone triage is important in improving the quality of services in the health system because researchers can evaluate the effectiveness of treatment, care and diagnostic measures in the form of obstetric telephone triage by developing a guideline. Therefore, this study aimed to design an Obstetric Telephone Triage Guideline (OTTG) using a mixed-method study. METHODS The present study was carried out using an exploratory sequential mixed method study in two qualitative and quantitative phases. An inductive-deductive approach was also used to determine the concept of obstetric telephone triage. In this respect, a qualitative study and a literature review were used in the inductive and deductive stages, respectively. Moreover, the validity of the developed guideline was confirmed based on experts' opinions and results of the AGREE II tool. RESULTS The guideline included the items for evaluating the severity of obstetric symptoms at five levels including "critical", "urgent", "less urgent", "no urgent", and "recommendations". The validity of the guideline was approved at 96%, 95%, 97%, 95%, 93%, and 100% for six dimensions of AGREE II including scope and purpose, stakeholder involvement, the rigor of development, clarity of presentation, applicability, and editorial independence, respectively. CONCLUSION The OTTG is a clinically comprehensive, easy-to-use, practical, and valid tool. This guideline is a standardized tool for evaluating the severity of symptoms and determining the urgency for obstetrics triage services. By using this integrated and uniform guideline, personal biases can be avoided, leading to improved performance and ensuring that patients are not overlooked. Additionally, the use of OTTG promotes independent decision-making and reduces errors in triage decision-making.
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Affiliation(s)
- Farzaneh Rashidi
- Midwifery and Reproductive Health Research Center, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoumeh Simbar
- Midwifery and Reproductive Health Research Center, Department of Midwifery and Reproductive Health, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Saeed Safari
- Department of Emergency Medicine, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Kiani
- Midwifery and Reproductive Health Research Center, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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van Dam PMEL, Lievens S, Zelis N, van Doorn WPTM, Meex SJR, Cals JWL, Stassen PM. Head-to-head comparison of 19 prediction models for short-term outcome in medical patients in the emergency department: a retrospective study. Ann Med 2023; 55:2290211. [PMID: 38065678 PMCID: PMC10786429 DOI: 10.1080/07853890.2023.2290211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/04/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION Prediction models for identifying emergency department (ED) patients at high risk of poor outcome are often not externally validated. We aimed to perform a head-to-head comparison of the discriminatory performance of several prediction models in a large cohort of ED patients. METHODS In this retrospective study, we selected prediction models that aim to predict poor outcome and we included adult medical ED patients. Primary outcome was 31-day mortality, secondary outcomes were 1-day mortality, 7-day mortality, and a composite endpoint of 31-day mortality and admission to intensive care unit (ICU).The discriminatory performance of the prediction models was assessed using an area under the receiver operating characteristic curve (AUC). Finally, the prediction models with the highest performance to predict 31-day mortality were selected to further examine calibration and appropriate clinical cut-off points. RESULTS We included 19 prediction models and applied these to 2185 ED patients. Thirty-one-day mortality was 10.6% (231 patients), 1-day mortality was 1.4%, 7-day mortality was 4.4%, and 331 patients (15.1%) met the composite endpoint. The RISE UP and COPE score showed similar and very good discriminatory performance for 31-day mortality (AUC 0.86), 1-day mortality (AUC 0.87), 7-day mortality (AUC 0.86) and for the composite endpoint (AUC 0.81). Both scores were well calibrated. Almost no patients with RISE UP and COPE scores below 5% had an adverse outcome, while those with scores above 20% were at high risk of adverse outcome. Some of the other prediction models (i.e. APACHE II, NEWS, WPSS, MEWS, EWS and SOFA) showed significantly higher discriminatory performance for 1-day and 7-day mortality than for 31-day mortality. CONCLUSIONS Head-to-head validation of 19 prediction models in medical ED patients showed that the RISE UP and COPE score outperformed other models regarding 31-day mortality.
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Affiliation(s)
- Paul M. E. L. van Dam
- Department of Internal Medicine, Division of General Internal Medicine, Section Acute Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Sien Lievens
- Department of Internal Medicine, Division of General Internal Medicine, Section Acute Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Noortje Zelis
- Department of Internal Medicine, Division of General Internal Medicine, Section Acute Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - William P. T. M. van Doorn
- Central Diagnostic Laboratory, Department of Clinical Chemistry, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Steven J. R. Meex
- Central Diagnostic Laboratory, Department of Clinical Chemistry, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Jochen W. L. Cals
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, the Netherlands
| | - Patricia M. Stassen
- Department of Internal Medicine, Division of General Internal Medicine, Section Acute Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, the Netherlands
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Peta D, Day A, Lugari WS, Gorman V, Ahayalimudin N, Pajo VMT. Triage: A Global Perspective. J Emerg Nurs 2023; 49:814-825. [PMID: 37925222 DOI: 10.1016/j.jen.2023.08.004] [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: 05/01/2023] [Revised: 07/28/2023] [Accepted: 08/11/2023] [Indexed: 11/06/2023]
Abstract
Triage is a process by which patients are assessed, classified, and sorted based on their presenting complaint and clinical urgency, providing assurance for timely access to emergency care. The goal is to get the right person to the right place, in the right amount of time, for the right reason, and within the context of resource availability. In many countries, a standardized triage system, underpinned through the use of guidelines, is used to provide clinicians with support and guidance. Triage is a globally adopted principle, and although triage guidelines are used in many countries, no single system has been internationally adopted. This paper discusses the importance of how triage process standardization improves patient care, resource management, and benchmarking at local, national, and international levels by applying 5 internationally recognized triage systems to fictional case studies. Evaluation of similarities and differences in severity scores, with a gap analysis, occurs.
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Bannour I, Limam M, Rjiba G, Bannour R, Ajmi T. [Gyneco-obstetrical emergencies at the obstetrics and gynecology department of Sousse: epidemiological study and becoming of the consultants]. Pan Afr Med J 2022; 43:53. [PMID: 36578808 PMCID: PMC9755549 DOI: 10.11604/pamj.2022.43.53.32867] [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: 12/17/2021] [Accepted: 08/12/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction the objective of this work was to establish the clinical profile of patients consulting in gyneco-obstetrical emergencies and identify the reasons for consultation and the becoming of the consultants. Methods a one-center retrospective descriptive observational study was performed including patients who consulted between January 1st and December 31st, 2018. Obstetric emergencies after 36 weeks of amenorrhea were not included. We drew lots 4 months of the year 2018 (one month per season). Then we drew lots 2 weeks of each month. A data collection sheet was developed for the purposes of this work. Results a total of 2007 patients were included in our study among 15,553 gynecological emergency room consultants during 2018. We found that the largest number of consultants was recorded at the start of the week and between 7 am and 7 pm. The most frequently obstetric reasons observed for consultation were pelvic pain (39.6%), bleeding (23.8%) and vomiting (8.7%). The most frequently gynecological reasons for consultation were pelvic pain (54.2%), then metrorrhagia (18.8%) and mastodynia (7.1%). Of the study participants, 66.82% received an ultrasound, 23% received a beta HCG test. The majority of emergency room consultants were referred to their home. Conclusion the majority of patients visiting the emergency room do not have any emergency-related pathologies.
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Affiliation(s)
- Imen Bannour
- Université de Sousse, Faculté de Médecine de Sousse, 4000, Sousse, Tunisie,,Hôpital Farhat Hached, Service de Gynécologie Obstétrique, « Laboratoire de Recherche “LR12ES03” », 4000, Sousse, Tunisie,,Corresponding author: Imen Bannour, Université de Sousse, Faculté de Médecine de Sousse, 4000, Sousse, Tunisie.
| | - Manel Limam
- Université de Sousse, Faculté de Médecine de Sousse, 4000, Sousse, Tunisie,,Département de Médecine de Famille et de Médecine Communautaire, «Laboratoire de Recherche “LR12ES03”», 4002 Sousse, Tunisia
| | - Ghada Rjiba
- Université de Sousse, Faculté de Médecine de Sousse, 4000, Sousse, Tunisie,,Hôpital Farhat Hached, Service de Gynécologie Obstétrique, « Laboratoire de Recherche “LR12ES03” », 4000, Sousse, Tunisie
| | - Rania Bannour
- Université de Sousse, Faculté de Médecine de Sousse, 4000, Sousse, Tunisie,,Département de Médecine de Famille et de Médecine Communautaire, «Laboratoire de Recherche “LR12ES03”», 4002 Sousse, Tunisia
| | - Thouraya Ajmi
- Université de Sousse, Faculté de Médecine de Sousse, 4000, Sousse, Tunisie,,Département de Médecine de Famille et de Médecine Communautaire, «Laboratoire de Recherche “LR12ES03”», 4002 Sousse, Tunisia
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Cooper A, Carson-Stevens A, Cooke M, Hibbert P, Hughes T, Hussain F, Siriwardena A, Snooks H, Donaldson LJ, Edwards A. Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis. BMC Emerg Med 2021; 21:139. [PMID: 34794381 PMCID: PMC8601096 DOI: 10.1186/s12873-021-00537-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 10/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Increasing demand on emergency healthcare systems has prompted introduction of new healthcare service models including the provision of GP services in or alongside emergency departments. In England this led to a policy proposal and £100million (US$130million) of funding for all emergency departments to have co-located GP services. However, there is a lack of evidence for whether such service models are effective and safe. We examined diagnostic errors reported in patient safety incident reports to develop theories to explain how and why they occurred to inform potential priority areas for improvement and inform qualitative data collection at case study sites to further refine the theories. METHODS We used a mixed-methods design using exploratory descriptive analysis to identify the most frequent and harmful sources of diagnostic error and thematic analysis, incorporating realist methodology to refine theories from an earlier rapid realist review, to describe how and why the events occurred and could be mitigated, to inform improvement recommendations. We used two UK data sources: Coroners' reports to prevent future deaths (30.7.13-14.08.18) and National Reporting and Learning System (NRLS) patient safety incident reports (03.01.05-30.11.15). RESULTS Nine Coroners' reports (from 1347 community and hospital reports, 2013-2018) and 217 NRLS reports (from 13 million, 2005-2015) were identified describing diagnostic error related to GP services in or alongside emergency departments. Initial theories to describe potential priority areas for improvement included: difficulty identifying appropriate patients for the GP service; under-investigation and misinterpretation of diagnostic tests; and inadequate communication and referral pathways between the emergency and GP services. High-risk presentations included: musculoskeletal injury, chest pain, headache, calf pain and sick children. CONCLUSION Initial theories include the following topics as potential priority areas for improvement interventions and evaluation to minimise the risk of diagnostic errors when GPs work in or alongside emergency departments: a standardised initial assessment with streaming guidance based on local service provision; clinical decision support for high-risk conditions; and standardised computer systems, communication and referral pathways between emergency and GP services. These theories require refinement and testing with qualitative data collection from case study (hospital) sites.
