Revision of the Canadian Emergency Department Information System (CEDIS) Presenting Complaint List version 1.1

Reliability of the Canadian Triage and Acuity Scale: interrater and intrarater agreement from a community and an academic emergency department

OBJECTIVES

The Canadian Triage and Acuity Scale (CTAS) is a five-level triage tool that is used to help prioritize the order in which emergency department (ED) patients should be seen. The objectives of this study were to determine the interrater and intrarater agreement of the 2008 CTAS guideline revisions by triage nurses and to compare agreement between triage nurses working in a small community ED and an academic ED.

METHODS

Seventy-eight triage nurses assigned CTAS scores and free-text presenting complaints for 10 paper-based case scenarios. For five scenarios, the CTAS score should have remained unchanged from previous guidelines, whereas the other five scenarios should have been triaged differently based on the 2008 CTAS first-order modifiers. Thirty-three participants repeated the questionnaire 90 days later, and intrarater agreement was measured.

RESULTS

There was a higher level of agreement (κ  =  0.73; 95% CI 0.68-0.79) for the five case scenarios, which relied on the older 2004 guidelines compared to the scenarios where the 2008 guidelines would have suggested a different triage level (κ  =  0.50; 95% CI 0.42-0.59). For the 10 case scenarios analyzed, the free-text presenting complaints matched the Canadian Emergency Department Information System (CEDIS) list 90.1% of the time (κ  =  0.80; 95% CI 0.76-0.84).

CONCLUSION

The reliability of CTAS scoring by academic and community ED nurses was relatively good; however, the application of the 2008 CTAS revisions appears less reliable than the 2004 CTAS guidelines. These results may be useful to develop educational materials to strengthen reliability and validity for triage scoring using the 2008 CTAS guideline revisions.

Speed and accuracy of mobile BlackBerry Messenger to transmit chest radiography images from a small community emergency department to a geographically remote referral center

BACKGROUND

Small emergency departments (EDs) may rely on radiologists at remote centers for interpretations of chest radiographs (CXRs). We investigated systematic transmission of CXR images from a small ED to a geographically remote referral center using the mobile BlackBerry Messenger (BBM) application.

METHODS

Investigators obtained de-identified CXR images of consecutive ED patients via mobile phone camera. Each CXR image, along with a brief clinical history, was sent via BBM to an emergency physician located at a remote referral site, and the receiving physician replied via BBM to confirm reception. All communications, image generation, and image analysis was conducted on mobile phones. The primary outcome was the proportion of BBMs received within two minutes of sending; the secondary outcome was the proportion of BBM replies to the sending physician within five minutes. Image accuracy-comparing the radiologist's interpretation with the receiving emergency physician's interpretation-was estimated using predefined criteria.

RESULTS

Of 1281 consecutive ED patients, 231 (18.0 %) had CXRs obtained, 320 CXRs were analyzed and 611 BBMs sent. All BBMs (100.0%, 95% confidence interval (CI) 99.4-00.0) arrived within two minutes; 595 BBMs (97.4%, 95% CI 95.8-98.4) were replied to within five minutes. Of the 58 CXRs with abnormalities requiring intervention, there were 55 concordances (overall agreement 94.2%, 95% CI 85.9-98.3; kappa 0.95, 95% CI 0.89-1.0) CONCLUSION: Systematic transmission of CXR images from a small ED to a remote large center using mobile phones may be a safe and effective strategy to rapidly communicate important patient information.

Impact of a New Medical Record System for Emergency Departments Designed to Accelerate Clinical Documentation: A Crossover Study

Recording information in emergency departments (EDs) constitutes a major obstacle to efficient treatment. A new electronic medical records (EMR) system focusing on clinical documentation was developed to accelerate patient flow. The aim of this study was to examine the impact of a new EMR system on ED length of stay and physician satisfaction.We integrated a new EMR system at a hospital already using a standard system. A crossover design was adopted whereby residents were randomized into 2 groups. Group A used the existing EMR system first, followed by the newly developed system, for 2 weeks each. Group B followed the opposite sequence. The time required to provide overall medical care, length of stay in ED, and degree of physician satisfaction were compared between the 2 EMR systems.The study involved 6 residents and 526 patients (277 assessed using the standard system and 249 assessed with the new system). Mean time for clinical documentation decreased from 133.7 ± 5.1 minutes to 107.5 ± 5.4 minutes with the new EMR system (P < 0.001). The time for overall medical care was significantly reduced in all patient groups except triage level 5 (nonurgent). The new EMR system significantly reduced the length of stay in ED for triage level 2 (emergency) patients (145.4 ± 13.6 minutes vs 184.3 ± 13.6 minutes for standard system; P = 0.047). As for the degree of physician satisfaction, there was a high degree of satisfaction in terms of the physical findings support system and the ability to capture images and enter negative findings.The new EMR system shortened the time for overall medical care and was associated with a high degree of resident satisfaction.

