Revisions to the Canadian Emergency Department Triage and Acuity Scale Implementation Guidelines

Those who opt to leave: Comparison by triage acuity of emergency patients who leave prior to seeing a medical practitioner

BACKGROUND

People who present to an emergency department but leave before seeing a medical practitioner (LWBS) pose a potential risk, especially those triaged with higher acuity care needs.

OBJECTIVE

To describe and compare characteristics of emergency patients who LWBS by triage acuity.

METHOD

Retrospective review of administrative data for a 1-year period. Chi-square and logistic regression analyses conducted to investigate differences in characteristics specific to individual and the timing of presentation between patients who LWBS and were triaged as higher acuity compared to those who left but were triaged as less- or non-urgent.

RESULTS

During study period, 12.6 % of patients LWBS with 30.0 % of these cases triaged as higher acuity. Number triaged as higher acuity who LWBS tended to be higher during days with a higher volume of higher acuity cases. The likelihood of LWBS for those triaged as higher acuity was higher among older age groups and those with a primary care provider who presented on weekdays, during evening and night shifts, and in the winter months.

CONCLUSIONS

Findings highlight differences in LWBS cases by triage acuity and raise questions about emergency nurses' professional responsibility to follow-up with those who LWBS if they have been triaged as higher acuity based on an assessment of their presenting complaint and risk for complications or deterioration. While continuing to work to reduce wait times and improve patient flow, it is important to identify factors affecting patients' decision to LWBS, especially for those triaged with higher acuity healthcare needs.

Using network analyses to characterise Australian and Canadian frequent attenders to the emergency department

OBJECTIVE

To explore and compare the characteristics of frequent attenders to the ED at an Australian and a Canadian tertiary hospitals by utilising a network analysis approach.

METHODS

We conducted a retrospective population-based study using administrative data over the 2018 and 2019 calendar years. Participants were from a tertiary hospital in Melbourne, Australia, and Toronto, Canada. Frequent attenders were defined as patients with four or more visits in 12 months. Characteristics of younger (18-39 years), middle-aged (40-69 years) and older (70 years and older) frequent attenders were described using descriptive statistics and network analyses.

RESULTS

Younger frequent attenders were characterised by mental illness and substance use, while older frequent attenders had high rates of physical (including chronic) diseases. Middle-aged frequent attenders were characterised by a combination of mental and physical illnesses. These findings were observed at both hospitals. Across all age groups, the network analyses between the Melbourne and Toronto hospitals were different. Among older frequent attender visits, more diagnoses were associated with high triage acuity at the Toronto hospital than at the Melbourne hospital. Some associations were similar at both sites, for example, the negative correlation between high triage acuity and joint pain.

CONCLUSION

Younger, middle-aged and older frequent attenders have distinct characteristics, made readily apparent by using network analyses. Future interventions to reduce ED visits should consider the heterogeneity of frequent attenders who have needs specific to their age, presenting problems and jurisdiction.

Machine learning-based prediction of critical illness in children visiting the emergency department

OBJECTIVES

Triage is an essential emergency department (ED) process designed to provide timely management depending on acuity and severity; however, the process may be inconsistent with clinical and hospitalization outcomes. Therefore, studies have attempted to augment this process with machine learning models, showing advantages in predicting critical conditions and hospitalization outcomes. The aim of this study was to utilize nationwide registry data to develop a machine learning-based classification model to predict the clinical course of pediatric ED visits.

METHODS

This cross-sectional observational study used data from the National Emergency Department Information System on emergency visits of children under 15 years of age from January 1, 2016, to December 31, 2017. The primary and secondary outcomes were to identify critically ill children and predict hospitalization from triage data, respectively. We developed and tested a random forest model with the under sampled dataset and validated the model using the entire dataset. We compared the model's performance with that of the conventional triage system.

RESULTS

A total of 2,621,710 children were eligible for the analysis and included 12,951 (0.5%) critical outcomes and 303,808 (11.6%) hospitalizations. After validation, the area under the receiver operating characteristic curve was 0.991 (95% confidence interval [CI] 0.991-0.992) for critical outcomes and 0.943 (95% CI 0.943-0.944) for hospitalization, which were higher than those of the conventional triage system.

CONCLUSIONS

The machine learning-based model using structured triage data from a nationwide database can effectively predict critical illness and hospitalizations among children visiting the ED.

Emergency department use in people who experience imprisonment in Ontario, Canada

OBJECTIVES

The aims of this study were to describe emergency department (ED) utilization by people in provincial prison and on release, and to compare with ED utilization for the general population.

METHODS

We linked correctional and health administrative data for people released from provincial prison in Ontario in 2010. We matched each person by age and sex with four people in the general population. We compared ED utilization rates using generalized estimating equations, by sex and for high urgency and ambulatory care sensitive conditions.

RESULTS

People who experienced imprisonment (N = 48,861) had higher ED utilization rates compared with the general population (N = 195,444), with rate ratios of 3.2 (95% CI 3.0-4.4) for men and 6.5 (95% CI 5.6-7.5) for women in prison and a range of rate ratios between 3.1 and 7.7 for men and 4.2 and 8.8 for women over the 2 years after release. Most ED visits were high urgency, and between 1.0% and 5.1% of visits were for ambulatory care sensitive conditions. ED utilization rates increased on release from prison.

CONCLUSIONS

People experiencing imprisonment in Ontario have higher ED utilization compared with matched people in the general population, primarily for urgent issues, and particularly in women and in the week after release. Providing high-quality ED care and implementing prison- and ED-based interventions could improve health for this population and prevent the need for ED use.

An Assessment of the Management of Patients with Advanced End-Stage Illness in the Emergency Department: An Observational Cohort Study

Background: Presentations to the emergency department (ED) by patients with end-of-life (EOL) conditions for their acute care needs are common. Objectives: The objective of this study was to identify and describe the ED management across presentations to the ED for EOL conditions. Design: Prospective observational cohort study. Settings/Subjects: Emergency physicians in two Canadian ED's were asked to identify presentations by adult patients with EOL conditions using a modified screening tool. Measurements: Patient characteristics and ED management for each presentation were collected through chart review by trained research assistants. Descriptive analyses were conducted as appropriate and bivariate comparisons of dichotomous and continuous variables were completed using χ² tests and using t test or Wilcoxon rank-sum test, respectively. Results: Physicians identified 663 ED presentations for EOL conditions, with advanced cancer (41%), dementia (23%), and chronic obstructive pulmonary disease (16%) being the most common EOL conditions. The majority of presentations involved consultations (77%), hospitalization (65%), and numerous investigations (97%), including blood work (97%) and imaging (92%). The majority of patients with EOL conditions had a history of ED visits (68%). Using a modified screening tool, 78% of presentations involved patients with unmet palliative care needs, but only 1% of presentations involved a palliative consultation or admission to a palliative care unit. Conclusion: Presentations to the ED for EOL conditions involve significant ED resources; however, only a handful of patients are referred to palliative services. Patients with EOL conditions are appropriate targets for palliative services and community support outside the ED.

Identifying a Clinical Risk Triage Score for Adult Emergency Department

Emergency triage is crucial for the treatment and prognosis of emergency patients, but its validity needs further improvement. The purpose of this study was to identify a risk score for adult triage. We conducted a regression analysis of physiological and biochemical data from 1,522 adult patients. A 60-point triage scoring model included temperature, pulse, systolic blood pressure, oxygen saturation, consciousness, dyspnea, admission mode, syncope history, chest pain or chest tightness, complexion, hematochezia or hematemesis, hemoptysis, white blood count, creatinine, bicarbonate, platelets, and creatine kinase. The area under curve in predicting ICU admission was 0.929 (95% CI [0.913-0.944]) for the derivation cohort and 0.911 (95% CI [0.884-0.938]) for the validation cohort. Four categories: critical level (≥13 points), severe level (6-12 points), urgency level (1-5 points), and sub-acute level (0 points) were divided, which significantly distinguished the severity of emergency patients.

Does pain severity predict stone characteristics or outcomes in emergency department patients with acute renal colic?

OBJECTIVES

After initial emergency department (ED) management of acute renal colic, recurrent or ongoing severe pain is the usual pathway to ED revisits, hospitalizations and rescue interventions. If index visit pain severity is associated with stone size or with subsequent failure of conservative management, then it might be useful in identifying patients who would benefit from early definitive imaging or intervention. Our objectives were to determine whether pain severity correlates with stone size, and to evaluate its utility in predicting important outcomes.