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Affiliation(s)
- Alison Cooper
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK.
| | - Andrew Carson-Stevens
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | | | | | - Faris Hussain
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | | | | | - Adrian Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
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Prävalenz und Ursachen von Fehltriagierung am Beispiel einer universitären Notaufnahme. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00946-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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O'Shaughnessy Í, Romero-Ortuno R, Edge L, Dillon A, Flynn S, Briggs R, Shields D, McMahon G, Hennessy A, Kennedy U, Staunton P, McNamara R, Timmons S, Horgan F, Cunningham C. Home FIRsT: interdisciplinary geriatric assessment and disposition outcomes in the Emergency Department. Eur J Intern Med 2021; 85:50-55. [PMID: 33243612 DOI: 10.1016/j.ejim.2020.11.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/08/2020] [Accepted: 11/15/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Older people in the Emergency Department (ED) are clinically heterogenous and some presentations may be better suited to alternative out-of-hospital pathways. A new interdisciplinary comprehensive geriatric assessment (CGA) team (Home FIRsT) was embedded in our acute hospital's ED in 2017. AIM To evaluate if routinely collected CGA metrics were associated with ED disposition outcomes. DESIGN Retrospective observational study. METHODS We included all first patients seen by Home FIRsT between 7th May and 19th October 2018. Collected measures were sociodemographic, baseline frailty (Clinical Frailty Scale), major diagnostic categories, illness acuity (Manchester Triage Score) and cognitive impairment/delirium (4AT). Multivariate binary logistic regression models were computed to predict ED disposition outcomes: hospital admission; discharge to GP and/or community services; discharge to specialist geriatric outpatients; discharge to the Geriatric Day Hospital. RESULTS In the study period, there were 1,045 Home FIRsT assessments (mean age 80.1 years). For hospital admission, strong independent predictors were acute illness severity (OR 2.01, 95% CI 1.50-2.70, P<0.001) and 4AT (OR 1.26, 95% CI 1.13 - 1.42, P<0.001). Discharge to specialist outpatients (e.g. falls/bone health) was predicted by musculoskeletal/injuries/trauma presentations (OR 6.45, 95% CI 1.52 - 27.32, P=0.011). Discharge to the Geriatric Day Hospital was only predicted by frailty (OR 1.52, 95% CI 1.17 - 1.97, P=0.002). Age and sex were not predictive in any of the models. CONCLUSIONS Routinely collected CGA metrics are useful to predict ED disposition. The ability of baseline frailty to predict ED outcomes needs to be considered together with acute illness severity and delirium.
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Affiliation(s)
- Íde O'Shaughnessy
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Roman Romero-Ortuno
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland; Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Ireland; Global Brain Health Institute, Trinity College Dublin, Ireland.
| | - Lucinda Edge
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Aoife Dillon
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Sinéad Flynn
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Robert Briggs
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland; Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Ireland
| | | | | | | | - Una Kennedy
- Emergency Department, St James's Hospital, Dublin, Ireland
| | - Paul Staunton
- Emergency Department, St James's Hospital, Dublin, Ireland
| | - Rosa McNamara
- Emergency Department, St James's Hospital, Dublin, Ireland
| | - Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Ireland
| | - Frances Horgan
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Conal Cunningham
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland; Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Ireland
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Wasingya-Kasereka L, Nabatanzi P, Nakitende I, Nabiryo J, Namujwiga T, Kellett J. Two simple replacements for the Triage Early Warning Score to facilitate the South African Triage Scale in low resource settings. Afr J Emerg Med 2021; 11:53-59. [PMID: 33489734 PMCID: PMC7806646 DOI: 10.1016/j.afjem.2020.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/17/2020] [Accepted: 11/30/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The South African Triage Scale (SATS) requires the calculation of the Triage Early Warning Score (TEWS), which takes time and is prone to error. AIM to derive and validate triage scores from a clinical database collected in a low-resource hospital in sub-Saharan Africa over four years and compare them with the ability of TEWS to triage patients. METHODS A retrospective observational study carried out in Kitovu Hospital, Masaka, Uganda as part of an ongoing quality improvement project. Data collected on 4482 patients was divided into two equal cohorts: one for the derivation of scores by logistic regression and the other for their validation. RESULTS Two scores identified the largest number of patients with the lowest in-hospital mortality. A score based on oxygen saturation, mental status and mobility had a c statistic for discrimination of 0.83 (95% CI 0.079-0.87) in the derivation, and 0.81 (95% CI 0.77-0.86) in the validation cohort. Another score based on respiratory rate, mental status and mobility had a c statistic of 0.82 (95% CI 0.078-0.87) in the derivation, and 0.81 (95% CI 0.77-0.86) in the validation cohort. The oxygen saturation-based score of zero points identified 51% of patients in the derivation cohort who had in-hospital mortality rate of 0.5%, and 49% of patients in the validation cohort who had in-hospital mortality of 1.0%. A respiratory rate-based score of zero points identified 45% in the derivation cohort who had in-hospital mortality rate of 0.5%, and 44% of patients in the validation cohort who had in-hospital mortality of 0.8%. Both scores had comparable performance to TEWS. CONCLUSION Two easy to calculate scores have comparable performance to TEWS and, therefore, could replace it to facilitate the adoption of SATS in low-resource settings.
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Affiliation(s)
| | | | | | - Joan Nabiryo
- Department of Medicine, Kitovu Hospital, Masaka, Uganda
| | | | - John Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - Kitovu Hospital Study Group
- Kitovu Hospital, Masaka, Uganda
- Department of Medicine, Kitovu Hospital, Masaka, Uganda
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
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Pereira H, Calé R, Pereira E, Mello S, Vitorino S, Jerónimo de Sousa P, Monteiro S, Pinto FJ, Ramos R, Coelho Dos Santos P, Ferreira J, Silveira J, Morais J. Five years of Stent for Life in Portugal. Rev Port Cardiol 2021; 40:81-90. [PMID: 33608197 DOI: 10.1016/j.repc.2020.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 04/26/2020] [Accepted: 05/05/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To analyze changes in performance indicators five years after Portugal joined the Stent for Life (SFL) initiative. METHODS National surveys were carried out annually over one-month periods designated as study Time Points between 2011 (Time Zero) and 2016 (Time Five). In this study, 1340 consecutive patients with suspected ST-elevation myocardial infarction (STEMI) who underwent coronary angiography, admitted to 18 24/7 primary percutaneous coronary intervention (PCI) centers, were enrolled. RESULTS There was a significant reduction in the proportion of patients who attended primary healthcare centers (20.3% vs. 4.8%, p<0.001) and non-PCI-capable centers (54.5% vs. 42.5%, p=0.013). The proportions of patients who called 112, the national emergency medical services (EMS) number (35.2% vs. 46.6%, p=0.022) and of those transported via the EMS to a PCI-capable center (13.1% vs. 30.5%, p<0.001) increased. The main improvement observed in timings for revascularization was a trend toward a reduction in patient delay (114 min in 2011 vs. 100 min in 2016, p=0.050). System delay and door-to-balloon time remained constant, at a median of 134 and 57 min in 2016, respectively. CONCLUSION During the lifetime of the SFL initiative in Portugal, there was a positive change in patient delay indicators, especially the lower proportion of patients who attended non-PCI centers, along with an increase in those who called 112. System delay did not change significantly over this period. These results should be taken into consideration in the current Stent - Save a Life initiative.
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Affiliation(s)
- Hélder Pereira
- Cardiology Department, Hospital Garcia de Orta, Almada, CCUL, CAML, University of Lisbon, Portugal.
| | - Rita Calé
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Ernesto Pereira
- Cardiology Department, Hospital Garcia de Orta, Almada; Escola Superior de Saude da Cruz Vermelha Portuguesa, Lisboa, Portugal
| | | | - Sílvia Vitorino
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | | | - Sílvia Monteiro
- Cardiology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Fausto J Pinto
- Cardiology Department, CCUL, CAML, University of Lisbon, Portugal
| | - Raquel Ramos
- National Institute of Medical Emergency (INEM), Portugal
| | | | | | - João Silveira
- Cardiology Department, Centro Hospitalar do Porto, Porto, Portugal
| | - João Morais
- Cardiology Department, Santo André Hospital, Leiria, Portugal
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Dippenaar E. An epidemiological study of a patient population, triage category allocations and principal diagnosis within the emergency centres of a private healthcare group in the Emirate of Dubai, United Arab Emirates. Nurs Open 2020; 7:1468-1474. [PMID: 32802366 PMCID: PMC7424460 DOI: 10.1002/nop2.518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 05/01/2020] [Indexed: 11/06/2022] Open
Abstract
Aim To describe, compare and correlate the number of patients seen, their demographics, triage category allocations and principal diagnosis in four emergency centres; to better understand the patient population and triage practices in this setting. Design An observational, cross-sectional, epidemiological study. Methods Electronic medical records were retrospectively evaluated from patients triaged in each of the four emergency centres over six months. Descriptive statistics were used to describe the patient demographics and variance between triage category allocations. Results A total of 56,984 patient records were captured, with an equal gender split and the workforce being the largest patient population (20-50 years). Acute upper respiratory infection was the most prolific diagnosis, and lower acuity triage categories were allocated the most. There were inconsistencies in the application of triage systems between the emergency centres, the most obvious being the variance in triage system selection and application.
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Affiliation(s)
- Enrico Dippenaar
- Division of Emergency MedicineUniversity of Cape TownCape TownSouth Africa
- Emergency Medicine Research GroupAnglia Ruskin UniversityChelmsfordUK
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12
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Roenhoej Rønhøj R, Hasselbalch RB, Schultz M, Pries-Heje M, Plesner LL, Ravn L, Lind M, Jensen BN, Hoei-Hansen Høi-Hansen T, Carlson N, Torp-Pedersen C, Rasmussen LS, Rasmussen LJH, Eugen-Olsen J, Koeber Køber L, Iversen K. Abnormal routine blood tests as predictors of mortality in acutely admitted patients. Clin Biochem 2019; 77:14-19. [PMID: 31843666 DOI: 10.1016/j.clinbiochem.2019.12.009] [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] [Received: 10/15/2019] [Revised: 12/07/2019] [Accepted: 12/12/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study aimed to improve early risk stratification in the emergency department by creating a simple blood test score based on routine biomarkers and assess its predictive ability for 30-day mortality of acutely admitted patients. METHODS This was a secondary analysis of data from the TRIAGE II study. It included unselected acutely admitted medical and surgical patients, who had albumin, C-reactive protein, creatinine, haemoglobin, leukocytes, potassium, sodium and thrombocytes levels analysed upon admission. Patients were classified according to the number of biomarker results outside the reference range into four risk groups termed "very low", "low", "intermediate", and "high" with 0-1, 2-3, 4-5 and 6-8 abnormal biomarker results, respectively. Logistic regression was used to calculate odds ratios for 30-day mortality and receiver operating characteristic was used to test the discriminative value. The primary analysis was done in patients triaged with ADAPT (Adaptive Process Triage). Subsequently, we analysed two other cohorts of acutely admitted patients. RESULTS The TRIAGE II cohort included 17,058 eligible patients, 30-day mortality was 5.2%. The primary analysis included 7782 patients. Logistic regression adjusted for age and sex showed an OR of 24.1 (95% CI 14.9-41.0) between the very low- and the high-risk group. The area under the curve (AUC) was 0.79 (95% CI 0.76-0.81) for the blood test score in predicting 30-day mortality. The subsequent analyses confirmed the results. CONCLUSIONS A blood test score based on number of routine biomarkers with an abnormal result was a predictor of 30-day mortality in acutely admitted patients.
