Effect of vital signs on triage decisions

Re-hospitalization factors and economic characteristics of urinary tract infected patients using machine learning

Objective

Urinary tract infection is one of the most prevalent bacterial infectious diseases in outpatient treatment, and 50-80% of women experience it more than once, with a recurrence rate of 40-50% within a year; consequently, preventing re-hospitalization of patients is critical. However, in the field of urology, no research on the analysis of the re-hospitalization status for urinary tract infections using machine learning algorithms has been reported to date. Therefore, this study uses various machine learning algorithms to analyze the clinical and nonclinical factors related to patients who were re-hospitalized within 30 days of urinary tract infection.

Methods

Data were collected from 497 patients re-hospitalized for urinary tract infections within 30 days and 496 patients who did not require re-hospitalization. The re-hospitalization factors were analyzed using four machine learning algorithms: gradient boosting classifier, random forest, naive Bayes, and logistic regression.

Results

The best-performing gradient boosting classifier identified respiratory rate, days of hospitalization, albumin, diastolic blood pressure, blood urea nitrogen, body mass index, systolic blood pressure, body temperature, total bilirubin, and pulse as the top-10 factors that affect re-hospitalization because of urinary tract infections. The 993 patients whose data were collected were divided into risk groups based on these factors, and the re-hospitalization rate, days of hospitalization, and medical expenses were observed to decrease from the high- to low-risk group.

Conclusions

This study showed new possibilities in analyzing the status of urinary tract infection-related re-hospitalization using machine learning. Identifying factors affecting re-hospitalization and incorporating preventable and reinforcement-based treatment programs can aid in reducing the re-hospitalization rate and average number of days of hospitalization, thereby reducing medical expenses.

Assessing Physiologic Reserve and Frailty in the Older Emergency Department Patient: Should the Paradigm Change?

Older patients are more vulnerable to acute illness or injury because of reduced physiologic reserve associated with aging. Therefore, their assessment in the emergency department (ED) should include not only vital signs and their baseline values but also changes that reflect physiologic reserve, such as mobility, mental status, and frailty. Combining aggregated vitals sign scores and frailty might improve risk stratification in the ED. Implementing these changes in ED assessment may require the introduction of senior-friendly processes to ensure ED treatment is appropriate to the older patients' immediate discomfort, personal goals, and likely prognosis.

Facilitators and barriers of appropriate and timely initiation of intravenous fluids in patients with sepsis in emergency departments: a consensus development Delphi study

BACKGROUND

Sepsis is a life-threatening medical emergency in which appropriate and timely administration of intravenous fluids to patients with features of hypotension is critical to prevent multi-organ failure and subsequent death. However, compliance with recommended fluid administration is reported to be poor. There is a lack of consensus among emergency clinicians on some of the determinant factors influencing fluid administration in sepsis. Thus, the aim of this study was to identify the level of consensus among key stakeholders in emergency departments regarding the facilitators, barriers, and strategies to improve fluid administration.

METHODS

The modified Delphi questionnaire with 23 statements exploring barriers, facilitators, and strategies to improve fluid administration was developed from the integration of findings from previous phases of the study involving emergency department clinicians. A two-round modified Delphi survey was conducted among key stakeholders with managerial, educational, supervision and leadership responsibilities using a "Reactive Delphi technique" from March 2023 to June 2023. The statements were rated for importance on a 9-point Likert scale. The RAND/UCLA Appropriateness Method (RAM) was used to identify the level of consensus (agreement/disagreement).

RESULTS

Of the 21 panellists who completed Round 1 survey, 18 (86%) also completed Round 2. The panellists rated 9 out of 10 (90%) barriers, 3 out of 4 (75%) facilitators and all 9 (100%) improvement strategies as important. Out of the total 23 statements, 18 (78%) had agreement among the panellists. Incomplete vital signs at triage (Median = 9, IQR 7.25 to 9.00) as a barrier, awareness of importance of fluid administration in sepsis (Median = 9, IQR 8.00 to 9.00) as facilitator and provision of nurse-initiated intravenous fluids (Median = 9, IQR 8.00 to 9.00) as an improvement strategy were the highest rated statements.

CONCLUSION

This is the first Delphi study identifying consensus on facilitators, barriers, and strategies to specifically improve intravenous fluid administration in sepsis in Australia. We identified 18 consensus-based factors associated with appropriate and timely administration of intravenous fluids in sepsis. This study offers empirical evidence to support the implementation of the identified strategies to improve patient outcomes.

Evaluation of emergency care education and triage implementation: an observational study at a hospital in rural Liberia

INTRODUCTION

In Liberia, emergency care is still in its early development. In 2019, two emergency care and triage education sessions were done at J. J. Dossen Hospital in Southeastern Liberia. The observational study objectives evaluated key process outcomes before and after the educational interventions.

METHODS

Emergency department paper records from 1 February 2019 to 31 December 2019 were retrospectively reviewed. Simple descriptive statistics were used to describe patient demographics and χ² analyses were used to test for significance. ORs were calculated for key predetermined process measures.

RESULTS

There were 8222 patient visits recorded that were included in our analysis. Patients in the post-intervention 1 group had higher odds of having a documented full set of vital signs compared with the baseline group (16% vs 3.5%, OR: 5.4 (95% CI: 4.3 to 6.7)). After triage implementation, patients who were triaged were 16 times more likely to have a full set of vitals compared with those who were not triaged. Similarly, compared with the baseline group, patients in the post-intervention 1 group had higher odds of having a glucose documented if they presented with altered mental status or a neurologic complaint (37% vs 30%, OR: 1.7 (95% CI: 1.3 to 2.2)), documented antibiotic administration if they had a presumed bacterial infection (87% vs 35%, OR: 12.8 (95% CI: 8.8 to 17.1)), documented malaria test if presenting with fever (76% vs 61%, OR: 2.05 (95% CI: 1.37 to 3.08)) or documented repeat set of vitals if presenting with shock (25% vs 6.6%, OR: 8.85 (95% CI: 1.67 to 14.06)). There was no significant difference in the above process outcomes between the education interventions.

CONCLUSION

This study showed improvement in most process measures between the baseline and post-intervention 1 groups, benefits that persisted post-intervention 2, thus supporting the importance of short-course education interventions to durably improve facility-based care.

Physical Activity and Diet in Older Women: A Narrative Review

Physical activity and diet are essential for maintaining good health and preventing the development of non-communicable diseases, especially in the older adults. One aspect that is often over-looked is the different response between men and women to exercise and nutrients. The body's response to exercise and to different nutrients as well as the choice of foods is different in the two sexes and is strongly influenced by the different hormonal ages in women. The present narrative review analyzes the effects of gender on nutrition and physical activity in older women. Understanding which components of diet and physical activity affect the health status of older women would help target non-pharmacological but lifestyle-related therapeutic interventions. It is interesting to note that this analysis shows a lack of studies dedicated to older women and a lack of studies dedicated to the interactions between diet and physical activity in women. Gender medicine is a current need that still finds little evidence.

Validation of a five-level triage system in pediatric trauma and the effectiveness of triage nurse modification: A multi-center cohort analysis

INTRODUCTION

Triage is one of the most important tasks for nurses in a modern emergency department (ED) and it plays a critical role in pediatric trauma. An appropriate triage system can improve patient outcomes and decrease resource wasting. However, triage systems for pediatric trauma have not been validated worldwide. To ensure clinical reliability, nurses are allowed to override the acuity level at the end of the routine triage process. This study aimed to validate the Taiwan Triage and Acuity Scale (TTAS) for pediatric trauma and evaluate the effectiveness of triage nurse modification.