METHODS

We used administrative data and structured chart review to study all ED patients with CT proven renal colic at six hospitals in two cities over one-year. Triage nurses recorded arrival numeric rating scale (NRS) pain scores. We excluded patients with missing pain assessments and stratified eligible patients into severe (NRS 8-10) and less-severe pain groups. Stone parameters were abstracted from imaging reports, while hospitalizations and interventions were identified in hospital databases. We determined the classification accuracy of pain severity for stones >5mm and used multivariable regression to determine the association of pain severity with 60-day treatment failure, defined by hospitalization or rescue intervention.

RESULTS

We studied 2206 patients, 68% male, with a mean age of 49 years. Severe pain was 52.0% sensitive and 45.3% specific for larger stones >5mm. After multivariable adjustment, we found a weak negative association (adjusted OR =0.96) between pain severity and stone width. For each unit of increasing pain, the odds of a larger stone fell by 4%. Index visit pain severity was not associated with the need for hospitalization or rescue intervention within 60-days.

CONCLUSIONS

Pain severity is not helpful in predicting stone size or renal colic outcomes. More severe pain does not indicate a larger stone or a worse prognosis.

Comprehensive residency-based point-of-care ultrasound training program increases ultrasound utilization in the emergency department

Point-of-care ultrasonography (POCUS) is a prompt and simple tool for the urgent diagnosis and treatment of patients in the emergency department (ED). We developed a comprehensive residency-based POCUS training program for ED residents and determined its effect on ultrasound utilization in the ED.We conducted a retrospective cohort study in the ED of a university-affiliated medical center, to evaluate a centralized residency-based POCUS training course for ED residents, which included 12 core ultrasound applications, from July 2017 to June 2018. Each application comprised a combined lecture and hands-on practice session that lasted for 2 hours. Pre-tests and post-tests, including still image and video interpretation, were performed. The use of POCUS (number of ultrasound studies performed divided by the number of patients each resident saw in 1 year) among ED residents, before and after the POCUS training course (July 2016-June 2017 and July 2018-June 2019), was calculated and analyzed using the Wilcoxon signed-rank test.Sixteen residents participated and completed the entire training course. The post-test score was significantly better than the pre-test score, by a median of 12 points (P = .04). Utilization of POCUS among the ED residents increased significantly, from 0.15 ultrasound studies per patient per year to 0.41 ultrasound studies per patient per year (P < .01), after completion of the entire training course. Increased POCUS scanning percentages over the cardiac tissue, soft tissue, abdominal region, vascular system, procedural guidance, and ocular regions were also noted after providing the curriculum.Conducting a comprehensive POCUS education program may enhance POCUS utilization among residents in the ED.

Predictors of Hospitalization for Children With Croup, a Population-Based Cohort Study

OBJECTIVES

We sought to determine predictors of hospitalization for children presenting with croup to emergency departments (EDs), as well as predictors of repeat ED presentation and of hospital readmissions within 18 months of index admission. We also aimed to develop a practical tool to predict hospitalization risk upon ED presentation.

METHODS

Multiple deterministically linked health administrative data sets from Ontario, Canada, were used to conduct this population-based cohort study between April 1, 2006 and March 31, 2017. Children born between April 1, 2006, and March 31, 2011, were eligible if they had 1 ED visit with a croup diagnosis. Multivariable logistic regression was used to determine factors associated with hospitalization, subsequent ED visits, and subsequent croup hospitalizations. A multivariable prediction tool and associated scoring system were created to predict hospitalization risk within 7 days of ED presentation.

RESULTS

Overall, 1811 (3.3%) of the 54 981 eligible children who presented to an Ontario ED were hospitalized. Significant hospitalization predictors included age, sex, Canadian Triage and Acuity Scale score, gestational age at birth, and newborn distress. Younger patients and boys were more likely to revisit the ED for croup. Our multivariable prediction tool could forecast hospitalization up to a 32% probability for a given patient.

CONCLUSIONS

This study is the first population-based study in which predictors of hospitalization for croup based on demographic and historical factors are identified. Our prediction tool emphasized the importance of symptom severity on ED presentation but will require refinement before clinical implementation.

Consistency of triage scores by presenting complaint pre- and post-implementation of a real-time electronic triage decision support tool

OBJECTIVE

eCTAS is a real-time electronic decision-support tool designed to standardize the application of the Canadian Triage and Acuity Scale (CTAS). This study addresses the variability of CTAS score distributions across institutions pre- and post-eCTAS implementation.

METHODS

We used population-based administrative data from 2016-2018 from all emergency departments (EDs) that had implemented eCTAS for 9 months. Following a 3-month stabilization period, we compared 6 months post-eCTAS data to the same 6 months the previous year (pre-eCTAS). We included triage encounters of adult (≥17 years) patients who presented with 1 of 16 pre-specified, high-volume complaints. For each ED, consistency was calculated as the absolute difference in CTAS distribution compared to the average of all included EDs for each presenting complaint. Pre-eCTAS and post-eCTAS change scores were compared using a paired-samples t-test. We also assessed if eCTAS modifiers were associated with triage consistency.

RESULTS

There were 363,214 (183,231 pre-eCTAS, 179,983 post-eCTAS) triage encounters included from 35 EDs. Triage scores were more consistent (P < 0.05) post-eCTAS for 6 (37.5%) presenting complaints: chest pain (cardiac features), extremity weakness/symptoms of cerebrovascular accident, fever, shortness of breath, syncope, and hyperglycemia. Triage consistency was similar pre- and post-eCTAS for altered level of consciousness, anxiety/situational crisis, confusion, depression/suicidal/deliberate self-harm, general weakness, head injury, palpitations, seizure, substance misuse/intoxication, and vertigo. Use of eCTAS modifiers was associated with increased triage consistency.

CONCLUSIONS

eCTAS increased triage consistency across many, but not all, high-volume presenting complaints. Modifier use was associated with increased triage consistency, particularly for non-specific complaints such as fever and general weakness.

Mixed methods investigation of the use of telephone triage within UK veterinary practices for horses with abdominal pain: A Participatory action research study

BACKGROUND

Telephone triage is an integral part of modern patient care systems in human medicine, and a key component of veterinary practice care systems. There is currently no published research on telephone triage within the veterinary profession.

OBJECTIVE

To investigate current approaches to telephone triage of horses with abdominal pain (colic) in veterinary practice and develop new resources to support decision-making.

STUDY DESIGN

Participatory action research using mixed-methods approach.

METHODS

An online survey assessed current approaches to telephone triage of horses with colic in UK veterinary practices. Structured group and individual interviews were conducted with four equine client care (reception) teams on their experiences around telephone triage of colic. Evidence-based resources, including an information pack, decision flow chart and recording form, were developed and implemented within the practices. Participant feedback was obtained through interviews six months after implementation of the resources.

RESULTS

There were 116 participants in the online survey. Management and client care staff (53/116) felt less confident giving owner advice (p<0.01) and recognising critical indicators (p = 0.03) compared to veterinary surgeons and nurses (63/116). Thirteen themes were identified in the survey relating to owner advice; exercise and owner safety were most frequently mentioned, but conflicting guidance was often given. Fourteen client care staff were interviewed. They were confident recognising colic during a telephone conversation with an owner and identified the most common signs of critical cases as sweating and recumbency. The new resources received positive feedback; the decision flow chart and information on critical indicators were identified as most useful. After resource implementation, there was an increase in confidence in recognising critical cases and giving owners advice.

MAIN LIMITATIONS

Limited sample population.

CONCLUSIONS

This study described existing approaches to telephone triage, identified variations in advice given, and worked with client care teams to develop new resources to aid decision-making.

The utility of the 1-hour high-sensitivity cardiac troponin T algorithm compared with and combined with five early rule-out scores in high-acuity chest pain emergency patients

BACKGROUND

Although the 0/1 h high-sensitivity cardiac troponin T (0/1 hs-cTnT) algorithm and many risk scores have been validated for use in emergency departments (EDs), their utility in high-acuity ED patients has not been validated. We aimed to validate the 0/1 hs-cTnT algorithm and the HEART, TIMI, GRACE, T-MACS and NOTR risk scores before and after combining the 0/1 algorithm in high-acuity ED chest pain patients.

METHODS

A prospective observational study was conducted in the high-acuity ED of Siriraj Hospital, a tertiary hospital in Bangkok, Thailand. Adult patients with chest pain were enrolled between November 2018 and November 2019. The primary outcome was 30-day major adverse cardiac events (30-day MACE), defined as a composite of mortality, acute myocardial infarction, significant coronary stenosis and revascularization procedures.

