How reliable is emergency department triage?

Performance of the South African triage score among HIV positive individuals presenting to an emergency department

Introduction

Over a quarter of patients presenting to South African Emergency Centres (EC) have concurrent human immunodeficiency virus (HIV), yet it is unclear how this impacts their presenting complaints, the severity of illness, and overall resource needs in the EC. The primary objective of this study was to compare the performance of the South African Triage Score (SATS) in people living with HIV (PLWH) compared to HIV-negative patients. Secondary objectives included comparing the presentation characteristics and resource utilisation of these populations.

Methods

A prospective cross-sectional observational study was conducted in the Livingstone Hospital EC, Gqeberha, South Africa, to compare triage designation and clinical outcomes in PLWH and HIV-negative patients. In this six-week study, all eligible patients received point-of-care HIV testing and extensive data abstraction, including SATS designation and EC clinical course. Descriptive statistical analysis was completed, and a log-binomial model was used to examine the association between HIV status and clinical outcomes using crude (unadjPR) and adjusted prevalence ratios (adjPR).

Results

During the study period, 755 adult patients who consented to a POC HIV test were enrolled, of which 193 (25.6%) were HIV positive. HIV-positive patients were significantly more likely to be admitted compared to their HIV-negative counterparts when triaged as low acuity (adjPR 1.48, 95% CI 1.14-1.92, (p=0.003)). HIV-positive patients were also significantly more likely to receive laboratory testing when triaged as low acuity (adjPR 1.31, 95% CI 1.08-1.59 (p=0.006)) and as high acuity (adjPR 1.38, 95% CI 1.08-1.59 (p=0.034)) compared to HIV negative patients of the same triage categories.

Conclusion

In our study, PLWH, compared to HIV-negative patients in the same category, were more likely to be admitted and require more EC resources, thus alluding to possible under triage of HIV-positive patients under the current SATS algorithm.

Investigation of the usability of the REMS, RAPS, and MPM II0 scoring systems in the prediction of short-term and long-term mortality in patients presenting to the emergency department triage

BACKGROUND

Appropriate triage is an important component of patient management in emergency departments. The risk scoring system used for triage purposes in emergency departments should be obtained quickly and based on parameters directly related to prognosis.

AIMS

To investigate the success of the Rapid Emergency Medicine Score (REMS) and Rapid Acute Physiology Score (RAPS) as triage scoring systems and the Mortality Probability Model (MPM II₀) as an intensive care scoring system in identifying critical patients visited to the emergency department (ED) triage and predicting mortality, and to evaluate their superiority over each other, if any.

METHODS

This research was planned as a single-center and prospectively. The data of the study were obtained by screening the medical records of all patients who presented to the ED triage between January 1, 2020 and January 31, 2020. Patients under the age of 18 years, those with missing information in their files and pregnant women were not included in the study. Only the patients for whom the REMS, RAPS, and MPM II₀ scores could be calculated were included in the sample.

RESULTS

After excluding the patients who did not meet the inclusion criteria, the study was completed with 12,210 patients. The mean age of these patients was 44.7 ± 18.7 years, and 47.3% were male. The area under the receiver operating characteristics curve values for the prediction of 24-h, 30-day, 90-day, and 180-day mortality were determined as 0.979, 0.921, 0.904, and 0.897, respectively, for REMS; 0.929, 0.778, 0.75, and 0.725, respectively, for RAPS; and 0.925, 0.888, 0.866, and 0.861, respectively, for MPM II₀.

CONCLUSIONS

In this study, it was concluded that the REMS score was superior to the MPM II₀ and RAPS scores in predicting the short-term and long-term mortality status of patients and determining the discharge and hospitalization status of the patients.

Queueing Problems in Emergency Departments: A Review of Practical Approaches and Research Methodologies

Problems related to patient scheduling and queueing in emergency departments are gaining increasing attention in theory, in the fields of operations research and emergency and healthcare services, and in practice. This paper aims to provide an extensive review of studies addressing queueing-related problems explicitly related to emergency departments. We have reviewed 229 articles and books spanning seven decades and have sought to organize the information they contain in a manner that is accessible and useful to researchers seeking to gain knowledge on specific aspects of such problems. We begin by presenting a historical overview of applications of queueing theory to healthcare-related problems. We subsequently elaborate on managerial approaches used to enhance efficiency in emergency departments. These approaches include bed management, fast-track, dynamic resource allocation, grouping/prioritization of patients, and triage approaches. Finally, we discuss scientific methodologies used to analyze and optimize these approaches: algorithms, priority models, queueing models, simulation, and statistical approaches.

Brain Tumor Analysis Empowered with Deep Learning: A Review, Taxonomy, and Future Challenges

Deep Learning (DL) algorithms enabled computational models consist of multiple processing layers that represent data with multiple levels of abstraction. In recent years, usage of deep learning is rapidly proliferating in almost every domain, especially in medical image processing, medical image analysis, and bioinformatics. Consequently, deep learning has dramatically changed and improved the means of recognition, prediction, and diagnosis effectively in numerous areas of healthcare such as pathology, brain tumor, lung cancer, abdomen, cardiac, and retina. Considering the wide range of applications of deep learning, the objective of this article is to review major deep learning concepts pertinent to brain tumor analysis (e.g., segmentation, classification, prediction, evaluation.). A review conducted by summarizing a large number of scientific contributions to the field (i.e., deep learning in brain tumor analysis) is presented in this study. A coherent taxonomy of research landscape from the literature has also been mapped, and the major aspects of this emerging field have been discussed and analyzed. A critical discussion section to show the limitations of deep learning techniques has been included at the end to elaborate open research challenges and directions for future work in this emergent area.

Triage in Australian emergency departments: Results of a New South Wales survey

AIM

To describe current models of triage, the preparation and education of triage nurses, and methods of auditing triage practice in New South Wales emergency departments.

BACKGROUND

Triage is a critical component of emergency department practice; affecting patient safety and access to emergency care. Within Australia, triage is an autonomous role predominantly conducted by trained emergency nurses. Patient safety and timely access to emergency care relies upon the experience, education and training of emergency triage nurses. To date, little is known about triage models of care, the preparation and education of triage nurses, and assessment of triage practice and decision accuracy.

