The Canadian Triage and Acuity Scale: A Canadian perspective on emergency department triage

Applying the chronic care model to homeless veterans: effect of a population approach to primary care on utilization and clinical outcomes

OBJECTIVES

We compared a population-tailored approach to primary care for homeless veterans with a usual care approach.

METHODS

We conducted a retrospective prolective cohort study of homeless veterans enrolled in a population-tailored primary care clinic matched to a historical sample in general internal medicine clinics. Overall, 177 patients were enrolled: 79 in the Homeless-Oriented Primary Care Clinic and 98 in general internal medicine primary care.

RESULTS

Homeless-oriented primary care-enrolled patients had greater improvements in hypertension, diabetes, and lipid control, and primary care use was higher during the first 6 months (5.96 visits per person vs 1.63 for general internal medicine) but stabilized to comparable rates during the second 6 months (2.01 vs 1.31, respectively). Emergency department (ED) use was also higher (2.59 vs 1.89 visits), although with 40% lower odds for nonacute ED visits than for the general internal medicine group (95% confidence interval = 0.2, 0.8). Excluding substance abuse and mental health admissions, hospitalizations were reduced among the homeless veterans between the 2 periods (28.6% vs 10.8%; P < .01) compared with the general internal medicine group (48.2% vs 44.4%; P = .6; difference of differences, P < .01).

CONCLUSIONS

Tailoring primary care to homeless veterans can decrease unnecessary ED use and medical admissions and improve chronic disease management.

Revealing triage behaviour patterns in ER using a new technology for handwritten data acquisition

INTRODUCTION

Data acquisition is still one of the important challenges to be met in clinical settings. This is even more critic in settings with high cognitive workloads, such as emergency room (ER). Observations in these settings are difficult to realize without biases and there is little means to trace fine acquisition activities done in natural environments, using pen and papers. This study is based on the usage of a digital pen and paper (DPP) technology for the acquisition of triage information by nurses in ER. The DPP technology has been used to ease acquisition using a natural mechanism; it also minimizes the external influence of observation during acquisition activities. The aim of this study is to determine whether data recorded by the DPP technology allows explaining how ER triage nurses use the triage forms in real working conditions.

METHODOLOGY

The chief physicians of the ER service wanted to have answers about three main concerns pertaining to the triage process: (1) the average time spent during the triage process; (2) the sequence in which the fields of the forms were filled and; (3) the contribution of objective measurements, such as vital signs, to the triage emergency level and decisions. In order to answer these questions, detailed log data recorded by the DPP during form filling as been analyzed and allowed to built several representations of the triage process. In addition, we completed this analysis with ethnographical-like observations.

RESULTS

For seven consecutive days, 1183 triage forms have been recorded in the ER for all patients admitted. Among them, 954 forms have been digitalized and 906 forms have been considered as valid and complete. Based on this set of data, the median duration of the triage process is 143 s. There are no converging habits in filling the forms and the sequence of filling fields present a high variability. The emphasis of the objective measurements in the decisional process is rather low, as vital signs are recorded in less than 17% of the cases.

CONCLUSION

The DPP technology is an original approach to study data acquisition processes in unbiased conditions. The technical raw data recorded by the DPP allows building the time series of all activities on the paper, therefore letting to constructing several representations of the process. However, the technology is not able to provide information about the context of use, for example interruptions of the form filling processes due to calls or other activities. Therefore, it is necessary to complete these analyses with qualitative approaches such as observational studies and interviews. Noticeably, as a result of this study, the head physicians of ER have redesigned the triage form to enforce the use of objective measurements and ease the data acquisition process.

Effects of a triage process conversion on the triage of high-risk presentations

OBJECTIVES

The objective was to determine effects of a modification in triage process on triage acuity distribution in general and among patients with conditions requiring time-sensitive therapy.

METHODS

The authors retrospectively reviewed triage acuity distributions before and after modification of their triage process that entailed conversion from the Canadian Triage and Acuity Scale (CTAS) to the Emergency Severity Index (ESI). The authors calculated the ratio of the odds of being triaged to a nonemergent level (3, 4, or 5) under ESI to the odds of being triaged as nonemergent under CTAS. The authors calculated sensitivity and specificity of triage to an emergent acuity level (1 or 2) for identifying patients with common presentations who required time-sensitive care.

RESULTS

There were shifts from higher to lower acuity levels for all subsets, with odds ratios ranging from 2.80 (95% confidence interval [CI] = 2.75 to 2.86) for all patients to 21.39 (95% CI = 14.66 to 31.21) for patients over 55 years of age with a chief complaint of chest pain. The sensitivity of triage for identifying abdominal pain patients requiring admission to an intensive care unit (ICU) or operating room (OR) or emergency department (ED) death was 80.7% (95% CI = 73.2 to 86.5) before versus 50.8% (95% CI = 43.5 to 58.1) following the transition to ESI. Specificity under CTAS, 55.2% (95% CI = 54.0 to 56.4), was significantly lower than under ESI, 83.6% (95% CI = 82.7 to 84.4). The authors found similar effects for patients presenting with chest pain.