RESULTS

Of 350 recruited patients, 59 (16.9%) developed 30-day MACE. For the 0/1 hs-cTnT algorithm, sensitivity and negative predictive value (NPV) were 91.3% (95%CI 79.2-97.6%) and 97.2% (95%CI 93.2-98.9%), respectively. Specificity and positive predictive value were 79.6% (95%CI 72.8-85.2%) and 53.9% (95%CI 46.2-61.3%), respectively. Of the risk scores, the HEART score had the highest area under the receiver operator characteristic curve (0.74 [95%CI 0.68-0.81]). Combining the 0/1 hs-cTnT algorithm, a TIMI score cut-off of ≤1 had the best sensitivity and NPV (both 100%) and identified the greatest proportion of patients (24.3%) suitable for safe discharge.

CONCLUSION

The 0/1 hs-cTnT algorithm may be feasible in Asian high-acuity ED patients. The HEART score outperformed other scores in predicting 30-day MACE. Combining the 0/1 hs-cTnT algorithm with a TIMI cut-off score ≤ 1 had the best rule-out performance.

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

INTRODUCTION

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The prevalence and health status of people with developmental disabilities in provincial prisons in Ontario, Canada: A retrospective cohort study

BACKGROUND

Data on the prevalence of developmental disabilities in people who experience imprisonment and on their characteristics are lacking.

METHODS

The present authors identified adults with developmental disabilities who were released from Ontario provincial prisons in 2010 and a general population comparator group using administrative data. The present authors examined demographic characteristics, morbidity and healthcare use.

RESULTS

The prevalence of developmental disabilities was 2.2% in the prison group (N = 52,302) and 0.7% in the general population (N = 10,466,847). The prevalence of psychotic illness, substance-related disorder and self-harm was higher among people in the prison group with developmental disabilities. People with developmental disabilities were more likely to have emergency department visits and hospitalizations in prison and in the year after release.

CONCLUSIONS

People with developmental disabilities are overrepresented in provincial prisons and have a high burden of disease. Strategies are indicated to prevent incarceration and to improve health.

Simulation-based training programme and preparedness testing for COVID-19 using system integration methodology

Background

COVID-19 pandemic is presenting serious challenges to the world’s healthcare systems. The high communicability of the COVID-19 necessitates robust medical preparedness and vigilance.

Objective

To report on the simulation-based training and test preparedness activities to prepare healthcare workers (HCWs) for effective and safe handling of patients with COVID-19.

Methodology

Two activities were conducted: simulation-based training to all HCWs and a full-scale unannounced simulation-based disaster exercise at King Fahad Medical City (KFMC). The online module was designed to enhance the knowledge on COVID-19. This module was available to all KFMC staff. The five hands-on practical part of the course was available to frontliner HCWs. The unannounced undercover simulated patients’ full-scale COVID-19 simulation-based disaster exercise took place in the emergency department over 3 hours. Six scenarios were executed to test the existing plan in providing care of suspected COVID-19 cases.

Results

2620 HCWs took the online module, 17 courses were conducted and 337 frontliner HCWs were trained. 94% of learners were satisfied and recommended the activity to others. The overall compliance rate of the full-scale COVID-19 disaster drill with infection control guidelines was 90%. Post-drill debriefing sessions recommended reinforcing PPE training, ensuring availability of different sizes of PPEs and developing an algorithm to transfer patients to designated quarantine areas.

Conclusion

Simulation-based training and preparedness testing activities are vital in identifying gaps to apply corrective actions immediately. In the presence of a highly hazardous contagious disease like COVID-19, such exercises are a necessity to any healthcare institution.

Interrater Reliability, Accuracy, and Triage Time Pre- and Post-implementation of a Real-Time Electronic Triage Decision-Support Tool

STUDY OBJECTIVE

The electronic Canadian Triage and Acuity Scale (eCTAS) is a real-time electronic triage decision-support tool designed to improve patient safety and quality of care by standardizing the application of the Canadian Triage and Acuity Scale (CTAS). The objective of this study is to determine interrater agreement of triage scores pre- and post-implementation of eCTAS.

METHODS

This was a prospective, observational study conducted in 7 emergency departments (EDs), selected to represent a mix of triage documentation practices, hospital types, and patient volumes. A provincial CTAS auditor observed triage nurses in the ED pre- and post-implementation of eCTAS and assigned an independent CTAS score in real time. Research assistants independently recorded triage time. Interrater agreement was estimated with κ statistics with 95% confidence intervals (CIs).

RESULTS

A total of 1,491 individual triage assessments (752 pre-eCTAS, 739 post-implementation) were audited during 42 7-hour triage shifts (21 pre-eCTAS, 21 post-implementation). Exact modal agreement was achieved for 567 patients (75.4%) pre-eCTAS compared with 685 patients (92.7%) triaged with eCTAS. With the auditor's CTAS score as the reference, eCTAS significantly reduced the number of patients over-triaged (12.0% versus 5.1%; Δ 6.9; 95% CI 4.0 to 9.7) and under-triaged (12.6% versus 2.2%; Δ 10.4; 95% CI 7.9 to 13.2). Interrater agreement was higher with eCTAS (unweighted κ 0.89 versus 0.63; quadratic-weighted κ 0.93 versus 0.79). Median triage time was 312 seconds (n=3,808 patients) pre-eCTAS and 347 seconds (n=3,489 patients) with eCTAS (Δ 35 seconds; 95% CI 29 to 40 seconds).

CONCLUSION

A standardized, electronic approach to performing triage assessments improves both interrater agreement and data accuracy without substantially increasing triage time.

Understanding irresponsible use of intensive care unit resources in the USA

Use of intensive care unit (ICU) resources in the USA far outpaces that of other countries. This increased use is not accompanied by superior clinical outcomes and is at times discordant with patient desires. This Series paper seeks to identify major drivers of ICU resource use in the USA, and to offer steps towards better aligning ICU resource use with clinical needs and patient preferences. After considering several factors, such as organisational, ethical, and economic factors, we suggest that there are four intersecting drivers of irresponsible use of ICU resources in the USA: first, excess ICU bed capacity and a scarcity of data to understand which patients that truly benefit from ICU compared with ward care; second, clinicians misinterpreting the goals and means of patient autonomy; third, an extreme fear of rationing by the general public; and fourth, fee-for-service driven use of advanced medical technologies and procedures that beget ICU expansion.

Over-triage occurs when considering the patient's pain in Korean Triage and Acuity Scale (KTAS)

Background

The Korean Triage and Acuity Scale (KTAS) was developed based on the Canadian Emergency Department Triage and Acuity Scale. In patients with pain, to determine the KTAS level, the pain scale is considered; however, since the degree of pain is subjective, this may affect the accuracy of KTAS. The purpose of this study was to evaluate the accuracy of KTAS in predicting patient's severity with the degree of pain used as a modifier.

Method

A retrospective observational cohort study was conducted in an urban tertiary hospital emergency department (ED). We investigated patients over 16 years old from January to June 2016. The patients were divided into the pain and non-pain groups according to whether the degree of pain was used as a modifier or not. We compared the predictive power of KTAS on the urgency of patients between the two groups. Acute area registration in the ED, emergency procedure, emergency operation, hospitalization, intensive care unit admission, and 7-day mortality were used as markers to determine urgent patients.

Results

Overall, 24,253 patients were included in the study, with 9,175 (37.8%) in the pain group. The proportions of patients with KTAS 1–3 were 61.4% in the pain and 75.6% in the non-pain groups. Among patients with KTAS 2–3, the proportion of urgent patients was higher in the non-pain group than the pain group (p<0.001). The odds ratios for urgent patients at each KTAS level revealed a more evident discriminatory power of KTAS for urgent patients in the non-pain group. The predictability of KTAS for urgent patients was higher in the non-pain group than the pain group (area under the curve; 0.736 vs. 0.765, p-value <0.001).

Conclusions

Considering the degree of pain with KTAS led to overestimation of patient severity and had a negative impact on the predictability of KTAS for urgent patients.

Sepsis now a priority: a quality improvement initiative for early sepsis recognition and care

Objective

To develop a triage-based screening algorithm and treatment order-sets aimed at improving the quality of care of all patients with sepsis presenting to our emergency department (ED).

Design

Retrospective cohort study conducted during a pre-intervention period from 1 April 2010 to 31 March 2011 and a post-intervention period from 1 September 2014 to 30 April 2015.

Setting

A large teaching hospital located in Toronto, Ontario, Canada with a 35-bed ED.

Participants

All patients meeting pre-specified sepsis criteria during the ED encounter.

Main Outcome Measures

Process of care measures included time to assessment by emergency physician, lactate measurement, blood culture collection, fluid and antibiotic administration. Intensive care unit (ICU) outcomes including admissions, length of stay (LOS) and deaths were reviewed.

