The Reliability of the Canadian Triage and Acuity Scale: Meta-analysis

Triage decisions and health outcomes among oncology patients: a comparative study of medical and surgical cancer cases in emergency departments

BACKGROUND

Cancer-related emergencies are a significant challenge for healthcare systems globally, including Jordan. Effective triage is critical in ensuring timely and accurate prioritization of care, especially for surgical cancer patients requiring urgent intervention. However, under-triage-misclassification of high-acuity patients into lower urgency categories-can lead to significant delays and worsened outcomes. Despite the recognized importance of accurate triage, limited research has evaluated its impact on cancer patients in Jordan, particularly those requiring surgical care.

OBJECTIVES

This study aimed to evaluate the timeliness and prioritization of care for cancer patients admitted through the emergency department (ED) in Jordan. The specific objectives were to examine the association between under-triage and treatment delays and assess its impact on key outcomes, including time to physician assessment, time to treatment, and hospital length of stay.

METHODS

A retrospective cohort design was used to analyze data from 481 cancer patients admitted through the ED in four governmental hospitals across Jordan. Two cohorts were established: surgical cancer patients requiring emergency interventions and non-surgical cancer patients presenting with other oncological emergencies. Triage accuracy was assessed using the Canadian Triage and Acuity Scale (CTAS), and under-triage was identified when patients requiring high urgency care (CTAS I-III) were misclassified into lower urgency categories (CTAS IV-V). Data were collected from electronic health records and analyzed using multiple linear regression to evaluate the association between under-triage and treatment outcomes.

RESULTS

The majority of patients were elderly, with a mean age of 62.6 years (± 10.7), and a significant proportion presented with advanced-stage cancer (83.4% in stages III and IV). Surgical patients frequently exhibited severe symptoms such as acute pain (51.6%) and respiratory discomfort (41.1%). Under-triage rates were 44.1% for surgical patients and 39.4% for non-surgical patients. Among surgical patients, under-triage significantly delayed time to physician assessment (β = 34.9 min, p < 0.001) and time to treatment (β = 68.0 min, p < 0.001). For non-surgical patients, under-triage delays were even greater, with prolonged physician assessment times (β = 48.6 min, p < 0.001) and ED length of stay (β = 7.3 h, p < 0.001). Both cohorts experienced significant increases in hospital length of stay (surgical: β = 3.2 days, p = 0.008; non-surgical: β = 3.2 days, p < 0.001).

CONCLUSION

Under-triage in Jordanian EDs is strongly associated with significant delays in care for both surgical and non-surgical cancer patients, highlighting systemic gaps in acuity recognition and triage processes. These findings underscore the need for targeted interventions to improve triage accuracy, particularly through oncology-specific training and the integration of evidence-based tools like SIRS criteria. Enhancing ED processes for cancer patients is crucial to reducing delays, optimizing resource allocation, and improving clinical outcomes in this vulnerable population.

CLINICAL TRIAL NUMBER

Not applicable.

Machine learning outperforms the Canadian Triage and Acuity Scale (CTAS) in predicting need for early critical care

STUDY OBJECTIVE

This study investigates the potential to improve emergency department (ED) triage using machine learning models by comparing their predictive performance with the Canadian Triage Acuity Scale (CTAS) in identifying the need for critical care within 12 h of ED arrival.

METHODS

Three machine learning models (LASSO regression, gradient-boosted trees, and a deep learning model with embeddings) were developed using retrospective data from 670,841 ED visits to the Jewish General Hospital from June 2012 to Jan 2021. The model outcome was the need for critical care within the first 12 h of ED arrival. Metrics, including the areas under the receiver-operator characteristic curve (ROC) and precision-recall curve (PRC) were used for performance evaluation. Shapley additive explanation scores were used to compare predictor importance.

RESULTS

The three machine learning models (deep learning, gradient-boosted trees and LASSO regression) had areas under the ROC of 0.926 ± 0.003, 0.912 ± 0.003 and 0.892 ± 0.004 respectively, and areas under the PRC of 0.27 ± 0.01, 0.24 ± 0.01 and 0.23 ± 0.01 respectively. In comparison, the CTAS score had an area under the ROC of 0.804 ± 0.006 and under the PRC of 0.11 ± 0.01. The predictors of most importance were similar between the models.

CONCLUSIONS

Machine learning models outperformed CTAS in identifying, at the point of ED triage, patients likely to need early critical care. If validated in future studies, machine learning models such as the ones developed here may be considered for incorporation in future revisions of the CTAS triage algorithm, potentially improving discrimination and reliability.

Optimizing triage education for emergency room nurses: A scoping review

AIMS

Accurate triage decisions by emergency room nurses are pivotal for patient prognosis and efficient utilization of resources. This study aimed to identify teaching methods, contents, intervention characteristics, and initial consideration of educational design for the development of triage education, targeting triage nurses.

DESIGN

A scoping review.

DATA SOURCES

PubMed, CINAHL, Web of Science, Embase, and RISS were searched for studies in either English or Korean, regardless of publication year.

REVIEW METHODS

The review was conducted according to the Joanna Briggs Institute guidelines. Studies published before November 15, 2023 were selected, based on the following index terms in each database: nurses, triage, education, and emergency services, hospital.

RESULTS

Of the 20 studies included in this review, five focused on severity classification of patients with cardiovascular diseases, one addressed infectious diseases, two examined pediatric patients, one explored patients with trauma, and the remaining eleven were not limited to specific diseases. Eleven studies (55 %) employed face-to-face (offline) education, whereas six (30 %) used non-face-to-face (online) education. The teaching methods were classified as teacher-centered learning and student-centered learning. The educational strategies included in-person lectures, online classes, demonstrations, simulations, mobile technology or web-based programs, group discussions, role-plays, and flipped learning. Outcome variables, such as triage accuracy, knowledge, performance ability, self-efficacy, satisfaction, wait time, and competency were measured as intervention effects.

CONCLUSIONS

This review demonstrates the key characteristics and contents of triage education interventions, along with key considerations in the initial design stages. Triage education covers a wide range of contents and diverse teaching methods pertinent to severity classification in triage practice. Effective educational programs hinge on the meticulous planning of objectives, optimal selection of the target population, needs assessment, and suitable teaching methods and materials. Future triage education for emergency room nurses should be tailored to specific participants while anticipating and planning all potential circumstances of implementation.

Low caregiver health literacy is associated with non-urgent pediatric emergency department use

OBJECTIVE

Caregivers with low health literacy are more likely to overestimate illness severity and have poor adherence with health-promoting behaviors. Our primary objective was to relate caregiver health literacy to the urgency of emergency department (ED) utilization. The secondary objective was to explore the relationship between social and demographic characteristics, health literacy, and urgency of ED use.

METHODS

This sub-study was a descriptive cross-sectional survey with health record review. Data were collected from ten Canadian pediatric EDs. Study variables included demographics, visit details, and the Newest Vital Sign measurement of health literacy. ED visits were classified as urgent or non-urgent based on the resource utilization method.

RESULTS

The response rate was 97.6% (n = 2005). Mean (SD) caregiver age was 37.0 (7.7) years, 74.3% (n = 1950) were mothers, 72.6% (n = 1953) spoke English as a primary language, 51.0% (n = 1946) had a university degree, and 45.1% (n = 1699) had a household income greater than $100,000. The mean (SD) age of the children was 5.9 (5.0) years and 48.1% (n = 1956) were female. 43.7% (n = 1957) of caregivers had low health literacy. Being a caregiver with a child < 2 years old [aOR 1.83 (1.35, 2.48)] and low health literacy [aOR 1.56 (1.18, 2.05)] were associated with greater non-urgent pediatric ED use. Interprovincial variation was evident: Quebec caregivers were less likely to use the pediatric ED for non-urgent presentations compared to Alberta, while those in Nova Scotia, Manitoba, British Columbia, and Ontario were more likely compared to Alberta.

CONCLUSION

Almost half of caregivers presenting to Canadian pediatric EDs have low health literacy, which may limit their ability to make appropriate healthcare decisions for their children. Low caregiver health literacy is a modifiable factor associated with increased non-urgent ED utilization. Efforts to address this may positively influence ED utilization.

The reliability and validity of triage tools in geriatric emergency departments: A scoping review

BACKGROUND

The nurse's ability to accurately identify urgent conditions and triage this vulnerable population tends to be complex and challenging. Little is known about the reliability and validity of common triage tools in geriatric patients.

AIM

To determine the reliability and validity of triage tools in geriatric emergency care and summarize the specific content of current triage tools for geriatric patients.

METHODS

The eligible literature was searched from the MEDLINE, CINAHL, EMBASE, and Cochrane Database using targeted search strategies. We defined the objectives and questions, set standards for article inclusion criteria, and conducted literature searching and screening. The mixed methods assessment tool (MMAT) appraised the article's quality. Finally, we extracted and analyzed the data from the included articles, summarizing the results. Endnote X9 was used for data extraction and collation.