METHOD

Descriptive, exploratory study design employing a self-reporting cross-sectional survey of clinical nurse consultants and educators in New South Wales.

RESULTS

The survey results reveal variability in models of triage, and the eligibility, preparation and education requirements of triage nurses; that appear geographically related. Auditing of triage practice was commonly undertaken retrospectively; feedback to triage nurses was infrequent. The survey found evidence of locally developed guidelines directing triage category allocation for specific conditions or symptoms.

CONCLUSION

The purpose of triage is to ensure that the level of emergency care provided is commensurate with clinical urgency. Variability in the preparation, education and evaluation of triage nurses may in and of itself, contribute to poor patient outcomes. Further, workforce size and geography may impede auditing and the provision of feedback, which are critical to improving triage practice and triage nurse performance. It is imperative that the Emergency Triage Education Kit be revised and maintained in tandem with future revisions of the Australasian Triage Scale.

Development and preliminary testing of an online software system to facilitate assessment of accuracy and consistency in applying the Australasian Triage Scale

PURPOSE

The aim of this project was to design and evaluate an online software system to facilitate the assessment of triage decision accuracy and consistency in applying the Australasian Triage Scale.

BACKGROUND

Triage is a critical component of emergency nursing practice, which affects patient access to emergency care. Accurate and consistent triage decisions are vital to ensuring patient safety, timely access to care and ED operation. Presently, there is no standard process to examine triage decisions, measure current performance and support department and individual performance development activities to improve patient safety and quality of emergency care.

METHOD

An iterative design guided by a human factors development approach was used to develop a retrospective, focus-based analysis system to evaluate triage decision accuracy and consistency, and enable the exploration of service gaps and opportunities for practice change and professional development.

RESULTS

Triage decision accuracy and consistency, including areas for improvement are detectable and quantifiable. Findings generated may aid in departmental performance and professional development of triage nurses.

CONCLUSION

This is the first system developed to assess decision accuracy and consistency in applying the Australasian Triage Scale. This paper has described the development and preliminary testing of a user-centred design process and implementation of a web-based system to evaluate triage decision accuracy and consistency.

Real-Time Remote Health-Monitoring Systems in a Medical Centre: A Review of the Provision of Healthcare Services-Based Body Sensor Information, Open Challenges and Methodological Aspects

Promoting patient care is a priority for all healthcare providers with the overall purpose of realising a high degree of patient satisfaction. A medical centre server is a remote computer that enables hospitals and physicians to analyse data in real time and offer appropriate services to patients. The server can also manage, organise and support professionals in telemedicine. Therefore, a remote medical centre server plays a crucial role in sustainably delivering quality healthcare services in telemedicine. This article presents a comprehensive review of the provision of healthcare services in telemedicine applications, especially in the medical centre server. Moreover, it highlights the open issues and challenges related to providing healthcare services in the medical centre server within telemedicine. Methodological aspects to control and manage the process of healthcare service provision and three distinct and successive phases are presented. The first phase presents the identification process to propose a decision matrix (DM) on the basis of a crossover of 'multi-healthcare services' and 'hospital list' within intelligent data and service management centre (Tier 4). The second phase discusses the development of a DM for hospital selection on the basis of integrated VIKOR-Analytic Hierarchy Process (AHP) methods. Finally, the last phase examines the validation process for the proposed framework.

Acuity Prediction Using Emergency Medical Services Prenotifications in a Pediatric Emergency Department

OBJECTIVES

Emergency medical services (EMS) prenotifications are critical, although they oftentimes inaccurately convey the arriving patient's true acuity, resulting in inappropriate preparation in the emergency department. The objectives of this study were (1) to determine interrater reliability of acuity prediction based on prenotifications among physicians and (2) to compare predicted versus actual patient acuity based on prenotifications.

METHODS

A panel of physicians reviewed recordings of EMS prenotifications and then predicted the patient's acuity using the Emergency Severity Index (ESI). The scores were analyzed for interrater reliability using the weighted κ statistic. In the prospective phase of the study, physicians predicted an ESI before patient arrival based solely on the EMS prenotification and then calculated an actual ESI upon arrival. Descriptive statistics were calculated, and comparisons between the predicted and actual ESI were performed using Wilcoxon signed rank for matched pairs.

RESULTS

Panelists reviewed a total of 23 recordings, and the interrater reliability was 0.23 overall (SE, 0.026; P < 0.001), indicating only fair agreement. One hundred patients were enrolled in the prospective analysis. There was a statistically significant difference between the predicted and actual ESI made by physicians (P = 0.0001). For 46 patients, the predicted and actual scores matched, but 13 patients were "undertriaged," and 41 patients were "overtriaged" based on predicted acuity.

CONCLUSIONS

Interpretation of acuity using EMS prenotifications among physicians was only fairly reliable, and physicians had difficulty predicting actual acuity based on prenotifications. Improper preparation based on these prenotifications can potentially impact patient care and resource allocation.

Based Real Time Remote Health Monitoring Systems: A Review on Patients Prioritization and Related "Big Data" Using Body Sensors information and Communication Technology

The growing worldwide population has increased the need for technologies, computerised software algorithms and smart devices that can monitor and assist patients anytime and anywhere and thus enable them to lead independent lives. The real-time remote monitoring of patients is an important issue in telemedicine. In the provision of healthcare services, patient prioritisation poses a significant challenge because of the complex decision-making process it involves when patients are considered 'big data'. To our knowledge, no study has highlighted the link between 'big data' characteristics and real-time remote healthcare monitoring in the patient prioritisation process, as well as the inherent challenges involved. Thus, we present comprehensive insights into the elements of big data characteristics according to the six 'Vs': volume, velocity, variety, veracity, value and variability. Each of these elements is presented and connected to a related part in the study of the connection between patient prioritisation and real-time remote healthcare monitoring systems. Then, we determine the weak points and recommend solutions as potential future work. This study makes the following contributions. (1) The link between big data characteristics and real-time remote healthcare monitoring in the patient prioritisation process is described. (2) The open issues and challenges for big data used in the patient prioritisation process are emphasised. (3) As a recommended solution, decision making using multiple criteria, such as vital signs and chief complaints, is utilised to prioritise the big data of patients with chronic diseases on the basis of the most urgent cases.