Results

There were 346 patients pre-intervention, and 270 patients post-intervention. We significantly improved all process measures including mean time to antibiotics by 60 min (P = 0.003) and proportion of patients receiving fluid resuscitation (64.7% vs. 94.4%, P < 0.001). There was no significant difference in the number of patients admitted to ICU (P = 0.14). The median ICU LOS was shorter in the post-intervention group [2.0 days (interquartile range (IQR) 1.0-4.5 days) vs. 5.0 days (IQR 1.5-10.8 days), P = 0.04], and there was no difference in in-hospital mortality between groups (P = 0.27).

Conclusions

We have demonstrated that a triage-based sepsis screening tool results in expedited and consistent delivery of care, with a significant improvement in initial resuscitation measures.

Triage des patients à l’accueil d’une structure d’urgences. Présentation de l’échelle de tri élaborée par la Société française de médecine d’urgence : la FRench Emergency Nurses Classification in Hospital (FRENCH)

La Société française de médecine d’urgence (SFMU) a recommandé la création d’une échelle spécifique, unique au niveau national, pour le triage des patients à l’accueil d’une structure d’urgences, prenant en compte les spécificités de l’adulte et de l’enfant. La commission de l’évaluation et de la qualité de la SFMU a créé, à l’instar des échelles de tri internationales, une échelle de tri avec cinq niveaux de priorité croissante (tris 5 à 1, du moins urgent au plus urgent) auxquels correspondent des motifs de recours aux soins de complexité/sévérité croissante. Le tri 3 a été subdivisé en deux groupes pour distinguer (et prioriser) les patients qui ont au moins une comorbidité en rapport avec le motif de recours aux soins ou qui sont adressés par un médecin (3A) des autres patients (3B). L’échelle de tri FRENCH (FRench Emergency Nurses Classification in Hospital) a donc six niveaux de priorité. À chaque niveau de tri correspondent des motifs de recours aux soins fréquents en médecine d’urgence, des modulateurs de tri, une répartition rationnelle des circuits patients et un délai maximum d’attente avant prise en charge médicale, après évaluation par l’infirmier(ière) d’accueil. Une première évaluation de la FRENCH a montré qu’elle répondait aux objectifs du triage en facilitant le repérage de l’urgence complexe/sévère de façon fiable et reproductible. De nouvelles évaluations sont nécessaires dans d’autres structures d’urgences pour confirmer sa performance et favoriser son évolution.

The proportion, conditions, and predictors of emergency department visits that can be potentially managed by pharmacists with expanded scope of practice

BACKGROUND

Pharmacists have been shown to be beneficial for inclusion in emergency department (ED) services; however, little has been done to assess these benefits with pharmacists having even wider scopes of practice, including limited prescribing authority.

OBJECTIVES

The aims of this study were to determine the proportion of ED visits that can potentially be managed by pharmacists, the most prevalent conditions within these cases, and the factors associated with patients presenting with such cases to the ED.

METHODS

This was a retrospective quantitative cohort study using administrative databases from 2010 to 2017. Among all unscheduled ED visits in Ontario, all visits with a Family Practice Sensitive Condition and Canadian Triage and Acuity Scale score of IV or V were identified, in addition to conditions that can be managed by pharmacists with expanded scope. Logistic regression was performed to identify determinants of having a potentially pharmacist-manageable condition.

RESULTS

Of 34,550,020 ED visits identified, 12.4% (n = 4,293,807) were considered FPSC with CTAS IV or V. Of these, 1,494,887 (34.8%) were for conditions considered to be potentially manageable by pharmacists, representing 4.3% of all ED visits. The most frequent diagnoses observed were: acute pharyngitis, conjunctivitis, rash and other nonspecific skin eruption, otitis externa, cough, acute sinusitis, and dermatitis. Female gender, having a family physician or presenting with a CTAS of IV were associated with higher odds of presenting to the ED, while increased age and income were associated with lower odds.

CONCLUSIONS

Under an expanded scope, pharmacists could potentially have managed nearly 1.5 million cases presenting to the ED over the study period. The introduction of ED-based or community pharmacists practicing under an expanded scope may have a positive impact on overcrowding in EDs.

Reliability of the revised Swiss Emergency Triage Scale: a computer simulation study

Background

The Swiss Emergency Triage Scale (SETS) is a four-level emergency scale that previously showed moderate reliability and high rates of undertriage due to a lack of standardization. It was revised to better standardize the measurement and interpretation of vital signs during the triage process.

Objective

The aim of this study was to explore the inter-rater and test–retest reliability, and the rate of correct triage of the revised SETS.

Patients and methods

Thirty clinical scenarios were evaluated twice at a 3-month interval using an interactive computerized triage simulator by 58 triage nurses at an urban teaching emergency department admitting 60 000 patients a year. Inter-rater and test–retest reliabilities were determined using κ statistics. Triage decisions were compared with a gold standard attributed by an expert panel. Rates of correct triage, undertriage, and overtriage were computed. A logistic regression model was used to identify the predictors of correct triage.

Results

A total of 3387 triage situations were analyzed. Inter-rater reliability showed substantial agreement [mean κ: 0.68; 95% confidence interval (CI): 0.60–0.78] and test–retest almost perfect agreement (mean κ: 0.86; 95% CI: 0.84–0.88). The rate of correct triage was 84.1%, and rates of undertriage and overtriage were 7.2 and 8.7%, respectively. Vital sign measurement was an independent predictor of correct triage (odds ratios for correct triage: 1.29 for each additional vital sign measured, 95% CI: 1.20–1.39).

Conclusion

The revised SETS incorporating standardized vital sign measurement and interpretation during the triage process resulted in high reliability and low rates of mistriage.

Combining Unmanned Aerial Vehicles, and Internet Protocol Cameras to Reconstruct 3-D Disaster Scenes During Rescue Operations

Objective: Strong earthquakes often cause massive structural and nonstructural damage, timely assessment of the catastrophe related massive casualty incidents (MCIs) for deploying rescue resource are critical in order to minimize ongoing fatalities. A magnitude 6.6 earthquake struck southern Taiwan on February 6, 2016 (the so-called 02/06 Meinong earthquake). It led to 117 deaths and 522 injuries. Advanced technologies including aerial devices and innovation concept were adopted for more effective rescue efforts. We would like to share our innovative concept in MCIs experienced in 02/06 Meinong earthquake in 2016. Methods: A collapsed building, Weiguan residential apartment complex, was the most devastating building collapsed in Tainan, resulting in 115 people killed. Regional Emergency Medical Operational Centers (REMOCs), supervised by Taiwan Ministry of Health and Welfare, were activated immediately and collaborated with Tainan City government command center to initiate emergency rescue reliefs. Results: We, for the first time, attempted to use cyber devices including an internet-protocol camera and a multi-rotor unmanned aerial vehicle (UAV) equipped with a high-resolution digital camera used to acquire imagery during the rescue operation. Moreover, a photo-realistic 3-D model reconstructed by the acquired UAV imagery could provide real-time information from UAV to rescue team leaders in remote location for effectively deploying medical posts and emergency resources at scene. Conclusion: We proposed the concept of real-time UAV imagery for reconstructing photo-realistic 3-D model, which might greatly improve prehospital emergency management after disaster.

Early physical therapy intervention in gynaecological surgery: "Case series"

PURPOSE

To implement a physical therapy intervention protocol targeting patients admitted for gynaecological surgery to the gynaecological ward of XXXX Hospital.

METHOD

A prospective, cross-sectional and observational study was conducted with women admitted to the gynaecology ward, from June 2014 through June 2015. The study was divided into three phases with data on admissions to the gynaecology ward. A total of 565 women were included, corresponding to phases I (197), II (178) and III (190). The physical therapy staff implemented an early ambulation protocol as well as a mobility assessment.

RESULTS

The physical therapy protocol was implemented, and the rate of adherence was 100%. All participants received preoperative instruction on the importance of early mobilisation. On postoperative day 1, the participants in phase I walked a mean of 77.4 m. Following implementation of the physical therapy protocol, the walked distance increased to 292.6 m in phase II, followed by a slight decrease to a mean of 233 m in phase III.

CONCLUSIONS

The physical therapy protocol could be implemented, and the patients' adherence was satisfactory. Early ambulation can be optimised, and the participants began ambulation starting at 13 h after surgery.

Efficiency of Using Pediatrics Emergency Services and Triage Evaluation

OBJECTIVE

The aim of the study was to evaluate the pediatric emergency department (PED) in a main teaching hospital.