RESULTS

Nine articles were eligible. These included six triage tools: CTAS, JTAS, KTAS, MTS, SETS, and ESI. The reliability of the CTAS was good when applied to triage geriatric patients. The SETS performed well in prehospital simulated triage. The ESI has moderate to excellent reliability. The CTAS has good to excellent validity, while the JTAS, KTAS, MTS, and ESI have fair to good results.

CONCLUSION

Several triage tools are useful in geriatrics, but the reliability and validity of these tools have mixed results. Applying triage tools to triage geriatric patients still has limitations.

Enhancing traumatic brain injury emergency care: the impact of grading and zoning nursing management

OBJECTIVE

This research aimed to evaluate the impact of grading and zoning nursing management on traumatic brain injury (TBI) patients' emergency treatment outcomes.

METHODS

This randomized controlled trial included 200 TBI patients. They were treated with a conventional care (control group, n = 100) and a novel grading and zoning approach (study group, n = 100), respectively. This innovative model organized care into levels based on urgency and complexity, facilitating targeted medical response and resource allocation. Key metrics compared included demographic profiles, consultation efficiency (time metrics and emergency treatment rates), physiological parameters (HR, RR, MAP, SpO2, RBS), and patient outcomes (hospital and ICU stays, complication rates, and emergency outcomes).

RESULTS

The study group demonstrated significantly improved consultation efficiency, with reduced times for physician visits, examinations, emergency stays, and specialist referrals (all p < 0.001), alongside a higher emergency treatment rate (93% vs. 79%, p = 0.004), notably better physiological stability, improved HR, RR, MAP, SpO2 and RBS (p < 0.001), shorter hospital and ICU stays, fewer complications, and superior emergency outcomes.

CONCLUSION

Grading and zoning nursing management substantially enhances TBI patients' emergency care efficiency and clinical outcomes, suggesting a viable model for improving emergency treatment protocols.

Who responds to longer wait times? The effects of predicted emergency wait times on the health and volume of patients who present for care

Healthcare is often free at the point-of-care so that price does not deter patients. However, the dis-utility from waiting for care that often occurs could also lead to deterrence. I investigate responses in the volume and types of patients that demand emergency care when predicted waiting times quasi-randomly change. I leverage a discontinuity to compare emergency sites with similar predicted wait times but with different apparent wait times displayed to patients. I use impulse response functions estimated by local projections to estimate effects of predicted wait times on patient demand for care. An additional thirty minutes of predicted wait time results in 15% fewer waiting patients at urgent cares and 2% fewer waiting patients at emergency departments within three hours of display. Patients that stop using emergency care are also triaged as healthier. However, at very high predicted wait times, there are reductions in demand for all patients including sicker patients.

Value-based comparison of ambulatory children with respiratory diseases in an emergency department and a walk-in clinic: a retrospective cohort study in Québec, Canada

OBJECTIVE

To compare health outcomes and costs given in the emergency department (ED) and walk-in clinics for ambulatory children presenting with acute respiratory diseases.

DESIGN

A retrospective cohort study.

SETTING

This study was conducted from April 2016 to March 2017 in one ED and one walk-in clinic. The ED is a paediatric tertiary care centre, and the clinic has access to lab tests and X-rays.

PARTICIPANTS

Inclusion criteria were children: (1) aged from 2 to 17 years old and (2) discharged home with a diagnosis of upper respiratory tract infection (URTI), pneumonia or acute asthma.

MAIN OUTCOME MEASURES

The primary outcome measure was the proportion of patients returning to any ED or clinic within 3 and 7 days of the index visit. The secondary outcome measures were the mean cost of care estimated using time-driven activity-based costing and the incidence of antibiotic prescription for URTI patients.

RESULTS

We included 532 children seen in the ED and 201 seen in the walk-in clinic. The incidence of return visits at 3 and 7 days was 20.7% and 27.3% in the ED vs 6.5% and 11.4% in the clinic (adjusted relative risk at 3 days (aRR) (95% CI) 3.17 (1.77 to 5.66) and aRR at 7 days 2.24 (1.46 to 3.44)). The mean cost (95% CI) of care (CAD) at the index visit was $C96.68 (92.62 to 100.74) in the ED vs $C48.82 (45.47 to 52.16) in the clinic (mean difference (95% CI): 46.15 (41.29 to 51.02)). Antibiotic prescription for URTI was less common in the ED than in the clinic (1.5% vs 16.4%; aRR 0.10 (95% CI 0.03 to 0.32)).

CONCLUSIONS

The incidence of return visits and cost of care were significantly higher in the ED, while antibiotic use for URTI was more frequent in the walk-in clinic. These data may help determine which setting offers the highest value to ambulatory children with acute respiratory conditions.

The Effectiveness and Relevance of the Canadian Triage System at Times of Overcrowding in the Emergency Department of a Private Tertiary Hospital: A United Arab Emirates (UAE) Study

OBJECTIVE

A systematic and straightforward triage system is crucial for the proper and timely care of patients within the emergency department (ED). This study unfolds a detailed understanding of the impact of the Canadian Triage and Acuity Scale (CTAS) on patient care and resource allocation in a private tertiary hospital. To the best of our knowledge, this is the only article studying the impact of the CTAS in one of the private hospitals in the United Arab Emirates (UAE) to achieve triage optimisation strategies. There is scope for further research in both public and private hospitals in the UAE. A triage system not only helps healthcare professionals prioritise cases conveniently but also guides patients to the most suitable area for a consultation. As a general rule, EDs follow an algorithm for the purpose of triage, and the aim of our study is to assess one such five-level triage system, CTAS, for its effectiveness and relevance during overcrowding in a UAE ED.

METHOD

Within a period of approximately three weeks, a total of 351 CTAS-triaged patients were included in a prospective observational study during peak hours (17:00-22:00) of an ED in the UAE. The CTAS app was used as the triage tool to assess relevance, in terms of patient waiting times, resource allocation, and urgency level distribution, to the Canadian scale. All patients presenting to the ED were included with no exclusion criteria. The relationship between urgency level, duration of visit, and resources used was assessed, and the department's triage results were compared with those of the CTAS app.

RESULTS

Our sample showed a female (187; 53.3%) and adult preponderance (215; 61.3%) with most of the adult patients aged between 30 and 40 (96; 44.65%). 41.5% (145) of the triage was mismatched between the department and the CTAS app with 115 (79.3%) cases of under-triaging and 30 (20.7%) cases of over-triaging. There was a statistically significant difference (p=0.004) between average waiting times across triage categories 4 and 5 with the former category patients waiting for a longer period of time. Cohen's kappa showed moderate inter-relatability (k=0.42). The average utilisation costs per triage category showed a positive correlation with the urgency level for CTAS (Pearson's r=0.59); however, the costs declined as the urgency level rose for the department.

CONCLUSIONS

The high compliance rate demonstrates that the CTAS can be applicable to institutions outside of Canada. The categorisation of patients by the CTAS and their resource allocation were more accurate than the standard triage proving its effectiveness as a triage tool. Lack of synchronisation among the triage nurses and inadequate triage training are the most plausible reasons for this comparison. The recommended "time to be seen by a physician" was achievable in our ED, and that, along with the expected relationship between CTAS and resource utilisation, can be seen as valid indicators for a quality triage system for use in the UAE.

Development of a machine learning-based acuity score prediction model for virtual care settings

OBJECTIVE

Healthcare is increasingly digitized, yet remote and automated machine learning (ML) triage prediction systems for virtual urgent care use remain limited. The Canadian Triage and Acuity Scale (CTAS) is the gold standard triage tool for in-person care in Canada. The current work describes the development of a ML-based acuity score modelled after the CTAS system.

METHODS

The ML-based acuity score model was developed using 2,460,109 de-identified patient-level encounter records from three large healthcare organizations (Ontario, Canada). Data included presenting complaint, clinical modifiers, age, sex, and self-reported pain. 2,041,987 records were high acuity (CTAS 1-3) and 416,870 records were low acuity (CTAS 4-5). Five models were trained: decision tree, k-nearest neighbors, random forest, gradient boosting regressor, and neural net. The outcome variable of interest was the acuity score predicted by the ML system compared to the CTAS score assigned by the triage nurse.

RESULTS

Gradient boosting regressor demonstrated the greatest prediction accuracy. This final model was tuned toward up triaging to minimize patient risk if adopted into the clinical context. The algorithm predicted the same score in 47.4% of cases, and the same or more acute score in 95.0% of cases.

CONCLUSIONS

The ML algorithm shows reasonable predictive accuracy and high predictive safety and was developed using the largest dataset of its kind to date. Future work will involve conducting a pilot study to validate and prospectively assess reliability of the ML algorithm to assign acuity scores remotely.