METHODS

This was a multicenter retrospective cohort study analyzing triage data of all pediatric trauma patients who visited six EDs across Taiwan from 2015 to 2019. Each patient was triaged by a well-trained nurse and assigned an acuity level. Triage nurses can modify their acuity based on their professional judgment. The primary outcome was the predictive performance of TTAS for pediatric trauma, including hospitalization, ED length of stay, emergency surgery, and costs. The secondary outcome was the accuracy of nurse modification and the contributing factors. Multivariate regression was used for data analysis. The Akaike information criterion and C-statistics were utilized to measure the prediction performance of TTAS.

RESULTS

In total, 45,364 pediatric patients were included in this study. Overall mortality, hospitalization, and emergency surgery rates were 0.17, 5.4, and 0.76%, respectively. In almost all cases (97.48%), the triage nurses agreed upon the original scale. All major outcomes showed a significant positive correlation with the upgrade of acuity levels in TTAS in pediatric trauma patients. After nurse modification, the Akaike information criterion decreased and C-statistics increased, indicating better prediction performance. The factors contributing to this modification were being under 6 years of age, heart rate, respiratory rate, and primary location of injuries.

CONCLUSION

The TTAS is a reliable triage tool for pediatric trauma patients. Modification by well-experienced triage nurses can enhance its prediction performance. Younger age, heart rate, respiratory rate, and primary location of injuries contributed to modifications of the triage nurse. Further external validation is required to determine its role in pediatric trauma worldwide.

Emergency department condition acuity, length of stay, and revisits among deaf and hard-of-hearing patients: A retrospective chart review

OBJECTIVE

Deaf and hard-of-hearing (DHH) patients are understudied in emergency medicine health services research. Theory and limited evidence suggest that DHH patients are at higher risk of emergency department (ED) utilization and poorer quality of care. This study assessed ED condition acuity, length of stay (LOS), and acute ED revisits among DHH patients. We hypothesized that DHH patients would experience poorer ED care outcomes.

METHODS

We conducted a retrospective chart review of a single health care system using data from a large academic medical center in the southeast United States. Data were received from the medical center's data office, and we sampled patients and encounters from between June 2011 and April 2020. We compared DHH American Sign Language (ASL) users (n = 108), DHH English speakers (n = 358), and non-DHH English speakers (n = 302). We used multilevel modeling to assess the differences among patient segments in outcomes related to ED use and care.

RESULTS

As hypothesized, DHH ASL users had longer ED LOS than non-DHH English speakers, on average 30 min longer. Differences in ED condition acuity, measured through Emergency Severity Index and triage pain scale, were not statistically significant. DHH English speakers represented a majority (61%) of acute ED revisit encounters.

CONCLUSIONS

Our study identified that DHH ASL users have longer ED LOS than non-DHH English speakers. Additional research is needed to further explain the association between DHH status and ED care outcomes (including ED LOS and acute revisit), which may be used to identify intervention targets to improve health equity.

Measuring sustainable practice change of the sepsis guideline in one emergency department: A retrospective health care record audit

AIMS AND OBJECTIVES

To explore the longitudinal impact of the New South Wales Sepsis guideline on time to antibiotics, triage assessment and emergency management before and four years after guideline implementation.

BACKGROUND

Globally, sepsis continues to be a significant cause of mortality and morbidity within hospitals. To reduce avoidable adverse patient outcomes the corner stone has been to improve the early recognition and management of sepsis. The New South Wales government in Australia introduced sepsis guidelines into Emergency Departments. However, the longitudinal impact of the sepsis guideline, has never been conducted.

METHODS

A 12-month retrospective randomised health care record audit of adult patients with a sepsis diagnosis was conducted 12-months before and four years after implementation of the sepsis guideline.

RESULTS

This study demonstrated sustained improvement in allocation of urgent triage categories in the follow-up group (n = 43; 53.1%) and a reduction in the median time to antibiotics from 189 min to 102 min (p ≤ 0.001) after the implementation of the sepsis guideline.

CONCLUSION

The study has demonstrated the sepsis guideline has improved a sustained change in early assessment, recognition and management of patients presenting with sepsis in one tertiary referral Emergency Department.

Comparative Analysis Of Triage Systems At Emergency Departments Of Different Countries: Implementation In Kazakhstan

Medical sorting is aimed at assessment of disease severity and has to be carried out within a short time to determine the priorities for patient care and transportation to the most appropriate place for future treatment. The goal of this study was to provide an integrative review by analyzing the publications on the most common triage systems worldwide in order to select and implement the most reliable system at emergency departments. We searched for publications relevant to our comparative analysis in evidence-based medicine databases. A total of 1,740 literary sources were identified, of which 42 were selected for analysis. Comparative analysis of different triage systems may help implementing the most efficient system in Kazakhstan. The Emergency Severity Index is considered the most reliable and accurate tool used in international practice, and it could provide a basis for introduction of triage system at emergency departments in Kazakhstan.

Validation of Songklanagarind Pediatric Triage Model in the Emergency Department; a Cross-Sectional Study

Introduction:

An effective triage needs to consider many factors, such as good triage protocol, experienced triage nurses, and patient factors. This study aimed to evaluate the validity of Songklanagarind Pediatric Triage (SPT) for triage of pediatric patients in the emergency department (ED) and identify the factors associated with triage appropriateness.

Methods:

This study was done in two phases. In the first phase, a team of emergency physicians, a pediatric emergency physician, and a pediatric critical care physician developed SPT model by considering and combining Emergency Severity Index (ESI), Pediatric Assessment Triangle (PAT), Pediatric Canadian Triage and Acuity Scale (PaedCTAS), and Pediatric Septic Shock early warning signs protocol of the hospital as the core concept. In the second phase, a prospective observational study was conducted in the ED of Songklanagarind Hospital, which is a tertiary university hospital in southern Thailand, from September to October 2019 to evaluate the accuracy of the developed triage model.

Results:

A total of 520 pediatric patients met the inclusion criteria. The pediatric triage model had sensitivity and specificity values of 98.28% and 26.24%, respectively, and positive and negative predictive values of 27.67% and 98.15%, respectively, in prediction of death, hospitalization, and resource utilization. The rates of appropriate triage, over-triage, and under-triage were 68.8%, 28.5%, and 2.7%, respectively. Significant factors associated with appropriateness of triage were underlying disease of the respiratory system (OR = 4.16, 95%CI: 1.75‒9.23), fever (OR = 0.60, 95%CI: 0.41‒0.88), dyspnea (OR: 6.38, 95%CI: 2.51‒16.22), diarrhea (OR = 0.26, 95%CI: 0.09‒0.73), oxygen saturation <95% (OR = 3.18, 95%CI: 1.09‒9.27), accessory muscle use during breathing (OR = 3.67, 95%CI: 1.09‒12.41), and wheezing or rhonchi (OR = 6.96, 95%CI: 3.14‒15.43).

Conclusion:

SPT showed good correlation of hospital admission rates and resource utilization with pediatric triage level of urgency. However, further efforts are needed to decrease the rates of over- and under-triage.