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Affiliation(s)
- Rasmus Roenhoej Rønhøj
- Department of Cardiology, Herlev-Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark.
| | - Rasmus B Hasselbalch
- Department of Cardiology, Herlev-Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Martin Schultz
- Department of Cardiology, Herlev-Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Mia Pries-Heje
- Department of Cardiology, Herlev-Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Louis L Plesner
- Department of Cardiology, Herlev-Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Lisbet Ravn
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Morten Lind
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Birgitte N Jensen
- Department of Emergency Medicine, Bispebjerg Hospital, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | | | - Nicholas Carlson
- Department of Cardiology, Gentofte Hospital, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark; The Danish Heart Foundation, Vognmagergade 7, 1120 Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Departments of Cardiology and Clinical Research, Nordsjaellands Hospital, Dyrehavevej 29, 3400 Hilleroed, Denmark; Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9100 Aalborg, Denmark
| | - Lars S Rasmussen
- Department of Anaesthesia, Center of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Line J H Rasmussen
- Clinical Research Centre, Hvidovre Hospital, University of Copenhagen, Kettegaard Alle 30, 2650 Hvidovre, Denmark
| | - Jesper Eugen-Olsen
- Clinical Research Centre, Hvidovre Hospital, University of Copenhagen, Kettegaard Alle 30, 2650 Hvidovre, Denmark
| | - Lars Koeber Køber
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Kasper Iversen
- Department of Cardiology, Herlev-Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark; Department of Emergency Medicine, Herlev-Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
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Andrade-Silva FB, Takemura RL, Bellato RT, Leonhardt MDC, Kojima KE, Silva JDS. VALIDITY AND RELIABILITY OF THE MANCHESTER SCALE USED IN THE ORTHOPEDIC EMERGENCY DEPARTMENT. ACTA ORTOPEDICA BRASILEIRA 2019; 27:50-54. [PMID: 30774531 PMCID: PMC6362691 DOI: 10.1590/1413-785220192701191577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objectives: To describe the clinical utility of the Manchester triage scale adapted for orthopedic emergency departments and to evaluate its validity in identifying patients with the need for hospital care and its reliability when reproduced by different professionals. Methods: Five triage flowcharts were developed based on the Manchester scale for the following orthopedic disorders: traumatic injuries, joint pain, vertebral pain, postoperative disorders, and musculoskeletal infections. A series of patients triaged by two orthopedists was analyzed to assess the concordance between the evaluators (reliability) and the validity of the Manchester scale as predictive of severity. Results: The reliability analysis included 231 patients, with an inter-observer agreement of 84% (Kappa = 0.77, p <0.001). The validity analysis included 138 patients. The risk category had a strong association with the need for hospital care in patients with trauma (OR = 6.57, p = 0.001) and was not significant for non-traumatic disorders (OR = 2.42; p = 0.208). The overall sensitivity and specificity were 64% and 76%, respectively. Conclusion: The evaluated system presented high reliability. Its validity was adequate, with good sensitivity for identifying patients requiring hospital care among those with traumatic lesions. However, the sensitivity was low for patients with non-traumatic lesions. Level of Evidence III, Retrospective Study.
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Taboulet P, Maillard-Acker C, Ranchon G, Goddet S, Dufau R, Vincent-Cassy C, Yordanov Y, El Khoury C. Triage des patients à l’accueil d’une structure d’urgences. Présentation de l’échelle de tri élaborée par la Société française de médecine d’urgence : la FRench Emergency Nurses Classification in Hospital (FRENCH). ANNALES FRANCAISES DE MEDECINE D URGENCE 2019. [DOI: 10.3166/afmu-2018-0101] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
La Société française de médecine d’urgence
(SFMU) a recommandé la création d’une échelle spécifique, unique au niveau national, pour le triage des patients à l’accueil d’une structure d’urgences, prenant en compte les spécificités de l’adulte et de l’enfant. La commission de l’évaluation et de la qualité de la SFMU a créé, à l’instar des échelles de tri internationales, une échelle de tri avec cinq niveaux de priorité croissante (tris 5 à 1, du moins urgent au plus urgent) auxquels correspondent des motifs de recours aux soins de complexité/sévérité croissante. Le tri 3 a été subdivisé en deux groupes pour distinguer (et prioriser) les patients qui ont au moins une comorbidité en rapport avec le motif de recours aux soins ou qui sont adressés par un médecin (3A) des autres patients (3B). L’échelle de tri FRENCH (FRench Emergency Nurses Classification in Hospital) a donc six niveaux de priorité. À chaque niveau de tri correspondent des motifs de recours aux soins fréquents en médecine d’urgence, des modulateurs de tri, une répartition rationnelle des circuits patients et un délai maximum d’attente avant prise en charge médicale, après évaluation par l’infirmier(ière) d’accueil. Une première évaluation de la FRENCH a montré qu’elle répondait aux objectifs du triage en facilitant le repérage de l’urgence complexe/sévère de façon fiable et reproductible. De nouvelles évaluations sont nécessaires dans d’autres structures d’urgences pour confirmer sa performance et favoriser son évolution.
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Brouns SHA, Mignot-Evers L, Derkx F, Lambooij SL, Dieleman JP, Haak HR. Performance of the Manchester triage system in older emergency department patients: a retrospective cohort study. BMC Emerg Med 2019; 19:3. [PMID: 30612552 PMCID: PMC6322327 DOI: 10.1186/s12873-018-0217-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 12/13/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Studies on the reliability of the MTS and its predictive power for hospitalisation and mortality in the older population have demonstrated mixed results. The objective is to evaluate the performance of the Manchester Triage System (MTS) in older patients (≥65 years) by assessing the predictive ability of the MTS for emergency department resource utilisation, emergency department length of stay (ED-LOS), hospitalisation, and in-hospital mortality rate. The secondary goal was to evaluate the performance of the MTS in older surgical versus medical patients. METHODS A retrospective cohort study was conducted of all emergency department visits by patients ≥65 years between 01 and 09-2011 and 31-08-2012. Performance of the MTS was assessed by comparing the association of the MTS with emergency department resource utilisation, ED-LOS, hospital admission, and in-hospital mortality in older patients and the reference group (18-64 years), and by estimating the area under the receiver operating characteristics curves. RESULTS Data on 7108 emergency department visits by older patients and 13,767 emergency department visits by patients aged 18-64 years were included. In both patient groups, a higher emergency department resource utilisation was associated with a higher MTS urgency. The AUC for the MTS and hospitalisation was 0.74 (95%CI 0.73-0.75) in older patients and 0.76 (95%CI 0.76-0.77) in patients aged 18-64 years. Comparison of the predictive ability of the MTS for in-hospital mortality in older patients with patients aged 18-64 years revealed an AUC of 0.71 (95%CI 0.68-0.74) versus 0.79 (95%CI 0.72-0.85). The majority of older patients (54.8%) were evaluated by a medical specialty and 45.2% by a surgical specialty. The predictive ability of the MTS for hospitalisation and in-hospital mortality was higher in older surgical patients than in medical patients (AUC 0.74, 95%CI 0.72-0.76 and 0.74, 95%CI 0.68-0.81 versus 0.69, 95%CI 0.67-0.71 and 0.66, 95%CI 0.62-0.69). CONCLUSION The performance of the MTS appeared inferior in older patients than younger patients, illustrated by a worse predictive ability of the MTS for in-hospital mortality in older patients. The MTS demonstrated a better performance in older surgical patients than older medical patients regarding hospitalisation and in-hospital mortality.
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Affiliation(s)
- Steffie H A Brouns
- Department of Internal Medicine, Máxima Medical Centre, 5600, BM, Eindhoven/Veldhoven, the Netherlands. .,Department of Health Services Research, and CAPHRI School for Public Health and Primary Care, Maastricht University, 6229, ER, Maastricht, the Netherlands.
| | - Lisette Mignot-Evers
- Department of Emergency medicine, Máxima Medical Centre, 5600, BM, Veldhoven, the Netherlands
| | - Floor Derkx
- Department of Emergency medicine, Máxima Medical Centre, 5600, BM, Veldhoven, the Netherlands
| | - Suze L Lambooij
- Department of Internal Medicine, Máxima Medical Centre, 5600, BM, Eindhoven/Veldhoven, the Netherlands
| | - Jeanne P Dieleman
- Máxima Medical Centre Academy, Máxima Medical Centre, Eindhoven/Veldhoven, the Netherlands
| | - Harm R Haak
- Department of Internal Medicine, Máxima Medical Centre, 5600, BM, Eindhoven/Veldhoven, the Netherlands.,Department of Health Services Research, and CAPHRI School for Public Health and Primary Care, Maastricht University, 6229, ER, Maastricht, the Netherlands.,Department of Internal Medicine, Division of general medicine, Maastricht University Medical Centre, 6229, HX, Maastricht, the Netherlands
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An Evaluation of a Modified CTAS at an Accident and Emergency Department in a Developing Country. Emerg Med Int 2018; 2018:6821323. [PMID: 29854462 PMCID: PMC5954883 DOI: 10.1155/2018/6821323] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 03/02/2018] [Accepted: 03/25/2018] [Indexed: 12/03/2022] Open
Abstract
Objectives To review the modified Canadian Triage and Acuity Scale used in an accident and emergency department in Trinidad and Tobago. Design and Methods A cross-sectional study was carried out. Times from assignment of triage category to being seen by a physician were collected from the patient notes on the days of presentation and compared to the reference standards. Times from decision to admit to obtaining a bed were also recorded. Results 200 patients were included in the study. The median waiting time for patients in the immediate/blue category was 3 minutes (range = 3); for the red category, it was 31.2 minutes (range = 121.8); in the yellow category, it was 61.8 minutes (range = 805.2). The overall admission rate was 30.5%, with an admission rate of 25% for the blue category; 20% of patients in the red category waited more than 4 hours for a hospital bed. Conclusion The patients assigned to the blue category were being seen almost immediately. Less critical persons wait longer than the reference times and this may be due to structural factors such as staffing. The admission rates per category highlighted a low admission rate for the blue category (25%), which is unusual. This study highlights the need for a further study to review clinical presentation, assignment to triage category, and outcomes.
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Warmerdam M, Stolwijk F, Boogert A, Sharma M, Tetteroo L, Lucke J, Mooijaart S, Ansems A, Esteve Cuevas L, Rijpsma D, de Groot B. Initial disease severity and quality of care of emergency department sepsis patients who are older or younger than 70 years of age. PLoS One 2017; 12:e0185214. [PMID: 28945774 PMCID: PMC5612649 DOI: 10.1371/journal.pone.0185214] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 09/10/2017] [Indexed: 12/05/2022] Open
Abstract
Objective Due to atypical symptom presentation older patients are more prone to delayed sepsis recognition. We investigated whether initial disease severity before emergency department (ED) treatment (including treatable acute organ dysfunction), quality of ED sepsis care and the impact on mortality was different between patients older and younger than 70 years. If differences exist, improvements are needed for ED management of older patients at risk for sepsis. Methods In this observational multicenter study, ED patients who were hospitalized with a suspected infection were stratified by age <70 and ≥70 years. The presence of treatable and potentially reversible acute organ dysfunction was measured by the RO components of the Predisposition, Infection, Response and Organ dysfunction (PIRO) score, reflecting acute sepsis-related organ dysfunction developed before ED presentation. Quality of care, as assessed by the full compliance with nine quality performance measures and the standardized mortality ratio (SMR: observed/expected in-hospital mortality), was compared between older and younger patients. Results The RO-components of the PIRO score were 8 (interquartile range; 4–9) in the 833 older patients, twice as high as the 4 (2–8; P<0.001) in the 1537 younger patients. However, full compliance with all nine quality performance measures was achieved in 34.2 (31.0–37.4)% of the older patients, not higher than the 33.0 (30.7–35.4)% in younger patients (P = 0.640). In-hospital mortality was 9.2% (95%-CI, 7.3–11.2) in patients ≥70, twice as high as the 4.6% (3.6–5.6) in patients <70 years, resulting in an SMR (in study period) of ~0.7 in both groups (P>0.05). Conclusion Older sepsis patients are sicker at ED presentation but are not treated more expediently or reliably despite their extra acuity The presence of twice as much treatable acute organ dysfunction before ED treatment suggests that acute organ dysfunction is recognized relatively late by general practitioners or patients in the out of hospital setting.