Transition in care from paramedics to emergency department nurses: a systematic review protocol

BACKGROUND

Effective and efficient transitions in care between emergency medical services (EMS) practitioners and emergency department (ED) nurses is vital as poor clinical transitions in care may place patients at increased risk for adverse events such as delay in treatment for time sensitive conditions (e.g., myocardial infarction) or worsening of status (e.g., sepsis). Such transitions in care are complex and prone to communication errors primarily caused by misunderstanding related to divergent professional perspectives leading to misunderstandings that are further susceptible to contextual factors and divergent professional lenses. In this systematic review, we aim to examine (1) factors that mitigate or improve transitions in care specifically from EMS practitioners to ED nurses, and (2) effectiveness of interventional strategies that lead to improvements in communication and fewer adverse events.

METHODS

We will search electronic databases (DARE, MEDLINE, EMBASE, Cochrane, CINAHL, Joanna Briggs Institute EBP; Communication Abstracts); gray literature (gray literature databases, organization websites, querying experts in emergency medicine); and reference lists and conduct forward citation searches of included studies. All English-language primary studies will be eligible for inclusion if the study includes (1) EMS practitioners or ED nurses involved in transitions for arriving EMS patients; and (2) an intervention to improve transitions in care or description of factors that influence transitions in care (barriers/facilitators, perceptions, experiences, quality of information exchange). Two reviewers will independently screen titles/abstracts and full texts for inclusion and methodological quality. We will use narrative and thematic synthesis to integrate and explore relationships within the data. Should the data permit, a meta-analysis will be conducted.

DISCUSSION

This systematic review will help identify factors that influence communication between EMS and ED nurses during transitions in care, and identify interventional strategies that lead to improved communication and decrease in adverse events. The findings can be used to develop an evidence-informed transitions in care tool that ensures efficient transfer of accurate patient information, continuity of care, enhances patient safety, and avoids duplication of services. This review will also identify gaps in the existing literature to inform future research efforts.

TRIAL REGISTRATION

PROSPERO CRD42017068844.

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.

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.

The reliability of the Australasian Triage Scale: a meta-analysis

BACKGROUND

Although the Australasian Triage Scale (ATS) has been developed two decades ago, its reliability has not been defined; therefore, we present a meta-analyis of the reliability of the ATS in order to reveal to what extent the ATS is reliable.

DATA SOURCES

Electronic databases were searched to March 2014. The included studies were those that reported samples size, reliability coefficients, and adequate description of the ATS reliability assessment. The guidelines for reporting reliability and agreement studies (GRRAS) were used. Two reviewers independently examined abstracts and extracted data. The effect size was obtained by the z-transformation of reliability coefficients. Data were pooled with random-effects models, and meta-regression was done based on the method of moment's estimator.

RESULTS

Six studies were included in this study at last. Pooled coefficient for the ATS was substantial 0.428 (95%CI 0.340-0.509). The rate of mis-triage was less than fifty percent. The agreement upon the adult version is higher than the pediatric version.

CONCLUSION

The ATS has shown an acceptable level of overall reliability in the emergency department, but it needs more development to reach an almost perfect agreement.

Impact of an ABCDE team triage process combined with public guidance on the division of work in an emergency department

OBJECTIVE

To study the effects of applying an emergency department (ED) triage system, combined with extensive publicity in local media about the "right" use of emergency services, on the division of work between ED nurses and general practitioners (GPs).

DESIGN

An observational and quasi-experimental study based on before-after comparisons.

SETTING

Implementation of the ABCDE triage system in a Finnish combined ED where secondary care is adjacent, and in a traditional primary care ED where secondary care is located elsewhere.

SUBJECTS

GPs and nurses from two different primary care EDs.

MAIN OUTCOME MEASURES

Numbers of monthly visits to different professional groups before and after intervention in the studied primary care EDs and numbers of monthly visits to doctors in the local secondary care ED.

RESULTS

The beginning of the triage process increased temporarily the number of independent consultations and patient record entries by ED nurses in both types of studied primary care EDs and reduced the number of patient visits to a doctor compared with previous years but had no effect on doctor visits in the adjacent secondary care ED. No further decrease in the number of nurse or GP visits was observed by inhibiting the entrance of non-urgent patients.

CONCLUSION

The ABCDE triage system combined with public guidance may reduce non-urgent patient visits to doctors in different kinds of primary care EDs without increasing visits in the secondary care ED. However, the additional work to implement the ABCDE system is mainly directed to nurses, which may pose a challenge for staffing.

Framework for classifying compliance and medical immediacy among low-acuity presentations at an urban trauma center

Background

This research offers two exploratory frameworks, one for medical regimen compliance and one for medical immediacy. The first classifies compliance awareness, compliance mitigation, and financial limitation for those patients that exhibit nonadherence with a medical regimen. The second classifies medical immediacy and characterizes avoidable utilization.

Methods

Representative sampling of adult patients presenting at an emergency department (62,000/ppy) triaged as low acuity; emergency department physician assessment of noncompliance with medical regimen for those patients with a complaint related to a chronic condition; and emergency department physician assessment of medical immediacy and avoidable utilization.

Results

Physicians report 48.3% (95% confidence interval (CI) 43.5% to 53.1%) of patients with at least a single chronic condition are presenting with symptoms or complaint related to a chronic condition, and 39.6% (CI 31.7% to 47.4%) of these exhibit noncompliance with the medical regimen associated with that chronic condition. 16.4% (CI 6.6% to 26.1%) of the patients exhibit pseudo compliance, a belief that the medical regimen is in compliance when in fact it is not. If the patient had been in compliance, 85.9% (CI 77.0% to 94.8%) of the presenting conditions may have been mitigated. Noncompliance cases (34.5% (CI 22.0% to 47.1%)) are partly attributable to financial constraints. Further, 19.1% (CI 15.7% to 22.5%) are assessed as requiring no medical intervention and 3.4% (CI 1.8% to 4.9%) require immediate stabilization.