Blood glucose levels should be considered as a new vital sign indicative of prognosis during hospitalization

BACKGROUND AND AIMS

The measurement of vital signs is an important part of clinical work up. Presently, measurement of blood glucose is a factor for concern mostly when treating individuals with diabetes. Significance of blood glucose measurement in prognosis of non-diabetic and hospitalized patients is not clear.

METHODS

A systematic search of literature published in the Electronic databases, PubMed and Google Scholar was performed using following keywords; blood glucose, hospital admissions, critical illness, hospitalizations, cardiovascular disease (CVD), morbidity, and mortality. This literature search was largely restricted to non-diabetic individuals.

RESULTS

Blood glucose level, even when in high normal range, or in slightly high range, is an important determinant of morbidity and mortality, especially in hospitalized patients. Further, even slight elevation of blood glucose may increase mortality in patients with COVID-19. Finally, blood glucose variability and hypoglycemia in critically ill individuals without diabetes causes excess in-hospital complications and mortality.

CONCLUSION

In view of these data, we emphasize the significance of blood glucose measurement in all patients admitted to the hospital regardless of presence of diabetes. We propose that blood glucose be included as the "fifth vital sign" for any hospitalized patient.

The impact of emergency department triage on the treatment outcomes of cancer patients with febrile neutropenia: A retrospective review

INTRODUCTION

The emergency department (ED) is an important entry point for patients with cancer requiring acute care due to oncological emergencies. Febrile neutropenia (FN) is one of the most common oncological emergencies and carries a significant risk of morbidity and mortality. There is evidence from previous studies that FN patients wait far longer in the ED than recommended by international guidelines.

PURPOSE

The aim was to examine whether individuals with cancer presenting at the ED with FN were triaged appropriately, and to explore if, and how, triage affected their treatment outcomes.

METHODS

A retrospective cohort design was employed to collect data over five years from all available ED records of adult cancer patients who presented with fever.

RESULTS

Of the 431 eligible patients, 63% (n = 272) were assigned triage scores that were detrimental to their immediate health. Findings from the multiple linear regression analyses showed that inaccurate or under triage was significantly associated with delayed times for the initial physician assessment, administration of antibiotics, and decision on admission. The absence of fever at the time of triage assessment contributed significantly to the prediction of under triage.

CONCLUSION

The allocation of patients with FN to a lower, inaccurate priority was partly responsible for the inability of those patients to meet the standard benchmarks for the initial physician assessment and the administration of antibiotics identified by the triage and febrile neutropenia guidelines. Ongoing strategies are needed to both enhance the application of the triage guidelines and institute organizational and system changes that promote timeliness and effectiveness throughout the entire ED episode of care.

Fever Incidence Is Much Lower in the Morning than the Evening: Boston and US National Triage Data

INTRODUCTION

In this observational study, we evaluated time-of-day variation in the incidence of fever that is seen at triage. The observed incidence of fever could change greatly over the day because body temperatures generally rise and fall in a daily cycle, yet fever is identified using a temperature threshold that is unchanging, such as ≥38.0° Celsius (C) (≥100.4° Fahrenheit [F]).

METHODS

We analyzed 93,225 triage temperature measurements from a Boston emergency department (ED) (2009-2012) and 264,617 triage temperature measurements from the National Hospital Ambulatory Medical Care Survey (NHAMCS, 2002-2010), making this the largest study of body temperature since the mid-1800s. Boston data were investigated exploratorily, while NHAMCS was used to corroborate Boston findings and check whether they generalized. NHAMCS results are nationally representative of United States EDs. Analyses focused on adults.

RESULTS

In the Boston ED, the proportion of patients with triage temperatures in the fever range (≥38.0°C, ≥100.4°F) increased 2.5-fold from morning to evening (7:00-8:59 PM vs 7:00-8:59 AM: risk ratio [RR] 2.5, 95% confidence interval [CI], 2.0-3.3). Similar time-of-day changes were observed when investigating alternative definitions of fever: temperatures ≥39.0°C (≥102.2°F) and ≥40.0°C (≥104.0°F) increased 2.4- and 3.6-fold from morning to evening (7:00-8:59 PM vs 7:00-8:59 AM: RRs [95% CIs] 2.4 [1.5-4.3] and 3.6 [1.5-17.7], respectively). Analyses of adult NHAMCS patients provided confirmation, showing mostly similar increases for the same fever definitions and times of day (RRs [95% CIs] 1.8 [1.6-2.1], 1.9 [1.4-2.5], and 2.8 [0.8-9.3], respectively), including after adjusting for 12 potential confounders using multivariable regression (adjusted RRs [95% CIs] 1.8 [1.5-2.1], 1.8 [1.3-2.4], and 2.7 [0.8-9.2], respectively), in age-group analyses (18-64 vs 65+ years), and in several sensitivity analyses. The patterns observed for fever mirror the circadian rhythm of body temperature, which reaches its highest and lowest points at similar times.

CONCLUSION

Fever incidence is lower at morning triages than at evening triages. High fevers are especially rare at morning triage and may warrant special consideration for this reason. Studies should examine whether fever-causing diseases are missed or underappreciated during mornings, especially for sepsis cases and during screenings for infectious disease outbreaks. The daily cycling of fever incidence may result from the circadian rhythm.

Vital Signs Data and Probability of Hospitalization, Transfer to Another Facility, or Emergency Department Death Among Adults Presenting for Medical Illnesses to the Emergency Department at a Large Urban Hospital in the United States

BACKGROUND

Vital signs are routinely measured from patients presenting to the emergency department (ED), but how they predict clinical outcomes like hospitalization is unclear.

OBJECTIVES

To evaluate how pulse, respiratory rate, temperature, and mean arterial pressure (MAP) at ED presentation predicted probability of hospitalization, transfer to another center, or death in the ED (as a composite outcome) vs. other ED dispositions (discharged, eloped, and sent to observation or labor and delivery), and to assess the performance of different modeling strategies, specifically, models including flexible forms of vital signs (as restricted cubic splines) vs. linear forms (untransformed numeric variables) vs. binary transformations (vital signs values categorized simply as normal or abnormal).

METHODS

We analyzed the data of 12,660 adults presenting for medical illnesses to the ED at the University of California, San Francisco Medical Center, San Francisco, California, throughout 2014. We used flexible forms of vital signs data at presentation (pulse, temperature, respiratory rate, and MAP) to predict ED disposition (admitted, transferred, or died, vs. other ED dispositions) and to guide binary transformation of vital signs. We compared performance of models including vital signs as flexible terms, binary transformations, or linear terms.

RESULTS

A model including flexible forms of vital signs and age to predict the outcome had good calibration and moderate discrimination (C-statistic = 71.2, 95% confidence interval [CI] 70.0-72.4). Binary transformation of vital signs had minimal impact on performance (C-statistic = 71.3, 95% CI 70.2-72.5). A model with linear forms was less calibrated and had slightly reduced discrimination (C-statistic = 70.3, 95% CI 69.1-71.5).

CONCLUSIONS

Findings suggest that flexible modeling of vital signs may better reflect their association with clinical outcomes. Future studies to evaluate how vital signs could assist clinical decision-making in acute care settings are suggested.

Use of Shock Index to Identify Mild Hemorrhage: An Observational Study in Military Blood Donors

Introduction:

Hemorrhage is the leading cause of preventable death in combat, although early recognition of hemorrhage is still challenging on the battlefield.