Comparing methods to classify admitted patients with SARS-CoV-2 as admitted for COVID-19 versus with incidental SARS-CoV-2: A cohort study

INTRODUCTION

Not all patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection develop symptomatic coronavirus disease 2019 (COVID-19), making it challenging to assess the burden of COVID-19-related hospitalizations and mortality. We aimed to determine the proportion, resource utilization, and outcomes of SARS-CoV-2 positive patients admitted for COVID-19, and assess the impact of using the Center for Disease Control's (CDC) discharge diagnosis-based algorithm and the Massachusetts state department's drug administration-based classification system on identifying admissions for COVID-19.

METHODS

In this retrospective cohort study, we enrolled consecutive SARS-CoV-2 positive patients admitted to one of five hospitals in British Columbia between December 19, 2021 and May 31,2022. We completed medical record reviews, and classified hospitalizations as being primarily for COVID-19 or with incidental SARS-CoV-2 infection. We applied the CDC algorithm and the Massachusetts classification to estimate the difference in hospital days, intensive care unit (ICU) days and in-hospital mortality and calculated sensitivity and specificity.

RESULTS

Of 42,505 Emergency Department patients, 1,651 were admitted and tested positive for SARS-CoV-2, with 858 (52.0%, 95% CI 49.6-54.4) admitted for COVID-19. Patients hospitalized for COVID-19 required ICU admission (14.0% versus 8.2%, p<0.001) and died (12.6% versus 6.4%, p<0.001) more frequently compared with patients with incidental SARS-CoV-2. Compared to case classification by clinicians, the CDC algorithm had a sensitivity of 82.9% (711/858, 95% CI 80.3%, 85.4%) and specificity of 98.1% (778/793, 95% CI 97.2%, 99.1%) for COVID-19-related admissions and underestimated COVID-19 attributable hospital days. The Massachusetts classification had a sensitivity of 60.5% (519/858, 95% CI 57.2%, 63.8%) and specificity of 78.6% (623/793, 95% CI 75.7%, 81.4%) for COVID-19-related admissions, underestimating total number of hospital and ICU bed days while overestimating COVID-19-related intubations, ICU admissions, and deaths.

CONCLUSION

Half of SARS-CoV-2 hospitalizations were for COVID-19 during the Omicron wave. The CDC algorithm was more specific and sensitive than the Massachusetts classification, but underestimated the burden of COVID-19 admissions.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT04702945.

Early clinical outcome prediction based on the initial National Early Warning Score + Lactate (News+L) Score among adult emergency department patients

BACKGROUND

The National Early Warning Score + Lactate (NEWS+L) Score has been previously shown to outperform NEWS alone in prediction of mortality and need for critical care in a small adult ED study. We validated the score in a large patient data set and constructed a model that allows early prediction of the probability of clinical outcomes based on the individual's NEWS+L Score.

METHODS

In this retrospective study, we included all adult patients who visited the ED of a single urban academic tertiary-care university hospital in South Korea for five consecutive years (1 January 2015 to 31 December 2019). The initial (<1 hour) NEWS+L Score is routinely recorded electronically at our ED and was abstracted for each visit. The outcomes were hospital death or a composite of hospital death and intensive care unit admission at 24 hours, 48 hours and 72 hours. The data set was randomly split into train and test sets (1:1) for internal validation. The area under the receiver operating characteristic curve (AUROC) value and area under the precision and recall curve (AUPRC) value were evaluated and logistic regression models were used to develop an equation to calculate the predicted probabilities for each of these outcomes according to the NEWS+L Score.

RESULTS

After excluding 808 patients (0.5%) from 149 007 patients in total, the study cohort consisted of 148 199 patients. The mean NEWS+L Score was 3.3±3.8. The AUROC value was 0.789~0.813 for the NEWS+L Score with good calibration (calibration-in-the-large=-0.082~0.001, slope=0.964~0.987, Brier Score=0.011~0.065). The AUPRC values of the NEWS+L Score for outcomes were 0.331~0.415. The AUROC and AUPRC values of the NEWS+L Score were greater than those of NEWS alone (AUROC 0.744~0.806 and AUPRC 0.316~0.380 for NEWS). Using the equation, 48 hours hospital mortality rates for NEWS+L Score of 5, 10 and 15 were found to be 1.1%, 3.1% and 8.8%, and for the composite outcome 9.2%, 27.5% and 58.5%, respectively.

CONCLUSION

The NEWS+L Score has acceptable to excellent performance for risk estimation among undifferentiated adult ED patients, and outperforms NEWS alone.

Predictive Validity of a New Triage System for Outcomes in Patients Visiting Pediatric Emergency Departments: A Nationwide Study in Korea

Triage is essential for rapid and efficient intervention in patients visiting an emergency department. In Korea, since 2016, the Pediatric Korean Triage and Acuity Scale (PedKTAS) has been implemented nationwide for the triage of patients visiting pediatric emergency departments (PEDs). The aim of this study was to evaluate the validity of the PedKTAS in patients who visit PEDs. This study was a retrospective observational study of national registry data collected from all emergency medical centers and institutions throughout Korea. We analyzed data from patients aged <15 years who visited emergency departments nationwide from January 2016 to December 2019. The hospitalization and intensive care unit (ICU) admission rates were analyzed on the basis of triage level. In total, 5,462,964 pediatric patients were included in the analysis. The hospitalization rates for PedKTAS Levels 1-5, were 63.5%, 41.1%, 17.0%, 6.5%, and 3.7%, respectively, and were significantly different (p < 0.001). The ICU admission rates for PedKTAS Levels 1-5 were 14.4%, 6.0%, 0.3%, 0.1%, and 0.1%, respectively, and were significantly different (p < 0.001). The hospitalization and ICU admission rates were highest for PedKTAS Level 1, and differences were significant based on the level. We identified that the PedKTAS is suitable for predicting the emergency status of pediatric patients who visit PEDs.

Does the definition of preventable emergency department visit matter? An empirical analysis using 20 million visits in Ontario and Alberta

OBJECTIVES

This study had two objectives: (1) to estimate the prevalence of preventable emergency department (ED) visits during the 2016-2020 time period among those living in 19 large urban centers in Alberta and Ontario, Canada, and (2) to assess if the definition of preventable ED visits matters in estimating the prevalence.

METHODS

A retrospective, population-based study of ED visits that were reported to the National Ambulatory Care Reporting System from April 1, 2016, to March 31, 2020, was conducted. Preventable ED visits were operationalized based on the following approaches: (1) Canadian Triage and Acuity Scale (CTAS), (2) ambulatory care-sensitive conditions (ACSC), (3) family practice-sensitive conditions (FPSC), and (4) sentinel nonurgent conditions (SNC). The overall proportion of ED visits that were preventable was estimated. We also estimated the adjusted relative risks of preventable ED visits by patients' sex and age, fiscal year, province of residence, and census metropolitan area (CMA) of residence.

RESULTS

There were 20,171,319 ED visits made by 8,919,618 patients ages 1 to 74 who resided in one of the 19 CMAs in Alberta or Ontario. On average, there were 2.26 visits per patient over the period of 4 fiscal years; most patients made one (44.22%) or two ED visits (20.72%). The overall unadjusted prevalence of preventable ED visits varied by definition; 35.33% of ED visits were defined as preventable based on CTAS, 12.88% based on FPSC, 3.41% based on SNC, and 2.33% based on ACSC.

CONCLUSIONS

There is a substantial level of variation in prevalence estimates across definitions of preventable ED visits, and care should be taken when interpreting these estimates as each has a different meaning and may lead to different conclusions. The conceptualization and measurement of preventable ED visits is complex and multifaceted and may not be adequately captured by a single definition.

Impact of the Covid-19 pandemic on rates of emergency department utilization and hospital admission due to general surgery conditions

BACKGROUND

Recent literature reports a decrease in healthcare-seeking behaviours by adults during the Covid-19 pandemic. Given that emergency general surgery (GS) conditions are often associated with high morbidity and mortality if left untreated, the objective of this study was to describe and quantify the impact of the Covid-19 pandemic on rates of emergency department (ED) utilization and hospital admission due to GS conditions.

METHODS

This cohort study involved the analysis of an institutional database and retrospective chart review. We identified adult patients presenting to the ED in a network of three teaching hospitals in Montreal, Canada during the first wave of the Covid-19 pandemic (March13-May13, 2020) and a control pre-pandemic period (March13-May13, 2019). Patients with GS conditions were included in the analysis. ED utilization rates, admission rates and 30-day outcomes were compared between the two periods using multivariate regression analysis.

RESULTS

During the pandemic period, 258 patients presented to ED with a GS diagnosis compared to 351 patients pre-pandemically (adjusted rate ratio (aRR) 0.75; p < 0.001). Rate of hospital admission during the pandemic was also significantly lower (aRR = 0.77, p < 0.001). Patients had a significantly shorter ED stay during the pandemic (adjusted mean difference 5.0 h; p < 0.001). Rates of operative management during the pandemic were preserved compared to the pre-pandemic period. There were no differences in 30-day complications (adjusted odds ratio (aOR) 1.46; p = 0.07), ED revisits (aOR 1.10; p = 0.66) and (re)admissions (aOR 1.42; p = 0.22) between the two periods.