Conclusions

A large portion of low-acuity presentations are related to a chronic condition and noncompliance with the associated medical regimen contributes to the need to seek medical services. Interventions addressing literacy and financial constraints may increase compliance and decrease utilization.

The effect of training on nurse agreement using an electronic triage system

Objectives:

Emergency department (ED) triage prioritizes patients based on urgency of care, and the Canadian Triage and Acuity Scale (CTAS) is the national standard. We describe the inter-rater agreement and manual overrides of nurses using a CTAS-compliant web-based triage tool (eTRIAGE) for 2 different intensities of staff training.

Methods:

This prospective study was conducted in an urban tertiary care ED. In phase 1, eTRIAGE was deployed after a 3-hour training course for 24 triage nurses who were asked to share this knowledge during regular triage shifts with colleagues who had not received training (n = 77). In phase 2, a targeted group of 8 triage nurses underwent further training with eTRIAGE. In each phase, patients were assessed first by the duty triage nurse and then by a blinded independent study nurse, both using eTRIAGE. Inter-rater agreement was calculated using kappa (weighted κ) statistics.

Results:

In phase 1, 569 patients were enrolled with 513 (90.2%) complete records; 577 patients were enrolled in phase 2 with 555 (96.2%) complete records. Inter-rater agreement during phase 1 was moderate (weighted κ = 0.55; 95% confidence interval [CI] 0.49–0.62); agreement improved in phase 2 (weighted κ = 0.65; 95% CI 0.60–0.70). Manual overrides of eTRIAGE scores were infrequent (approximately 10%) during both periods.

Conclusions:

Agreement between study nurses and duty triage nurses, both using eTRIAGE, was moderate to good, with a trend toward improvement with additional training. Triage overrides were infrequent. Continued attempts to refine the triage process and training appear warranted.

Prospective time study derivation of emergency physician workload predictors

Background:

A reliable emergency department (ED) workload measurement tool would provide a method of quantifying clinical productivity for performance evaluation and physician incentive programs; it would enable health administrators to measure ED outputs; and it could provide the basis for an equitable formula to estimate ED physician staffing requirements. Our objectives were to identify predictors that correlate with physician time needed to treat patients and to develop a multivariable model to predict physician workload.

Methods:

During 31 day, evening, night and weekend shifts, a research assistant (RA) shadowed 20 emergency physicians, documenting time spent performing clinical and non-clinical functions for 585 patient visits. The RA recorded key predictors including patient gender, age, vital signs and Glasgow Coma Scale (GCS) score, and the mode of arrival, triage level assigned, comorbidity and procedures performed. Multiple linear regression was used to describe the associations between predictor variables and total physician time per patient visit (TPPV), and to derive an equation for physician workload. Model derivation was based on 16 shifts and 314 patient visits; model validation was based on 15 shifts and 271 additional patient visits.

Results:

The strongest predictor variables were: procedure required, triage level, arrival by ambulance, GCS, age, any comorbidity, and number of prior visits. The derived regression equation is: TPPV = 29.7 + 8.6 (procedure required [Yes]) – 3.8 (triage level [1–5]) + 7.1 (ambulance arrival) – 1.1 (GCS [3–15]) + 0.1 (age in years) – 0.05 (n of previous visits) + 3.1 (any comorbidity). This model predicted 31.3% of the variance in physician TPPV (F [12, 29] = 13.2; p &lt; 0.0001).

Conclusions:

This study clarifies important determinants of emergency physician workload. If validated in other settings, the predictive formula derived and internally validated here is a potential alternative to current simplistic models based solely on patient volume and perceived acuity. An evidence-based workload estimation tool like that described here could facilitate ED productivity measurement, benchmarking, physician performance evaluation, and provide the substrate for an equitable formula to estimate ED physician staffing requirements.

Prognosis Research Strategy (PROGRESS) 3: prognostic model research

Prognostic models are abundant in the medical literature yet their use in practice seems limited. In this article, the third in the PROGRESS series, the authors review how such models are developed and validated, and then address how prognostic models are assessed for their impact on practice and patient outcomes, illustrating these ideas with examples.

Classification of patients by severity grades during triage in the emergency department using data mining methods

OBJECTIVE

To test the feasibility of classifying emergency department patients into severity grades using data mining methods.

DESIGN

Emergency department records of 402 patients were classified into five severity grades by two expert physicians. The Naïve Bayes and C4.5 algorithms were applied to produce classifiers from patient data into severity grades. The classifiers' results over several subsets of the data were compared with the physicians' assessments, with a random classifier, and with a classifier that selects the maximal-prevalence class.

MEASUREMENTS

Positive predictive value, multiple-class extensions of sensitivity and specificity combinations, and entropy change.

RESULTS

The mean accuracy of the data mining classifiers was 52.94 ± 5.89%, significantly better (P < 0.05) than the mean accuracy of a random classifier (34.60 ± 2.40%). The entropy of the input data sets was reduced through classification by a mean of 10.1%. Allowing for classification deviations of one severity grade led to mean accuracy of 85.42 ± 1.42%. The classifiers' accuracy in that case was similar to the physicians' consensus rate. Learning from consensus records led to better performance. Reducing the number of severity grades improved results in certain cases. The performance of the Naïve Bayes and C4.5 algorithms was similar; in unbalanced data sets, Naïve Bayes performed better.

CONCLUSIONS

It is possible to produce a computerized classification model for the severity grade of triage patients, using data mining methods. Learning from patient records regarding which there is a consensus of several physicians is preferable to learning from each physician's patients. Either Naïve Bayes or C4.5 can be used; Naïve Bayes is preferable for unbalanced data sets. An ambiguity in the intermediate severity grades seems to hamper both the physicians' agreement and the classifiers' accuracy.

Impact of the ABCDE triage in primary care emergency department on the number of patient visits to different parts of the health care system in Espoo City

BACKGROUND

Many Finnish emergency departments (ED) serve both primary and secondary health care patients and are therefore referred to as combined emergency departments. Primary care doctors are responsible for the initial assessment and treatment. They, thereby, also regulate referral and access to secondary care. Primary health care EDs are easy for the public to access, leading to non-acute patient visits to the emergency department. This has caused increased queues and unnecessary difficulties in providing immediate treatment for urgent patients. The primary aim of this study was to assess whether the flow of patients was changed by implementing the ABCDE-triage system in the EDs of Espoo City, Finland.