Hypothesis/Problem:

The objective of this study was to describe the shock index (SI) in a healthy military population, and to measure its variation during a controlled blood loss, simulated by blood donation.

Methods:

A prospective observational study that enrolled military subjects, volunteers for blood donation, was conducted. Demographic and clinical information, concerning both the patient and the blood collection, were recorded. Baseline vital signs were measured, before and after donation, in a 45° supine position. Statistical analysis was performed after calculation of SI.

Results:

A total of 483 participants were included in the study. The mean blood donation volume was 473mL (SD = 44mL). The median pre- and post-blood donation SI were significantly different: 0.54 (IQR = 0.48-0.63) and 0.57 (IQR = 0.49-0.66), respectively (P = .002). Changes in pre-/post-donation blood pressure (BP) and heart rate (HR) also reached statistical difference but represented a clinically poor relevance. The multivariate analysis showed no significant associations between SI variations and age, sex, body mass index (BMI), sport activities, blood donation volume, and enteral volume replacement (EVR).

Conclusion:

In this model of mild hemorrhage, SI exhibited significant variations but failed to reach clinical relevance. Further studies are needed to prove the benefit of SI calculation as a possible parameter for early recognition of hemorrhage in combat casualties at the point of injury.

Pasquier P, Duron S, Pouget T, Carbonnel AC, Boutonnet M, Malgras B, Barbier O, de Saint Maurice G, Sailliol A, Ausset S, Martinaud C. Use of shock index to identify mild hemorrhage: an observational study in military blood donors. Prehosp Disaster Med. 2019;34(3):303–307.

Exploring the sorting of patients in community health centres across Gauteng Province, South Africa

BACKGROUND

Primary health care worldwide faces large numbers of patients daily. Poor waiting times, low patient satisfaction and staff burnout are some problems facing such facilities. Limited research has been done on sorting patients in non-emergency settings in Africa. This research looked at community health centres (CHCs) in Gauteng Province, South Africa where queues appear to be poorly managed and patients waiting for hours. This study explores the views of clinicians in CHCs across Gauteng on sorting systems in the non-emergency ambulatory setting.

METHODS

The qualitative study design used one-to-one, in-depth interviews of purposively selected doctors. Interviews were conducted in English, with open-ended exploratory questions. Interviews were recorded, transcribed, anonymised and checked by interviewees later. Data collection and analysis stopped with information saturation. The co-author supervised and cross-checked the process. A thematic framework was developed by both authors, before final thematic coding of all transcripts was undertaken by the principal author. This analysis was based on the thematic framework approach.

RESULTS

Twelve primary health care (PHC) doctors with experience in patient sorting, from health districts across Gauteng, were interviewed. Two themes were identified, two major themes, namely Systems Implemented and Innovative Suggestions, and Factors Affecting Triage. Systems Implemented included those using vital signs, sorting by specialties, and using the Integrated Management of Childhood Illnesses approach. Systems Implemented also included doctor - nurse triage, first come first serve, eyeball triage and sorting based on main complaint. Innovative Suggestions, such as triage room treatment and investigations, telephone triage, longer clinic hours and a booking system emerged. There were three Factors Affecting Triage: Management Factor, including general management issues, equipment, documentation, infrastructure, protocol, and uniformity; and Staff Factor, including general staffing issues education and teamwork; and Patient Factor.

CONCLUSION

Developing a functional triage protocol with innovative systems for Gauteng is important. Findings from this study can guide the development of a functional triage system in the primary health care non-emergency outpatient setting of Gauteng's CHCs. The Emergency Triage, Assessment and Treatment (ETAT) tool, modified for adult and non-clinician use, could help this. However, addressing management, staff and patient factors must be integral.

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.

Exploring the Predictors of Emergency Department Triage Acuity Assignment in Patients With Sepsis

Background and purpose

Evidence suggests that septic patients, who require prompt medical attention, may be undertriaged, resulting in delayed treatment. The purpose of this study was to examine patient and contextual variables that contribute to high- versus low-acuity triage classification of patients with sepsis.

Methods

Data were abstracted from the medical records of 154 adult patients with sepsis admitted to hospital through a Canadian Emergency Department. Logistic regression was used to explore the predictors of triage classification.

Results

Language barriers or chronic cognitive impairment (odds ratio 5.7; 95% confidence interval 2.15, 15.01), acute confusion (odds ratio 3.4; confidence interval 1.3, 8.2), unwell appearance (odds ratio 3.4; 95% confidence interval 1.7, 7.0), and hypotension (odds ratio 0.98; confidence interval 0.96, 1.0) were predictive of higher acuity classification. Temperature, heart rate, respiratory rate, and contextual factors were not related to triage classification.

Conclusions

Several patient-related factors were related to triage classification. However, the finding that temperature and heart and respiratory rates were not related to triage classification was troubling. Our findings point to a need for enhanced education for triage nurses regarding the physiological indices of sepsis. The sensitivity of the Canadian Triage Assessment Scale, used in Canadian Emergency Rooms, also needs to be examined.

Evaluation of the feasibility and performance of early warning scores to identify patients at risk of adverse outcomes in a low-middle income country setting

OBJECTIVE

This study describes the availability of core parameters for Early Warning Scores (EWS), evaluates the ability of selected EWS to identify patients at risk of death or other adverse outcome and describes the burden of triggering that front-line staff would experience if implemented.

DESIGN

Longitudinal observational cohort study.

SETTING

District General Hospital Monaragala.

PARTICIPANTS

All adult (age >17 years) admitted patients.

MAIN OUTCOME MEASURES

Existing physiological parameters, adverse outcomes and survival status at hospital discharge were extracted daily from existing paper records for all patients over an 8-month period.

STATISTICAL ANALYSIS

Discrimination for selected aggregate weighted track and trigger systems (AWTTS) was assessed by the area under the receiver operating characteristic (AUROC) curve.Performance of EWS are further evaluated at time points during admission and across diagnostic groups. The burden of trigger to correctly identify patients who died was evaluated using positive predictive value (PPV).

RESULTS

Of the 16 386 patients included, 502 (3.06%) had one or more adverse outcomes (cardiac arrests, unplanned intensive care unit admissions and transfers). Availability of physiological parameters on admission ranged from 90.97% (95% CI 90.52% to 91.40%) for heart rate to 23.94% (95% CI 23.29% to 24.60%) for oxygen saturation. Ability to discriminate death on admission was less than 0.81 (AUROC) for all selected EWS. Performance of the best performing of the EWS varied depending on admission diagnosis, and was diminished at 24 hours prior to event. PPV was low (10.44%).

CONCLUSION

There is limited observation reporting in this setting. Indiscriminate application of EWS to all patients admitted to wards in this setting may result in an unnecessary burden of monitoring and may detract from clinician care of sicker patients. Physiological parameters in combination with diagnosis may have a place when applied on admission to help identify patients for whom increased vital sign monitoring may not be beneficial. Further research is required to understand the priorities and cues that influence monitoring of ward patients.

TRIAL REGISTRATION NUMBER

NCT02523456.

