The future of casemix in emergency medicine and ambulatory care

Inter-observer agreement using the Canadian Emergency Department Triage and Acuity Scale

Objective:

To determine the inter-observer agreement on triage assignment by first-time users with diverse training and background using the Canadian Emergency Department Triage and Acuity Scale (CTAS).

Methods:

Twenty emergency care providers (5 physicians, 5 nurses, 5 Basic Life Support paramedics and 5 Advanced Life Support paramedics) at a large urban teaching hospital participated in the study. Observers used the 5-level CTAS to independently assign triage levels for 42 case scenarios abstracted from actual emergency department patient presentations. Case scenarios consisted of vital signs, mode of arrival, presenting complaint and verbatim triage nursing notes. Participants were not given any specific training on the scale, although a detailed one-page summary was included with each questionnaire. Kappa values with quadratic weights were used to measure agreement for the study group as a whole and for each profession.

Results:

For the 41 case scenarios analyzed, the overall agreement was significant (quadratic-weighted κ = 0.77, 95% confidence interval, 0.76–0.78). For all observers, modal agreement within one triage level was 94.9%. Exact modal agreement was 63.4%. Agreement varied by triage level and was highest for Level I (most urgent). A reasonably high level of intra- and inter-professional agreement was also seen.

Conclusions:

Despite minimal experience with the CTAS, inter-observer agreement among emergency care providers with different backgrounds was significant.

Agreement among pediatric health care professionals with the pediatric Canadian triage and acuity scale guidelines

OBJECTIVES

To compare triage level assignment, using case scenarios, in a pediatric emergency department between registered nurses (RNs) and pediatric emergency physicians (PEPs) based on the Pediatric Canadian Triage and Acuity Scale (P-CTAS) guidelines. To compare triage level assignment of the RNs and PEPs to that done by a panel of experts using the same P-CTAS guidelines.

METHODS

A cross-sectional questionnaire survey (55 case scenarios) was sent to all RNs and PEPs working in the emergency department after the P-CTAS was implemented. Participants were instructed to assign a triage level for each case. A priori, all cases were assigned a triage level by a panel of experts using the P-CTAS guidelines. Kappa statistics and the mean number (+/-1SD) of correct responses were calculated.

RESULTS

A response rate of 85% was achieved (29 RNs, 15 PEPs). The kappa level of agreement (95% CI) among RNs was 0.51 (0.50-0.52) and was 0.39 (0.38-0.41) among PEPs (P < 0.001). The mean number of correct responses (+/-1SD) for RNs was 64% +/- 27% and for PEPs 60% +/- 22% (P = 0.31). Levels of agreement did not vary according to experience or type of shift work done or work status of RNs and PEPs.

CONCLUSIONS

With the introduction of the P-CTAS, the level of agreement and accuracy of triage categorization remained moderate for both RNs and PEPs. The reliability of the P-CTAS needs to be further assessed and the requirements for revisions considered prior to its widespread use.

[Emergency department discharge reports as a management tool of clinical information]

BACKGROUND AND OBJECTIVES

Our goal was to assess the degree of readability, quality and amount of information included in discharge reports of Emergency Departments (ED) in order to evaluate their usefulness for the management of clinical information.

MATERIAL AND METHOD

Analysis of a sample of ED discharge reports from 6 Barcelona hospitals (Hospital General Vall d'Hebron, Hospital Clínic de Barcelona, Institut Municipal d'Assistència Sanitària [IMAS] hospitals, Hospital Germans Trias i Pujol and Hospital Sant Joan de Déu). We assessed their readability together with the information included for the development of an ED Uniform Discharge Data Set (CMBDAU).

RESULTS

11,188 ED discharge reports were analyzed. Overall, 39% reports were found to have enough and readable information. However, the interpretation of the written information was deemed to be fairly difficult in 46% cases and very difficult in the remaining 15% reports.

CONCLUSIONS

Formal quality and comprehensiveness of the information included in ED discharge reports is a critical factor for the precision and usefulness of any registry of data and ED patients classification systems.

Experience of coding ambulatory visits to outpatient clinics

Clinical data for all current outpatients at a large tertiary hospital has been collected for analysis. Patient diagnoses for selected "key" clinics have been coded to ICD-9-CM standards. Methods to reduce the volume of coding required for such data collection are discussed, and include short-lists of codes, default assignment of diagnoses codes according to the nature of visit, and producing a "discharge" summary for outpatients, similar to that routinely produced for inpatients.