CONCLUSION

There was a decrease in rates of ED utilization and hospital admissions due to GS conditions during the first wave of the Covid -19 pandemic; however, rates of operative management, complications and healthcare reutilization were unchanged. Although our findings are not generalizable to patients who did not seek healthcare, it was possible to successfully uphold institutional standards of care once patients presented to the ED.

Characterizing people with frequent emergency department visits and substance use: a retrospective cohort study of linked administrative data in Ontario, Alberta, and B.C., Canada

Background

Substance use is common among people who visit emergency departments (EDs) frequently. We aimed to characterize subgroups within this cohort to better understand care needs/gaps, and generalizability of characteristics in three Canadian provinces.

Methods

This was a retrospective cohort study (April 1^st, 2013 to March 31^st, 2016) of ED patients in Ontario, Alberta, and British Columbia (B.C.) We included patients ≥ 18 years with substance use-related healthcare contact during the study period and frequent ED visits, defined as those in the top 10% of ED utilization when all patients were ordered by annual ED visit number. We used linked administrative databases including ED visits and hospitalizations (all provinces); mental heath-related hospitalizations (Ontario and Alberta); and prescriptions, physician services, and mortality (B.C.). We compared to cohorts of people with (1) frequent ED visits and no substance use, and (2) non-frequent ED visits and substance use.

We employed cluster analysis to identify subgroups with distinct visit patterns and clinical characteristics during index year, April 1^st, 2014 to March 31^st, 2015.

Results

In 2014/15, we identified 19,604, 7,706, and 9,404 people with frequent ED visits and substance use in Ontario, Alberta, and B.C (median 37–43 years; 60.9–63.0% male), whose ED visits and hospitalizations were higher than comparison groups.

In all provinces, cluster analyses identified subgroups with “extreme” and “moderate” frequent visits (median 13–19 versus 4–6 visits/year). “Extreme” versus “moderate” subgroups had more hospitalizations, mental health-related ED visits, general practitioner visits but less continuity with one provider, more commonly left against medical advice, and had higher 365-day mortality in B.C. (9.3% versus 6.6%; versus 10.4% among people with frequent ED visits and no substance use, and 4.3% among people with non-frequent ED visits and substance use). The most common ED diagnosis was acute alcohol intoxication in all subgroups.

Conclusions

Subgroups of people with “extreme” (13–19 visits/year) and “moderate” (4–6 visits/year) frequent ED visits and substance use had similar utilization patterns and characteristics in Ontario, Alberta, and B.C., and the “extreme” subgroup had high mortality. Our findings suggest a need for improved evidence-based substance use disorder management, and strengthened continuity with primary and mental healthcare.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00673-x.

Reliability and Validity of a New Computer-Based Triage Decision Support Tool: ANKUTRIAGE

OBJECTIVE

Triage is a tool used to determine patients' severity of illness or injury within minutes of arrival. This study aims to assess the reliability and validity of a new computer-based triage decision support tool, ANKUTRIAGE, prospectively.

METHODS

ANKUTRIAGE, a 5-level triage tool was established considering 2 major factors, patient's vital signs and characteristics of the admission complaint. Adult patients admitted to the ED between July and October, 2019 were consecutively and independently double triaged by 2 assessors using ANKUTRIAGE system. To measure inter-rater reliability, quadratic-weighted kappa coefficients (Kw) were calculated. For the validity, associations among urgency levels, resource use, and clinical outcomes were evaluated.

RESULTS

The inter-rater reliability between users of ANKUTRIAGE was excellent with an agreement coefficient (Kw) greater than 0.8 in all compared groups. In the validity phase, hospitalization rate, intensive care unit admission and mortality rate decreased from level 1 to 5. Likewise, according to the urgency levels, resource use decreased significantly as the triage level decreased (P < 0.05).

CONCLUSIONS

ANKUTRIAGE proved to be a valid and reliable tool in the emergency department. The results showed that displaying the key discriminator for each complaint to assist decision leads to a high inter-rater agreement with good correlation between urgency levels and clinical outcomes, as well as between urgency levels and resource consumptions.

Does an Overcrowded Emergency Department Reduce Moral Hazard? Lessons from Emergency Department Visits to Three Hospitals in an Israeli Metropolitan Area

Metropolitan Haifa, Israel, has three hospitals: Rambam Health Care Campus, Bnai Zion Medical Center, and Carmel Medical Center. In 2007-2014, the length of stay at RHCC's emergency department increased, while the number of visits decreased. We ask whether the increase in LOS is associated with the falling numbers of visits to other EDs, whether an increase in LOS induces more referrals to competing hospitals in the metropolitan area, and whether it pays to be a crowded ED in mitigating moral hazard. Average LOS at Rambam climbed from 3.5 h in 2000-2007 to 6.4 in 2008-2018. While the number of visits to Rambam decreased significantly, those to Bnai Zion increased significantly and quite linearly. A one-way ANOVA test reveals a statistically significant difference among the three hospitals. In addition, Rambam was significantly different from Carmel but not from Bnai Zion. When LOS stabilized at Rambam from 2016 to 2018 and increased at Bnai Zion, referrals to Rambam went up again. Policymakers should instruct all hospitals to publish LOS data, regulate referrals to EDs, and find an optimal LOS that will reduce competition, non-urgent visits, and moral hazard.

Implementing a new emergency medical triage tool in one health region in Norway: some lessons learned

BACKGROUND

Acutely sick or injured patients depend on ambulance and emergency department personnel performing an accurate initial assessment and prioritisation (triage) to effectively identify patients in need of immediate treatment. Triage also ensures that each patient receives fair initial assessment. To improve the patient safety, quality of care, and communication about a patient's medical condition, we implemented a new triage tool (the South African Triage Scale Norway (SATS-N) in all the ambulance services and emergency departments in one health region in Norway. This article describes the lessons we learnt during this implementation process.

METHODS

The main framework in this quality improvement (QI) work was the plan-do-study-act cycle. Additional process sources were 'The Institute for Healthcare Improvement Model for improvement' and the Norwegian Patient Safety Programme.

RESULTS

Based on the QI process as a whole, we defined subjects influencing this work to be successful, such as identifying areas for improvement, establishing multidisciplinary teams, coaching, implementing measurements and securing sustainability. After these subjects were connected to the relevant challenges and desired effects, we described the lessons we learnt during this comprehensive QI process.

CONCLUSION

We learnt the importance of following a structured framework for QI process during the implementation of the SATS-N triage tool. Furthermore, securing anchoring at all levels, from the managements to the medical professionals in direct patient-orientated work, was relevant important. Moreover, establishing multidisciplinary teams with ambulance personnel, emergency department nurses and doctors with various medical specialties provided ownership to the participants. Meanwhile, coaching provided necessary security for the staff directly involved in caring for patients. Keeping the spirit and perseverance high were important factors in completing the implementation. Establishment of the regional network group was found to be important for sustainability and further improvements.

Safety assessment of a redirection program using an electronic application for low-acuity patients visiting an emergency department

Background

Emergency departments (EDs) are operating at or above capacity, which has negative consequences on patients in terms of quality of care and morbi-mortality. Redirection strategies for low-acuity ED patients to primary care practices are usually based on subjective eligibility criteria that sometimes necessitate formal medical assessment. Literature investigating the effect of those interventions is equivocal. The aim of the present study was to assess the safety of a redirection process using an electronic clinical support system used by the triage nurse without physician assessment.

Methods

A single cohort observational study was performed in the ED of a level 1 academic trauma center. All low-acuity patients redirected to nearby clinics through a clinical decision support system (February–August 2017) were included. This system uses different sets of medical prerequisites to identify patients eligible to redirection. Data on safety and patient experience were collected through phone questionnaires on day 2 and 10 after ED visit. The primary endpoint was the rate of redirected patients returning to any ED for an unexpected visit within 48 h. Secondary endpoints were the incidence of 7-day return visit and satisfaction rates.

Results

A total of 980 redirected low-acuity patients were included over the period: 18 patients (2.8%) returned unexpectedly to an ED within 48 h and 31 patients (4.8%) within 7 days. No hospital admission or death were reported within 7 days following the first ED visit. Among redirected patients, 81% were satisfied with care provided by the clinic staff.

Conclusion

The implementation of a specific electronic-guided decision support redirection protocol appeared to provide safe deferral to nearby clinics for redirected low-acuity patients. EDs are pivotal elements of the healthcare system pathway and redirection process could represent an interesting tool to improve the care to low-acuity patients.

ABCD approach at the #7119 center, telephone triage system in Tokyo, Japan; a retrospective cohort study

Background

The algorithm and protocol of the #7119 telephone triage in Tokyo, Japan, had been originally established and consists of three steps. In this study, we investigated the outcome of patients treated with physiological abnormality (ABCD approach: A, airway; B, breathing; C, circulation, and D, dysfunction of central nervous system) in step 2 during the #7119 telephone triage and clarified the meaning of evaluation of this approach.