METHODS

Retrospective review of all children presented to PED at King Abdulaziz University Hospital from September to November 2014 was performed. We classified priority into the following 5 stages: 1, need resuscitation; 2, emergent; 3, urgent; 4, less urgent; and 5, nonurgent.

RESULTS

A total of 2567 children (58.9% boys) attended PED for 3 months. Toddler age group was the highest. Respiratory complaints were the commonest (36%), followed by gastrointestinal complaints (20%). The majority were classified as priority 3 (52.3%) and priority 4 (30.7%). The admission rate was 12.3% and the mean (range) length of stay (LOS) was 5.85 (0.2-25) hours. Saudi nationals were less likely to wait for 5 hours or longer, less likely to be admitted, but more likely to leave PED without being evaluated. There was a negative correlation between higher priorities and time from triage to PED. There was a positive correlation between the higher priorities and LOS.

CONCLUSIONS

Most children who were seen in PED were priority 3 and therefore needed to be seen. However, a considerable percentage of priority 4 and 5 could have been seen in ambulatory clinics. Most lower priorities were Saudi nationals who were most likely to leave without being seen. Prolonged LOS, overcrowding, and high percentage of admission are the main challenges.

Physician follow-up and long-term use of evidence-based medication for patients with hypertension who were discharged from an emergency department: a prospective cohort study

BACKGROUND

More than 25% of the population has hypertension. The number of patients seeking care for hypertension in emergency departments has increased by more than 60% in the last decade, with less than 10% of these patients subsequently admitted to hospital. Managing physicians recommend early follow-up to patients who are discharged from the emergency department, but there is a paucity of literature assessing the impact or timing of follow-up on patient outcomes.

METHODS

Using a population-based cohort design, we included patients more than 65 years of age who were discharged from an Ontario emergency department with a primary diagnosis of hypertension between 2007 and 2014. We identified 2 cohorts: an incident cohort, and a cohort in which patients were on no more than 1 class of evidence-based antihypertensive medication at the time of presentation. Using logistic regression, we assessed the association of early follow-up care (within 7 d) and basic care (8-30 d), compared with no care within 30 days, on patient use of a new evidence-based antihypertensive medication 1 year later.

RESULTS

Our study included 2088 patients with a new diagnosis of hypertension (the first cohort), and 6420 patients in the second cohort. Of patients with new diagnoses, 48.2% and 30.2% obtained early and basic follow-up care, respectively, compared with 50.0% and 30.9% of patients in the second cohort. Compared with patients without follow-up care within 30 days, the adjusted odds of filling an evidence-based antihypertensive medication prescription 1 year later in the incident group were 2.36 (95% confidence interval [CI] 1.86-2.99) for those who received early care, and 2.00 (95% CI 1.55-2.58) for those who received basic care. The adjusted odds in the second cohort were 2.12 (95% CI 1.84-2.43) and 1.96 (95% CI 1.69-2.27), respectively.

INTERPRETATION

Early follow-up care after leaving an emergency department with a diagnosis of hypertension was associated with improved long-term use of evidence-based antihypertensive medication. As patients increasingly present to the emergency department for hypertension, a formal, timely follow-up care system could improve patient use of evidence-based antihypertensive medication.

Characteristics and outcomes of older emergency department patients assigned a low acuity triage score

Objective

Although older patients are a high-risk population in the emergency department (ED), little is known about those identified as “less acute” at triage. We aimed to describe the outcomes of patients ages 65 years and older who receive low acuity triage scores.

Methods

This health records review assessed ED patients who were ages 65 years and above or ages 40 to 55 years (controls) who received a Canadian Triage Acuity Scale score of 4 or 5. Data collected included patient demographics, ED management, disposition, and a return visit or hospital admission at 14 days. Data were analysed descriptively and chi-square testing performed. A pre-planned stratified analysis of patients ages 65 to 74, 75 to 84, and 85 and older was conducted.

Results

Three hundred fifty older patients with a mean age of 76.5 years and 150 control patients were included. Most patients presented with musculoskeletal or skin complaints and were triaged to the ambulatory care area. Older patients were significantly more likely than controls to be admitted on the index visit (5.0% v. 0.3%, p=0.016) and on re-presentation (4.0% v. 0.7%, p=0.045). In a subgroup analysis, patients ages 85 years and above were most likely to be admitted (8.9%, p=0.003).

Conclusions

Older patients who present to the ED with issues labelled as “less acute” at triage are 16 times more likely to be admitted than younger controls. Patients ages 85 years and up are the primary drivers of this higher admission rate. Our study indicates that even “low acuity” elders presenting to the ED are at risk for re-presentation and admission within 14 days.

Assessment of consultation impact on emergency department operations through novel metrics of responsiveness and decision-making efficiency

OBJECTIVES

Requests for specialty consultation are common in emergency departments (EDs) and often contribute to delays in throughput. Our objectives were to describe the contribution of the consultation process to total ED length of stay (LOS) through novel metrics and illustrate causes of delay.

METHODS

We conducted a prospective cross-sectional study at three Canadian tertiary care centres. Adult ED patients with requested medical/surgical consultations were enrolled. We created original metric intervals: total consultation time (TCT) defined as the interval from the initial consultation request to the disposition decision, consult response time (CRT) from the request to the consultant arrival, and decision-making interval (DMI) from arrival to the disposition decision. The consultation impact index (CII) was defined as the percentage of ED LOS consumed by the TCT. Reasons for delay were documented if time stamps exceeded preset benchmarks.

RESULTS

The median TCT for 285 patients was 138 minutes (interquartile range [IQR]: 82-239 minutes), whereas the median total ED LOS was 778 minutes (IQR 485-1,274 minutes). The median CRT was 55 minutes (IQR 21-115 minutes), and the median DMI was 58 minutes (IQR 25-126 minutes). The CII measured 26% (95% CI 23-28). Major contributors to consultation delay included urgent ward issues, simultaneous ED consultations, and the need for additional laboratory or radiographic investigations.

CONCLUSION

The consultation process is highly variable and has an important impact on ED LOS. We describe novel measures related to consultation performance and provide an analysis of what causes delays. These results can be used to seek improvements in the consulting process.

Is a mobile emergency severity index (ESI) triage better than the paper ESI?

This study aims to evaluate the mobile emergency severity index (ESI) tool in terms of validity compared with the original ESI triage. The original ESI and mobile ESI were used with patients at the Department of Emergency Medicine, Ramathibodi Hospital, Thailand. Eligible patients were evaluated by sixth-year medical students/emergency physicians using either the original or mobile ESI. The ESI results for each patient were compared with the standard ESI. Concordance and kappa statistics were calculated for pairs of the evaluators. There were 486 patients enrolled in the study; 235 patients (48.4%) were assessed using the mobile ESI, and 251 patients (51.6%) were in the original ESI group. The baseline characteristics of patients in both groups were mostly comparable except for the ED visit time. The percentages of concordance and kappa statistics in the original ESI group were lower than in the mobile group in all three comparisons (medical students vs gold standard, emergency physicians vs gold standard, and medical students vs emergency physicians). The highest kappa in the original ESI group is 0.69, comparing emergency physicians vs gold standard, while the lowest kappa in the application group is 0.84 comparing the medical students vs gold standard. Both medical students and emergency physicians are more confident with the mobile ESI application triage. In conclusion, the mobile ESI has better inter-rater reliability, and is more user-friendly than the original paper form.

A cross-sectional study of ethnicity-based differences in treatment seeking for symptoms of acute coronary syndrome

BACKGROUND

Patient-related delays in acquiring medical care for symptoms of acute coronary syndrome remain unacceptably long. Many clinical and sociodemographic characteristics associated with treatment-seeking delay are known; however, ethnicity has not been extensively evaluated.

OBJECTIVE

The purpose of this study was to examine ethnicity-based differences in the time-to-treatment-seeking intervals of patients experiencing symptoms of acute coronary syndrome.

METHOD

Data for this descriptive study were collected for the larger Acute Coronary Syndrome Care in Emergency Departments (ASCEND) study. The larger study is a prospective, observational study in which patients presenting to hospital emergency departments and triaged as having symptoms suggestive of acute coronary syndrome are identified. The primary outcome of this study, the time-to-treatment-seeking interval, was defined as the time between symptom onset and treatment seeking. The predictor variable, ethnicity, was measured with self-reported data and categorised as Chinese, South Asian, or 'Other' ethnic group. Participants in the 'Other' ethnic group were predominantly of European ancestry. Univariate and multivariate analyses were undertaken, along with nonparametric testing.

RESULTS

The study sample consisted of 419 participants: 36 Chinese, 126 South Asian, and 257 'Other' participants. The median time-to-treatment-seeking interval, for the total sample, was 180 minutes. A Kruskal-Wallis test demonstrated no statistically significant differences in the time-to-treatment-seeking intervals by ethnicity.