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Affiliation(s)
- Mats Warmerdam
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, the Netherlands
- * E-mail:
| | - Frank Stolwijk
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, the Netherlands
| | - Anjelica Boogert
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, the Netherlands
| | - Meera Sharma
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, the Netherlands
| | - Lisa Tetteroo
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, the Netherlands
| | - Jacinta Lucke
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, the Netherlands
| | - Simon Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Centre, Leiden, Zuid-Holland, The Netherlands & Institute for Evidence-based Medicine in Old Age | IEMO, Leiden, The Netherlands
| | - Annemieke Ansems
- Emergency Department, Albert Schweitzer Ziekenhuis, Dordrecht, Zuid-Holland, the Netherlands
| | - Laura Esteve Cuevas
- Emergency Department, Albert Schweitzer Ziekenhuis, Dordrecht, Zuid-Holland, the Netherlands
| | - Douwe Rijpsma
- Emergency Department, Rijnstate Ziekenhuis, Arnhem, Gelderland, the Netherlands
| | - Bas de Groot
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, the Netherlands
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Kenyon S, Hewison A, Dann SA, Easterbrook J, Hamilton-Giachritsis C, Beckmann A, Johns N. The design and implementation of an obstetric triage system for unscheduled pregnancy related attendances: a mixed methods evaluation. BMC Pregnancy Childbirth 2017; 17:309. [PMID: 28923021 PMCID: PMC5604363 DOI: 10.1186/s12884-017-1503-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 09/11/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND No standardised system of triage exists in Maternity Care and local audit identified this to be problematic. We designed, implemented and evaluated an Obstetric Triage System in a large UK maternity unit. This includes a standard clinical triage assessment by a midwife, within 15 min of attendance, leading to assignment to a category of clinical urgency (on a 4-category scale). This guides timing of subsequent standardised immediate care for the eight most common reasons for attendance. A training programme was integral to the introduction. METHODS A mixed methods evaluation was conducted. A structured audit of 994 sets of maternity notes before and after implementation identified the number of women seen within 15 min of attendance. Secondary measures reviewed included time to subsequent care and attendance. An inter-operator reliability study using scenarios was completed by midwives. A focus group and two questionnaire studies were undertaken to explore midwives' views of the system and to evaluate the training. In addition a national postal survey of practice in UK maternity units was undertaken in 2015. RESULTS The structured audit of 974/992 (98%) of notes demonstrated an increase in the number of women seen within 15 min of attendance from 39% before implementation to 54% afterwards (RR (95% CI) 1.4 (1.2, 1.7) p = <0.0001). Excellent inter-operator reliability (ICC 0.961 (95% CI 0.91-0.99)) was demonstrated with breakdown showing consistently good rates. Thematic analysis of focus group data (n = 12) informed the development of the questionnaire which was sent to all appropriate midwives. The response rate was 53/79 (67%) and the midwives reported that the new system helped them manage the department and improved safety. The National Survey (response rate 85/135 [63%]) demonstrated wide variation in where women are seen and staffing models in place. The majority of units 69/85 (81%) did not use a triage system based on clinical assessment to prioritise care. CONCLUSIONS This obstetric triage system has excellent inter- operator reliability and appears to be a reliable way of assessing the clinical priority of women as well as improving organisation of the department. Our survey has demonstrated the widespread need for implementation of such a system.
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Affiliation(s)
- Sara Kenyon
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT UK
| | - Alistair Hewison
- Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT UK
| | - Sophie-Anna Dann
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT UK
| | - Jolene Easterbrook
- Day Assessment Unit, Birmingham Women’s and Children’s NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TT UK
| | | | - April Beckmann
- Pacific Institution, 33344 King Road, Abbotsford, BC V2S 4P4 Canada
| | - Nina Johns
- Birmingham Women’s and Children’s NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TG UK
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de Groot B, Stolwijk F, Warmerdam M, Lucke JA, Singh GK, Abbas M, Mooijaart SP, Ansems A, Esteve Cuevas L, Rijpsma D. The most commonly used disease severity scores are inappropriate for risk stratification of older emergency department sepsis patients: an observational multi-centre study. Scand J Trauma Resusc Emerg Med 2017; 25:91. [PMID: 28893325 PMCID: PMC5594503 DOI: 10.1186/s13049-017-0436-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 09/05/2017] [Indexed: 12/12/2022] Open
Abstract
Background Sepsis recognition in older emergency department (ED) patients is difficult due to atypical symptom presentation. We therefore investigated whether the prognostic and discriminative performance of the five most commonly used disease severity scores were appropriate for risk stratification of older ED sepsis patients (≥70 years) compared to a younger control group (<70 years). Methods This was an observational multi-centre study using an existing database in which ED patients who were hospitalized with a suspected infection were prospectively included. Patients were stratified by age < 70 and ≥70 years. We assessed the association with in-hospital mortality (primary outcome) and the area under the curve (AUC) with receiver operator characteristics of the Predisposition, Infection, Response, Organ dysfunction (PIRO), quick Sequential Organ Failure Assessment (qSOFA), Mortality in ED Sepsis (MEDS), and the Modified and National Early Warning (MEWS and NEWS) scores. Results In-hospital mortality was 9.5% ((95%-CI); 7.4–11.5) in the 783 included older patients, and 4.6% (3.6–5.7) in the 1497 included younger patients. In contrast to younger patients, disease severity scores in older patients associated poorly with mortality. The AUCs of all disease severity scores were poor and ranged from 0.56 to 0.64 in older patients, significantly lower than the good AUC range from 0.72 to 0.86 in younger patients. The MEDS had the best AUC (0.64 (0.57–0.71)) in older patients. In older and younger patients, the newly proposed qSOFA score (Sepsis 3.0) had a lower AUC than the PIRO score (sepsis 2.0). Conclusion The prognostic and discriminative performance of the five most commonly used disease severity scores was poor and less useful for risk stratification of older ED sepsis patients. Electronic supplementary material The online version of this article (10.1186/s13049-017-0436-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bas de Groot
- Department of emergency medicine, Leiden University Medical Centre, Albinusdreef 2, 2300, RC, Leiden, the Netherlands.
| | - Frank Stolwijk
- Department of emergency medicine, Leiden University Medical Centre, Albinusdreef 2, 2300, RC, Leiden, the Netherlands
| | - Mats Warmerdam
- Department of emergency medicine, Leiden University Medical Centre, Albinusdreef 2, 2300, RC, Leiden, the Netherlands
| | - Jacinta A Lucke
- Department of emergency medicine, Leiden University Medical Centre, Albinusdreef 2, 2300, RC, Leiden, the Netherlands
| | - Gurpreet K Singh
- Department of emergency medicine, Leiden University Medical Centre, Albinusdreef 2, 2300, RC, Leiden, the Netherlands
| | - Mo Abbas
- Department of emergency medicine, Leiden University Medical Centre, Albinusdreef 2, 2300, RC, Leiden, the Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Centre, Albinusdreef 2, 2300, RC, Leiden, The Netherlands.,Institute for Evidence-based Medicine in Old Age
- IEMO, Albinusdreef 2, 2300, RC, Leiden, The Netherlands
| | - Annemieke Ansems
- Department of emergency medicine, Albert Schweitzer Ziekenhuis, Albert Schweitzerplaats 25, 3318, AT, Dordrecht, the Netherlands
| | - Laura Esteve Cuevas
- Department of emergency medicine, Albert Schweitzer Ziekenhuis, Albert Schweitzerplaats 25, 3318, AT, Dordrecht, the Netherlands
| | - Douwe Rijpsma
- Department of emergency medicine, Rijnstate Ziekenhuis, Wagnerlaan 55, 6815, AD, Arnhem, the Netherlands
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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: 13] [Impact Index Per Article: 1.9] [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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Out of hours care in Germany - High utilization by adult patients with minor ailments? BMC FAMILY PRACTICE 2017; 18:42. [PMID: 28327082 PMCID: PMC5361861 DOI: 10.1186/s12875-017-0609-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 01/05/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Family practitioners (FPs) who work in Out-Of-Hours Care (OOHC) - especially in rural areas - complain about high workload related to low urgency and potentially unnecessary patient presentations with minor ailments. The aim of this study was to describe Reasons for Encounter (RFEs) in primary OOHC taken into account the doctor's perspective in the context of high workload without knowing patients' motives for visiting an OOHC-centre. METHODS Within this descriptive study, OOHC data from 2012 were evaluated from a German statutory health insurance company in the federal state of Baden-Wuerttemberg. 1.53 Million of the 10.5 Million inhabitants of Baden-Wuerttemberg were covered. The frequency of the ICD-10 diagnoses was determined at the three- and four-digit-level. The rate of hospitalizations was used to estimate the severity of the evaluated cases. RESULTS Taken as a whole, 163,711 reasons for encounter with 1,174 ICD-10 single diagnoses were documented, of these 62.2% were on weekends. Less than 5.0% of the examined patients were hospitalized. Low back pain-dorsalgia (M54) was the most common diagnosis in OOHC, with 10,843 cases. Injuries were found twelve times in the list of the 30 most frequent diagnoses. The most frequent infectious disease was acute upper respiratory infection of multiple and unspecified sites (J06). By analysing the ICD codes to four-digits and looking at the rate of hospitalizations, it can be assumed that many RFEs were of less urgency in terms of the prompt need for medical treatment. CONCLUSION While it is acknowledged that it can be difficult to make an exact diagnosis in an OOHC setting, after analysing the ICD-10 diagnoses, the majority of reasons for encounter in OOHC were determined to be of low urgency, meaning that patients could have waited until regular consultation hours. In the OOHC setting, it is important to understand RFEs from both the patient perspective and the family practitioner perspective. Additionally, results like these can be used in staff education especially improving triage methods and medical recommendations and in developing specific guidelines for OOHC in Germany. Analysis of routine data, such as in this study, contributes to this understanding and contributes to resolving problems of coding.
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Zachariasse JM, Seiger N, Rood PPM, Alves CF, Freitas P, Smit FJ, Roukema GR, Moll HA. Validity of the Manchester Triage System in emergency care: A prospective observational study. PLoS One 2017; 12:e0170811. [PMID: 28151987 PMCID: PMC5289484 DOI: 10.1371/journal.pone.0170811] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 01/11/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To determine the validity of the Manchester Triage System (MTS) in emergency care for the general population of patients attending the emergency department, for children and elderly, and for commonly used MTS flowcharts and discriminators across three different emergency care settings. METHODS This was a prospective observational study in three European emergency departments. All consecutive patients attending the emergency department during a 1-year study period (2010-2012) were included. Validity of the MTS was assessed by comparing MTS urgency as determined by triage nurses with patient urgency according to a predefined 3-category reference standard as proxy for true patient urgency. RESULTS 288,663 patients were included in the analysis. Sensitivity of the MTS in the three hospitals ranged from 0.47 (95%CI 0.44-0.49) to 0.87 (95%CI 0.85-0.90), and specificity from 0.84 (95%CI 0.84-0.84) to 0.94 (95%CI 0.94-0.94) for the triage of adult patients. In children, sensitivity ranged from 0.65 (95%CI 0.61-0.70) to 0.83 (95%CI 0.79-0.87), and specificity from 0.83 (95%CI 0.82-0.83) to 0.89 (95%CI 0.88-0.90). The diagnostic odds ratio ranged from 13.5 (95%CI 12.1-15.0) to 35.3 (95%CI 28.4-43.9) in adults and from 9.8 (95%CI 6.7-14.5) to 23.8 (95%CI 17.7-32.0) in children, and was lowest in the youngest patients in 2 out of 3 settings and in the oldest patients in all settings. Performance varied considerably between the different emergency departments. CONCLUSIONS Validity of the MTS in emergency care is moderate to good, with lowest performance in the young and elderly patients. Future studies on the validity of triage systems should be restricted to large, multicenter studies to define modifications and improve generalizability of the findings.
