Performance of the Canadian Triage and Acuity Scale for Children: A Multicenter Database Study

Factors that influence the acceptance of telemetry by emergency medical technicians in ambulances: an application of the extended technology acceptance model

OBJECTIVE

The aim of the study was to verify the effects of patient factors perceived by emergency medical technicians (EMTs) as well as their social and organizational factors on prehospital telemetry use intention based on the technology use intention and elaboration likelihood models.

MATERIALS AND METHODS

This is a retrospective empirical study. Questionnaires were developed on the basis of clinical factors of 72,907 patients assessed by prehospital telemetry from January 1, 2009 to April 30, 2012 by reviewing their prehospital medical care records and in-hospital medical records. Questionnaires regarding the social and organizational factors of EMTs were created on the basis of a literature review. To verify which factors affect the utilization of telemetry, we developed a partial least-squares route model on the basis of each characteristic. In total, 136 EMTs who had experience in using prehospital telemetry were surveyed from April 1 to April 7, 2013. Reliability, validity, hypotheses, and the model goodness of fit of the study tools were tested.

RESULTS

The clinical factors of the patients (path coefficient=-0.12; t=2.38), subjective norm (path coefficient=0.18; t=2.63), and job fit (path coefficient=0.45; t=5.29) positively affected the perceived usefulness (p<0.010). Meanwhile, the clinical factors of the patients (path coefficients=-0.19; t=4.46), subjective norm (path coefficient=0.08; t=1.97), loyalty incentives (path coefficient=-0.17; t=3.83), job fit (path coefficient=-0.32; t=7.06), organizational facilitations (path coefficient=0.08; t=1.99), and technical factors (i.e., usefulness and ease of use) positively affected attitudes (path coefficient=0.10, 0.58; t=2.62, 5.81; p<0.010). Attitudes and perceived usefulness significantly positively affected use intention.

CONCLUSIONS

Factors that influence the use of telemetry by EMTs in ambulances included patients' clinical factors, as well as complex organizational and environmental factors surrounding the EMTs' occupational environments. This suggests that the rapid use intention and dissemination of such systems require EMTs to be supported at both the technical and organizational levels.

Pediatric Canadian Triage and Acuity Scale (PaedsCTAS) as a Measure of Injury Severity

This research explored whether the pediatric version of the Canadian Triage Acuity Scale (PaedsCTAS) represented a valid alternative indicator for surveillance of injury severity. Every patient presenting in a Canadian emergency department is assigned a CTAS or PaedsCTAS score in order to prioritize access to care and to predict the nature and scope of care that is likely to be required. The five-level PaedsCTAS score ranges from I (resuscitation) to V (non-urgent). A total of 256 children, 0 to 17-years-old, who attended a pediatric hospital for an injury were followed longitudinally. Of these children, 32.4% (n = 83) were hospitalized and 67.6% (n = 173) were treated in the emergency department and released. They completed the PedsQL(TM), a validated measure of health related quality of life, at baseline (pre-injury status), one-month, four- to six-months, and 12-months post-injury. In this secondary data analysis, PaedsCTAS was found to be significantly associated with hospitalization and length of stay, sensitive to the differences between PaedsCTAS II and III, and related to physical but not psychosocial HRQoL. The findings suggest that PaedsCTAS may be a useful proxy measure of injury severity to supplement or replace hospitalization status and/or length of stay, currently proxy measures.

Development of stratification criteria of green codes in a pediatric emergency department: a pilot study

BACKGROUND

The aim of this study was to find stratification criteria in a group of children assigned to the green triage category at an emergency department (ED).

METHODS

We analyzed a sample of patients admitted to the ED of Gaslini Children's Hospital in Genoa between February 2014 and January 2015 who had been given a green code on triage. We analyzed the following parameters: age, sex, nationality, reason for admission, number and type of the procedures performed, length of stay in the ED, destination on discharge, color code and diagnosis on discharge.