Make vital signs great again - A call for action

Vital signs are the simplest, cheapest and probably the most important information gathered on patients in hospital. In this narrative review we present a large amount of evidence that vital signs are currently little valued, not regularly or accurately recorded, and frequently not acted on appropriately. It is probable that few hospitals would keep their accreditation with regulatory bodies if they collected and acted on their laboratory results in the same way that they collect and act on vital signs. Professional societies and regulatory bodies need to address this issue: if vital signs were more accurately and frequently measured, and acted on promptly and appropriately hospital care would be safer, better and cheaper.

Derivation and validation of a universal vital assessment (UVA) score: a tool for predicting mortality in adult hospitalised patients in sub-Saharan Africa

Background

Critical illness is a leading cause of morbidity and mortality in sub-Saharan Africa (SSA). Identifying patients with the highest risk of death could help with resource allocation and clinical decision making. Accordingly, we derived and validated a universal vital assessment (UVA) score for use in SSA.

Methods

We pooled data from hospital-based cohort studies conducted in six countries in SSA spanning the years 2009–2015. We derived and internally validated a UVA score using decision trees and linear regression and compared its performance with the modified early warning score (MEWS) and the quick sepsis-related organ failure assessment (qSOFA) score.

Results

Of 5573 patients included in the analysis, 2829 (50.8%) were female, the median (IQR) age was 36 (27–49) years, 2122 (38.1%) were HIV-infected and 996 (17.3%) died in-hospital. The UVA score included points for temperature, heart and respiratory rates, systolic blood pressure, oxygen saturation, Glasgow Coma Scale score and HIV serostatus, and had an area under the receiver operating characteristic curve (AUC) of 0.77 (95% CI 0.75 to 0.79), which outperformed MEWS (AUC 0.70 (95% CI 0.67 to 0.71)) and qSOFA (AUC 0.69 (95% CI 0.67 to 0.72)).

Conclusion

We identified predictors of in-hospital mortality irrespective of the underlying condition(s) in a large population of hospitalised patients in SSA and derived and internally validated a UVA score to assist clinicians in risk-stratifying patients for in-hospital mortality. The UVA score could help improve patient triage in resource-limited environments and serve as a standard for mortality risk in future studies.

Is Tachycardia at Discharge From the Pediatric Emergency Department a Cause for Concern? A Nonconcurrent Cohort Study

STUDY OBJECTIVE

We evaluate the association between discharge tachycardia and (1) emergency department (ED) and urgent care revisit and (2) receipt of clinically important intervention at the revisit.

METHODS

The study included a nonconcurrent cohort of children aged 0 to younger than 19 years, discharged from 2 pediatric EDs and 4 pediatric urgent care centers in 2013. The primary exposure was discharge tachycardia (last recorded pulse rate ≥99th percentile for age). The main outcome was ED or urgent care revisit within 72 hours of discharge. Additional outcomes included interventions received and disposition at the revisit, prevalence of discharge tachycardia at the index visit, and associations of pain, fever, and medications with discharge tachycardia. Multivariable logistic regression determined relative risk ratios for revisit and receipt of clinically important intervention at the revisit.

RESULTS

Of eligible visits, 126,774 were included, of which 10,470 patients (8.3%) had discharge tachycardia. Discharge tachycardia was associated with an increased risk of revisit (adjusted RR 1.3; 95% confidence interval 1.2 to 1.5), increased risk of tachycardia at the revisit (relative risk 3.1; 95% confidence interval 2.6 to 3.7), and of the receipt of certain clinically important interventions (supplemental oxygen, respiratory medications and admission, antibiotics and admission, and peripheral intravenous line placement and admission). However, there was no increased risk for the composite outcome of receipt of any clinically important intervention or admission on revisit.

CONCLUSION

Discharge tachycardia is associated with an increased risk of revisit. It is likely that tachycardia at discharge is not a critical factor associated with impending physiologic deterioration.

Inter-rater reliability between nurses for a new paediatric triage system based primarily on vital parameters: the Paediatric Triage Instrument (PETI)

INTRODUCTION

The major paediatric triage systems are primarily based on flow charts involving signs and symptoms for orientation and subjective estimates of the patient's condition. In contrast, the 4-level Paediatric Triage Instrument (PETI) is primarily based on vital parameters and was developed exclusively for paediatric triage in patients with medical symptoms. The aim of this study was to assess the inter-rater reliability of this triage system in children when used by nurses.

METHODS

A design was employed in which triage was performed simultaneously and independently by a research nurse and an emergency department (ED) nurse using the PETI. All patients aged ≤12 years who presented at the ED with a medical symptom were considered eligible for participation.

RESULTS

The 89 participants exhibited a median age of 2 years and were triaged by 28 different nurses. The inter-rater reliability between nurses calculated with the quadratic-weighted κ was 0.78 (95% CI 0.67 to 0.89); the linear-weighted κ was 0.67 (95% CI 0.56 to 0.80) and the unweighted κ was 0.59 (95% CI 0.44 to 0.73). For the patients aged <1, 1-3 and >3 years, the quadratic-weighted κ values were 0.67 (95% CI 0.39 to 0.94), 0.86 (95% CI 0.75 to 0.97) and 0.73 (95% CI 0.49 to 0.97), respectively. The median triage duration was 6 min.

CONCLUSIONS

The PETI exhibited substantial reliability when used in children aged ≤12 years and almost perfect reliability among children aged 1-3 years. Moreover, rapid application of the PETI was demonstrated. This study has some limitations, including sample size and generalisability, but the PETI exhibited promise regarding reliability, and the next step could be either a larger reliability study or a validation study.

Revision for the Rapid Emergency Triage and Treatment System Adult (RETTS-A) needed?

The study highlights the prognostic role of patient's vital signs at presentation to the emergency department (ED): The predictive role of vital signs in ED triage has been controversially discussed probably due to a paucity of data on the value of vital signs in ED at presentation. However, the authors did not find a suitable way to adjust for the inherent influence of triage decision and medical treatment on mortality. We have discussed that ambiguity concerning the assessment of vital signs criteria in RETTS-A Red priority may threaten any association between patient acuity and fatal outcome.

Using the Five-Level Taiwan Triage and Acuity Scale Computerized System: Factors in Decision Making by Emergency Department Triage Nurses

Triage classifies and prioritizes patients' care based on the acuity of the illness in emergency departments (EDs). In Taiwan, the five-level Taiwan Triage and Acuity Scale (TTAS) computerized system was implemented nationally in 2010. The purpose of this study was to understand which factors affect decision-making practices of triage nurses in the light of the implementation of the new TTAS tool and computerized system. The qualitative data were collected by in-depth interviews. Data saturation was reached with 16 participants. Content analysis was used. The results demonstrated that the factors affecting nurses' decision making in the light of the newly implemented computerized system sit within three main categories: external environmental, patients' health status, and nurses' experiences. This study suggests ensuring the patient's privacy while attending the triage desk, improving the critical thinking of triage nurses, and strengthening the public's understanding of the ED visits. These will make ED triage more efficient.

How vital are the vital signs? A multi-center observational study from emergency departments of Pakistan

BACKGROUND

Vital signs play a critical role in prioritizing patients in emergency departments (EDs), and are the foundation of most triage methods and disposition decisions. This study was conducted to determine the frequency of vital signs documentation anytime during emergency department treatment and to explore if abnormal vital signs were associated with the likelihood of admission for a set of common presenting complaints.