METHODS

The numbers of monthly visits to doctors were recorded before and after intervention in Espoo primary care EDs. To study if the implementation of the triage system redirects patients to other health services, the numbers of monthly visits to doctors were also scored in the private health care, the public sector health services of Espoo primary care during office hours and local secondary health care ED (Jorvi hospital). A face-to-face triage system was applied in the primary care EDs as an attempt to provide immediate treatment for the most acute patients. It is based on the letters A (patient sent directly to secondary care), B (to be examined within 10 min), C (to be examined within 1 h), D (to be examined within 2 h) and E (no need for immediate treatment) for assessing the urgency of patients' treatment needs. The first step was an initial patient assessment by a health care professional (triage nurse). The introduction of this triage system was combined with information to the public on the "correct" use of emergency services.

RESULTS

After implementation of the ABCDE-triage system the number of patient visits to a primary care doctor decreased by up to 24% (962 visits/month) as compared to the three previous years in the EDs. The Number of visits to public sector GPs during office hours did not alter. Implementation of ABCDE-triage combined with public guidance was associated with decreased total number of doctor visits in public health care. During same period, the number of patient visits in the private health care increased. Simultaneously, the number of doctor visits in secondary health care ED did not alter.

CONCLUSIONS

The present ABCDE-triage system combined with public guidance may reduce patient visits to primary health care EDs but not to the secondary health care EDs. Limiting the access of less urgent patients to ED may redirect the demands of patients to private sector rather than office hours GP services.

Comparison of an informally structured triage system, the emergency severity index, and the manchester triage system to distinguish patient priority in the emergency department

OBJECTIVES

The objective was to compare the validity of an existing informally structured triage system with the Emergency Severity Index (ESI) and the Manchester Triage System (MTS).

METHODS

A total of 900 patients were prospectively triaged by six trained triage nurses using the three systems. Triage ratings of 421 (48%) patients treated only by emergency department (ED) physicians were compared with a reference standard determined by an expert panel. The percentage of undertriage, the sensitivity, and the specificity for each urgency level were calculated. The relationship between urgency level, resource use, hospitalization, and length of stay (LOS) in the 900 triaged patients was determined.

RESULTS

The percentage of undertriage using the ESI (86 of 421; 20%) was significantly higher than in the MTS (48 of 421; 11%). When combining urgency levels 4 and 5, the percentage of undertriage was 8% for the informally structured system (ISS), 14% for the ESI, and 11% for the MTS. In all three systems, sensitivity for all urgency levels was low, but specificity for levels 1 and 2 was high (>92%). Sensitivity and specificity were significantly different between ESI and MTS only in urgency level 4. In all 900 patients triaged, urgency levels across all systems were associated with significantly increased resource use, hospitalization rate, and LOS.

CONCLUSIONS

All three triage systems appear to be equally valid. Although the ESI showed the highest percentage of undertriage and the ISS the lowest, it seems preferable to use a verifiable, formally structured triage system.

Assessment of inter-observer reliability of two five-level triage and acuity scales: a randomized controlled trial

INTRODUCTION

The Emergency Severity Index (ESI) is an initial measure of patient assessment in the emergency department (ED). It rates patients based on acuity and predicted resource intensity from Level 1 (most ill) to Level 5 (least resource intensive). Already implemented and evaluated in several US hospitals, ESI has yet to be evaluated in a Canadian setting or compared with the five-level Canadian Emergency Department Triage and Acuity Scale (CTAS).

OBJECTIVE

To compare the inter-observer reliability of 2 five-level triage and acuity scales.

METHODS

Ten triage nurses, who had all been trained in the use of CTAS, from 4 urban, academic Canadian EDs were randomly assigned either to training in ESI version 3 (ESI v.3) or to refresher training in CTAS. They independently assigned triage scores to 200 emergency cases, unaware of the rating by the other nurses.

RESULTS

Number of years of nursing practice was the only significant demographic difference found between the 2 groups (p = 0.014). A quadratically weighted kappa to measure the inter-observer reliability of the CTAS group was 0.91 (0.90, 0.99) and not significantly different from that of the ESI group 0.89 (0.88, 0.99). An inter-test generalizability (G) study performed on the variance components derived from an analysis of variance (ANOVA) revealed G(5) = 0.90 (0.82, 0.99).

CONCLUSIONS

After 3 hours of training, experienced triage nurses were able to perform triage assessments using ESI v.3 with the same inter-observer reliability as those with experience and refresher training in using the CTAS.

Impact of the ABCDE triage on the number of patient visits to the emergency department

Background

Many Finnish emergency departments (ED) serve both primary and secondary health care patients and are therefore referred to as combined emergency departments. Primary care specialists are responsible for the initial assessment and treatment. They, thereby, also regulate referral and access to tertiary care. Primary health care EDs are easy for the public to access, leading to non-acute patient visits to the emergency department. This has caused increased queues and unnecessary difficulties in providing immediate treatment for those patients who need it the most.

Methods

A face-to-face triage system based on the letters A (patient directly to secondary care), B (to be examined within 10 min), C (to be examined within 1 h), D (to be examined within 2 h) and E (no need for immediate treatment) for assessing the urgency of patients' treatment needs was applied in the main ED in the City of Vantaa, Finland (Peijas Hospital) as an attempt to provide immediate treatment for the most acute patients. The first step was an initial patient assessment by a health care professional (triage nurse). If the patient was not considered to be in need of immediate care (i.e. A-D) he was allocated to group E and examined after the more urgent patients were treated. The introduction of this triage system was combined with information to the public on the "correct" use of emergency services. The primary aim of this study was to assess whether the flow of patients was changed by implementing the ABCDE-triage system in the combined ED. To study the effect of the intervention on patient flow, numbers monthly visits to doctors were recorded before and after intervention in Peijas ED and, simultaneously, in control EDs (Myyrmäki in Vantaa, Jorvi and Puolarmetsä in Espoo). To study does the implementation of the triage system redirect patients to other health services, numbers of monthly visits to doctors were also scored in the private health care and public office hour services of Vantaa primary care.