CONCLUSIONS

Monitoring for changes in the sensitivity of the triage process for detecting patients with potentially time-sensitive conditions should be considered when modifying triage processes. Further work should be done to determine if the decreased sensitivity seen in this study occurs in other institutions converting to ESI, and potential causative factors should be explored.

Validation of the Emergency Severity Index (ESI) in self-referred patients in a European emergency department

OBJECTIVE

To validate the Emergency Severity Index (ESI) triage algorithm in predicting resource consumption and disposition by self-referred patients in a European emergency department.

METHODS

This was a prospective, observational cohort study using a convenience sample of self-referred emergency department patients >14 years of age presenting to a busy urban teaching hospital during a 39-day period (27 May-4 July 2001). Observed resource use was compared with resource utilisation predicted by the ESI. Outpatient referrals after discharge and hospitalisations were also recorded.

RESULTS

ESI levels were obtained in 1832/3703 (50%) self-referred patients, most of whom were in the less severe ESI-4 (n = 685, 37%) and ESI-5 (n = 983, 54%) categories. Use of resources was strongly associated with the triage level, rising from 15% in ESI-5 to 97% in ESI-2 patients. Specialty consultations and admissions also rose with increasing ESI severity. Only 5% of ESI-5 patients required consultation and <1% were admitted, whereas 85% of ESI-2 patients received a consultation and 56% were admitted, 26% to a critical care bed. Only 2% of the ESI-5 patients underwent blood tests, compared with 76% of the sicker ESI-2 patients. X rays were the most commonly used resource in patients triaged to ESI-4 and ESI-5.

CONCLUSION

The ESI triage category reliably predicts the severity of a patient's condition, as reflected by resource utilisation, consultations and admissions in a population of self-referred patients in a European emergency department. It clearly identifies patients who require minimal resources, or at most an x ray, and those unlikely to require admission.

Sex differences in hospital admissions from emergency departments in asthmatic adults: a population-based study

BACKGROUND

Women represent the majority of adult patients hospitalized for asthma. Analyzing the course of emergency department (ED) visits before hospital admission can help understanding of the mechanisms behind the excess of hospitalizations in women.

OBJECTIVE

To investigate sex differences in hospital admission rates in adult patients with asthma visiting EDs in Ontario.

METHODS

Asthmatic patients 18 to 55 years old who visited Ontario EDs between April 1, 2003, and March 31, 2004, were identified using the Canadian Institute for Health Information's National Ambulatory Care Reporting System. The generalized estimating equations for binary outcome were used to model rates of hospital admission with sex, age, and triage (severity) score as covariates. Analysis was further stratified by the ED volume.

RESULTS

Women represented 62.2% of all ED visits. They were on average older than men, but both groups had similar distributions of triage scores. Female patients accounted for more hospital admissions than male patients (7.4% vs 4.5%). After adjusting for age and triage score, women were more likely to be admitted than men (odds ratio, 1.64; 95% confidence interval, 1.41-1.90). The interaction found between sex and triage level indicates that hospitalized women may have less severe asthma than hospitalized men. Analysis by ED volume did not significantly alter the results.

CONCLUSION

The higher admission rates in women may be related to sex differences in the subjective perception of dyspnea, management of asthma by ED physician, or inadequate ambulatory care strategies in women and thus merit further investigation.

Effect of gender, age, and severity of asthma attack on patterns of emergency department visits due to asthma by month and day of the week

OBJECTIVE

To examine the pattern and strength of seasonal fluctuations in emergency department (ED) visits due to asthma, by month and day of the week, by the patient's age, gender, and severity of asthma attack.

METHODS

Time series analysis of ED visits was conducted among patients with asthma aged from 18 to 55 years who visited Ontario EDs between April 1, 2001 and March 31, 2004. Autoregressive regression models with months and days of the week as predictors were fitted for (1) all patients; (2) females and males separately; (3) each combination of gender and age group, and (4) each combination of gender and level of severity. The strength of seasonality in each group of patients was estimated from the R2-statistic derived from autoregression models.

RESULTS

For all patient groups, the highest number of ED visits occurred in October and December, and on Sundays and Mondays. Month of January and Fridays were associated with a decreased number of visits. The strength of seasonality was similar in men and women (R2 = 0.52), was the highest in young patients and decreased with age, in men more rapidly than in women. Severe cases of asthma attacks exhibited weaker seasonality (R2 = 0.30) compared to mild (R2 = 0.45) or moderate (R2 = 0.53) cases.

CONCLUSION

The strength of seasonal patterns of asthma ED visits is influenced by age and the severity of attack, and to a lesser extent, gender. Understanding the significance of seasonal precipitants of asthma in different patients subgroups could lead to better management strategies.