Common Diagnoses and Outcomes in Elderly Patients Who Present to the Emergency Department with Non-Specific Complaints

OBJECTIVE

Elderly patients often present to the emergency department (ED) with non-specific complaints. Previous studies indicate that such patients are at greater risk for life-threatening illnesses than similarly aged patients with specific complaints. We evaluated the diagnoses and outcomes of elderly patients presenting with non-specific complaints.

METHODS

Two trained data abstractors independently reviewed all records of patients over 70 years old presenting (to two academic EDs) with non-specific complaints, as defined by the Canadian Emergency Department Information System (CEDIS). Outcomes of interest were ED discharge diagnosis, hospital admission, length of stay, and ED revisit within 30 days.

RESULTS

Of the 743 patients screened for the study, 265 were excluded because they had dizziness, vertigo, or a specific complaint recorded in the triage notes. 419 patients (87.7%) presented with weakness and 59 patients (12.3%) presented with general fatigue or unwellness. The most common diagnoses were urinary tract infection (UTI) (11.3%), transient ischemic attack (TIA) (10.0%), and dehydration (5.6%). There were 11 hospital admissions with median length of stay of five days. Eighty-one (16.9%) patients revisited the ED within 30 days of discharge. Regression analysis indicated that arrival to the ED by ambulance was independently associated with hospital admission.

CONCLUSIONS

Our results suggest that elderly patients presenting to the ED with non-specific complaints are not at high risk for life-threatening illnesses. The most common diagnoses are UTI, TIA, and dehydration. Most patients can be discharged safely, although a relatively high proportion revisit the ED within 30 days.

Development of the Canadian Emergency Department Diagnosis Shortlist

Objective:

Managers of emergency departments (EDs), governments and researchers would benefit from reliable data sets that characterize use of EDs. Although Canadian ED lists for chief complaints and triage acuity exist, no such list exists for diagnosis classification. This study was aimed at developing a standardized Canadian Emergency Department Diagnosis Shortlist (CED-DxS), as a subset of the full International Classification of Diseases, 10th revision, with Canadian Enhancement (ICD-10-CA).

Methods:

Emergency physicians from across Canada participated in the revision of the ICD-10-CA through 2 rounds of the modified Delphi method. We randomly assigned chapters from the ICD-10-CA (approximately 3000 diagnoses) to reviewers, who rated the importance of including each diagnosis in the ED-specific diagnosis list. If 80% or more of the reviewers agreed on the importance of a diagnosis, it was retained for the final revision. The retained diagnoses were further aggregated and adjusted, thus creating the CED-DxS.

Results:

Of the 83 reviewers, 76% were emergency medicine (EM)–trained physicians with an average of 12 years of experience in EM, and 92% were affiliated with a university teaching hospital. The modified Delphi process and further adjustments resulted in the creation of the CED-DxS, containing 837 items. The chapter with the largest number of retained diagnoses was injury and poisoning (n= 292), followed by gastrointestinal (n= 59), musculoskeletal (n= 55) and infectious disease (n= 42). Chapters with the lowest number retained were neoplasm (n= 18) and pregnancy (n= 12).

Conclusion:

We report the creation of the uniform CED-DxS, tailored for Canadian EDs. The addition of ED diagnoses to existing standardized parameters for the ED will contribute to homogeneity of data across the country.

Beat the clock! Wait times and the production of 'quality' in emergency departments

Emergency care in large urban hospitals across the country is in the midst of major redesign intended to deliver quality care through improved access, decreased wait times, and maximum efficiency. The central argument in this paper is that the conceptualization of quality including the documentary facts and figures produced to substantiate quality emergency care is socially organized within a powerful ruling discourse that inserts the interests of politics and economics into nurses' work. The Canadian Triage and Acuity Scale figures prominently in the analysis as a high-level organizer of triage work and knowledge production that underpins the way those who administer the system define, measure and evaluate emergency care processes, and then use this information for restructuring. Managerial targets and thinking not only dominate the way emergency work is understood, determined, and controlled but also subsume the actual work of health-care providers in spaces called 'wait times', where it is systematically rendered 'unknowable'. The analysis is supported with evidence from an extensive institutional ethnography that shows what nurses actually do to manage the safe passage of patients through their emergency care process starting with the work of triage nurses.