Methods

We retrospectively reviewed data from the Tokyo Fire Department from January 2016 to December 2017. Almost all the patients triaged using the ABCD approach were transferred to the hospital by ambulance and assigned severity by a physician. We divided patients into groups with combinations of 15 patterns including A, B, C, D, AB, AC, AD, BC, BD, CD, ABC, ABD, ACD, BCD, and ABCD. We compared the proportion of severe cases in each group using a Fisher's exact test, followed by residual analysis.

Results

We analyzed 13,793 cases triaged using the ABCD approach. In this analysis, 31% of total cases were assessed as severe cases. Groupwise analysis showed that the proportion of severe cases was significantly higher in the AD, BC, CD, ABD, and ABCD groups, while it was significantly less in the C and AB groups than in the total cases.

Conclusion

At the #7119 telephone triage, we can pick up the severe cases by the ABCD approach. This may contribute to the prompt transportation of severe patients to hospitals by dispatching ambulance cars using the #7119 telephone triage methods.

The Effect of Human Supervision on an Electronic Implementation of the Canadian Triage Acuity Scale (CTAS)

BACKGROUND

Most electronic emergency department (ED) triage systems allow nurses to modify computer-generated triage scores. It is currently unclear how this affects triage validity.

OBJECTIVE

Are nurse-generated triage scores more strongly associated with rates of admission, intensive care unit (ICU) consultation, and mortality than computer-generated scores?

METHODS

Retrospective observational cohort study of all adult visits to a tertiary ED. An electronic implementation of the Canadian Triage Acuity Scale (CTAS) generated a CTAS score for each visit. In some cases, the triage nurse overwrote the computer-generated CTAS score with a score they felt was more appropriate. Among visits with nurse-modified triage scores, we compared the rate of acuity-related outcomes (mortality, ICU consultation, hospital admission) in each CTAS level as categorized by nurse-generated vs. computer-generated scores.

RESULTS

In a cohort of 229,744 patients, 19,566 (8.51%) had nurse-modified triage scores. Most modifications consisted of assigning a higher acuity triage score than recommended by the computer. Visits with triage scores 1-2 according to the nurse-generated scores had the same or higher rates of the acuity outcomes than visits that were CTAS 1-2 according to the computer-generated CTAS scores. Conversely, visits with triage scores 4-5 according to the nurse-generated scores had lower rates of the outcomes than visits that were CTAS 4-5 according to the computer-generated CTAS scores.

CONCLUSIONS

Nursing supervision of the computer-automated CTAS triage system was associated with fewer hospital admissions, ICU consultations, and deaths in the triage score 4-5 categories, suggesting a safer triage process than the automated CTAS algorithm alone.

Low back pain presentations to rural, regional, and metropolitan emergency departments

Objective

To describe the context of low back pain (LBP) presentations to emergency departments (EDs) by remoteness areas, hospital delineation level and staffing portfolios.

Design

A retrospective observational study using routinely captured ED and admission data over a 5‐year period (July 2014–June 2019).

Settings

Thirty seven EDs across a large health district in NSW, Australia, covering major cities, inner regional areas and outer regional areas.

Participants

Emergency department (ED) presentations with a principal or secondary diagnosis of LBP based on ICD‐10 code (M54.5).

Main outcome measures

ED presentation and associated admission measures, including presentation rate, referral source, time in ED, re‐presentation rate, admission details and cost to the health system.

Results

There were 26 509 ED presentations for LBP across the 5 years. Time spent in ED was 206 min for EDs in major cities, 146 min for inner regional EDs and 89 min for outer regional EDs. Re‐presentation rates were 6% in major cities, 8.8% in inner regional EDs and 11.8% in outer regional EDs. Admission rates were 20.4%, 15.8% and 18.8%, respectively.

Conclusions

This study describes LBP presentations across 37 EDs, highlighting the potential burden these presentations place on hospitals. LBP presentations appear to follow different pathways depending on the ED remoteness area, delineation level and staff portfolio.

Premorbid Clinical Frailty Score and 30-day mortality among older adults in the emergency department

OBJECTIVES

The association between frailty and short-term prognosis has not been established in critically ill older adults presenting to the emergency department. We sought to examine the association between premorbid frailty and 30-day mortality in this patient population.

METHODS

This is a retrospective observational study on older adults aged over 75 who were triaged as Level 1 resuscitation with subsequent admissions to intermediate units or intensive care units (ICUs) in a single critical care center, from January to December 2019. We excluded patients with out-of-hospital cardiac arrest or those transferred from other hospitals. Frailty was evaluated by the Clinical Frailty Scale (CFS) from the patients' chart reviews. The primary outcome was 30-day mortality, and we examined the association between frailty scored on the CFS and 30-day mortality using a multivariable logistic regression model with CFS 1-4 as a reference.

RESULTS

A total of 544 patients, median age: 82 years (interquartile rang 78 to 87), were included in the study. Of these, 29% were in shock and 33% were in respiratory failure. The overall 30-day mortality was 15.1%. The adjusted risk difference (95% confidence interval [CI]) in mortality for CFS 5, CFS 6, and CFS 7-9 was 6.3% (-3.4 to 15.9), 11.2% (0.4 to 22.0), and 17.7% (5.3 to 30.1), respectively; and the adjusted risk ratio (95% CI) was 1.45 (0.87 to 2.41), 1.85 (1.13 to 3.03), and 2.44 (1.50 to 3.96), respectively.

CONCLUSION

The risk of 30-day mortality increased as frailty advanced in critically ill older adults. Given this high risk of short-term outcomes, ED clinicians should consider goals of care conversations carefully to avoid unwanted medical care for these patients.

Improving Emergency Care Through a Dedicated Redesigned Obstetrics and Gynecology Emergency Unit at the Women's Hospital, Doha, Qatar

BACKGROUND

OBJECTIVE

STUDY DESIGN

RESULTS

CONCLUSION

Subgroups of people who make frequent emergency department visits in Ontario and Alberta: a retrospective cohort study

BACKGROUND

The population that visits emergency departments frequently is heterogeneous and at high risk for mortality. This study aimed to characterize these patients in Ontario and Alberta, compare them with controls who do not visit emergency departments frequently, and identify subgroups.

METHODS

This was a retrospective cohort study that captured patients in Ontario or Alberta from fiscal years 2011/12 to 2015/16 in the Dynamic Cohort from the Canadian Institute for Health Information, which defined people with frequent visits to the emergency department in the top 10% of annual visits and randomly selected controls from the bottom 90%. We included patients 18 years of age or older and linked to emergency department, hospitalization, continuing care, home care and mental health-related hospitalization data. We characterized people who made frequent visits to the emergency department over time, compared them with controls and identified subgroups using cluster analysis. We examined emergency department visit acuity using the Canadian Triage and Acuity Scale.

RESULTS

The number of patients who made frequent visits to the emergency department ranged from 435 334 to 477 647 each year in Ontario (≥ 4 visits per year), and from 98 840 to 105 047 in Alberta (≥ 5 visits per year). The acuity of these visits increased over time. Those who made frequent visits to the emergency department were older and used more health care services than controls. We identified 4 subgroups of those who made frequent visits: "short duration" (frequent, regularly spaced visits), "older patients" (median ages 69 and 64 years in Ontario and Alberta, respectively; more comorbidities; and more admissions), "young mental health" (median ages 45 and 40 years in Ontario and Alberta, respectively; and common mental health-related and alcohol-related visits) and "injury" (increased prevalence of injury-related visits).

INTERPRETATION

From 2011/12 to 2015/16, people who visited emergency departments frequently had increasing visit acuity, had higher health care use than controls, and comprised distinct subgroups. Emergency departments should codevelop interventions with the identified subgroups to address patient needs.

People who make frequent emergency department visits based on persistence of frequent use in Ontario and Alberta: a retrospective cohort study

BACKGROUND

The factors that underlie persistent frequent visits to the emergency department are poorly understood. This study aimed to characterize people who visit emergency departments frequently in Ontario and Alberta, by number of years of frequent use.

METHODS

This was a retrospective cohort study aimed at capturing information about patients visiting emergency departments in Ontario and Alberta, Canada, from Apr. 1, 2011, to Mar. 31, 2016. We identified people 18 years or older with frequent emergency department use (top 10% of emergency department use) in fiscal year 2015/16, using the Dynamic Cohort from the Canadian Institute of Health Information. We then organized them into subgroups based on the number of years (1 to 5) in which they met the threshold for frequent use over the study period. We characterized subgroups using linked emergency department, hospitalization and mental health-related hospitalization data.