Results

The number of patient visits to a primary care doctor in 2004 decreased by up to eight percent (340 visits/month) as compared to the previous year in the Peijas ED after implementation of the ABCDE-triage system. Simultaneously, doctor visits in tertiary health care ED increased by ten percent (125 visits/month). ABCDE-triage was not associated with a subsequent increase in the number of patient visits in the private health care or office hour services. The number of ED visits in the City of Espoo, used as a control where no triage was applied, remained unchanged.

Conclusions

The present ABCDE-triage system combined with public guidance may reduce patient visits to primary health care EDs but not to the tertiary health care EDs.

Advanced medical simulation applications for emergency medicine microsystems evaluation and training

Participants in the 2008 Academic Emergency Medicine Consensus Conference "The Science of Simulation in Healthcare: Defining and Developing Clinical Expertise" morning workshop session on developing systems expertise were tasked with evaluating best applications of simulation techniques and technologies to small-scale systems in emergency medicine (EM). We collaborated to achieve several objectives: 1) describe relevant theories and terminology for discussion of health care systems and medical simulation, 2) review prior and ongoing efforts employing systems thinking and simulation programs in general medical sectors and acute care medicine, 3) develop a framework for discussion of systems thinking for EM, and 4) explore the rational application of advanced medical simulation methods to a defined framework of EM microsystems (EMMs) to promote a "quality-by-design" approach. This article details the materials compiled and questions raised during the consensus process, and the resulting simulation application framework, with proposed solutions as well as their limitations for EM systems education and improvement.

Reliability of a computerized version of the Pediatric Canadian Triage and Acuity Scale

BACKGROUND

The use of a standardized triage tool allows better comparison of the patients; a computerized version could theoretically improve its reliability.

OBJECTIVES

To compare the interrater agreement of the Pediatric Canadian Triage and Acuity Scale (PedCTAS) and a computerized version (Staturg).

METHODS

A two-phase experimental study was conducted to compare the interrater agreement between nurses assigning triage level to written case scenarios using either traditional PedCTAS or Staturg. Participants were nurses with at least one year of experience in pediatric emergency medicine and trained at triage. Each of the 54 scenarios was evaluated first by all nurses using either one of the strategies. Four weeks later, they evaluated the same scenarios using the other tool. The primary outcome was the interrater agreement measured using kappa score.

RESULTS

Eighteen of the 29 eligible nurses participated in the study. The computerized triage tool showed a better interrater agreement, with a Staturg kappa score of 0.55 (95% confidence interval = 0.53 to 0.57) versus a PedCTAS kappa score of 0.51 (95% confidence interval = 0.49 to 0.53). The computerized version was also associated with higher agreements for scenarios describing patients with the highest severity of triage (kappa score of 0.72 vs. 0.55 for level 1; kappa score of 0.70 vs. 0.51 for level 2).

CONCLUSIONS

A computerized version of the PedCTAS showed a statistically significant improvement in the interrater agreement for nurses evaluating the triage level of 54 clinical scenarios, but this difference has probably small clinical significance.

Do knowledge and experience have specific roles in triage decision-making?

Accuracy of triage decisions is a major influence on patient outcomes. Triage nurses' knowledge and experience have been cited as influential factors in triage decision-making. The aim of this article is to examine the independent roles of factual knowledge and experience in triage decisions. All of the articles cited in this review were research papers that examined the relationship between triage decisions and knowledge and/or experience of triage nurses. Numerous studies have shown that factual knowledge is an important factor in improving triage decisions. Although a number of studies have examined the role of experience as an independent influence on triage decisions, none have found a significant relationship between experience and triage decision-making. Factual knowledge appears to be more important than years of emergency nursing or triage experience in triage decision accuracy. Many triage education programs are underpinned by the assumption that knowledge acquisition will result in improved triage decisions. A better understanding of the relationships between clinical decisions, knowledge, and experience is pivotal for the rigorous evaluation of education programs.

Effect of an evidence-based paediatric fever education program on emergency nurses’ knowledge

INTRODUCTION

This study examined the effect of an educational intervention of factual knowledge on emergency nurses' knowledge and clinical decisions related to paediatric fever.

METHOD

A prospective pre-test/post-test design was used. Emergency nurses' factual knowledge was measured by parallel multiple choice questions and the intervention for the study was an educational intervention consisting of two tutorials. Pre-test data were collected in early June 2005 and post-test data were collected during August 2005.

RESULTS

Thirty-one emergency nurses completed the pre and post-test multiple choice questions. Emergency nurses' knowledge increased following the tutorials. Pre-test score was positively correlated with knowledge acquisition. Self-reports of independent decisions related to fever management were influenced by experience, hours of employment, level of appointment, postgraduate qualifications and pre-test score.

DISCUSSION

High levels of variability in knowledge and knowledge acquisition suggest a review of undergraduate and postgraduate curricula is warranted. Although this study identified associations between independent fever management decisions and participant characteristics, further research is pivotal to better understanding these relationships.

Validity of the Manchester Triage System in paediatric emergency care

OBJECTIVE

To assess the validity of the Manchester Triage System (MTS) in paediatric emergency care, using information on vital signs, resource utilisation and hospitalisation.

METHODS

Patients were eligible if they had attended the emergency department of a large inner-city hospital in The Netherlands from August 2003 to November 2004 and were <16 years of age. A representative sample of 1065 patients was drawn from 18,469 eligible patients. The originally assigned MTS urgency levels were compared with resource utilisation, hospitalisation and a predefined reference classification for true urgency, based on vital signs, resource utilisation and follow-up. Sensitivity, specificity and percentage of overtriage and undertriage of the MTS were calculated.

RESULTS

The number of patients who used more than two resources increased with a higher level of MTS urgency. The percentage of hospital admissions increased with the increase in level of urgency, from 1% in the non-urgent patients to 54% in emergent patients. According to the reference classification, the sensitivity of the MTS to detect emergent/very urgent cases was 63%, and the specificity was 78%. Undertriage occurred in 15% of patients, of which 96% were by one urgency category lower than the reference classification. Overtriage occurred in 40%, mostly in lower MTS categories. In 36% of these cases, the MTS classified two or more urgency categories higher than the reference classification.