Pattern of use and presenting complaints of older patients visiting an Emergency Department in Italy

BACKGROUND AND AIMS

The number of older persons admitted to the Emergency Department (ED) is dramatically increasing due to their complex medical and social problems, which in turn lead to longer clinical evaluation times and increased use of resources compared to younger adults. However, scant data are available for Italian EDs. Similarly, no data are available about the reasons to ED visit and its role in determining the ED utilization pattern. The study aimed at describing the pattern of ED use by older patients and main presenting complaints.

METHODS

Cross-sectional descriptive study of 5,826 ED patients in the city of Fano (Italy). Identifiers and triage, clinical and social data were collected. Presenting complaints as recorded by triage nurses have been recoded according to the Canadian Emergency Department Information System list version 1.1. Data were analyzed comparing older patients (more than 65 years-old) with younger adults (less than 65 years-old).

RESULTS

The prevalence of ED visits by older adults was 23.9 %. Their visits were characterized by higher emergency levels, admission rate and length of ED stay. Trauma was the main reason for ED presentation, especially among young adults, but elderly trauma patients were more frequently admitted because of hip fracture. Dyspnea and abdominal pain were the most frequent non-trauma presenting complaints among geriatric patients and represented the main causes for admission.

CONCLUSIONS

Older adults use the ED appropriately also in Italy. Trauma with complications (fracture) and various presenting complaints underlying medical problems accounted for more than 50 % of ED visits and hospital admissions.

Comparison of adaptive neuro-fuzzy inference system and artificial neutral networks model to categorize patients in the emergency department

Unexpected disease outbreaks and disasters are becoming primary issues facing our world. The first points of contact either at the disaster scenes or emergency department exposed the frontline workers and medical physicians to the risk of infections. Therefore, there is a persuasive demand for the integration and exploitation of heterogeneous biomedical information to improve clinical practice, medical research and point of care. In this paper, a primary triage model was designed using two different methods: an adaptive neuro-fuzzy inference system (ANFIS) and artificial neural network (ANN).When the patient is presented at the triage counter, the system will capture their vital signs and chief complains beside physiology stat and general appearance of the patient. This data will be managed and analyzed in the data server and the patient's emergency status will be reported immediately. The proposed method will help to reduce the queue time at the triage counter and the emergency physician's burden especially duringdisease outbreak and serious disaster. The models have been built with 2223 data set extracted from the Emergency Department of the Universiti Kebangsaan Malaysia Medical Centre to predict the primary triage category. Multilayer feed forward with one hidden layer having 12 neurons has been used for the ANN architecture. Fuzzy subtractive clustering has been used to find the fuzzy rules for the ANFIS model. The results showed that the RMSE, %RME and the accuracy which evaluated by measuring specificity and sensitivity for binary classificationof the training data were 0.14, 5.7 and 99 respectively for the ANN model and 0.85, 32.00 and 96.00 respectively for the ANFIS model. As for unseen data the root mean square error, percentage the root mean square error and the accuracy for ANN is 0.18, 7.16 and 96.7 respectively, 1.30, 49.84 and 94 respectively for ANFIS model. The ANN model was performed better for both training and unseen data than ANFIS model in term of generalization. It was therefore chosen as the technique to develop the primary triage prediction model. This primary triage model will be combined with the secondary triage prediction model to produce the final triage category as a tool to assist the medical officer in the emergency department.

Severity illness scoring systems for early identification and prediction of in-hospital mortality in patients with suspected sepsis presenting to the emergency department

The in-hospital mortality of patients with severe sepsis and septic shock (SSSS) is high. In this study we examined the diagnostic and prognostic accuracy of the emergency severity index (ESI), the modified early warning score (MEWS), and the mortality in emergency department (ED) sepsis (MEDS) score. This is a single-centre, prospective and observational study of 151 consecutive patients presenting to the ED of the Nuremberg Hospital with suspected sepsis (age 68.3 ± 18 years, 54.3 % men, 45 % with SSSS, in-hospital mortality of SSSS: 27.8 %). In this study, 37.7 % of the studied patients had a urinary tract infection (n = 57/151), 33.8 % a pneumonia (n = 51/151), 8.6 % an acute abdominal infection (n = 13/151), and in 12.6 % the focus of infection was not further specified or identifiable (n = 19/151). The diagnostic and prognostic accuracy was analyzed by means of the receiver operating characteristic (ROC) curve. The areas under curve (AUC) in terms of diagnostic accuracy were 0.609, 0.641, and 0.778 for the ESI, MEWS, and MEDS score respectively. The AUCs concerning prognostic accuracy were 0.617, 0.642, and 0.871 for ESI, MEWS, and MEDS score respectively.By using the MEDS score systematically, critically ill patients with sepsis could be detected in the ED. Finally, the MEDS score provides the basis for a risk adjusted disposition management that follows objective criteria.