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Affiliation(s)
- Joany M. Zachariasse
- Department of General Paediatrics, Erasmus MC- Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Nienke Seiger
- Department of General Paediatrics, Erasmus MC- Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Pleunie P. M. Rood
- Department of Emergency Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Claudio F. Alves
- Department of Paediatrics, Emergency Unit, Hospital Professor Doutor Fernando da Fonseca, Amadora, Portugal
| | - Paulo Freitas
- Intensive Care Unit, Hospital Professor Doutor Fernando da Fonseca, Amadora, Lisbon, Portugal
| | - Frank J. Smit
- Department of Paediatrics, Maasstad Hospital, Rotterdam, The Netherlands
| | - Gert R. Roukema
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - Henriëtte A. Moll
- Department of General Paediatrics, Erasmus MC- Sophia Children’s Hospital, Rotterdam, The Netherlands
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Hasselbalch RB, Plesner LL, Pries-Heje M, Ravn L, Lind M, Greibe R, Jensen BN, Rasmussen LS, Iversen K. The Copenhagen Triage Algorithm: a randomized controlled trial. Scand J Trauma Resusc Emerg Med 2016; 24:123. [PMID: 27724978 PMCID: PMC5057417 DOI: 10.1186/s13049-016-0312-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 09/30/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Crowding in the emergency department (ED) is a well-known problem resulting in an increased risk of adverse outcomes. Effective triage might counteract this problem by identifying the sickest patients and ensuring early treatment. In the last two decades, systematic triage has become the standard in ED's worldwide. However, triage models are also time consuming, supported by limited evidence and could potentially be of more harm than benefit. The aim of this study is to develop a quicker triage model using data from a large cohort of unselected ED patients and evaluate if this new model is non-inferior to an existing triage model in a prospective randomized trial. METHODS The Copenhagen Triage Algorithm (CTA) study is a prospective two-center, cluster-randomized, cross-over, non-inferiority trial comparing CTA to the Danish Emergency Process Triage (DEPT). We include patients ≥16 years (n = 50.000) admitted to the ED in two large acute hospitals. Centers are randomly assigned to perform either CTA or DEPT triage first and then use the other triage model in the last time period. The CTA stratifies patients into 5 acuity levels in two steps. First, a scoring chart based on vital values is used to classify patients in an immediate category. Second, a clinical assessment by the ED nurse can alter the result suggested by the score up to two categories up or one down. The primary end-point is 30-day mortality and secondary end-points are length of stay, time to treatment, admission to intensive care unit, and readmission within 30 days. DISCUSSION If proven non-inferior to standard DEPT triage, CTA will be a faster and simpler triage model that is still able to detect the critically ill. Simplifying triage will lessen the burden for the ED staff and possibly allow faster treatment. TRIAL REGISTRATION Clinicaltrials.gov: NCT02698319 , registered 24. of February 2016, retrospectively registered.
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Affiliation(s)
| | | | - Mia Pries-Heje
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Lisbet Ravn
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Morten Lind
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Rasmus Greibe
- Department of Cardiology, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Lars S. Rasmussen
- Department of Anaesthesia, Center of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Iversen
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
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Zachariasse JM, Kuiper JW, de Hoog M, Moll HA, van Veen M. Safety of the Manchester Triage System to Detect Critically Ill Children at the Emergency Department. J Pediatr 2016; 177:232-237.e1. [PMID: 27480197 DOI: 10.1016/j.jpeds.2016.06.068] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 05/31/2016] [Accepted: 06/24/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To assess the safety of the Manchester Triage System in pediatric emergency care for children who require admission to the intensive care unit (ICU). STUDY DESIGN Between 2006 and 2013, 50 062 consecutive emergency department visits of children younger than the age of 16 years were included. We determined the percentage of undertriage, defined as the proportion of children admitted to ICU triaged as low urgent according to the Manchester Triage System, and diagnostic performance measures, including sensitivity, specificity, and diagnostic OR. Characteristics of undertriaged patients were compared with correctly triaged patients. In a logistic regression model, risk factors for undertriage were determined. RESULTS In total, 238 (28.7%) of the 830 children admitted to ICU during the study period were undertriaged. Sensitivity of high Manchester Triage System urgency levels to detect ICU admission was 71% (95% CI 68%-74%) and specificity 85% (95% CI 85%-85%). Severity of illness was lower in undertriaged children than correctly triaged children admitted to ICU. Risk factors for undertriage were age <3 months, medical presenting problem, comorbidity, referral by a medical specialist or emergency medical services, and presentation during the evening or night shift. CONCLUSION The Manchester Triage System misclassifies a substantial number of children who require ICU admission. Modifications targeted at young children and children with a comorbid condition could possibly improve safety of the Manchester Triage System in pediatric emergency care.
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Affiliation(s)
- Joany M Zachariasse
- Department of General Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jan Willem Kuiper
- Department of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Matthijs de Hoog
- Department of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Henriëtte A Moll
- Department of General Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Mirjam van Veen
- Department of General Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands; Department of Pediatrics, Groene Hart Hospital, Gouda, The Netherlands.
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Vassallo J, Smith JE, Bruijns SR, Wallis LA. Major incident triage: A consensus based definition of the essential life-saving interventions during the definitive care phase of a major incident. Injury 2016; 47:1898-902. [PMID: 27375012 DOI: 10.1016/j.injury.2016.06.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 05/16/2016] [Accepted: 06/17/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Triage is a key principle in the effective management of major incidents. The process currently relies on algorithms assigning patients to specific triage categories; there is, however, little guidance as to what these categories represent. Previously, these algorithms were validated against injury severity scores, but it is accepted now that the need for life-saving intervention is a more important outcome. However, the definition of a life-saving intervention is unclear. The aim of this study was to define what constitutes a life-saving intervention, in order to facilitate the definition of an adult priority one patient during the definitive care phase of a major incident. METHODS We conducted a modified Delphi study, using a panel of subject matter experts drawn from the United Kingdom and Republic of South Africa with a background in Emergency Care or Major Incident Management. The study was conducted using an online survey tool, over three rounds between July and December 2013. A four point Likert scale was used to seek consensus for 50 possible interventions, with a consensus level set at 70%. RESULTS 24 participants completed all three rounds of the Delphi, with 32 life-saving interventions reaching consensus. CONCLUSIONS This study provides a consensus definition of what constitutes a life-saving intervention in the context of an adult, priority one patient during the definitive care phase of a major incident. The definition will contribute to further research into major incident triage, specifically in terms of validation of an adult major incident triage tool.
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Affiliation(s)
- James Vassallo
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa; Institute of Naval Medicine, Alverstoke, Gosport, UK.
| | - Jason E Smith
- Emergency Department, Derriford Hospital, Plymouth, UK; Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Joint Medical Command, Birmingham, UK
| | - Stevan R Bruijns
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
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Perry M, Carter D. The ethics of ambulance ramping. Emerg Med Australas 2016; 29:116-118. [PMID: 27400802 DOI: 10.1111/1742-6723.12625] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 05/03/2016] [Indexed: 11/28/2022]
Abstract
Ramping is the practice of requiring paramedics to continue to care for patients rather than hand over clinical responsibility to the ED. It arose as an alternative to admitting patients to EDs that are deemed to be already operating at or beyond capacity. This paper analyses the ethics of ramping. Ramping has been embraced by some ED practitioners and policymakers as a solution to the problem of ED patients suffering increased risks of harm as a result of waiting times within ED. However, this perspective fails to adequately consider the implications, especially the opportunity cost of requiring paramedics to remain at the hospital rather than make themselves available for other patients. From this perspective, ramping negatively impacts the wider provision of emergency medical services, with potentially serious consequences for people's health. Advocates of ramping must consider people in the community who require a medical emergency response.
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Affiliation(s)
- Matthew Perry
- Paramedic Emergency Care, Department of Applied Health and Professional Development, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK
| | - Drew Carter
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
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Abstract
A review of the literature underpinning modern triage methodology is presented. The philosophy and history is described prior to a review of triage scoring methodology relevant to modern day practice. The importance of triage is most acute during major incidents and the triage process is highlighted within this framework. Triage has wide-ranging applications throughout medical practice and these are included as part of the discussion.
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Affiliation(s)
- M. O'Meara
- Porter K, O'Meara M. Academic department of traumatology, University of Birmingham, Vincent Drive, Birmingham
| | - K. Porter
- Porter K, O'Meara M. Academic department of traumatology, University of Birmingham, Vincent Drive, Birmingham,
| | - I. Greaves
- Greaves I, Department of Academic Emergency medicine, James Cook University Hospital, Middlesbrough
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de Groot B, van den Berg S, Kessler J, Ansems A, Rijpsma D. Independent predictors of major adverse cardiovascular events in emergency department patients who are hospitalised with a suspected infection: a retrospective cohort study. BMJ Open 2016; 6:e009598. [PMID: 26817637 PMCID: PMC4735138 DOI: 10.1136/bmjopen-2015-009598] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Emergency department (ED) patients hospitalised with a suspected infection have an increased risk for major adverse cardiovascular events (MACE). This study aims to identify independent predictors of MACE after hospital admission which could be used for identification of high-risk patients who may benefit from preventive strategies. SETTING Dutch tertiary care centre and urban hospital. PARTICIPANTS Consecutive, hospitalised, ED patients with a suspected infection. DESIGN This was a secondary analysis using an existing database in which consecutive, hospitalised, ED patients with a suspected infection were prospectively enrolled. Potential independent predictors, including illness severity, as assessed by the Predisposition, Infection, Response, Organ failure (PIRO) score, and classic cardiac risk factors were analysed by multivariable binary logistic regression. Prognostic and discriminative performance of the model was quantified by the Hosmer-Lemeshow test and receiver operator characteristics with area under the curve (AUC) analyses, respectively. Maximum sensitivity and specificity for identification of MACE were calculated. PRIMARY OUTCOME MACE within 90 days after hospital admission. RESULTS 36 (2.1%) of the 1728 included patients developed MACE <90 days after ED presentation. Independent predictors of MACE were the RO components of the PIRO score, reflecting acute organ failure, with a corrected OR (OR (95% CI) 1.1 (1.0 to 1.3) per point increase), presence of atrial fibrillation/flutter; OR 3.9 (2.0 to 7.7) and >2 classic cardiovascular risk factors; 2.2 (1.1 to 4.3). The AUC was 0.773, and the goodness-of-fit test had a p value of 0.714. These predictors identified MACE with 75% sensitivity and 70% specificity. CONCLUSIONS Besides the classical cardiovascular risk factors, atrial fibrillation and signs of acute organ failure were independent risk factors of MACE in ED patients hospitalised with a suspected infection. Future studies should investigate whether preventive measures like antiplatelet therapy should be initialised in hospitalised ED patients with suspected infection and high risk for MACE.