CONCLUSION

No ethnicity-based differences in the time-to-treatment-seeking intervals for symptoms of acute coronary syndrome were found. It is possible that Chinese and South Asian patients living in western countries are more aware of the potential signs and symptoms of acute coronary syndrome or feel more confident to access healthcare services than they have been previously.

Can an emergency department clinical "triggers" program based on abnormal vital signs improve patient outcomes?

BACKGROUND

Because abnormal vital signs indicate the potential for clinical deterioration, it is logical to make emergency physicians immediately aware of those patients who present with abnormal vital signs.

OBJECTIVES

To determine if a clinical triggers program in the emergency department (ED) setting that utilized predetermined abnormal vital signs to activate a rapid assessment by an emergency physician-led multidisciplinary team had a measurable effect on inpatient hospital metrics.

METHODS

The study design was a retrospective pre and post intervention study. The intervention was the implementation of an ED clinical "triggers" program. Abnormal vital sign criteria that warranted a trigger response included: heart rate 130 beats/minutes, respiratory rate 30 breaths/minute, systolic blood pressure <90 mm Hg, or oxygen saturation <90% on room air. The primary outcome investigated was the median days admitted with secondary outcomes of median days in special care unit, in-hospital 30-day mortality and proportion of patients who required an upgrade in inpatient care level.

RESULTS

There was no difference in median days admitted for inpatient care (3.8 v. 4.0 days, p=0.21) or median days spent in a special care unit (5.0 v. 5.6 days, p=0.42) between the groups. There was no difference in the percentage of in-hospital patient deaths (6.0% v. 5.6%, p=0.66) or frequency of upgrade in level of care within 24 hours (4.9% v. 4.0%, p=0.52).

CONCLUSIONS

In our study, the implementation of an ED clinical triggers program did not result in a significant change in measured inpatient outcomes.

Evaluating the Effectiveness of a Nurse Practitioner-Led Outreach Program for Long-Term-Care Homes

An observational prospective cohort study was conducted on 1,353 observations from a convenience sample of 311 long-term-care (LTC) residents to evaluate the effectiveness of a nurse practitioner-led outreach program on the health outcomes, emergency department (ED) transfers, and hospital admissions of LTC residents. The results show that ED transfers by the NPs were 27% less likely to be non-urgent than transfers made by MDs (OR = .73; 95% CI .54-.97) and that ED transfers by the NPs were 3.23 times more likely to be admitted to hospital than transfers by MDs (OR = 3.23; 95% CI 1.17-8.90). These findings highlight the potential benefits of the NP-led outreach program for LTC residents and for the health-care system.

Implementation of a Pediatric Emergency Triage System in Xiamen, China

Background:

Pediatric emergency rooms (PERs) in Chinese hospitals are perpetually full of sick and injured children because of the lack of sufficiently developed community hospitals and low access to family physicians. The aim of this study was to evaluate the clinical value of a new five-level Chinese pediatric emergency triage system (CPETS), modeled after the Canadian Triage System and Acuity Scale.

Methods:

In this study, we compared CPETS outcomes in our PER relative to those of the prior two-level system. Patients who visited our PER before (January 2013–June 2013) and after (January 2014–June 2014) the CPETS was implemented served as the control and experimental group, respectively. Patient flow, triage rates, triage accuracy, wait times (overall and for severe patients), and patient/family satisfaction were compared between the two groups.

Results:

Relative to the performance of the former system experienced by the control group, the CPETS experienced by the experimental group was associated with a reduced patient flow through the PER (Cox-Stuart test, t = 0, P < 0.05), a higher triage rate (93.40% vs. 90.75%; χ² = 801.546, P < 0.001), better triage accuracy (96.32% vs. 85.09%; χ² = 710.904, P < 0.001), shorter overall wait times (37.30 ± 13.80 min vs. 41.60 ± 15.40 min; t = 11.27, P < 0.001), markedly shorter wait times for severe patients (2.07 [0.65, 4.11] min vs. 3.23 [1.90,4.36] min; z = –2.057, P = 0.040), and higher family satisfaction rates (94.23% vs. 92.21%; χ² = 321.528, P < 0.001).

Conclusions:

Implementing the CPETS improved nurses’ abilities to triage severe patients and, thus, to deliver the urgent treatments more quickly. The system shunted nonurgent patients to outpatient care effectively, resulting in improved efficiency of PER health-care delivery.

Current management practices for patients presenting with low back pain to a large emergency department in Canada

Background

Low back pain (LBP) is one of the leading causes of disability. Presentations to the emergency department (ED) are common and consume significant healthcare resources. However, treatment of patients with LBP is variable and highly physician dependent. Our study objective was to describe the demographic and clinical characteristics of patients presenting to the ED with LBP, the diagnostic strategies employed by ED physicians, and the subsequent management.

Methods

We conducted a retrospective study using clinical and electronic health data at the Queen Elizabeth II Health Science Center’s Charles V. Keating Emergency and Trauma Centre. We selected a simple random sample of 325 adult participants who presented to the ED with non-urgent LBP over a six-year period. Data for all participants, including demographic characteristics, diagnostic testing, and interventions received, was retrieved from the Emergency Department Information System database and from patient charts.

Results

Participants had a median age of 43 years and 55% were female. The majority (92.9%) were acute presentations of LBP (less than 4 weeks of duration), with an assigned Canadian Triage Acuity Scale score of 3-4 (92.4%). A range of pain intensity scores were reported, mostly without associated neurological symptoms (81%) or sciatica (68%). At triage, pain score was most commonly reported as moderate intensity (57.6%), followed by severe (32.6%) and mild (9.9%). Documentation of pain rating during assessment was similar (moderate 68.6%; severe 25.9%; mild 5.6%). Laboratory investigations were conducted on 22.5% of participants and 30% received an imaging study. Medications were delivered to 59.4% of participants during their stay in the ED. Of the medications administered, ibuprofen (28.3%), hydromorphone (24.9%), and acetaminophen (21.5%) were the most frequent. Almost all (94%) had a record of having a primary care provider in EDIS and referrals back to the participant’s family physician were recorded for 41.2% of non-urgent LBP encounters.

Conclusions

We presented a complete description of patient characteristics, LBP descriptors, and health service use for a random sample of non-urgent LBP patients presenting to the ED. This has allowed for a better understanding of patients who seek care in the ED for their non-urgent LBP.

Emergency Department Return Visits Within a Large Geographic Area

BACKGROUND

Return visits to the emergency department (RTED) contribute to overcrowding and may be a quality of care indicator. Previous studies focused on factors predicting returns to and from the same center. Little is known about RTEDs across a range of community and specialty hospitals within a large geographic area.

OBJECTIVE

We sought to measure the frequency of pediatric RTEDs and describe their directional pattern across centers in a large catchment area.

METHODS

We conducted a multicenter, retrospective cross-sectional study of pediatric emergency visits in the Vancouver lower mainland within 1 year. Visits were linked across study sites, including one pediatric quaternary care referral center and 17 sites ranging from large regional centers to smaller community emergency departments (EDs). Returns were defined as subsequent visits to any site with a compatible diagnosis within 7 days of an index visit.

RESULTS

Among a total of 139,278 index ED visits by children, 12,133 (8.7% [95% confidence interval 8.6-8.9%]) were associated with 14,645 return visits to an ED. Three quarters of all index visits occurred at a general ED center, of which 8.9% had at least one RTED and 22% of these returns occurred at the pediatric ED (PED). Among PED index visits, 8.2% had at least one RTED and 13.6% of these returned to a general center. Overall, 38.9% of all RTEDs occurred at the PED. Multivariate regression did not identify any statistically significant association between ED crowding measures and likelihood of RTEDs.

CONCLUSIONS

Compared to single-center studies, this study linking hospitals within a large geographic area identified a higher proportion of RTEDs with a disproportionate burden on the PED.

Emergency severity index compared with 4-level triage at the emergency department of Ramathibodi University Hospital

Background

Emergency department (ED) triage is important for categorizing and prioritizing patients. Effective triage may assist in crowd reduction in the ED and appropriate patient management. There are several systems, including the 5-level Emergency Severity Index (ESI) and the 4-level Ramathibodi-nurse triage. Currently, there are limited data by which to compare the 5- versus 4-level triage; particularly on health outcomes, such as length of stay in the ED, mortality, and resource needs.

Objective

To compare the accuracy of 5- and 4-level triage in an ED.