METHODS

Data were collected over a four-month period from the EDs of seven urban tertiary care hospitals in Pakistan. The variables included age, sex, hospital type (government run vs. private), presenting complaint, ED vital signs, and final disposition. Patients who were >12 years of age were included in the analysis. The data were analyzed to describe the proportion of patients with documented vitals signs, which was then crossed-tabulated with top the ten presenting complaints to identify high-acuity patients and correlation with their admission status.

RESULTS

A total of 274,436 patients were captured in the Pakistan National Emergency Department Surveillance (Pak-NEDS), out of which 259,288 patients were included in our study. Vital signs information was available for 90,569 (34.9%) patients and the most commonly recorded vitals sign was pulse (25.7%). Important information such as level of consciousness was missing in the majority of patients with head injuries. Based on available information, only 13.3% with chest pain, 12.8% with fever and 12.8% patients with diarrhea could be classified as high-acuity. In addition, hospital admission rates were two- to four-times higher among patients with abnormal vital signs, compared with those with normal vital signs.

CONCLUSION

Most patients seen in the EDs in Pakistan did not have any documented vital signs during their visit. Where available, the presence of abnormal vital signs were associated with higher chances of admission to the hospital for the most common presenting symptoms.

High reliability in respiratory rate assessment in children with respiratory symptomatology in a rural area in Mozambique

Early recognition of severe medical conditions is often based on clinical scores and vital sign measurements such as the respiratory rate (RR) count. We designed this study to determine the reliability of RR assessment counted three times during a full minute by independent observers in children in a developing country setting. A total of 55 participants were enrolled in the study. Participant ages ranged from 10 days to 7 years (median 22 months). Agreement for RR count was high (intraclass correlation coefficient of 0.95; 95% confidence interval: 0.93-0.97). Agreement for presence of tachypnea was also high (Kappa coefficient of 0.83, p < 0.001). However, a single reading would have misclassified 5-11% of the participants as non-tachypneic. Repeated RR counts offer reliable results if done during a full minute. Patients not fulfilling tachypnea criterion but with a high RR count should have the measurement repeated.

Improving the Manchester Triage System for pediatric emergency care: an international multicenter study

Objectives

This multicenter study examines the performance of the Manchester Triage System (MTS) after changing discriminators, and with the addition use of abnormal vital sign in patients presenting to pediatric emergency departments (EDs).

Design

International multicenter study

Settings

EDs of two hospitals in The Netherlands (2006–2009), one in Portugal (November–December 2010), and one in UK (June–November 2010).

Patients

Children (<16years) triaged with the MTS who presented at the ED.

Methods

Changes to discriminators (MTS 1) and the value of including abnormal vital signs (MTS 2) were studied to test if this would decrease the number of incorrect assignment. Admission to hospital using the new MTS was compared with those in the original MTS. Likelihood ratios, diagnostic odds ratios (DORs), and c-statistics were calculated as measures for performance and compared with the original MTS. To calculate likelihood ratios and DORs, the MTS had to be dichotomized in low urgent and high urgent.

Results

60,375 patients were included, of whom 13% were admitted. When MTS 1 was used, admission to hospital increased from 25% to 29% for MTS ‘very urgent’ patients and remained similar in lower MTS urgency levels. The diagnostic odds ratio improved from 4.8 (95%CI 4.5–5.1) to 6.2 (95%CI 5.9–6.6) and the c-statistic remained 0.74. MTS 2 did not improve the performance of the MTS.

Conclusions

MTS 1 performed slightly better than the original MTS. The use of vital signs (MTS 2) did not improve the MTS performance.

Validating emergency department vital signs using a data quality engine for data warehouse

Background :

Vital signs in our emergency department information system were entered into free-text fields for heart rate, respiratory rate, blood pressure, temperature and oxygen saturation.

Objective :

We sought to convert these text entries into a more useful form, for research and QA purposes, upon entry into a data warehouse.

Methods :

We derived a series of rules and assigned quality scores to the transformed values, conforming to physiologic parameters for vital signs across the age range and spectrum of illness seen in the emergency department.

Results :

Validating these entries revealed that 98% of free-text data had perfect quality scores, conforming to established vital sign parameters. Average vital signs varied as expected by age. Degradations in quality scores were most commonly attributed logging temperature in Fahrenheit instead of Celsius; vital signs with this error could still be transformed for use. Errors occurred more frequently during periods of high triage, though error rates did not correlate with triage volume.

Conclusions :

In developing a method for importing free-text vital sign data from our emergency department information system, we now have a data warehouse with a broad array of quality-checked vital signs, permitting analysis and correlation with demographics and outcomes.

Predictive value of initial triage vital signs for critically ill older adults

INTRODUCTION

Triage of patients is critical to patient safety, yet no clear information exists as to the utility of initial vital signs in identifying critically ill older emergency department (ED) patients. The objective of this study is to evaluate a set of initial vital sign thresholds as predictors of severe illness and injury among older adults presenting to the ED.

METHODS

We reviewed all visits by patients aged 75 and older seen during 2007 at an academic ED serving a large community of older adults. Patients' charts were abstracted for demographic and clinical information including vital signs, via automated electronic methods. We used bivariate analysis to investigate the relationship between vital sign abnormalities and severe illness or injury, defined as intensive care unit (ICU) admission or ED death. In addition, we calculated likelihood ratios for normal and abnormal vital signs in predicting severe illness or injury.

RESULTS

4,873 visits by patients aged 75 and above were made to the ED during 2007, and of these 3,848 had a complete set of triage vital signs. For these elderly patients, the sensitivity and specificity of an abnormal vital sign taken at triage for predicting death or admission to an ICU were 73% (66,81) and 50% (48,52) respectively (positive likelihood ratio 1.47 (1.30,1.60); negative likelihood ratio 0.54 (0.30,0.60).

CONCLUSION

Emergency provider assessment and triage scores that rely primarily on initial vital signs are likely to miss a substantial portion of critically ill older adults.

High rate of missing vital signs data at triage in a paediatric emergency department

BACKGROUND

Vital signs measurement is considered standard practice in paediatric emergency department triage assessment, but studies have shown variable incidence of missing data.

OBJECTIVES

To evaluate the rate of missing data for vital signs at triage and to determine clinical and environmental predictive factors.

METHODS

A retrospective cohort design was used to study a database of consecutive patients registered at a tertiary paediatric emergency department during randomly chosen shifts. Demographic and clinical data were collected. Univariate and multivariate logistic regression analyses were performed to evaluate the determinants of missing data for body temperature, heart rate, respiratory rate, blood pressure and pulse oximetry.

RESULTS

There were 2081 patients triaged during the study periods. On multivariate logistic regression analysis, triage level (from 1 = priority to 4 = nonurgent) was an independent predictor of missing data for heart rate, respiratory rate, blood pressure and pulse oximetry (OR 1.48 to 2.05). Patients visiting the emergency department during the day shift (OR 1.08 to 4.72) and the evening shift (OR 1.38 to 9.24) had a higher rate of missing data than those visiting during the night shift. A decreased level of consciousness, an immunocompromised state and referral by a physician did not meet statistical significance as predictive factors.

CONCLUSIONS

There was a high rate of missing data for vital signs. Factors related to patients' clinical characteristics, such as acuity of triage level, were associated with a higher rate of vital signs documentation at triage. An environmental factor, shift of presentation, was also independently associated with a higher rate.