Development of information systems and clinical decision support systems for emergency departments: a long road ahead for Japan

Emergency care services face common challenges worldwide, including the failure to identify emergency illnesses, deviations from standard treatments, deterioration in the quality of medical care, increased costs from unnecessary testing, and insufficient education and training of emergency personnel. These issues are currently being addressed by implementing emergency department information systems (EDIS) and clinical decision support systems (CDSS). Such systems have been shown to increase the efficiency and safety of emergency medical care. In Japan, however, their development is hindered by a shortage of emergency physicians and insufficient funding. In addition, language barriers make it difficult to introduce EDIS and CDSS in Japan that have been created for an English-speaking market. This perspective addresses the key events that motivated a campaign to prioritise these services in Japan and the need to customise EDIS and CDSS for its population.

Structured classification for ED presenting complaints - from free text field-based approach to ICPC-2 ED application

BACKGROUND

Although there is a major need to record and analyse presenting complaints in emergency departments (EDs), no international standard exists. The aim of the present study was to produce structured complaint classification suitable for ED use and to implement it in practice. The structured classification evolved from a study of free text fields and ICPC-2 classification.

METHODS

Presenting complaints in a free text field of ED admissions during a one-year period (n=40610) were analyzed and summarized to 70 presenting complaint groups. The results were compared to ICPC-2 based complaints collected in another ED. An expert panel reviewed the results and produced an ED application of ICPC-2 classification. This study implemented the new classification into an ED.

RESULTS

The presenting complaints summarized from free text fields and those from ICPC-2 categories were remarkably similar. However, the ICPC-2 classification was too broad for ED; an adapted version was needed. The newly developed classification includes 89 presenting complaints and ED staff found it easy to use.

CONCLUSIONS

ICPC-2 classification can be adapted for ED use. The authors suggest a list of 89 presenting complaints for use in EDs adult patients.

The formation and design of the 'Acute Admission Database'- a database including a prospective, observational cohort of 6279 patients triaged in the emergency department in a larger Danish hospital

BACKGROUND

Management and care of the acutely ill patient has improved over the last years due to introduction of systematic assessment and accelerated treatment protocols. We have, however, sparse knowledge of the association between patient status at admission to hospital and patient outcome. A likely explanation is the difficulty in retrieving all relevant information from one database. The objective of this article was 1) to describe the formation and design of the 'Acute Admission Database', and 2) to characterize the cohort included.

METHODS

All adult patients triaged at the Emergency Department at Hillerød Hospital and admitted either to the observationary unit or to a general ward in-hospital were prospectively included during a period of 22 weeks. The triage system used was a Danish adaptation of the Swedish triage system, ADAPT. Data from 3 different data sources was merged using a unique identifier, the Central Personal Registry number; 1) Data from patient admission; time and date, vital signs, presenting complaint and triage category, 2) Blood sample results taken at admission, including a venous acid-base status, and 3) Outcome measures, e.g. length of stay, admission to Intensive Care Unit, and mortality within 7 and 28 days after admission.

RESULTS

In primary triage, patients were categorized as red (4.4%), orange (25.2%), yellow (38.7%) and green (31.7%). Abnormal vital signs were present at admission in 25% of the patients, most often temperature (10.5%), saturation of peripheral oxygen (9.2%), Glasgow Coma Score (6.6%) and respiratory rate (4.8%). A venous acid-base status was obtained in 43% of all patients. The majority (78%) had a pH within the normal range (7.35-7.45), 15% had acidosis (pH < 7.35) and 7% had alkalosis (pH > 7.45). Median length of stay was 2 days (range 1-123). The proportion of patients admitted to Intensive Care Unit was 1.6% (95% CI 1.2-2.0), 1.8% (95% CI 1.5-2.2) died within 7 days, and 4.2% (95% CI 3.7-4.7) died within 28 days after admission.

CONCLUSIONS

Despite challenges of data registration, we succeeded in creating a database of adequate size and data quality. Future studies will focus on the association between patient status at admission and patient outcome, e.g. admission to Intensive Care Unit or in-hospital mortality.

Abnormal vital signs are strong predictors for intensive care unit admission and in-hospital mortality in adults triaged in the emergency department - a prospective cohort study

BACKGROUND

Assessment and treatment of the acutely ill patient have improved by introducing systematic assessment and accelerated protocols for specific patient groups. Triage systems are widely used, but few studies have investigated the ability of the triage systems in predicting outcome in the unselected acute population. The aim of this study was to quantify the association between the main component of the Hillerød Acute Process Triage (HAPT) system and the outcome measures; Admission to Intensive Care Unit (ICU) and in-hospital mortality, and to identify the vital signs, scored and categorized at admission, that are most strongly associated with the outcome measures.