Method

This observational study was conducted on a cross-section of patients in the ED at Ramathibodi Hospital of Mahidol University, Bangkok, Thailand. Eligible patients were those who visited the ED and were evaluated by ESI and nurse triage. Each evaluation was blinded to the results of the other. Discrimination performance between the 5- and 4-level triage was compared by using the area under a receiver operating characteristic (ROC) curve and concordance statistic for prediction of life saving intervention. Net reclassification improvement (NRI) of the 5-level ESI over the 4-level triage was performed.

Result

Study criteria were met by 520 patients. The areas under the ROC curves of the ESI and nurse triage on life-saving intervention were 92.2% (95% confidence intervals were 87.3%, 96.9%) and 81.3% (95% CI 75.2%, 87.3%), respectively. Areas under the ROC curve differed significantly (P < 0.001). The overall reclassification improvement was 42.4%.

Conclusion

The 5-level emergency severity index was more accurate than the 4-level triage in terms of lifesaving intervention.

A determination of emergency department pre-triage times in patients not arriving by ambulance compared to widely used guideline recommendations

OBJECTIVES

Emergency department (ED) lengths of stay are measured from the time of patient registration or triage. The time that patients wait in line prior to registration and triage has not been well described. We sought to characterize pre-triage wait times and compare them to recommended physician response times, as per the Canadian Triage and Acuity Scale (CTAS).

METHODS

This observational study documented the time that consenting patients entered the ED and the time that they were formally registered and triaged. Participants' CTAS scores were collected from the electronic record. Patients arriving to the ED by ambulance were excluded.

RESULTS

A total of 536 participants were timed over 13 separate intervals. Of these, 11 left without being triaged. Participants who scored either CTAS 1 or 2 (n=53) waited a median time of 3.1 (interquartile range [IQR]: 0.43, 11.1) minutes. Patients triaged as CTAS 3 (n=187) waited a median of 11.4 (IQR: 1.6, 24.9) minutes, CTAS 4 (n=139) a median of 16.6 (IQR: 6.0, 29.7) minutes, and CTAS 5 (n=146) a median of 17.5 (IQR: 6.8, 37.3) minutes. Of patients subsequently categorized as CTAS 1 or 2, 20.8% waited longer than the recommended time-to-physician of 15 minutes to be triaged.

CONCLUSIONS

All urban EDs closely follow patients' wait times, often stratified according to triage category, which are assumed to be time-stamped upon a patient's arrival in the ED. We note that pre-triage times exceed the CTAS recommended time-to-physician in a possibly significant proportion of patients. EDs should consider documenting times to treatment from the moment of patient arrival rather than registration.

A Decision support system (DSS) for municipal nurses encountering health deterioration among older people

Background

This study is part of a larger project called ViSam and includes testing of a decision support system developed and adapted for older people on the basis of M (R) ETTS (Rapid Emergency Triage and Treatment System). The system is designed to allow municipal nurses to determine the optimal level of care for older people whose health has deteriorated. This new system will allow more structured assessment, the patient should receive optimal care and improved data transmission to the next caregiver.

Methods

This study has an explanatory approach, commencing with quantitative data collection phase followed by qualitative data arising from focus group discussions over the RNs professional experience using the Decision Support system. Focus group discussions were performed to complement the quantitative data to get a more holistic view of the decision support system.

Results

Using elements of the decision support system (vital parameters for saturation, pain and affected general health) together with the nurses' decision showed that 94 % of the older persons referred to hospital were ultimately hospitalized. Nurses felt that they worked more systematically, communicated more effectively with others and felt more professional when using the decision support system.

Conclusions

The results of this study showed that, with the help of a decision support system, the correct patients are sent to the Emergency Department from municipal home care. Unnecessary referrals of older patients that might lead to poorer health, decreased well-being and confusion can thus be avoided. Using the decision support system means that healthcare co-workers (nurses, ambulance/emergency department/district doctor/SOS alarm) begin to communicate more optimally. There is increased understanding leading to the risk of misinterpretation being reduced and the relationship between healthcare co-workers is improved. However, the decision support system requires more extensive testing in order to enhance the evidence base relating to the vital parameters among older people and the use of the decision support system.

Importance of respiratory rate for the prediction of clinical deterioration after emergency department discharge: a single-center, case-control study

Aim

The purpose of the present study was to investigate the predictors of clinical deterioration soon after emergency department (ED) discharge.

Methods

We undertook a case–control study using the ED database of the Nagano Municipal Hospital (Nagano, Japan) from January 2012 to December 2013. We selected adult patients with medical conditions who revisited the ED with deterioration within 2 days of ED discharge (deterioration group). The deterioration group was compared with a control group.

Results

During the study period, 15,724 adult medical patients were discharged from the ED. Of these, 170 patients revisited the ED because of clinical deterioration within 2 days. Among the initial vital signs, respiratory rate was less frequently recorded than other vital signs (P < 0.001 versus all other vital signs in each group). The frequency of recording each vital sign did not differ significantly between the groups. Overall, patients in the deterioration group had significantly higher respiratory rates than those in the control group (21 ± 5/min versus 18 ± 5/min, respectively; P = 0.002). A binary logistic regression analysis revealed that respiratory rate was an independent risk factor for clinical deterioration (unadjusted odds ratio, 1.15; 95% confidence interval, 1.04−1.26; adjusted odds ratio, 1.15; 95% confidence interval, 1.01−1.29).

Conclusions

An increased respiratory rate is a predictor of early clinical deterioration after ED discharge. Vital signs, especially respiratory rate, should be carefully evaluated when making decisions about patient disposition in the ED.

Prehospital Application of the Canadian Triage and Acuity Scale by Emergency Medical Services

OBJECTIVES

Triage is fundamental to emergency patient assessment. Effective triage systems accurately prioritize patients and help predict resource utilization. CTAS is a validated five-level triage score utilized in Emergency Departments (EDs) across Canada and internationally. Historically CTAS has been applied by triage nurses in EDs. Observational evidence suggests that the CTAS might be implemented reliably by paramedics in the prehospital setting. This is the first system-wide assessment of CTAS interrater reliability between paramedics and triage nurses during clinical practice.

METHODS

Variables were extracted from hospital and EMS databases. EMS providers determined CTAS on-scene, CTAS pre-transport, and CTAS on-arrival at hospital for each patient (N=14,378). The hospital arrival EMS CTAS (CTAS arrival ) score was compared to the initial nursing CTAS score (CTAS initial ) and the final nursing CTAS score (CTAS final ) incuding nursing overrides. Interrater reliability between ED CTAS initial and EMS CTAS arrival scores was assessed. Interrater reliability between ED CTAS final and EMS CTAS arrival scores, as well as proportion of patient encounters with perfect or near-perfect agreement, were evaluated.

RESULTS

Our primary outcome, interrater reliability [kappa=0.437 (p<0.001, 95% CI 0.421-0.452)], indicated moderate agreement. EMS CTAS arrival and ED CTAS initial scores had an exact or within one point match 84.3% of the time. The secondary interrater reliability outcome between hospital arrival EMS CTAS (CTAS arrival ) score and the final ED triage CTAS score (CTAS final ) showed moderate agreement with kappa =0.452 (p<0.001, 95% CI 0.437-0.466).

CONCLUSIONS

Interrater reliability of CTAS scoring between triage nurses and paramedics was moderate in this system-wide implementation study.

Predictors of patient satisfaction in an emergency care centre in central Saudi Arabia: a prospective study

Aim

This study aimed to (i) assess the level of patient satisfaction and its association with different sociodemographic and healthcare characteristics in an emergency care centre (ECC) in Saudi Arabia and (ii) to identify the predictors of patients' satisfaction.

Methods

A prospective cohort study of 390 adult patients with Canadian triage category III and IV who visited ECC at King Abdulaziz Medical City, Riyadh, Saudi Arabia, between 1 July and end of September 2011 was conducted. All patients were followed up from the time of arrival at the front desk of ECC until being seen by a doctor, and were then interviewed. Patient satisfaction was measured using a previously validated interview-questionnaire, within two domains: clarity of medical information and relationship with staff. Patient perception of health status after as compared with before the visit, and overall life satisfaction were also measured. Data on patient characteristics and healthcare characteristics were collected. Multiple linear regression analysis was used, and significance was considered at p≤0.05.

Results

One-third (32.8%) of patients showed high level of overall satisfaction and 26.7% were unsatisfied, with percentage mean score of 70.36% (17.40), reflecting moderate satisfaction. After adjusting for all potential confounders, lower satisfaction with the ED visit was significantly associated with male gender (p<0.001), long waiting time (p=0.032) and low perceived health status compared with status at admission (p<0.001). Overall life satisfaction was not a significant predictor of patient satisfaction.