RESULTS

We identified 252 737 people in Ontario and 63 238 people in Alberta who made frequent visits to the emergency department. In Ontario and Alberta, 44.3% and 44.7%, respectively, met the threshold for frequent use in only 1 year and made 37.9% and 38.5% of visits; 6.8% and 8.2% met the threshold for frequent use over 5 years and made 11.9% and 13.2% of visits. Many characteristics followed gradients based on persistence of frequent use: as years of frequent visits increased (1 to 5 years), people had more comorbidities, homelessness, rural residence, annual emergency department visits, alcohol- and substance use-related presentations, mental health hospitalizations and instances of leaving hospital against medical advice.

INTERPRETATION

Higher levels of comorbidities, mental health issues, substance use and rural residence were seen with increasing years of frequent emergency department use. Interventions upstream and in the emergency department must address unmet needs, including services for substance use and social supports.

Mortality among patients with frequent emergency department use for alcohol-related reasons in Ontario: a population-based cohort study

BACKGROUND

Little is known about the risk of death among people who visit emergency departments frequently for alcohol-related reasons, including whether mortality risk increases with increasing frequency of visits. Our primary objective was to describe the sociodemographic and clinical characteristics of this high-risk population and examine their 1-year overall mortality, premature mortality and cause of death as a function of emergency department visit frequency in Ontario, Canada.

METHODS

We conducted a population-based retrospective cohort study using linked health administrative data (Jan. 1, 2010, to Dec. 31, 2016) in Ontario for people aged 16-105 years who made at least 2 emergency department visits for mental or behavioural disorders due to alcohol within 1 year. We subdivided the cohort based on visit frequency (2, 3 or 4, or ≥ 5). The primary outcome was 1-year mortality, adjusted for age, sex, income, rural residence and presence of comorbidities. We examined premature mortality using years of potential life lost (YPLL).

RESULTS

Of the 25 813 people included in the cohort, 17 020 (65.9%) had 2 emergency department visits within 1 year, 5704 (22.1%) had 3 or 4 visits, and 3089 (12.0%) had 5 or more visits. Males, people aged 45-64 years, and those living in urban centres and lower-income neighbourhoods were more likely to have 3 or 4 visits, or 5 or more visits. The all-cause 1-year mortality rate was 5.4% overall, ranging from 4.7% among patients with 2 visits to 8.8% among those with 5 or more visits. Death due to external causes (e.g., suicide, accidents) was most common. The adjusted mortality rate was 38% higher for patients with 5 or more visits than for those with 2 visits (adjusted hazard ratio 1.38, 95% confidence interval 1.19-1.59). Among 25 298 people aged 16-74 years, this represented 30 607 YPLL.

INTERPRETATION

We observed a high mortality rate among relatively young, mostly urban, lower-income people with frequent emergency department visits for alcohol-related reasons. These visits are opportunities for intervention in a high-risk population to reduce a substantial mortality burden.

Revision of the Protocol of the Telephone Triage System in Tokyo, Japan

Introduction

The Emergency Telephone Consultation Center in Tokyo (#7119) was the first telephone triage system in Japan and has operated since 2007. This study examined the revision of the #7119 protocol by referring the linked data to each code of the triage protocol.

Methods

We selected candidates based on the medical codes targeted by the revision, linking data from the nurses' decisions in triage and the patients' condition severity when the ambulance arrived at the hospital, gathering data from June 1, 2016, to December 31, 2017. Then, several emergency physicians evaluated the cases and decided whether the code should be moved to the more or less urgent category or if new protocols and codes would be established.

Results

In this revision, 371 codes were moved to the less urgent category, 35 codes were moved to the more urgent category, and 128 codes were newly established. In all, 59 red codes (transfer to the ambulance dispatcher) were reduced, while 254 orange codes (attendance at hospital within 1 hour) and yellow codes (within 6 hours) were moved to less urgent, and 12 yellow and green codes (within 24 hours) were moved to more urgent.

Conclusion

We adjusted the triage codes for the revision by linking the call data with the case data. This revision should decrease the inappropriate use of ambulances and reduce the primary care workload. To achieve a more accurate revision, we need to refine the process of evaluating the validity of patients' acuity over the telephone during triage.

Triage Accuracy and Its Association with Patient Factors Using Emergency Severity Index: Findings from United Arab Emirates

Introduction

The Ministry of Health and Prevention of the UAE acquired an electronic medical record system (Wareed) through which they incorporated the Emergency Severity Index as the standard triaging tool. This raised the need to review population dynamics and the accuracy of triage performed by the health-care providers utilizing the tool.

Objective

This research aimed to study demographics and dynamics of the population presenting to emergency departments (EDs) during 2018, evaluate the accuracy of triage assessment using comparative analysis techniques, and determine relationships between patient factors (severity of illness, age-group) and the accuracy of triage.

Methods

This was an observational study that aimed to ascertain findings from ED data over 1 year (January 2018-December 2018) and explore factors associated with reduced accuracy in acuity assignment. We employed comparative analysis to measure the level of agreement between standard guidelines and local findings.

Results

A total of 576,154 patients visited EDs in 2018, of which 54.4% were male. A statistically significant increase in length of stay with increasing severity of illness was observed (Kruskal-Wallis test). Overall triage accuracy was 41.6%, with a positive association with increasing severity of illness. We found a positive association between severity of illness and accuracy of triage (OR 0.14, p=0). We also found on logistic regression that the age-group 11-20 years had the highest probability of accurate triage acuity (R ²=0.41, p=0).

Conclusion

Conducted on a very large data set from the UAE, our study reflects upon population dynamics and triage accuracy distribution among different variables. This study paves the way for further in-depth analysis of factors that may impact triage accuracy within EDs, and utilizing a similar approach it can be replicated in other settings as well.

Factors Associated with Triage Modifications Using Vital Signs in Pediatric Triage: a Nationwide Cross-Sectional Study in Korea

BACKGROUND

Previous studies on inter-rater reliability of pediatric triage systems have compared triage levels classified by two or more triage providers using the same information about individual patients. This overlooks the fact that the evaluator can decide whether or not to use the information provided. The authors therefore aimed to analyze the differences in the use of vital signs for triage modification in pediatric triage.

METHODS

This was an observational cross-sectional study of national registry data collected in real time from all emergency medical services beyond the local emergency medical centers (EMCs) throughout Korea. Data from patients under the age of 15 who visited EMC nationwide from January 2016 to December 2016 were analyzed. Depending on whether triage modifications were made using respiratory rate or heart rate beyond the normal range by age during the pediatric triage process, they were divided into down-triage and non-down-triage groups. The proportions in the down-triage group were analyzed according to the triage provider's profession, mental status, arrival mode, presence of trauma, and the EMC class.

RESULTS

During the study period, 1,385,579 patients' data were analyzed. Of these, 981,281 patients were eligible for triage modification. The differences in down-triage proportions according to the profession of the triage provider (resident, 50.5%; paramedics, 47.7%; specialist, 44.9%; nurses, 44.2%) was statistically significant (P < 0.001). The triage provider's professional down-triage proportion according to the medical condition of the patients showed statistically significant differences except for the unresponsive mental state (P = 0.502) and the case of air transport (P = 0.468).

CONCLUSION

Down-triage proportion due to abnormal heart rates and respiratory rates was significantly different according to the triage provider's condition. The existing concept of inter-rater reliability of the pediatric triage system needs to be reconsidered.

A quality-improvement approach to effective trauma team activation

Background

Appropriate, timely trauma team activation (TTA) can directly affect outcomes for patients with trauma. A review of quality-performance indicators at our Canadian level 1 trauma centre showed a high level of undertriage, with TTA compliance rates less than 60% for major trauma. A quality-improvement project was undertaken, targeting a sustained goal of at least 90% TTA compliance based on Accreditation Canada guidelines.

Methods

Quality-improvement action followed a well-defined process. Baseline data collection was performed, and, in keeping with the Donabedian approach, we brought together stakeholders to collectively review and understand the reasons behind poor TTA compliance; and root-cause analysis. This was followed by rapid change cycles that focused on structure and processes with ongoing audits to support and sustain change.

Results

Trauma team activation compliance improved from 58.8% to more than 90% over 2 years. Quality indicators showed a statistically significant reduction in the time to computed tomography scanner, time in the acute care region of the emergency department and total time in the emergency department, with improved TTA compliance.

Conclusion

Compliance with TTA protocols improved to more than 90% over a 2-year period, which shows the benefit of having a clearly outlined qualityimprovement process. This well-defined quality-improvement method provides a framework for use by other institutions that seek to improve their processes of trauma care, including activation rates.

Validation of the five-tier Taiwan Triage and Acuity Scale for prehospital use by Emergency Medical Technicians

OBJECTIVES

This study aimed to determine the inter-rater reliability of the five-level Taiwan Triage and Acuity Scale (TTAS) when used by emergency medical technicians (EMTs) and triage registered nurses (TRNs). Furthermore, it sought to validate the prehospital TTAS scores according to ED hospitalisation rates and medical resource consumption.