RESULTS

Of the 2875 patients enrolled, 258 (8.97%) were hospitalized, 135 (4.70%) were placed in short intensive observation, 1609 (55.97%) were discharged from the ED without any intervention, 829 (28.83%) were discharged after undergoing procedures (blood tests, microbiology investigation, imaging, specialist evaluation) and 44 (1.5%) spontaneously left the ED. Among the patients who were hospitalized and those kept under short intensive observation, the most frequent discharge diagnosis was gastrointestinal disease; among those patients discharged with and without undergoing procedures, the most frequent diagnosis was respiratory disease. The mean age of patients admitted to hospital and of those discharged without undergoing procedures was 46 months, while the mean ages of patients kept under short intensive observation and of those discharged after undergoing procedures were 54 and 61 months, respectively.

CONCLUSIONS

These preliminary results suggest that one of the main criteria of stratification of green codes on triage is the association between 2 variables: age and pathology.

'Down-triage' for children with abnormal vital signs: evaluation of a new triage practice at a paediatric emergency department in Japan

OBJECTIVE

Assessment of abnormal vital signs in triage is a challenge in the paediatric emergency department (PED), since vital signs may reflect anxiety, fever or pain rather than the clinical deterioration of the child. We aimed to evaluate the efficacy of subjective 'down-triage' (change of the initially determined acuity levels) of Japanese Triage and Acuity Scale (JTAS).

METHODS

This is a retrospective cohort study of patients in PED up to 15 years of age at a tertiary paediatric medical centre in Japan during a 1-year period. At the end of every JTAS triage process, PED nurses were allowed to 'down-triage' acuity levels of well-appearing patients with abnormal HR or RR, which were presumably attributable to fever, crying or being upset. We compared predictive performance of the triage system before and after 'down-triage' using admission rate as the primary outcome.

RESULTS

Among 37 961 PED visits during the study period, we analysed 37 219 records. A total of 17 089 patients (45.9%) were 'down-triaged' after their initial triage allocation upon arrival. Admission rates after 'down-triage' (83%, 33%, 7%, 1% and 3% for levels 1-5, respectively), compared with those of unmodified initial level (16%, 11%, 6%, 2% and 6% for levels 1-5, respectively), had a better apparent relevance with the anticipated admission rates of Canadian Triage and Acuity Scale.

CONCLUSIONS

Modification of JTAS through 'down-triage' by experienced staff improves prediction of disposition in a PED. Further research is needed to determine an objective protocol for 'down-triage' to ensure safe practice in a PED.

Acuity Assessment in Obstetrical Triage

OBJECTIVE

A five-category Obstetrical Triage Acuity Scale (OTAS) was developed with a comprehensive set of obstetrical determinants. The purposes of this study were: (1) to compare the inter-rater reliability (IRR) in tertiary and community hospital settings and measure the intra-rater reliability (ITR) of OTAS; (2) to establish the validity of OTAS; and (3) to present the first revision of OTAS from the National Obstetrical Triage Working Group.

METHODS

To assess IRR, obstetrical triage nurses were randomly selected from London Health Sciences Centre (LHSC) (n = 8), Stratford General Hospital (n = 11), and Chatham General Hospital (n= 7) to assign acuity levels to clinical scenarios based on actual patient visits. At LHSC, a group of nurses were retested at nine months to measure ITR. To assess validity, OTAS acuity level was correlated with measures of resource utilization.

RESULTS

OTAS has significant and comparable IRR in a tertiary care hospital and in two community hospitals. Repeat assessment in a cohort of nurses demonstrated significant ITR. Acuity level correlated significantly with performance of routine and second order laboratory investigations, point of care ultrasound, nursing work load, and health care provider attendance. A National Obstetrical Triage Working Group was formed and guided the first revision. Four acuity modifiers were added based on hemodynamics, respiratory distress, cervical dilatation, and fetal well-being.

CONCLUSION

OTAS is the first obstetrical triage scale with established reliability and validity. OTAS enables standardized assessments of acuity within and across institutions. Further, it facilitates assessment of patient care and flow based on acuity.

A reliability study of the rapid emergency triage and treatment system for children

BACKGROUND

To evaluate inter- and intrarater reliability of a new Scandinavian triage system for children, the Rapid Emergency Triage and Treatment System-pediatric (RETTS-p).