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Affiliation(s)
- Bas de Groot
- Emergency Department, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Joanne Kessler
- Emergency Department, Leiden University Medical Centre, Leiden, The Netherlands
| | - Annemieke Ansems
- Emergency Department, Rijnstate Hospital, Arnhem, The Netherlands
| | - Douwe Rijpsma
- Emergency Department, Rijnstate Hospital, Arnhem, The Netherlands
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Leite L, Baptista R, Leitão J, Cochicho J, Breda F, Elvas L, Fonseca I, Carvalho A, Costa JN. Chest pain in the emergency department: risk stratification with Manchester triage system and HEART score. BMC Cardiovasc Disord 2015; 15:48. [PMID: 26062607 PMCID: PMC4462114 DOI: 10.1186/s12872-015-0049-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 06/01/2015] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Fast and accurate chest pain risk stratification in the emergency department (ED) is critical. The HEART score predicts the short-term incidence of major adverse cardiac events (MACE) in this population, dividing it in three risk categories. We aimed to describe the population with chest pain, to characterize the subgroup of patients with acute coronary syndrome (ACS) and to assess the prognostic value of Manchester triage system and of HEART score. METHODS Retrospective observational study including patients admitted to the ED of a tertiary hospital with chest pain as the presenting symptom. The primary outcome was a composite of all-cause mortality, myocardial infarction or unscheduled revascularization at 6 weeks. RESULTS We enrolled 233 patients (age 58 ± 19; 55.4 % males). The most common final diagnosis was non-specific chest pain (n = 86, 36.9 %), followed by ACS (n = 22, 9.4 %). Male gender, smoking and chronic kidney disease were associated with higher risk of ACS. According to Manchester triage system, chest pain patients stratified with red or orange priority had a higher incidence of ACS (16.5 % vs. 3.8 %, p = 0.006). The application of HEART score showed that most patients were in low risk category (56.3 %). The six-week incidence of MACE in each category was 2 %, 15.6 % and 76.9 % (p < 0.001). HEART score accurately predicted the short-term incidence of MACE in chest pain patients (c-statistic 0.880; 95 % CI, 0.807-0.950, p < 0.001). CONCLUSIONS Chest pain patients have very different levels of severity and the discriminatory power of Manchester triage system should be used in the assessment of this population. The HEART score seems to be an effective tool for risk stratification in the ED.
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Affiliation(s)
- Luís Leite
- Departament of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal.
| | - Rui Baptista
- Departament of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal.
| | - Jorge Leitão
- Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal.
| | - Joana Cochicho
- Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal.
| | - Filipe Breda
- Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal.
| | - Luís Elvas
- Departament of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal.
| | - Isabel Fonseca
- Emergency Department, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal.
| | - Armando Carvalho
- Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal.
| | - José Nascimento Costa
- Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal.
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de Groot B, Ansems A, Gerling DH, Rijpsma D, van Amstel P, Linzel D, Kostense PJ, Jonker M, de Jonge E. The association between time to antibiotics and relevant clinical outcomes in emergency department patients with various stages of sepsis: a prospective multi-center study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:194. [PMID: 25925412 PMCID: PMC4440486 DOI: 10.1186/s13054-015-0936-3] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 04/21/2015] [Indexed: 01/20/2023]
Abstract
Introduction In early sepsis stages, optimal treatment could contribute to prevention of progression to severe sepsis. Therefore, we investigated if there was an association between time to antibiotics and relevant clinical outcomes in hospitalized emergency department (ED) patients with mild to severe sepsis stages. Methods This is a prospective multicenter study in three Dutch EDs. Patients were stratified into three categories of illness severity, as assessed by the predisposition, infection, response, and organ failure (PIRO) score: PIRO score 1 to 7, 8 to 14 and >14 points, reflected low, intermediate, and high illness severity, respectively. Consecutive hospitalized ED patients with a suspected infection who were treated with intravenous antibiotics were eligible to participate in the study. The primary outcome measure was the number of surviving days outside the hospital at day 28 which was used as an inverse measure of hospital length of stay (LOS). The secondary outcome measure was 28-day mortality, taking into account the time to mortality. Multivariable Cox regression analysis was used to estimate the association between time to antibiotics and the primary and secondary outcome measures corrected for confounders, including appropriateness of antibiotics and initial ED resuscitation, in three categories of illness severity. Results Of the 1,168 included patients, 112 died (10%), while 85% and 95% received antibiotics within three and six hours, respectively. No association between time to antibiotics and surviving days outside the hospital or mortality was found. Only in PIRO group 1 to 7 was delayed administration of antibiotics (>3 hours) associated with an increase in surviving days outside the hospital at day 28 (hazard ratio: 1.46, 95% confidence interval: 1.05 to 2.02 after correction for potential confounders). Conclusions In ED patients with mild to severe sepsis who received antibiotics within six hours after ED presentation, a reduction in time to antibiotics was not found to be associated with an improvement in relevant clinical outcomes. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0936-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bas de Groot
- Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, the Netherlands.
| | - Annemieke Ansems
- Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, the Netherlands.
| | - Daan H Gerling
- Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, the Netherlands.
| | - Douwe Rijpsma
- Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, the Netherlands.
| | - Paul van Amstel
- VU Medical Center, Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.
| | - Durk Linzel
- VU Medical Center, Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.
| | - Piet J Kostense
- VU Medical Center, Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.
| | - Marianne Jonker
- VU Medical Center, Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.
| | - Evert de Jonge
- Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, the Netherlands.
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Silcock DJ, Corfield AR, Gowens PA, Rooney KD. Validation of the National Early Warning Score in the prehospital setting. Resuscitation 2015; 89:31-5. [PMID: 25583148 DOI: 10.1016/j.resuscitation.2014.12.029] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 11/26/2014] [Accepted: 12/08/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Early intervention and response to deranged physiological parameters in the critically ill patient improves outcomes. A National Early Warning Score (NEWS) based on physiological observations has been developed for use throughout the National Health Service (NHS) in the UK. Although a good predictor of mortality and deterioration in inpatients, its performance in the prehospital setting is largely untested. This study aimed to assess the validity of the NEWS in unselected prehospital patients. METHODS All clinical observations taken by emergency ambulance crews transporting patients to a single hospital were collated along with information relating to hospital outcome over a two month period. The performance of the NEWS in identifying the endpoints of 48h and 30 day mortality, intensive care unit (ICU) admission, and a combined endpoint of 48h mortality or ICU admission was analysed. RESULTS 1684 patients were analysed. All three of the primary endpoints and the combined endpoint were associated with higher NEWS scores (p<0.01 for each). The medium-risk NEWS group was associated with a statistically significant increase in ICU admission (RR=2.466, 95% CI 1.0-6.09), but not in-hospital mortality relative to the low risk group. The high risk NEWS group had significant increases in 48h mortality (RR 35.32 [10.08-123.7]), 30 day mortality (RR 6.7 [3.79-11.88]), and ICU admission (5.43 [2.29-12.89]). Similar results were noted when trauma and non-trauma patients were analysed separately. CONCLUSIONS Elevated NEWS among unselected prehospital patients is associated with a higher incidence of adverse outcomes. Calculation of prehospital NEWS may facilitate earlier recognition of deteriorating patients, early involvement of senior Emergency Department staff and appropriate critical care.
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Affiliation(s)
| | | | | | - Kevin D Rooney
- Royal Alexandra Hospital, Paisley, UK; Institute for Care and Practice Improvement, University of the West of Scotland, UK
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Kennelly SP, Drumm B, Coughlan T, Collins R, O'Neill D, Romero-Ortuno R. Characteristics and outcomes of older persons attending the emergency department: a retrospective cohort study. QJM 2014; 107:977-87. [PMID: 24935811 DOI: 10.1093/qjmed/hcu111] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The analysis of routinely collected hospital data informs the design of specialist services for at-risk older people. AIM Describe the outcomes of a cohort of older emergency department (ED) attendees and identify predictors of these outcomes. DESIGN retrospective cohort study. METHODS All patients aged 65 years or older attending an urban university hospital ED in January 2012 were included (N = 550). Outcomes were retrospectively followed for 12 months. Statistical analyses were based on multivariate binary logistic regression models and classification trees. RESULTS Of N = 550, 40.5% spent ≤6 h in the ED, but the proportion was 22.4% among those older than 81 years and not presenting with musculoskeletal problems/fractures. N = 349 (63.5%) were admitted from the ED. A significant multivariate predictor of in-hospital mortality was Charlson comorbidity index [CCI; odds ratio = 1.19, 95% confidence interval: 1.07, 1.34, P = 0.002]. Among patients who were discharged from ED without admission or after their first in-patient admission (N = 499), 232 (46.5%) re-attended ED within 1 year, with CCI being the best predictor of re-attendance (CCI ≤ 4: 25.8%, CCI > 5: 60.4%). Among N = 499, 34 (6.8%) had died after 1 year of initial ED presentation. The subgroup (N = 114) with the highest mortality (17.5%) was composed by those aged >77 years and brought in by ambulance on initial presentation. CONCLUSIONS Advanced age and comorbidity are important drivers of outcomes among older ED attendees. There is a need to embed specialist geriatric services within frontline services to make them more gerontologically attuned. Our results predate the opening of an acute medical unit with specialist geriatric input.
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Affiliation(s)
- S P Kennelly
- From the Department of Age-Related Health Care, Tallaght Hospital, Dublin, Ireland
| | - B Drumm
- From the Department of Age-Related Health Care, Tallaght Hospital, Dublin, Ireland
| | - T Coughlan
- From the Department of Age-Related Health Care, Tallaght Hospital, Dublin, Ireland
| | - R Collins
- From the Department of Age-Related Health Care, Tallaght Hospital, Dublin, Ireland
| | - D O'Neill
- From the Department of Age-Related Health Care, Tallaght Hospital, Dublin, Ireland
| | - R Romero-Ortuno
- From the Department of Age-Related Health Care, Tallaght Hospital, Dublin, Ireland
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Subbe CP, Kellett J, Whitaker CJ, Jishi F, White A, Price S, Ward-Jones J, Hubbard RE, Eeles E, Williams L. A pragmatic triage system to reduce length of stay in medical emergency admission: feasibility study and health economic analysis. Eur J Intern Med 2014; 25:815-20. [PMID: 25044094 DOI: 10.1016/j.ejim.2014.06.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Revised: 05/31/2014] [Accepted: 06/03/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Departments of Internal Medicine tend to treat patients on a first come first served basis. The effects of using triage systems are not known. METHODS We studied a cohort in an Acute Medical Unit (AMU). A computer-assisted triage system using acute physiology, pre-existing illness and mobility identified five distinct risk categories. Management of the category of very low risk patients was streamlined by a dedicated Navigator. Main outcome parameters were length of hospital stay (LOS) and overall costs. Results were adjusted for the degree of frailty as measured by the Clinical Frailty Scale (CFS). A six month baseline phase and intervention phase were compared. RESULTS 6764 patients were included: 3084 in the baseline and 3680 in the intervention phase. Patients with very low risk of death accounted for 40% of the cohort. The LOS of the 1489 patients with very low risk of death in the intervention group was reduced by a mean of 1.85days if compared with the 1276 patients with very low risk in the baseline cohort. This was true even after adjustment for frailty. Over the six month period the cost of care was reduced by £250,158 in very low patients with no increase in readmissions or 30day mortality. CONCLUSIONS Implementation of an advanced triage system had a measurable impact on cost of care for patients with very low risk of death. Patients were safely discharged earlier to their own home and the intervention was cost-effective.