METHODS

This was a prospective observational study. After training in five-level triage, EMTs triaged patients arriving to the ED and agreement with the nurse triage (TRN) was assessed. Subsequently, these trained research EMTs rode along on ambulance calls and assigned TTAS scores for each patient at the scene, while the on-duty EMTs applied their standard two-tier prehospital triage scale and followed standard practice, blinded to the TTAS scores. The accuracy of the TTAS scores in the field for prediction of hospitalisation and medical resource consumption were analysed using logistic regression and a linear model, respectively, and compared with the accuracy of the current two-tier prehospital triage scale.

RESULTS

After EMT's underwent initial training in five-level TTAS, inter-rater agreement between EMTs and TRNs for triage of ED patients was very good (κw=0.825, CI 0.750 to 0.900). For the outcome of hospitalisation, TTAS five-level system (Akaike's Information Criteria (AIC)=486, area under the curve (AUC)=0.75) showed better discrimination compared with TPTS two-level system (AIC=508, AUC=0.66). Triage assignments by the EMTs using the the five-level TTAS was linearly associated with hospitalisation and medical resource consumption.

CONCLUSIONS

A five-level prehospital triage scale shows good inter-rater reliability and superior discrimination compared with the two-level system for prediction of hospitalisation and medical resource requirements.

Triage accuracy and causes of mistriage using the Korean Triage and Acuity Scale

Purpose

To identify emergency department triage accuracy using the Korean Triage and Acuity Scale (KTAS) and evaluate the causes of mistriage.

Methods

This cross-sectional retrospective study was based on 1267 systematically selected records of adult patients admitted to two emergency departments between October 2016 and September 2017. Twenty-four variables were assessed, including chief complaints, vital signs according to the initial nursing records, and clinical outcomes. Three triage experts, a certified emergency nurse, a KTAS provider and instructor, and a nurse recommended based on excellent emergency department experience and competence determined the true KTAS. Triage accuracy was evaluated by inter-rater agreement between the expert and emergency nurse KTAS scores. The comments of the experts were analyzed to evaluate the cause of triage error. An independent sample t-test was conducted to compare the number of patient visits per hour in terms of the accuracy and inaccuracy of triage.

Results

Inter-rater reliability between the emergency nurse and the true KTAS score was weighted kappa = .83 and Pearson’s r = .88 (p < .001). Of 1267 records, 186 (14.7%) showed some disagreement (under triage = 131, over triage = 55). Causes of mistriage included: error applying the numerical rating scale (n = 64) and misjudgment of the physical symptoms associated with the chief complaint (n = 47). There was no statistically significant difference in the number of patient visits per hour for accurate and inaccurate triage (t = -0.77, p = .442).

Conclusion

There was highly agreement between the KTAS scores determined by emergency nurses and those determined by experts. The main cause of mistriage was misapplication of the pain scale to the KTAS algorithm.

Reliability of Korean Triage and Acuity Scale: Interrater Agreement between Two Experienced Nurses by Real-Time Triage and Analysis of Influencing Factors to Disagreement of Triage Levels

BACKGROUND

All emergency centers in Korea use the Korean Triage and Acuity Scale (KTAS) as their initial triage tool. However, KTAS has been used without verification of its reliability. In this study, we assess the interrater agreement of KTAS by two independent nurses in real-time and analyse the factors which have an effect on the disagreement of KTAS levels.

METHODS

This study was a prospective observational study conducted with patients who visited an emergency department (ED). Two teams, each composed of two nurses, triaged patients and recorded KTAS level and the main complaint from the list of 167 KTAS complaints, as well as modifiers. Interrater reliability between the two nurses in each team was assessed by weighted-kappa. Pearson's χ² test was conducted to determine if there were differences between each nurse's KTAS levels, depending on whether they chose the same complaints and the same modifiers or not.

RESULTS

The two teams triaged a total of 1,998 patients who visited the ED. Weighted-kappa value was 0.772 (95% confidence interval [CI], 0.750-0.794). Patients triaged by different chosen complaints showed (38.0%) higher inconsistency rate in KTAS levels than those triaged by the same complaint (10.9%, P < 0.001). When nurses chose the same complaint and different modifiers, the ratio of different levels (50.5%) was higher than that of the same complaint and same modifier (8.1%, P < 0.001).

CONCLUSION

This study showed that KTAS is a reliable tool. Selected complaints and modifiers are confirmed as important factors for reliability; therefore, selecting them properly should be emphasized during KTAS training courses.

["Triage"-primary assessment of patients in the emergency department : An overview with a systematic review]

BACKGROUND

"Triage" means the primary assessment of a previously unknown patient with an acute health disorder, initially considered a medical emergency. The initial triage is part of the primary assessment, which also includes the registration of administrative data and patient's mode of arrival.

OBJECTIVES

The aim of the work is to provide an overview of frequently used structured primary assessment tools and the underlying evidence for their use in the emergency room.

METHODS

Based on a systematic literature search in PubMed, 41 articles were selected according to predefined criteria.

RESULTS

The most frequently used primary assessment systems in Germany are the Emergency Severity Index (ESI) and the Manchester Triage System (MTS). Scientific evidence exists for the accuracy and reliability of the primary assessment with these instruments. However, there are no gold standards for measuring urgency, so that separate criteria must be defined. Sufficient data to determine a treatment sector or the necessary staffing levels are lacking.

CONCLUSIONS

Structured primary assessment using formalized systems alone is inadequate to categorize the urgency of emergency and acute patients. In fact, a combination of different measures in an interprofessional team is required. Primary assessment systems and processes generally do not allow patients to be referred to downstream structures without a thorough medical examination.

Over-triage occurs when considering the patient's pain in Korean Triage and Acuity Scale (KTAS)

Background

The Korean Triage and Acuity Scale (KTAS) was developed based on the Canadian Emergency Department Triage and Acuity Scale. In patients with pain, to determine the KTAS level, the pain scale is considered; however, since the degree of pain is subjective, this may affect the accuracy of KTAS. The purpose of this study was to evaluate the accuracy of KTAS in predicting patient's severity with the degree of pain used as a modifier.

Method

A retrospective observational cohort study was conducted in an urban tertiary hospital emergency department (ED). We investigated patients over 16 years old from January to June 2016. The patients were divided into the pain and non-pain groups according to whether the degree of pain was used as a modifier or not. We compared the predictive power of KTAS on the urgency of patients between the two groups. Acute area registration in the ED, emergency procedure, emergency operation, hospitalization, intensive care unit admission, and 7-day mortality were used as markers to determine urgent patients.

Results

Overall, 24,253 patients were included in the study, with 9,175 (37.8%) in the pain group. The proportions of patients with KTAS 1–3 were 61.4% in the pain and 75.6% in the non-pain groups. Among patients with KTAS 2–3, the proportion of urgent patients was higher in the non-pain group than the pain group (p<0.001). The odds ratios for urgent patients at each KTAS level revealed a more evident discriminatory power of KTAS for urgent patients in the non-pain group. The predictability of KTAS for urgent patients was higher in the non-pain group than the pain group (area under the curve; 0.736 vs. 0.765, p-value <0.001).

Conclusions

Considering the degree of pain with KTAS led to overestimation of patient severity and had a negative impact on the predictability of KTAS for urgent patients.

Evaluation of triage quality in the emergency department: a scoping review protocol

REVIEW OBJECTIVE/QUESTIONS

The objective of this scoping review is to explore the existing literature on the evaluation of the quality of triage for patients of all ages and medical conditions in emergency departments (EDs).The question for this review is: How is triage in the ED evaluated? More specifically, we are interested in answering the following sub-questions.

Responsibility-Evading Performance: The Experiences of Healthcare Staff about Triage in Emergency Departments: A Qualitative Study

Background:

Correct triage is one of the most important issues in delivering proper healthcare in the emergency department. Despite the availability of various triage guidelines, triage is not still appropriately implemented. Therefore, this study was conducted to investigate the role of different underlying factors in triaging emergency patients through a qualitative approach.

Materials and Methods:

This study was conducted by conventional content analysis. For this purpose, 30 interviews were conducted with 25 participants. The participants included triage nurses, emergency general physicians, emergency medicine specialists, and expert managers at different position rankings in hospitals and educational and administrative centers in Yazd, selected by purposeful sampling. Data were collected through in-depth and unstructured interviews from April 2017 to January 2018, and then analyzed by inductive content analysis.

Results:

Four categories of profit triage, exhibitive triage, enigmatic, and tentative performance triage were drawn from the data, collectively comprising the main theme of responsibility-evading performance.

Conclusions:

The dominant approach to the triage in the emergency departments in a central city of Iran is responsibility evasion; however, the triage is performed tentatively, especially in critical cases. To achieve a better implementation of triage, consideration of the underlying factors and prevention of their involvement in triage decision-making is necessary.

Reliability of the revised Swiss Emergency Triage Scale: a computer simulation study

Background

The Swiss Emergency Triage Scale (SETS) is a four-level emergency scale that previously showed moderate reliability and high rates of undertriage due to a lack of standardization. It was revised to better standardize the measurement and interpretation of vital signs during the triage process.