Conclusions

An appreciation of waiting time as the only significant modifiable risk factor of patient satisfaction is essential to improve the healthcare services, especially at emergency settings.

A Population-Based Analysis of Outcomes in Patients With a Primary Diagnosis of Hypertension in the Emergency Department

STUDY OBJECTIVE

Patients treated primarily for hypertension are common in the emergency department (ED). The outcomes of these patients who were given a primary ED diagnosis of hypertension have not been described at a population level. In this study, we describe the characteristics and outcomes of these patients, as well as changes over time.

METHODS

This retrospective cohort study used linked health databases from the province of Ontario, Canada, to assess ED visits made between April 1, 2002, and March 31, 2012, with a primary diagnosis of hypertension. We determined the annual number of visits, as well as the age- and sex-standardized rates. We examined visit disposition and assessed mortality outcomes and potential hypertensive complications at 7, 30, 90, and 365 days and at 2 years subsequent to the ED visit.

RESULTS

There were 206,147 qualifying ED visits from 180 sites. Visits increased by 64% between 2002 and 2012, from 15,793 to 25,950 annual visits, respectively. The age- and sex-standardized rate increased from 170 per 100,000 persons to 228 per 100,000 persons during the same period, a 34% increase. Eight percent of visits ended in hospitalization, but this proportion decreased from 9.9% to 7.1% during the study period. Mortality was very low: less than 1% within 90 days, 2.5% within 1 year, and 4.1% within 2 years. Among subsequent hospitalizations for potential hypertensive complications, stroke was the most frequent admitting diagnosis, but the frequency was still less than 1% at 1 year. Together hospitalizations for stroke, heart failure, acute myocardial infarction, atrial fibrillation, renal failure, hypertensive encephalopathy, and dissection were less than 1% at 30 days.

CONCLUSION

The number of visits made primarily for hypertension has increased significantly during the last decade. Although some of the increase is due to aging of the population, other forces are contributing to it as well. Subsequent mortality and complication rates are low and have declined. With current practice patterns, the feared complications of hypertension are extremely infrequent.

Implementation of the Canadian Emergency Department Triage and Acuity Scale (CTAS) in an Urgent Care Center in Saudi Arabia

OBJECTIVES

The objectives of the study is to review and assess the implementation of the applied modified five-level triage and acuity scale triage system in AL-Yarmook Urgent Care Center (UCC), King Abdulaziz Residential City, Riyadh, Saudi Arabia.

METHOD

An observational cross-sectional study was conducted, where a data collection sheet was designed and distributed to triage nurses. The data collection was done during the triage process and was directly observed by the co-investigator. The triage system was reviewed by measuring three time intervals as quality indicators: time before triage (TBT), time before being seen by physician (TBP), and total length of stay (TLS) taking in consideration the timing of presentation and the level of triage.

RESULTS

A total of 187 patients visiting the UCC during December 2014 were included. There was an almost equal distribution of males 98 (52 %) and females 89 (48 %) with most of the patients being in the age group of 14 years and younger (n = 85, 46 %). The visits of the patients were classified according to the level of triage from patients to be seen immediately by the physician to those who had been triaged out. Overall, 173 patients (92.5 %) were seen by the physician in a timely manner according to triage guidelines, while 14 patients (7.5 %) were not. The mean time was 5.36 min in TBT, 22.6 min in TBP, and 59 min in TLS. The median time to be seen by the physician was significantly greater (p = 0.001) for the urgent cases on the weekends (25 min; IQR, 21,30) as compared to the weekdays (17 min; IQR, 14,21). Generally, the results did not show significant increases in TBT, TBP, the number of patients not seen at the proper time, or referral and admission rates during weekends.

CONCLUSION

The Canadian Emergency Department Triage and Acuity Scale (CTAS) is adaptable to countries beyond Canada and can be implemented successfully. The applied CTAS triage system in Al-Yarmouk UCC in Riyadh, Saudi Arabia, is considered to be well applied. Overall, urgent cases have been seen by physicians in a timely manner according to the triage system, and there was no delay in the management of critical cases which need prompt attention.

Variations in Resource Intensity and Cost Among High Users of the Emergency Department

OBJECTIVES

High users of emergency department (ED) services are often identified by number of visits per year, with little exploration of the distribution/pattern of visits over time. The purpose of this study was to examine patient- and encounter-level factors and costs related to periods of short-term resource intensity among high users of the ED within a tertiary care teaching facility.

METHODS

We identified all adults with at least three visits to the Ottawa Hospital ED within a 1-year period from April 1, 2012, to March 31, 2013. Within this high-user cohort, we then measured intensity of use by calculating average daily visit rates to identify individuals with a cluster of ED visits. Those with at least three ED visits/7 days at any point during follow-up were considered patients with clustered ED use (i.e., a period of short-term resource intensity). Detailed clinical and administrative data were used to compare patient- and encounter-level characteristics and cost profiles between the clustered and nonclustered groups. Analyses were repeated using varying cut points to define high users (at least five and at least eight visits per year).

RESULTS

Of the 16,153 patients identified as high ED users during the study period, 13.5% had their visits clustered within a short period of time. These clustered users were more likely to be homeless, to require psychiatric services, and to leave without being seen by a physician and less likely to be admitted to the hospital. Approximately one in three (31.2%) high ED users with clustered visits returned for the same medical problem (namely pain-related disorders, shortness of breath, and cellulitis) within a 1-week period. Similar trends were observed when the high-user cohort was restricted to those with at least five and at least eight ED visits/year. Finally, patients with short-term intensity periods had lower direct and indirect costs per encounter than those without.

CONCLUSIONS

Using a novel methodology that accounts for both number and intensity of ED encounters over time, we were able to identify specific subpopulations of high ED users. Further work is required to determine if this methodology has utility for targeting care pathways within this heterogeneous and high-risk patient group.

Emergency department use by people with HIV in Ontario: a population-based cohort study

BACKGROUND

Emergency department use may reflect poor access to primary care. Our objective was to compare rates and causes of emergency department use between adults living with and without HIV.

METHODS

We conducted a population-based study involving Ontario residents living with and without HIV between Apr. 1, 2011, and Mar. 31, 2012. We frequency matched adults with HIV to 4 HIV-negative people by age, sex and census division, and used random-effects negative binomial regression to compare rates of emergency department use. We classified visits as low urgency or high urgency, and also examined visits for ambulatory care sensitive conditions. Hospital admission following an emergency department visit was a secondary outcome.

RESULTS

We identified 14 534 people with HIV and 58 136 HIV-negative individuals. Rates of emergency department use were higher among people with HIV (67.3 v. 31.2 visits per 100 person-years; adjusted rate ratio 1.58, 95% confidence interval [CI] 1.51-1.65). Similar results were observed for low-urgency visits. With the exception of hypertension, visit rates for ambulatory care sensitive conditions were higher among people with HIV. People with HIV were also more likely than HIV-negative individuals to be admitted to hospital following an emergency department visit (adjusted odds ratio 1.55, 95% CI 1.43-1.69).

INTERPRETATION

Compared with HIV-negative individuals, people with HIV had high rates of emergency department use, including potentially avoidable visits. These findings strongly support the need for comprehensive care for people with HIV.

Emergency Department Revisits by Urban Immigrant Children in Canada: A Population-Based Cohort Study

OBJECTIVES

To examine the relationship between family immigrant status and unscheduled 7-day revisits to the emergency department (ED) and to test this relationship within subgroups of immigrants by visa class (family, economic, refugee), native tongue on landing in Canada, and region of origin.

STUDY DESIGN

Population-based cohort study that used multiple linked health administrative and demographic datasets of landed immigrant and nonimmigrant children (<18 years) in urban Ontario who visited an ED and were discharged between April 2003 and March 2010. Logistic regression was used to model the odds of 7-day ED revisits with family immigrant status, with adjustment for patient and ED characteristics.

RESULTS

Of 3,322,901 initial visits to the ED, 249,648 (7.5%) resulted in a 7-day revisit. There was no significant association of immigrant status with either ED revisits or poor revisit outcomes (greater acuity visit or need for admission) in the adjusted models. Within immigrants, the odds of revisit were not associated with immigrant classes or region of origin; however, immigrants whose native tongue was not English or French had a slightly greater odds of revisiting the ED (aOR 1.05; 95% CI 1.01, 1.09). Significant predictors of revisits included younger age, greater triage acuity score, greater predilection for using an ED, daytime shifts, and greater deprivation index.

CONCLUSIONS

Immigrant children are not more likely to have short-term revisits to the ED, but there may be barriers to care related to language fluency that need to be addressed. These findings may be relevant for improving translation services in EDs.