Effectiveness of a five-level Paediatric Triage System: an analysis of resource utilisation in the emergency department in Taiwan

Objectives

To examine the effectiveness of a five-level Paediatric Triage and Acuity System (Ped-TTAS) by comparing the reliability of patient prioritisation and resource utilisation with the four-level Paediatric Taiwan Triage System (Ped-TTS) among non-trauma paediatric patients in the emergency department (ED).

Methods

The study design used was a retrospective longitudinal analysis based on medical chart review and a computer database. Except for a shorter list of complaints and some abnormal vital sign criteria modifications, the structure and triage process for applying Ped-TTAS was similar to that of the Paediatric Canadian Emergency Triage and Acuity Scale. Non-trauma paediatric patients presenting to the ED were triaged by well-trained triage nurses using the four-level Ped-TTS in 2008 and five-level Ped-TTAS in 2010. Hospitalisation rates and medical resource utilisation were analysed by acuity levels between the contrasting study groups.

Results

There was a significant difference in patient prioritisation between the four-level Ped-TTS and five-level Ped-TTAS. Improved differentiation was observed with the five-level Ped-TTAS in predicting hospitalisation rates and medical costs.

Conclusions

The five-level Ped-TTAS is better able to discriminate paediatric patients by triage acuity in the ED and is also more precise in predicting resource utilisation. The introduction of a more accurate acuity and triage system for use in paediatric emergency care should provide greater patient safety and more timely utilisation of appropriate ED resources.

Revitalizing a vital sign: improving detection of tachypnea at primary triage

STUDY OBJECTIVE

This study evaluates the accuracy of emergency department (ED) triage respiratory rate measurement using the usual care method and a new electronic respiratory rate sensor (BioHarness, Zephyr Technology Corp.), both compared to a criterion standard measurement.

METHODS

This is a cross-sectional study with convenience sampling conducted in an urban academic adult ED, including 3 separate respiratory rate measurements performed at ED triage: usual care measurement, electronic BioHarness measurement, and criterion standard measurement. The criterion standard measurement used was defined by the World Health Organization as manual observation or auscultation of respirations for 60 seconds. The resultant usual care and BioHarness measurements were compared with the criterion standard, evaluating accuracy (sensitivity and specificity) for detecting tachypnea, as well as potential systematic biases of usual care and BioHarness measurements using a Bland Altman analysis.

RESULTS

Of 191 analyzed patients, 44 presented with tachypnea (>20 breaths/min). Relative to criterion standard measurement, usual care measurement had a sensitivity of 23% (95% confidence interval [CI] 12% to 37%) and specificity of 99% (95% CI 97% to 100%) for tachypnea, whereas BioHarness had a sensitivity of 91% (95% CI 80% to 97%) and specificity of 97% (95% CI 93% to 99%) for tachypnea. Usual care measurements clustered around respiratory rates of 16 and 18 breaths/min (n=144), with poor agreement with criterion standard measurement. Conversely, BioHarness measurement closely tracked criterion standard values over the range of respiratory rates.

CONCLUSION

Current methods of respiratory rate measurement at ED triage are inaccurate. A new electronic respiratory rate sensor, BioHarness, has significantly greater sensitivity for detecting tachypnea versus usual care method of measurement.

The importance of vital signs in the triage of injured patients

BACKGROUND

Vital signs are indicators of a patient presenting to an emergency department (ED). Abnormal vital signs have been associated with an increased likelihood of admission to the hospital. Physicians have long recognized the importance of vital sign observations, and vital sign measurement has proven to be useful for detecting serious diseases during triage in EDs.

METHODS

The study included all patients with injuries presented to the ED of a general hospital in Greece. For these patients, sex, age, cause of injury, vital signs at the time of admission to ED (systolic blood pressure, diastolic blood pressure, mean blood pressure, heart rate, and oxygen saturation), and the course of the patient (admission to hospital, discharge from ED) were recorded. The statistical analysis of data was done by the statistical package SPSS 15. It was performed using univariate regression and Spearman correlation coefficient.

RESULTS

A total of 2703 patients were registered, of which 71% were men aged 31.9 ± 0.38 years and 29% were women aged 45.7 ± 0.79 years. The main causes of injury were car accident, motor accident, pedestrian accident, fall from a height, and assault. By logistic regression, the correlation was found between mean blood pressure, systolic blood pressure, oxygen saturation, and hospitalization or discharge of the patients.

CONCLUSIONS

The measurement of mean blood pressure, systolic blood pressure, and oxygen saturation of the injured patients during the admission to the ED can predict the disease course of patients.

Improving vital sign documentation at triage: an emergency department quality improvement project

BACKGROUND

Improving the quality and safety of patients seen in an emergency department (ED) has become a priority in Italy. The Tuscan Regional Health Ministry has supported quality improvement projects in several Tuscan EDs in cooperation with Harvard Medical International and Harvard Medical School.

OBJECTIVE

To improve the triage process, we assessed the completeness of documenting the vital signs of patients seen at triage in the ED of the University Hospital Santa Chiara, Pisa, Italy. At the University Hospital of Pisa's ED, triage is based on 5 categories, each identified by a color: white (lowest priority), blue, green, yellow, and red (highest priority). For patients triaged as "yellow," blood pressure, heart rate, and oxygen saturation are considered mandatory vital signs and important components of a complete patient record. The aims of this project were as follows: 1) to assess the percentage of patients seen during ED triage in whom vital signs were recorded in the clinical record, 2) to analyze the reasons for missing vital sign data, and 3) to design and implement a strategy to improve the percentage of patients in whom vital signs were recorded.

METHODS

This project began in November 2005 with the identification of a multidisciplinary ED Quality Team. Faculty from Harvard Medical School provided a 2-day training course on the methods and tools of clinical quality improvement. After the training, the team defined their improvement project. The clinical quality improvement project followed a Plan-Do-Study-Act cycle. Preintervention and postintervention data collection consisted of a retrospective analysis of one-third of all patients triaged in the "yellow" category who were admitted to the ED during 1 month, randomly selected using a computer-generated list.

RESULTS

A total of 245 clinical records in the preintervention (March 2006) and 251 (April-May 2007) during the postintervention were included. We found that in 77.9% (191/245) of these records, vital signs were correctly recorded during the preintervention period. Patients with limb trauma and those with abdominal complaints represented the vast majority of patients in whom vital sign data were missing. The postintervention data revealed an improvement in the documentation of mandatory vital signs from 77.9% to 87.9%.

CONCLUSIONS

Creating a multidisciplinary team and implementing a formal quality improvement project improved vital sign documentation at triage for a group of patients seen during ED triage in 1 Italian hospital.

Importance of vital signs to the early diagnosis and severity of sepsis: association between vital signs and sequential organ failure assessment score in patients with sepsis

OBJECTIVE

While much attention is given to the fifth vital sign, the utility of the 4 classic vital signs (blood pressure, respiratory rate, body temperature, and heart rate) has been neglected. The aim of this study was to assess a possible association between vital signs and the Sequential Organ Failure Assessment (SOFA) score in patients with sepsis.

METHODS

We performed a prospective, observational study of 206 patients with sepsis. Blood pressure, respiratory rate, body temperature, and heart rate were measured on arrival at the hospital. The SOFA score was also determined on the day of admission.