CONCLUSIONS

The MTS has moderate sensitivity and specificity in paediatric emergency care. Specific modifications of the MTS should be considered in paediatric emergency care to reduce overtriage, while maintaining sensitivity in the highest urgency categories.

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.

Impact of Emergency Department Volume on Registered Nurse Time at the Bedside

STUDY OBJECTIVE

We determine how emergency department (ED) registered nurses (RNs) allocate their time between various tasks and describe how RN task distribution changes as a function of various measures of ED patient volume and patient acuity.

METHODS

This is a 3-year direct observational study using a convenience sample of 63 8-hour nurse shifts. Four RN task categories were defined: (1) direct patient care, (2) indirect patient care, (3) non-RN care, and (4) personal time. Two measures of nurse workload were used, the patient-to-nurse ratio and the ED acuity index (ED acuity index=(Sigma reverse order triage scores/half hour)/total number of nurses staffing). Trained observers classified RN activity at 1-minute intervals during 8-hour shifts daily for 7 nonconsecutive 24-hour periods. RN staffing data, ED patient census, and patient triage scores were collected every half hour. Summary statistics, correlation tables, and regression analysis were used to establish relationships between RN task allocation, patients per nurse, and the ED acuity index.

RESULTS

For the 63 nursing shifts studied, on average RNs spent 25.6% of their time performing direct patient care, 48.4% on indirect patient care, 6.8% on non-RN care, and 19.1% on personal time. Regardless of the number of patients per RN, approximately twice as much time is spent on indirect patient care as direct patient care. The correlation between the ED acuity index and the patient-to-nurse ratio was 0.98.

CONCLUSION

Regardless of workload, RNs spend the majority of their time performing indirect patient care. RNs spend little time performing tasks that could be performed by ancillary staff. The patient-to-nurse ratio performs just as well as a more complicated acuity index to measure the workload of RNs within an ED.

Triage in emergency departments: national survey

AIM

This paper reports a study the aim of which was to describe how triage-related work was organized and performed in Swedish emergency departments.

BACKGROUND

Hospitals in many developed countries use some kind of system to prioritize the patients attending emergency departments. Triage is a commonly used term to refer to the process of sorting and prioritizing patients for care. How the triage procedure is organized and which personnel perform this type of work vary considerably throughout the world. In Sweden, few studies have explored this important issue.

METHOD

A national survey was conducted using telephone interviews, with nurse managers at each of the emergency departments. The sample represented 87% of emergency departments in Sweden.

RESULTS

The findings clearly illustrate the organization of emergency department triage, focusing on personnel who perform triage, as well as the facilities, resources and procedures available for triage. However, the results indicate that work associated with such triage in Sweden is not organized in any consistent matter. In 81% of the emergency departments a clerk, Licensed Practical Nurse or Registered Nurse were assigned to assess patients not arriving by ambulance. There was also diversity in other areas, including requirements for staff to have particular qualifications and clinical experience for being allocated to triage work, as well as facilities for triage personnel assessing and prioritizing patients. The use of triage scales and acuity ratings also lacked uniformity and disparities were observed in both the design and use of triage scales. A little less than half (46%) of the emergency departments did not use any kind of triage scale to document patient acuity ratings.

CONCLUSION

In contrast to several other countries, this study shows that Swedish emergency departments do not adhere well to established standards and guidelines about triage in emergency care. Research on emergency department triage, especially in the areas of personnel performing triage, triage scales and standards and guidelines are recommended.

RELEVANCE TO CLINICAL PRACTICE

The diversity among several aspects of nursing triage (e.g. use of less qualified personnel performing triage, the use of different triage scales) presented in the study points to a safety risk for the patients. It also shows the need of further education for the personnel in clinical practice as well as further research on triage in order to gain national consensus about this nursing task.

An exploration of accident and emergency nurse experiences of triage decision making in Hong Kong

This study used a descriptive qualitative design to explore emergency nurse experiences of decision making about triage in Hong Kong. Seven experienced nurses who were working in three different accident and emergency departments participated in the study. Unstructured interviews were used to provide the nurses with opportunities to describe their experiences. The findings fall into three main categories, including the experience of triage decision making, the use of information in the triage decision-making process, and the factors that influence triage decision making. Although the experience of triage was generally positive, the nurses felt frustrated and uncertain in some circumstances. In addition, triage decision making was influenced by a series of factors that occur in daily practice. The findings of this study have implications for the development of formal triage training and triage decision-making protocols in accident and emergency nursing. They also provide positive reinforcement and support to triage nurses that will enhance their ability to make decisions about triage. Avenues for further research in the area are recommended.

Human Patient Simulators: A New Face in Baccalaureate Nursing Education at Brigham Young University

Simulation has been used to augment learning in the health care professions. The human patient simulator (HPS) has been used primarily by medical students but is now being used by nursing students, as well. This study explored the benefits and limitations of using an HPS as a patient substitute for one day of actual clinical experience for junior nursing students. Learning outcomes included increased student knowledge, ability, and confidence in medication administration.

Making an IMPACT on emergency department flow: improving patient processing assisted by consultant at triage

OBJECTIVES

To assess whether initial patient consult by senior clinicians reduces numbers of patients waiting to be seen as an indirect measure of waiting time throughout the emergency department (ED).

METHODS

An emergency medicine consultant and a senior ED nurse (G or F grade), known as the IMPACT team, staffed the triage area for four periods of four hours per week, Monday to Friday between 9 am to 5 pm for three months between December 2001 and February 2002 when staffing levels permitted. Patients normally triaged by a nurse in this area instead had an early consultation with the IMPACT team. Data were collected prospectively on all patients seen by the IMPACT team. The number of patients waiting to be seen (for triage, in majors and in minors) was assessed every two hours during the IMPACT sessions and at corresponding times when no IMPACT team was operational.

RESULTS

There was an overall reduction in the number of patients waiting to be seen in the department from 18.3 to 5.5 (p<0.0001) at formal two hourly assessments. The largest difference was seen in minors. Of the patients seen at triage by the IMPACT team, 48.9% were discharged home immediately after assessment and treatment. With the IMPACT team present, no patient waited more than four hours for initial clinical consult.