Objective

The aim of this study was to explore the inter-rater and test–retest reliability, and the rate of correct triage of the revised SETS.

Patients and methods

Thirty clinical scenarios were evaluated twice at a 3-month interval using an interactive computerized triage simulator by 58 triage nurses at an urban teaching emergency department admitting 60 000 patients a year. Inter-rater and test–retest reliabilities were determined using κ statistics. Triage decisions were compared with a gold standard attributed by an expert panel. Rates of correct triage, undertriage, and overtriage were computed. A logistic regression model was used to identify the predictors of correct triage.

Results

A total of 3387 triage situations were analyzed. Inter-rater reliability showed substantial agreement [mean κ: 0.68; 95% confidence interval (CI): 0.60–0.78] and test–retest almost perfect agreement (mean κ: 0.86; 95% CI: 0.84–0.88). The rate of correct triage was 84.1%, and rates of undertriage and overtriage were 7.2 and 8.7%, respectively. Vital sign measurement was an independent predictor of correct triage (odds ratios for correct triage: 1.29 for each additional vital sign measured, 95% CI: 1.20–1.39).

Conclusion

The revised SETS incorporating standardized vital sign measurement and interpretation during the triage process resulted in high reliability and low rates of mistriage.

Agreement of triage decisions between gastroenterologists and nurses in a hospital endoscopy unit

Introduction

Efficient and accurate triage of endoscopy referrals is essential. Many of the decisions made are based on national and local triage criteria. Standardizing this approach for nurse use could maintain quality, address clinical risk and significantly improve resource utilization.

Aims

This study aimed to compare gastroenterologist and nurse triage of unselected gastroenterology referrals in order to evaluate the proportion of referrals felt able to be triaged to endoscopy and the inter-rater agreement between a triage gastroenterologist and endoscopy nurses for clinical triage decisions regarding the urgency of gastroscopy and colonoscopy.

Methods

The proportion of referrals triaged to endoscopy by a consultant gastroenterologist performing triage as a part of normal practice and two endoscopy nurses using a decision algorithm was measured. The inter-rater agreement for the triage category decision (urgency of referral) between the three triage clinicians was assessed. An adjudication panel provided a consensus decision triage category decision in cases where there was not complete agreement between the three triage clinicians.

Results

Each clinician assessed 105 referrals. Nurse A was able to triage 54 (51%) referrals to a triage category and Nurse B 44 (42%) referrals. Cohen’s κ was run to determine if there was agreement between clinicians for the triage categories allocated. The agreement between the two nurses was substantial (k=0.645, P<0.0005). Between the gastroenterologist and each nurse, moderate agreement was seen (Nurse A, k=0.589, P<0.0005; Nurse B, k=0.437, P<0.0005). Moderate agreement was seen between the nurses and an adjudication panel (Nurse A, k=0.423, P<0.0005; Nurse B, k=0.464, P<0.0005). However, there was only slight agreement between the adjudication panel and the gastroenterologist (k=0.099, P=0.010).

Conclusion

Nurse triage using a decision algorithm is feasible, and inter-rater agreement is substantial between nurses and moderate to substantial between the nurses and a gastroenterologist. An adjudication panel demonstrated moderate agreement with the nurses but only slight agreement with the triage gastroenterologist. This suggests that nurse triage using a decision algorithm can approximate decision making by an experienced gastroenterologist.

Embracing the wild profusion: A Foucauldian analysis of the impact of healthcare standardization on nursing knowledge and practice

Standardization has emerged as the dominant principle guiding the organization and provision of healthcare, with standards resultantly shaping how nurses conceptualize and deliver patient care. Standardization has been critiqued as homogenizing diverse patient experiences and diminishing nurses' skills and critical thinking; however, there has been limited examination of the philosophical implications of standardization for nursing knowledge and practice. In this manuscript, I draw on Foucault's philosophy of order and categorization to inform an analysis of the consequences of healthcare standardization for the profession of nursing. I utilize three exemplars to illustrate the impact of the primacy of standardized thinking and practices on nurses, patients and families: pain assessments using the 0-10 pain scale; patient triage emergency departments through the Canadian Triage and Acuity Scale; and determination of cause of death within the context of the current opioid crisis. Through each exemplar, I demonstrate that standardization reductively constrains nursing knowledge and the health and healthcare experiences of patients and populations. I argue that the centrality of standardization must be re-envisioned to embrace the complexity of health and more effectively and meaningfully frame nursing knowledge and practice within healthcare systems.

Characteristics and outcomes of older emergency department patients assigned a low acuity triage score

Objective

Although older patients are a high-risk population in the emergency department (ED), little is known about those identified as “less acute” at triage. We aimed to describe the outcomes of patients ages 65 years and older who receive low acuity triage scores.

Methods

This health records review assessed ED patients who were ages 65 years and above or ages 40 to 55 years (controls) who received a Canadian Triage Acuity Scale score of 4 or 5. Data collected included patient demographics, ED management, disposition, and a return visit or hospital admission at 14 days. Data were analysed descriptively and chi-square testing performed. A pre-planned stratified analysis of patients ages 65 to 74, 75 to 84, and 85 and older was conducted.

Results

Three hundred fifty older patients with a mean age of 76.5 years and 150 control patients were included. Most patients presented with musculoskeletal or skin complaints and were triaged to the ambulatory care area. Older patients were significantly more likely than controls to be admitted on the index visit (5.0% v. 0.3%, p=0.016) and on re-presentation (4.0% v. 0.7%, p=0.045). In a subgroup analysis, patients ages 85 years and above were most likely to be admitted (8.9%, p=0.003).

Conclusions

Older patients who present to the ED with issues labelled as “less acute” at triage are 16 times more likely to be admitted than younger controls. Patients ages 85 years and up are the primary drivers of this higher admission rate. Our study indicates that even “low acuity” elders presenting to the ED are at risk for re-presentation and admission within 14 days.

Prognostic performance of Emergency Severity Index (ESI) combined with qSOFA score

OBJECTIVE

We conducted this study to investigate whether ESI combined with qSOFA score (ESI+qSOFA) predicts hospital outcome better than ESI alone in the emergency department (ED).

METHODS

This was a retrospective study for patients aged over 15years who visited an ED of a tertiary referral hospital from January 1st, 2015 to December 31st, 2015. We calculated and compared predictive performances of ESI alone and ESI+qSOFA for prespecified outcomes. The primary outcome was hospital mortality, and the secondary outcome was composite outcome of in-hospital mortality and ICU admission. We calculated in-hospital mortality rates by positive qSOFA in each subgroup divided according to ESI levels (1, 2, 3, 4+5).

RESULTS

43,748 patients were enrolled. The area under receiver-operating characteristics curves were higher in ESI+qSOFA than in ESI alone for both mortality and composite outcome (0.786 vs. 0.777, P<.001 for mortality; 0.778 vs. 0.774, P<.001 for composite outcome). In each subgroup divided by ESI levels, patients with positive qSOFA had significantly higher in-hospital mortality rate compared to those with negative qSOFA (20.4% vs. 14.7%, P=.117 in ESI level 1 subgroup; 11.3% vs. 2.7%, P=.001 in ESI level 2 subgroup; 2.3% vs. 0.4%, P<.001 in ESI level 3 subgroup; 0.0% vs. 0.0% in ESI level 4 or 5 subgroup).

CONCLUSION

The prognostic performance of ESI+qSOFA for in-hospital mortality was significantly higher than that of ESI alone. Within each subgroup, patients with positive qSOFA had higher in-hospital mortality compared to those with negative qSOFA.

Reliability and performance of the Swiss Emergency Triage Scale used by paramedics

Objectives

No general emergency department triage scale has been evaluated for prehospital triage. The objective of this study was to evaluate the reliability and the performance of the Swiss Emergency Triage Scale (SETS) used by paramedics to determine the emergency level and orientation of simulated patients.

Patients and methods

In a prospective cross-sectional study, 23 paramedics evaluated 28 clinical scenarios with the SETS using interactive computerized triage software simulating real-life triage. The primary outcome was inter-rater reliability regarding the triage level among participants measured by intraclass correlation coefficient (ICC). Secondary outcomes were the accuracy of triage level and the reliability and accuracy of orientation of patients of at least 75 years to a dedicated geriatric emergency centre.

Results

Twenty-three paramedics completed the evaluation of the 28 scenarios (644 triage decisions). Overall, ICC for triage level was 0.84 (95% confidence interval: 0.77–0.99). Correct emergency level was assigned in 89% of cases, overtriage rate was 4.8%, and undertriage was 6.2%. ICC regarding orientation in the subgroup of simulated patients of at least 75 years was 0.76 (95% confidence interval: 0.61–0.89), with 93% correct orientation.

Conclusion

Reliability of paramedics rating simulated emergency situations using the SETS was excellent, and the accuracy of their rating was very high. This suggests that in Switzerland, the SETS could be safely used in the prehospital setting by paramedics to determine the level of emergency and guide patients to the most appropriate hospital.