RESULTS

Bivariate correlation analysis showed that all of the vital signs were correlated with the SOFA score. Multiple regression analysis indicated that decreased values of systolic blood pressure (multivariate regression coefficient [Coef] = -0.030, 95% confidence interval [CI] = -0.046 to -0.013) and diastolic blood pressure (Coef = -0.045, 95% CI = -0.070 to -0.019), increased respiratory rate (Coef = 0.176, 95% CI = 0.112 to 0.240), and increased shock index (Coef = 4.232, 95% CI = 2.401 to 6.062) significantly influenced the SOFA score.

CONCLUSION

Increased respiratory rate and shock index were significantly correlated with disease severity in patients with sepsis. Evaluation of these signs may therefore improve early identification of severely ill patients at triage, allowing more aggressive and timely interventions to improve the prognosis of these patients.

Validation of the APLS age-based vital signs reference ranges in a Chinese population

Reference ranges for vital signs may differ significantly among children of different ethnic origins.

AIM

(1) To validate the Advanced Paediatric Life Support (APLS) age-based vital signs reference ranges in Chinese children in Hong Kong. (2) To derive age-based centile curves for systolic blood pressure, heart rate and respiratory rate for Chinese children. (3) To summarize the reference ranges in a table format appropriate for applying APLS to ethnic Chinese patients.

METHOD

A cross-sectional study was performed on a population of healthy Chinese children recruited from 8 kindergartens and 6 primary schools in Hong Kong. Trained operators visit the sites to obtain measurements. Age-groups: small toddlers (12-23 months); pre-school (24-59 months); and school (60-143 months). Z-test was used to assess statistical significance for proportions of each parameter falling outside the APLS reference range. One-sample t-test was used for comparison with APLS means according to age-groups. LMS Chartmaker Pro v2.3 software was used to describe the data in centile curves.

RESULTS

A total of 1353 patients (55.1% boys) were included. For heart rate, systolic blood pressure and respiratory rate respectively, 34.1%, 55.9% and 55.7% of corresponding measurements were outside the APLS age-based reference ranges. In the 'pre-school' and 'school' age-groups, the mean value for blood pressure is significantly higher, and the mean values for heart rate and respiratory rate significantly lower, in comparison to APLS mean values.

CONCLUSION

Independently derived vital signs reference ranges are more appropriate for use when applying APLS to Chinese patients in Hong Kong.

Vital sign triage to rule out diabetic ketoacidosis and non-ketotic hyperosmolar syndrome in hyperglycemic patients

AIMS

To develop a prediction algorithm to rule out diabetic ketoacidosis (DKA) and non-ketotic hyperosmolar syndrome (NKHS) based on vital signs for early triage of patients with diabetes.

METHODS

The subjects were consecutive adult diabetic patients with hyperglycemia (blood glucose >or=250mg/dl) who presented at an emergency department. Based on a derivation sample (n=392, 70% of 544 patients at a hospital in Okinawa), recursive partitioning analysis was used to develop a tree-based algorithm. Validation was conducted using the other 30% of the patients in Okinawa (n=152, internal validation) and patients at a hospital in Tokyo (n=95, external validation).

RESULTS

Three risk groups for DKA/NKHS were identified: a high-risk group of patients with glucose >400mg/dl or systolic blood pressure <100mmHg; a low risk group of patients with glucose <or=400mg/dl and normal vital signs (systolic blood pressure >or=100mmHg, pulse <or=90/min, and respiratory rate <or=20/min); and an intermediate risk group. The prevalences of DKA/NKHS were 2% (derivation set), 0% (internal validation set), and 0% (external validation set) in the low risk group, respectively.

CONCLUSIONS

Our algorithm may help DKA/NKHS triage and patients with normal vital signs can be initially triaged as low risk for DKA/NKHS.

Calibrating urgency: triage decision-making in a pediatric emergency department

Triage, the first step in the assessment of emergency department patients, occurs in a highly dynamic environment that functions under constraints of time, physical space, and patient needs that may exceed available resources. Through triage, patients are placed into one of a limited number of categories using a subset of diagnostic information. To facilitate this task and standardize the triage decision process, triage guidelines have been implemented. However, these protocols are interpreted differently by highly experienced (expert) nurses and less experienced (novice) nurses. This study investigates the process of triage; the factors that influence triage decision-making, and how the guidelines are used in the process. Using observations and semi-structured interviews of triage nurses, data was collected in the pediatric emergency department of a large Canadian teaching hospital. Results show that in emergency situations (1) triage decisions were often non-analytic and based on intuition, particularly with increasing expertise, and (2) guidelines were used differently by nurses during the triage process. These results suggest that explicit guideline information becomes internalized and implicitly used in emergency triage practice as nurses gain experience. Implications of these results for nursing education and training, and guideline development for emergency care are discussed.

Predictive values of triage temperature and pulse for antibiotic administration and hospital admission in elderly patients with potential infection

To determine how well triage temperature and pulse abnormalities in elderly patients with potential infections predict antibiotic administration and hospital admission. Data from the National Hospital Ambulatory Care Survey (2001-2002), a sample of US emergency departments, were used. Patients (>or=65 years) with a reason for visit suggesting potential infection were included. Of 10,586 patients 65 years or older, 32% had reasons for visit suggesting potential infection. The negative predictive value for predicting intensive care unit admission (n = 154) for triage hyperthermia (temperature >or=38 degrees C) was 96% (95% confidence interval, 95%-96%); hypothermia (temperature <or=36 degrees C), 95% (95%-96%); pulse higher than 90, 97% (96%-98%); both pulse higher than 90 and hypothermia or hyperthermia, 96% (95%-96%); and either pulse higher than 90 or hypothermia or hyperthermia, 96% (95%-97%). The negative predictive value for the combined outcome of hospital admission and antibiotic administration (n = 432) for hyperthermia was 90% (88%-91%); hypothermia, 87% (86%-88%); pulse higher than 90, 90% (89%-92%); for both pulse higher than 90 and hypothermia or hyperthermia, 89% (88%-90%); and for either pulse higher than 90 or hypothermia or hyperthermia, 91% (90%-93%). Although the absence of pulse and temperature abnormalities in elderly patients with potential infection is predictive of not being admitted to the intensive care unit and the combined outcome of admission and hospitalization, this information should not be used alone to determine the presence or absence of a potentially time-sensitive infection.

Interactive triage simulator revealed important variability in both process and outcome of emergency triage

BACKGROUND AND OBJECTIVES

(1) to evaluate the performance of emergency department triage; (2) to explore the variability of the triage process; and (3) to examine the reliability of a four-level triage scale, using an interactive triage simulator.

METHODS

We developed 22 interactive computerized vignettes describing patients presenting at the Emergency Department. Each vignette displayed the presenting complaint and offered the possibility to ask questions and obtain vital signs before deciding on the triage severity rating. The vignettes were rated twice by 45 nurses and 8 physicians.

RESULTS

(1) The concordance between the observed triage decision and an expert-attributed emergency level was perfect in 58% of the situations. Triage acuity was overestimated in 11%, and underestimated in 31%. (2) There was a wide variability in the triage process across observers and vignettes. The mean number of questions varied from 1.77 to 18.95 across individuals, and from 3.96 to 11.60 across vignettes. (3) Finally, the test-retest reliability of our instrument was good (weighted kappa = 0.82) but the interrater reliability was moderate (weighted kappa = 0.41).

CONCLUSIONS

The computerized triage simulator is an innovative tool to evaluate the process and the performance of triage and to evaluate the reliability of a triage instrument.