CONCLUSIONS

By using a senior clinical team for initial patient consultation, the numbers of patients waiting fell dramatically throughout the ED. Many patients can be effectively treated and discharged after initial consult by the IMPACT team.

Paramedics and triage: effect of one training session on triage in the emergency department

This 3-stage intervention study enrolled all adult patients referred to a university-based emergency department (ED) during randomly assigned 1-week preeducation or posteducation periods. Triage decisions recorded by ED paramedics (n = 8) both before and after an educational training session were compared to decisions made by emergency physicians (EPs). Triage decisions of paramedics and EPs in the preeducation phase showed poor consistency (K = 0.317, K = 0.388). Triage decisions in the posteducation phase increased slightly but were still found to be low. On the other hand, consistency between the triage assessments recorded by paramedics and EPs of the general appearance of patients increased from low in the preeducation phase to moderate in the posteducation phase (K = 0.327, K = 0.500, respectively). The training session was associated with a slight increase in the consistency of triage decisions recorded by paramedics and EPs.

Triage of the pediatric patient in the emergency department: are we all in agreement?

OBJECTIVE

To compare triage categorization as a measure of perceived patient acuity on presentation to the emergency department by pediatric emergency medicine (PEM) attending physicians, nurses, and pediatric residents with their general emergency medicine (GEM) counterparts.

METHODS

A questionnaire that contained 12 pediatric triage scenarios was sent to all PEM attending physicians, triage-trained nurses, and pediatric residents and their GEM counterparts at a large urban hospital with separate pediatric and general emergency departments. Participants were asked to use a 3-tier triage system (emergent, urgent, nonurgent) to assign a triage level for each patient scenario.

RESULTS

The response rate was 99%. The kappa level of agreement was highest (.39) among the PEM physicians. Significantly more GEM attending physicians triaged the following scenarios at a higher acuity level as compared with PEM attending physicians with a trend toward emergent triage: simple febrile seizure, 50% (95% confidence interval [CI]: 30%-70%) versus 7.7% (95% CI: 1%-34%); 18-month-old with fever and bumps on lips, 21% (95% CI: 9%-43%) versus 0% (95% CI: 0%-23%); and 15-month-old well-appearing child with high fever, 50% (95% CI: 30%-70%) versus 7.7% (95% CI: 1%-34%). Significant differences were found between GEM and PEM triage-trained nurses only in the 15-month-old high fever scenario and between GEM and pediatric residents in the 15-month-old high fever scenario, the 18-month-old with fever and bumps on lips scenario, and a fever/limp scenario.

CONCLUSIONS

The level of agreement of triage assignment within each group was only fair. GEM participants and PEM participants agreed on most scenarios. However, GEM participants were more likely to triage children with certain febrile illnesses at higher acuity levels as compared with their PEM counterparts.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Nursing perspectives on the emergency department

Although emergency departments (ED's) vary in shape, size, and technology, similarities in responsibilities exist. The primary responsibility is to provide quality health care to the communities served. The (ED) constitutes a substantial business in any hospital. Because of changing acuity levels, patient volume, and mix, success in the ED requires effective management to coordinate the many facets of this ever-changing environment. The ED nurse manager must have an understanding of how outside influences affect the operational aspect of the ED. Having this body of knowledge enhances the viability of the department and positively affects the quality of care.

The Emergency Severity Index (version 3) 5-level triage system scores predict ED resource consumption

OBJECTIVES

The Emergency Severity Index (ESI) version 3 is a valid and reliable 5-level triage instrument that is gaining in popularity. A unique component of the ESI algorithm is prediction of resource consumption. Our objective was to validate the ESI version 3 triage algorithm in a clinical setting for the following outcome measures: actual resource consumption and patient length of stay in the emergency department and hospital.

METHODS

We conducted a retrospective, descriptive study of 403 ED patients who presented to a large academic medical center. The following dependent variables were abstracted from the ED record: number of ED resources used and emergency department and hospital length of stay. The relationship between ESI level and each of the dependent variables was determined.

RESULTS

Mean resource use decreased monotonically as a function of ESI level 1 (5), 2 (3.89), 3 (3.3), 4 (1.2) and 5 (0.2). The ED average length of stay (minutes) per ESI level was as follows: 1 (195), 2 (255), 3 (304), 4 (193), and 5 (98). ESI triage level did not predict hospital length of stay.

CONCLUSIONS

The ESI algorithm accurately predicted ED resource intensity and gives administrators the opportunity to benchmark ED length of stay according to triage acuity level.

Effect of vital signs on triage decisions

STUDY OBJECTIVE

We sought to determine whether knowledge of vital signs changes nurse triage designations (TDs). We also sought to determine whether patient age and ability to communicate modify the effect of vital signs on triage decisions.

METHODS

We performed a prospective observational study, in 24 emergency departments, of nurse-assigned TDs of all ED patients undergoing triage. Nurses performed their typical triage routine, except that they chose 1 of 5 hypothetical TDs (call 911, ED <2 hours, physician's office 2 to 8 hours, physician's office 8 to 24 hours, or home care) before and after measurement of vital signs. The main outcome measure was the change of TD after knowledge of a patient's vital signs, with stratification on the basis of patient age and communication barriers. The secondary outcome was the final ED disposition.

RESULTS

Six hundred twenty-five experienced triage nurses at 24 different EDs collected data on 14,285 patients. TDs were downgraded (decreased in urgency) in 2.4% of patients, and 5.5% were upgraded (increased in urgency) after vital signs were known. Changes were more likely to occur in the young (< or = 2 years old; 11.4%) and the elderly (> or = 75 years old; 9.9%) than in those 3 to 74 years of age (7.5%). When nurses reported a communication barrier, a change in post-vital signs TD was also more common (11.2% versus 7.7%). The post-vital signs TD better predicted patient ED disposition.

CONCLUSION

In this sample, 92.1% of the nurses' TDs were not affected by the knowledge of patient vital signs. For the other 7.9%, including many patients from vulnerable populations, the vital signs changed the nurses' assessments of the patients' triage designation. Methods of triage that do not determine vital signs may not adequately reflect the urgency of the patient's presentation.