METHODS

The HAPT system is a minor modification of the Swedish Adaptive Process Triage (ADAPT) and ranks patients into five level colour-coded triage categories. Each patient is assigned a triage category for the two main descriptors; vital signs, T(vitals), and presenting complaint, T(complaint). The more urgent of the two determines the final triage category, T(final). We retrieved 6279 unique adult patients admitted through the Emergency Department (ED) from the Acute Admission Database. We performed regression analysis to evaluate the association between the covariates and the outcome measures.

RESULTS

The covariates, T(vitals), T(complaint) and T(final) were all significantly associated with ICU admission and in-hospital mortality, the odds increasing with the urgency of the triage category. The vital signs best predicting in-hospital mortality were saturation of peripheral oxygen (SpO(2)), respiratory rate (RR), systolic blood pressure (BP) and Glasgow Coma Score (GCS). Not only the type, but also the number of abnormal vital signs, were predictive for adverse outcome. The presenting complaints associated with the highest in-hospital mortality were 'dyspnoea' (11.5%) and 'altered level of consciousness' (10.6%). More than half of the patients had a T(complaint) more urgent than T(vitals), the opposite was true in just 6% of the patients.

CONCLUSION

The HAPT system is valid in terms of predicting in-hospital mortality and ICU admission in the adult acute population. Abnormal vital signs are strongly associated with adverse outcome, while including the presenting complaint in the triage model may result in over-triage.

A method for reviewing the accuracy and reliability of a five-level triage process (canadian triage and acuity scale) in a community emergency department setting: building the crowding measurement infrastructure

Objectives. Triage data are widely used to evaluate patient flow, disease severity, and emergency department (ED) workload, factors used in ED crowding evaluation and management. We defined an indicator-based methodology that can be easily used to review the accuracy of Canadian Triage and Acuity Scale (CTAS) performance. Methods. A trained nurse reviewer (NR) retrospectively triaged two separate month's ED charts relative to a set of clinical indicators based on CTAS Chief Complaints. Interobserver reliability and accuracy were compared using Kappa and comparative statistics. Results. There were 2838 patients in Trial 1 and 3091 in Trial 2. The rate of inconsistent triage was 14% and 16% (Kappa 0.596 and 0.604). Clinical Indicators “pain scale, chest pain, musculoskeletal injury, respiratory illness, and headache” captured 68% and 62% of visits. Conclusions. We have demonstrated a system to measure the levels of process accuracy and reliability for triage over time. We identified five key clinical indicators which captured over 60% of visits. A simple method for quality review uses a small set of indicators, capturing a majority of cases. Performance consistency and data collection using indicators may be important areas to direct training efforts.

Exploring differences in the clinical management of pediatric mental health in the emergency department

OBJECTIVE

: We examine psychiatric and pediatric clinical management of pediatric mental health in the emergency department (ED).

METHODS

: We conducted a retrospective review of health care delivery with a random sample of all pediatric mental health presentations (≤18 years) to 2 urban tertiary care EDs between 2004 and 2006 (N = 580).

RESULTS

: The EDs differed significantly in services offered. General emergency medicine-trained physicians provided care at 1 site (54.6%) with a number of visits also managed by a psychiatric crisis team (45.4%). Care at the other ED was delivered by pediatric emergency medicine-trained physicians (99.4%) with no regular on-site psychiatric services. The most common assessment provided across sites and all presentations was for suicidality (66.2%). After controlling for potential confounders, receipt of clinical assessment for homicidality, mood, or reality testing differed between EDs (P = 0.044, P = 0.006, and P = 0.002) with more assessments documented at the psychiatric-resourced ED. Brief counseling was lacking for visits (absence of documentation: 56.1% pediatric-resourced, 23.1% psychiatric-resourced ED); there was no evidence of site differences in provision. More psychiatric consultation was provided at the psychiatric-resourced ED (34.1% vs 27.4%, P = 0.030). Discharge recommendations were lacking in both EDs but were more incomplete for pediatric-resourced ED visits (P = 0.035).

CONCLUSIONS

: Consistent and comprehensive clinical management of pediatric mental health presentations was lacking in EDs that had pediatric and psychiatric resources. Prospective evaluations are needed to determine the effect of current clinical ED practices on patient and family outcomes, including symptom reduction and stress, as well as subsequent system use.