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Affiliation(s)
- C P Subbe
- School of Medical Sciences, Bangor University, Bangor, United Kingdom
| | | | - C J Whitaker
- NWORTH, Clinical Trials Unit, Bangor University, Bangor. United Kingdom
| | - F Jishi
- Wrexham Maelor Hospital, Croesnewydd Road, Wrexham, United Kingdom
| | - A White
- Wrexham Maelor Hospital, Croesnewydd Road, Wrexham, United Kingdom
| | - S Price
- Wrexham Maelor Hospital, Croesnewydd Road, Wrexham, United Kingdom
| | - J Ward-Jones
- Wrexham Maelor Hospital, Croesnewydd Road, Wrexham, United Kingdom
| | - R E Hubbard
- Centre for Research in Geriatric Medicine, University of Queensland, Brisbane, Australia
| | - E Eeles
- Centre for Research in Geriatric Medicine, University of Queensland, Brisbane, Australia
| | - L Williams
- Wrexham Maelor Hospital, Croesnewydd Road, Wrexham, United Kingdom
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Horne ST, Vassallo J. Triage in the Defence Medical Services. J ROY ARMY MED CORPS 2014; 161:90-3. [DOI: 10.1136/jramc-2014-000275] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 05/17/2014] [Indexed: 11/04/2022]
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Efficacy of the Manchester Triage System: a systematic review. Int Emerg Nurs 2014; 23:47-52. [PMID: 25087059 DOI: 10.1016/j.ienj.2014.06.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Revised: 05/19/2014] [Accepted: 06/14/2014] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The growing number of patients in emergency departments can lead to overcrowding, often adding to organisational problems. Triage aims to predict the severity of disease, with the aim of organising patient flow. The aim of this study was to analyse the efficacy of the Manchester Triage System (MTS) for risk classification of patients. METHODS A systematic review of the literature in Ebscohost, Pubmed and Scielo (2002-2013) was undertaken. Articles were selected independently by two researchers using selection criteria. Twenty-two articles were selected for inclusion in this review. RESULTS The results support the applicability of the MTS, which has proven validity for use in children, adults, patients with coronary syndrome and patients with acute pulmonary embolism. The MTS was found to be inclusive, and to predict emergency department admission and death in the short term. CONCLUSION The majority of studies found that the MTS was useful in triage of patients in emergency departments, but sub-triage and super-triage (i.e. under and over classification of severity, respectively) still occur.
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Gräff I, Goldschmidt B, Glien P, Bogdanow M, Fimmers R, Hoeft A, Kim SC, Grigutsch D. The German Version of the Manchester Triage System and its quality criteria--first assessment of validity and reliability. PLoS One 2014; 9:e88995. [PMID: 24586477 PMCID: PMC3933424 DOI: 10.1371/journal.pone.0088995] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 01/13/2014] [Indexed: 11/18/2022] Open
Abstract
Background The German Version of the Manchester Triage System (MTS) has found widespread use in EDs across German-speaking Europe. Studies about the quality criteria validity and reliability of the MTS currently only exist for the English-language version. Most importantly, the content of the German version differs from the English version with respect to presentation diagrams and change indicators, which have a significant impact on the category assigned. This investigation offers a preliminary assessment in terms of validity and inter-rater reliability of the German MTS. Methods Construct validity of assigned MTS level was assessed based on comparisons to hospitalization (general / intensive care), mortality, ED and hospital length of stay, level of prehospital care and number of invasive diagnostics. A sample of 45,469 patients was used. Inter-rater agreement between an expert and triage nurses (reliability) was calculated separately for a subset group of 167 emergency patients. Results For general hospital admission the area under the curve (AUC) of the receiver operating characteristic was 0.749; for admission to ICU it was 0.871. An examination of MTS-level and number of deceased patients showed that the higher the priority derived from MTS, the higher the number of deaths (p<0.0001 / χ2 Test). There was a substantial difference in the 30-day survival among the 5 MTS categories (p<0.0001 / log-rank test).The AUC for the predict 30-day mortality was 0.613. Categories orange and red had the highest numbers of heart catheter and endoscopy. Category red and orange were mostly accompanied by an emergency physician, whereas categories blue and green were walk-in patients. Inter-rater agreement between expert triage nurses was almost perfect (κ = 0.954). Conclusion The German version of the MTS is a reliable and valid instrument for a first assessment of emergency patients in the emergency department.
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Affiliation(s)
- Ingo Gräff
- Clinician Scientist, Emergency Department, University Bonn, Bonn, Germany
- * E-mail:
| | | | - Procula Glien
- Emergency Department, University Bonn, Bonn, Germany
| | - Manuela Bogdanow
- Institute for Medical Biometry, Informatics and Epidemiology, German Center for Neurodegenerative Diseases, University Bonn, Bonn, Germany
| | - Rolf Fimmers
- Institute for Medical Biometry, Informatics and Epidemiology, German Center for Neurodegenerative Diseases, University Bonn, Bonn, Germany
| | - Andreas Hoeft
- Department of Anesthesiology, University Bonn, Bonn, Germany
| | - Se-Chan Kim
- Department of Anesthesiology, University Bonn, Bonn, Germany
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Glynn N, Owens L, Bennett K, Healy ML, Silke B. Glucose as a risk predictor in acute medical emergency admissions. Diabetes Res Clin Pract 2014; 103:119-26. [PMID: 24269157 DOI: 10.1016/j.diabres.2013.10.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Revised: 08/17/2013] [Accepted: 10/28/2013] [Indexed: 01/08/2023]
Abstract
AIMS The aims of this study were to examine the relationship between admission blood glucose and mortality in a large, unselected cohort of acutely ill medical patients and to assess the impact of diabetes on this relationship. METHODS We studied the broad pattern of acute medical admissions over an eight year period and the impact of admission serum glucose on in-hospital mortality. Significant predictors of outcome, including acute illness severity and co-morbidity, were entered into a multivariate regression model, adjusting the univariate estimates of the glycaemic status on mortality. RESULTS There were 45,068 consecutive acute medical emergency admissions between 2005 and 2012. The normoglycaemic (>4.0 ≤7.0 mmol/l) cohort (86%) had a 3.9% in-hospital mortality. Both hypoglycaemia (OR: 3.23: 95% CI: 2.59-4.04; p<0.001) and hyperglycaemia (OR: 2.1; 95% CI: 1.9-2.4; p<0.001) predicted an increased risk of an in-hospital death. Neither of these increased risks were fully adjusted nor explained by a highly predictive outcome model, using multiple acute illness parameters. Hyperglycaemia did not carry similar adverse prognostic implications for patients with diabetes. CONCLUSION In patients without diabetes, an abnormal serum glucose is independently predictive of an increased mortality among the broad cohort of acute emergency medical patients. Similar disturbances of glucose homeostasis for patients with diabetes do not confer equivalent adverse prognostic implications.
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Affiliation(s)
- Nigel Glynn
- Division of Internal Medicine, St. James's Hospital, Dublin 8, Ireland
| | - Lisa Owens
- Division of Endocrinology, St. James's Hospital, Dublin 8, Ireland
| | - Kathleen Bennett
- Department of Pharmacology and Therapeutics, Trinity Centre for Health Sciences, St. James's Hospital, Dublin 8, Ireland
| | | | - Bernard Silke
- Division of Internal Medicine, St. James's Hospital, Dublin 8, Ireland.
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Byrne J. Reducing time to reperfusion for ST elevation myocardial infarction patients by a simple process change in the Emergency Department. BMJ QUALITY IMPROVEMENT REPORTS 2014; 3:bmjquality_uu204753.w2063. [PMID: 26734280 PMCID: PMC4645850 DOI: 10.1136/bmjquality.u204753.w2063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 05/03/2014] [Indexed: 11/04/2022]
Abstract
Current reperfusion guidelines from the European Society of Cardiology (ESC) recommend that First Medical Contact to Balloon times (FMC-B) for ST elevation myocardial infarction (STEMI) should not exceed 120 minutes. Many factors can cause delay in door to balloon times for patients suffering from STEMI. Previous studies have found that longest times for FMC-B occur if the patient presents initially to a non-percutaneous intervention (PCI) capable hospital. As a non-PCI capable site we looked at ways of reducing FMC-B times. Audit revealed that registration to electrocardiogram (ECG) times were sometimes prolonged due to undertriage, long waiting times and lack of space and staff to record an ECG, resulting in some prolonged FMC-B times. To address this, we have changed the system so that patients bypass triage and go directly to a dedicated investigation cubicle for an ECG. The patient books on at reception with chest pain and is immediately directed to the investigation cubicle. The ECG is reviewed immediately and the patient is either kept in the department for further management or allowed back to the waiting room to await triage if the ECG is non-diagnostic and history not worrying. Data on patients presenting with STEMI on the initial ECG were collected for one year pre-intervention (n=21 )and one year post-intervention (n=17). The median FMC-B time for the pre-intervention group was 108.5 minutes (IQR 96 – 143.5). Median FMC-B time for the post-intervention group was 82 minutes (IQR 66.5–93.5). This is a simple, low-cost intervention which could be transferable to other sites who have an interest in reducing FMC-B times. It is necessary to have a key person to carry out audit of all potential areas of delay, and a collaborative, multidisciplinary approach to making change to improve quality of care.
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Pinto D, Salgado PDO, Chianca TCM. Predictive validity of the Manchester Triage System: evaluation of outcomes of patients admitted to an emergency department. Rev Lat Am Enfermagem 2013; 20:1041-7. [PMID: 23258716 DOI: 10.1590/s0104-11692012000600005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Accepted: 10/12/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to assess the predictive validity of the Manchester Triage System implemented in a municipal hospital in Belo Horizonte, MG, Brazil. METHOD cohort prospective and analytical study. The sample of 300 patients was stratified by color groups. The outcome measured was the scores, obtained by patients in each classification group in the Therapeutic Intervention Scoring System--28, 24 hours after admission to the emergency department. RESULTS A total of 172 (57%) patients were men and the average age of all patients was 57.3 years old. The median score concerning the severity of their conditions was 6.5 points in the yellow group, 11.5 in the orange group, and 22 points in the red group. Statistically significant differences were found among the three groups (p<0.001). CONCLUSION the data confirm that the conditions of patients within the color groups progressed at different levels of severity.
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L’infirmière organisatrice de l’accueil (IOA) : rôle et fonctions. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0727-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Vituri DW, Inoue KC, Bellucci Júnior JA, de Oliveira CA, Rossi RM, Matsuda LM. Welcoming with risk classification in teaching hospitals: assessment of structure, process and result. Rev Lat Am Enfermagem 2013; 21:1179-87. [PMID: 24142229 DOI: 10.1590/s0104-11692013000500023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Accepted: 07/15/2013] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To assess, from the worker's viewpoint, the structure, the process and the results of the Emergency Hospital Services that have taken up the guideline of "Welcoming with Risk Classification" in two teaching hospitals of the state of Paraná. METHOD Quantitative and descriptive research, exploratory and prospective, using random sampling stratified by professional category, comprising a universe of 216 professional people. RESULTS They found some points of agreement regarding the promotion of a welcoming and humane environment; privacy and security; welcome and shelter of the companion and also the sheltering and classification of all patients; however, there was disagreement about the comfort of the environment, reference system and counter-reference, prioritisation of seriously ill patients in post-classification service, communication between the members of the multi-professional team and reassessment of the guideline. CONCLUSION The workers assess the development of the guideline as being precarious, due mainly to the lack of physical structure, due to the lack of physical structure and shortcomings in the service process.
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Briggs R, Coughlan T, Collins R, O'Neill D, Kennelly SP. Nursing home residents attending the emergency department: clinical characteristics and outcomes. QJM 2013; 106:803-8. [PMID: 23818688 DOI: 10.1093/qjmed/hct136] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Nursing home (NH) residents represent the frailest group of older people, and providing gerontologically attuned care that addresses these frailties is often a challenge within the emergency department (ED). This study sought to prospectively profile acutely unwell NH residents in order to clarify some of the challenges of providing emergency care to this group. Over an 18-week period, we prospectively reviewed all NH residents presenting to the ED of an urban university teaching hospital. Relevant data were retrieved by direct physician review (as part of a comprehensive geriatric assessment in the ED), collateral history from NH staff and primary carers, and review of electronic records. There were 155 ED visits by 116 NH residents. Their mean age was 80.3 (±9.6) years. High pre-morbid levels of dependency were reflected by a mean Barthel Index of 34.1 (±20) and almost two-thirds had a pre-existing diagnosis of dementia. One-third of visits were during 'normal' working hours. Patients were reviewed by their regular NH doctor pre-transfer for 36% of visits. Using accepted international criteria, over half of the visits were deemed 'potentially preventable'. Unwell NH residents have complex medical needs. The decision to refer these patients to the ED is often made by 'out of hours' general practitioners and their initial care in the ED is directed by physicians with limited experience in geriatric medicine. Most referrals to the ED are potentially preventable but this would require enhancements to the package of care available in NHs.