METHODS

Two observational studies were conducted at the Pediatric Emergency Department (PED), St. Olav's University Hospital, Trondheim, Norway. Using RETTS-p, nurses assign one of five triage priority levels to each patient on the basis of clinical signs and symptoms evaluations and vital parameter measurements. Study 1: Prior to the introduction of RETTS-p in 2012, all nurses in the PED completed a theoretical and practical training. Four months later, 19 nurses triaged 20 fictive but realistic pediatric cases two times 9 months apart (Waves A and B). Study 2: Nurse pairs consisting of a regular nurse and a research nurse simultaneously and independently triaged 200 pediatric patients who were referred with various common medical and surgical complaints.

RESULTS

Study 1: Kendall's W for Waves A and B were 0.822 and 0.844, respectively. Using a mixed linear model, we found no difference in triage priority levels between Waves A and B. Compared to a consensus level made by the research group, the nurses rated 85.1 % fictive cases correctly, and 99 % were rated correctly or within one adjacent priority score. Study 2: The interrater correlation coefficient in a linear mixed model was 0.762, confirming a high interrater reliability in real-life triaging.

DISCUSSION

We found a very high degree of agreement between nurses who used RETTS-p to prioritize children, both in a theoretical case scenarios study, but also in real-life triaging.

CONCLUSIONS

RETTS-p may be a credible and robust triage system, but it has not been validated yet.

Development and Initial Psychometric Evaluation of the Post-Acute Acuity Rating for Children

The Post-Acute Acuity Rating for Children (PAARC) is the first known acuity rating intended to reflect medical severity based on age, reason for admission, diagnoses, dependence in activities of daily living, and technology reliance for children admitted to post-acute care rehabilitation hospitals. Content validity was tested using an expert panel scoring the Content Validity Index (CVI). Concurrent validity was examined using clinician's opinion of acuity at admission, the Complexity Index, and All Patient Refined Diagnosis Related Group (APR-DRG) codes. Predictive validity was examined with acute care readmission within 30 days. Interrater reliability was assessed using admission histories from closed cases. Content validity was established and concurrent validity was moderate to high with clinician opinion (rho = .76, p < .001), the Complexity Index (rho = .76, p < .001), and APR-DRGs (rho = .349, p = .001). Predictive validity was moderate (rho = .504, p = .005) and returns to acute care within 30 days. Interrater reliability was excellent (ICC = 0.97; 95% CI = 0.92–0.90, p < .001). Experts agreed that the PAARC's content is relevant, simple, and representative of the population. The PAARC measured well against indicators of medical complexity for pediatric outpatient care and medical record coding and was reliable between raters. This work supports proceeding with additional development and validity testing of the PAARC.

Validation of the Calgary Spine Severity Score

BACKGROUND CONTEXT

The Calgary Spine Severity Score (CSSS) is a published triage score reported in the Spine Journal in 2010. It separates spine referrals into four time categories of urgency. It stratifies patients according to clinical, radiologic, and pathologic findings. The CSSS however still requires external validation at another institution and in an unselected sample of patients.

PURPOSE

The aim was to validate the CSSS.

STUDY DESIGN/SETTING

This was a validation study.

PATIENT SAMPLE

The sample included a total of 316 consecutive patients undergoing spinal surgery between April 2014 and September 2014 at a tertiary care hospital in Canada.

OUTCOME MEASURES

The outcome was validity of the CSSS via its predicted time to operating room (OR) to predict actual time to OR.

METHODS

We applied the CSSS to an unselected sample of consecutive patients from a tertiary care hospital between April 2014 and September 2014. Demographic and clinical data were collected. The CSSS was determined. We compared the time with OR predicted by the CSSS in one of four categories (routine>6 months=CSSS 3-5, priority<6 months=CSSS 6-8, urgent<1 month=CSSS 9-11, and emergent<1 week=CSSS 12-15) with the actual time to OR. We used Kaplan-Meier survival analysis to assess the CSSS predictive ability. Cox proportional hazard models were built and compared via analysis of variance to determine whether the models differed in their ability to fit the data.

RESULTS

Three hundred sixteen patients were eligible. Two hundred eighty-nine had sufficient data. One hundred eighteen were a mismatch with the actual time to OR yielding an accuracy of 63%. The CSSS overestimated the urgency in 68 cases and underestimated it in 50 cases. Notably, seven cauda equina syndrome cases were classified as priority (<6 months) instead of emergent. The concordance was 0.70 and the R-square 0.33. We proposed several adjustments to the CSSS to increase its accuracy. The modified CSSS had an accuracy of 96%, overestimating nine cases and underestimating one case. The concordance was 0.77, and the R-square 0.70.

CONCLUSIONS

The modified CSSS is an easy-to-use triage score, which represents a substantial improvement as compared with the original CSSS. It now requires further external validation.

Understanding Low-Acuity Visits to the Pediatric Emergency Department

Background

Canadian pediatric emergency department visits are increasing, with a disproportionate increase in low-acuity visits locally (33% of volume in 2008-09, 41% in 2011-12). We sought to understand: 1) presentation patterns and resource implications; 2) parents’ perceptions and motivations; and 3) alternate health care options considered prior to presenting with low-acuity problems.

Methods

We conducted a prospective cohort study at our tertiary pediatric emergency department serving two provinces to explore differences between patients with and without a primary care provider. During four, 2-week study periods over 1 year, parents of low-acuity visits received an anonymous survey. Presentation times, interventions, diagnoses and dispositions were captured on a data collection form linked to the survey by study number.

Results

Parents completed 2,443 surveys (74.1% response rate), with survey-data collection form pairs available for 2,146 visits. Overall, 89.7% of respondents had a primary care provider; 68% were family physicians. Surprisingly, 40% of visits occurred during weekday office hours and 27.3% occurred within 4 hours of symptom onset; 67.5% of those early presenters were for injuries. Few parents sought care from their primary care provider (25%), health information line (20.7%), or urgent care clinic (18.5%); 36% reported that they believed their child’s problem required the emergency department. Forty-five percent required only a history, physical exam and reassurance; only 11% required an intervention not available in an office setting. Patients without a primary care provider were significantly more likely to present during weekday office hours (p = 0.003), have longer symptom duration (p<0.001), and not know of other options (p = 0.001).

Conclusions

Many parents seek pediatric emergency department care for low-acuity problems despite their child having a primary care provider. Ensuring timely access to these providers may help reduce pediatric emergency department overuse. Educational initiatives should inform parents about low-acuity problems and where appropriate care can/should be accessed.

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.

Implementing an obstetric triage acuity scale: interrater reliability and patient flow analysis

A 5-category Obstetric Triage Acuity Scale (OTAS) was developed with a comprehensive set of obstetrical determinants. The objectives of this study were as follows: (1) to test the interrater reliability of OTAS and (2) to determine the distribution of patient acuity and flow by OTAS level. To test the interrater reliability, 110 triage charts were used to generate vignettes and the consistency of the OTAS level assigned by 8 triage nurses was measured. OTAS performed with substantial (Kappa, 0.61 - 0.77, OTAS 1-4) and near perfect correlation (0.87, OTAS 5). To assess patient flow, the times to primary and secondary health care provider assessments and lengths of stay stratified by acuity were abstracted from the patient management system. Two-thirds of triage visits were low acuity (OTAS 4, 5). There was a decrease in length of stay (median [interquartile range], minutes) as acuity decreased from OTAS 1 (120.0 [156.0] minutes) to OTAS 3 (75.0 [120.8]). The major contributor to length of stay was time to secondary health care provider assessment and this did not change with acuity. The percentage of patients admitted to the antenatal or birthing unit decreased from 80% (OTAS 1) to 12% (OTAS 5). OTAS provides a reliable assessment of acuity and its implementation has allowed for triaging of obstetric patients based on acuity, and a more in-depth assessment of the patient flow. By standardizing assessment, OTAS allows for opportunities to improve performance and make comparisons of patient care and flow across organizations.