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Affiliation(s)
- R Briggs
- Age-Related Health Care, Tallaght Hospital, Dublin, Ireland.
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de Groot B, Verdoorn RCW, Lameijer J, van der Velden J. High-sensitivity cardiac troponin T is an independent predictor of inhospital mortality in emergency department patients with suspected infection: a prospective observational derivation study. Emerg Med J 2013; 31:882-8. [PMID: 23965276 DOI: 10.1136/emermed-2013-202865] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCION To assess the prognostic and discriminative accuracy of high-sensitivity cardiac troponin T (hs-cTnT) for prediction of inhospital mortality in emergency department (ED) patients with suspected infection. METHODS Prospective observational derivation study in ED patients with suspected infection. Prognostic performance of hs-cTnT (divided in four quartiles because of non-linearity) for prediction of inhospital mortality was assessed using multivariable logistic regression, correcting for predisposition, infection, response and organ failure (PIRO) score as a measure of illness severity and quality of ED treatment as quantified by the number of 'Surviving Sepsis Campaign' goals achieved. Discriminative power of hs-cTnT was assessed by receiver operator characteristics with area under the curve (AUC) analysis. RESULTS Hs-cTnT (median (IQR) was 57 (25-90) ng/L (n=23) in non-survivors, significantly higher than the 15 (7-28) ng/L in survivors (n=269, p<0.001). Additionally, the lowest quartile of hs-cTnT was a perfect predictor of survival because zero death occurred. Therefore, the second quartile was used as a reference category in the multivariable logistic regression analysis showing that hs-cTnT was an independent predictor of inhospital mortality: Corrected ORs were 2.2 (95% CI 0.4 to 12.1) and 5.8 (1.2 to 27.3) for the 3rd and 4th quartile compared with the 2nd hs-cTnT quartile. The AUCs of hs-TnT was 0.81 (0.74 to 0.88), similar to the AUC of 0.78 (0.68 to 0.87) of the PIRO score (p>0.05). Overall negative predictive value of hs-cTnT was 99%. CONCLUSIONS In ED patients with suspected infection, the routinely used biomarker hs-cTnT is an independent predictor of inhospital mortality with excellent discriminative performance. Future studies should focus on the additional value of hs-cTnT to existing risk stratification tools.
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Affiliation(s)
- Bas de Groot
- SEH, Leiden University Medical Centre, Leiden, Zuid Holland, The Netherlands
| | - Ruben C W Verdoorn
- SEH, Leiden University Medical Centre, Leiden, Zuid Holland, The Netherlands
| | - Joost Lameijer
- SEH, Leiden University Medical Centre, Leiden, Zuid Holland, The Netherlands
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Balossini V, Zanin A, Alberti C, Freund Y, Decobert M, Tarantino A, La Rocca M, Lacroix L, Spiri D, Lejay E, Armoogum P, Wood C, Gervaix A, Zuccotti GV, Perilongo G, Bona G, Mercier JC, Titomanlio L. Triage of children with headache at the ED: a guideline implementation study. Am J Emerg Med 2013; 31:670-5. [DOI: 10.1016/j.ajem.2012.11.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 10/21/2012] [Accepted: 11/23/2012] [Indexed: 12/01/2022] Open
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de Groot B, Lameijer J, de Deckere ERJT, Vis A. The prognostic performance of the predisposition, infection, response and organ failure (PIRO) classification in high-risk and low-risk emergency department sepsis populations: comparison with clinical judgement and sepsis category. Emerg Med J 2013; 31:292-300. [PMID: 23413151 DOI: 10.1136/emermed-2012-202165] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare the prognostic performance of the predisposition, infection, response and organ failure (PIRO) score with the traditional sepsis category and clinical judgement in high-risk and low-risk Dutch emergency department (ED) sepsis populations. METHODS Prospective study in ED patients with severe sepsis and septic shock (high-risk cohort), or suspected infection (low-risk cohort). OUTCOME 28-day mortality. Prognostic performance of PIRO, sepsis category and clinical judgement were assessed with Cox regression analysis with correction for quality of ED treatment and disposition. Illness severity measures were divided into four groups with the lowest illness severity as reference category; discrimination was quantified by receiver operator characteristics with area under the curve (AUC) analysis. RESULTS Death occurred in 72/323 (22%, high-risk) and 23/385 (6%, low-risk) patients. For the low-risk cohort, corrected HRs (95% CI) for categories 2-4 were 2.0 (0.4 to 11.9), 4.3 (0.8 to 24.7) and 17.8 (2.8 to 113.0: PIRO); 0.5 (0.05 to 5.4), 2.1 (0.2 to 21.8) and 7.5 (0.6 to 92.9: sepsis category). Patients discharged home (category 1) all survived. HRs were 4.5 (0.5 to 39.1) and 13.6 (4.3 to 43.5) for clinical judgement categories 3-4. Prognostic performance was consistently better in the low-risk than in the high-risk cohort. For PIRO AUCs were 0.68 (0.61 to 0.74; high-risk) and 0.83 (0.75 to 0.91; low-risk); for sepsis category AUCs were 0.50 (0.42 to 0.57; high-risk) and 0.73 (0.61 to 0.86; low-risk); for clinical judgement AUCs were 0.69 (0.60 to 0.78; high-risk) and 0.84 (0.73 to 0.96; low-risk). CONCLUSIONS The accuracy and discriminative performance of the PIRO score and clinical judgement are similar, but better than the sepsis category. Prognostic performance of illness severity scores is less in high-risk cohorts, while in high-risk populations a risk stratification tool would be most useful.
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Affiliation(s)
- Bas de Groot
- SEH, LUMC, , Leiden, Zuid Holland, The Netherlands
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Jobé J, Ghuysen A, Gérard P, Hartstein G, D'Orio V. Reliability and validity of a new French-language triage algorithm: the ELISA scale. Emerg Med J 2013; 31:115-20. [DOI: 10.1136/emermed-2012-201927] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Santos AP, Freitas P, Martins HMG. Manchester Triage System version II and resource utilisation in the emergency department. Emerg Med J 2013; 31:148-52. [PMID: 23345313 DOI: 10.1136/emermed-2012-201782] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Emergency department (ED) triage systems aim to direct the best clinical assistance to those who are in the greatest urgency and guarantee that resources are efficiently applied. The study's purpose was to determine whether the Manchester Triage System (MTS) second version is a useful instrument for determining the risk of hospital admission, intrahospital death and resource utilisation in ED and to compare it with the MTS first version. This was a prospective study of patients that attended the ED at a large hospital. It comprised a total of 25,218 cases that were triaged between 11 July and 13 October 2011. The MTS codes were grouped into two clusters: red and orange into a 'high acuity/priority' (HP) cluster, and yellow, green and blue into a 'low acuity/priority' cluster. The risk of hospital admission in the HP cluster was 4.86 times that of the LP cluster for both admission route and ages. The percentage of patient hospital admission between medical and surgical specialties, in high and low priority clusters, was similar. We found the risk of death in the HP cluster to be 5.58 times that of the risk of the low acuity/priority cluster. The MTS had an inconsistent association relative to the utilisation of x-ray, while it seemed to portray a consistent association between ECG and laboratory utilisation and MTS cluster. There were no differences between medical and surgical specialities risk of admission. This suggests that improvements were made in the second version of MTS, particularly in the discriminators of patients triaged to surgical specialties, because this was not true for the first version of MTS.
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Affiliation(s)
- André Peralta Santos
- Center for Research and Creativity in Informatics, Hospital Professor Doutor Fernando da Fonseca, , Amadora, Lisboa, Portugal
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Matzer F, Wisiak UV, Graninger M, Söllner W, Stilling HP, Glawischnig-Goschnik M, Lueger A, Fazekas C. Biopsychosocial health care needs at the emergency room: challenge of complexity. PLoS One 2012; 7:e41775. [PMID: 22952586 PMCID: PMC3429453 DOI: 10.1371/journal.pone.0041775] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 06/25/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In an emergency room of internal medicine, triage and treatment of patients deserve first priority. However, biopsychosocial case complexity may also affect patient health outcome but has not yet been explored in this setting. Therefore, the aims of the study are (1) to estimate prevalence rates of complex patients in the emergency room (ER), (2) to describe biopsychosocial complexity in this population and (3) to evaluate possible correlations between patient profiles regarding case complexity and further clinical treatment. METHODS During a study period of one week, all patients of an emergency room of internal medicine who were triaged to Manchester levels three to five were invited to participate in the study. Biopsychosocial case complexity was assessed by the INTERMED method. Psychosocial interventions were evaluated based on all documented interventions and recommendations given at the emergency room and during inpatient treatment. RESULTS Study participants consisted of 167 patients with a subgroup of 19% (n = 32) receiving subsequent inpatient-treatment at the department. High biopsychosocial case complexity was found in 12% (n = 20) of the total sample (INTERMED score >20). This finding was paralleled by a cluster analysis suggesting three clusters with one highly complex patient group of 14%. These highly complex patients differed significantly from the other clusters as they had visited the emergency room more often within the last year and lived alone more frequently. In addition, admission rates were highest in this group. During ER treatment and subsequent inpatient treatment, 21% of highly complex patients received interventions addressing psychosocial factors as compared to 6% and 7%, respectively, in the other clusters. CONCLUSIONS A standardized screening of biopsychosocial case complexity among 'frequent utilizers' of the ER would be helpful to detect specific multidisciplinary health care needs among this particularly burdened patient group.
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Affiliation(s)
- Franziska Matzer
- Department of Medical Psychology and Psychotherapy, Medical University of Graz, Graz, Austria
| | - Ursula V. Wisiak
- Department of Medical Psychology and Psychotherapy, Medical University of Graz, Graz, Austria
| | - Monika Graninger
- Department of Medical Psychology and Psychotherapy, Medical University of Graz, Graz, Austria
| | - Wolfgang Söllner
- Department of Psychosomatics and Psychotherapy, General Hospital Nuremberg, Nuremberg, Germany
| | - Hans Peter Stilling
- Department of Medical Psychology and Psychotherapy, Medical University of Graz, Graz, Austria
| | | | - Andreas Lueger
- Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Christian Fazekas
- Department of Medical Psychology and Psychotherapy, Medical University of Graz, Graz, Austria
- * E-mail:
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Ruys LJ, Gunning M, Teske E, Robben JH, Sigrist NE. Evaluation of a veterinary triage list modified from a human five-point triage system in 485 dogs and cats. J Vet Emerg Crit Care (San Antonio) 2012; 22:303-12. [DOI: 10.1111/j.1476-4431.2012.00736.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Laura J. Ruys
- Medisch Centrum voor Dieren [Animal Medical Center]; Isolatorweg 45 1014 AS Amsterdam The Netherlands
- Department of Veterinary Clinical Medicine; Vetsuisse Faculty of Bern; Bern Switzerland
| | - Myrna Gunning
- Medisch Centrum voor Dieren [Animal Medical Center]; Isolatorweg 45 1014 AS Amsterdam The Netherlands
| | - Erik Teske
- Department of Clinical Sciences of Companion Animals; Faculty of Veterinary Medicine; Utrecht University; The Netherlands
| | - Joris H. Robben
- Department of Clinical Sciences of Companion Animals; Faculty of Veterinary Medicine; Utrecht University; The Netherlands
| | - Nadja E. Sigrist
- Department of Veterinary Clinical Medicine; Vetsuisse Faculty of Bern; Bern Switzerland
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Forsman B, Forsgren S, Carlström ED. Nurses working with Manchester triage – The impact of experience on patient security. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.aenj.2012.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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